Advances in
resuscitation and
critical care management have resulted in the survival of many patients despite severe brain damage. These patients may remain in
coma or in
vegetative state. The probability of recovery of conscious function is dependent on the extent of structural brain damage, which is difficult to assess by clinical, laboratory or functional tests. Positron emission tomography (PET) of 18F-fluordeoxyglucose (FDG) can be used to investigate metabolic and functional impairment of the brain. In acute
vegetative state (AVS, duration <1 month), overall
glucose utilization was significantly reduced in comparison with age-matched controls. In a few cases with
locked-in syndrome, cortical metabolism was in the normal range. 11C-Flumazenil (FMZ) measures the density of
benzodiazepine receptors (BZRs) and thereby furnishes an estimate of neuronal integrity. PET with this tracer demonstrated a considerable reduction in BZRs in cortical areas, but indicated that the cerebellum was spared from neuronal loss. The comparison of FDG- and FMZ-PET findings in AVS demonstrates that alterations of cerebral
glucose consumption do not represent mere functional inactivation, but also irreversible structural damage. In some cases with
minimally conscious state, auditory stimuli with emotional valence induced more brain activation (investigated by H215O-PET) than meaningless noise; such studies can be used to detect residual cortical function. To improve prognostication of chances for recovery, a combination of functional activation studies and assessment of the extent of neuronal damage might be the optimal procedure and should be tested in larger cohorts of patients with
comatose states of different severity.