Locked in syndrome:No cases here say docs

They see diagnosis as still a challenge but say modern tests will mean slimmer chance of error.

DOCTORS here say they have not come across any cases of locked in syndrome", that rare condition in which a
person is awake and can reason but is otherwise paralysed.

Such a person is neither in a coma nor in a vegetative state. Last week news broke that a Belgian man thought to have been in a vegetative state for 23 years was found to have been conscious all along-following a brain scan.

Reports said Mr Rom Houben, now 46, has since told doctors via a special touchscreen, that he knew what was going on around him but could not move or speak. His plight was discovered after a Belgian coma research team did a high-tech image scan of his brain three years ago. His brain was found to be functioning almost normally.

It is now believed that Mr Houben had been misdiagnosed as having lapsed into a vegetative state after falling into a coma from a car accident.

Commenting on this neurology experts here agree it is possible he might have been wrongly diagnosed earlier.

But they added that, with limited information on his case, it was hard to say what had really happened.

Mr Houben s doctors had used internationally accepted tests to check his eye, verbal and motor responses then.
Someone in a vegetative state may have his eyes open and may react to stimuli but is unaware of what is happening around him.

In Mr Houben s case after three years of rehabilitation he can now - with help move his finger to indicate his thoughts on a touchscreen.

Doctors here while saying that locked in syndrome is rare and that they have not come across any cases added
that this docs not mean there were none.

Associate Professor Ivan Ng, head of neurosurgery at the National Neuroscience Institute, said" How are you going to verify, unless you have actually picked out such a patient?"

But with better test protocols and technology now compared to when Mr Houben had his car accident 26 years
ago chances of getting it wrong are slimmer, said Prof Ng.

Reports had said the research team also showed that Mr Houben could move his foot to push a computer device placed by the team.

That, to Associate Professor Einar Wilder-Smith a senior consultant neurologist at the National University Hospital, should have been a warning sign.

But he acknowledges that accurate diagnosis is still a challenge and that each case needs careful investigation. Medical conditions like peripheral nerve diseases and muscle diseases may also render a patient unable to respond, he added.

But with more assessment tools and better awareness of their limitations, he:"said I don t think we re missing a lot."

The Belgian team believes that as many as four in 10 patients like Mr Houben may have been misdiagnosed in the past. However, scans which are now commonly done can tell which part of the brain is damaged.

If the part of the brain governing higher functions like thought is impaired, then there is little chance of loeked-in syndrome, said Prof Ng.

But doctors also say that using imaging in a routine manner to detect brain activity in people already found to be in a vegetative state such as that tried out by the Belgian researchers is not something to jump into.

"There is still no universal criteria for imaging and the amount of false positives far outweighs its value," said Prof Ng Even those in a persistent vegetative state can sometimes show some brain activation and it is hard to pinpoint the results, he added.

The cost of using such technology is also an issue.

Then there is the question of what to do next if a patient is found to be conscious but still fully paralysed. Not everyone can afford the kind of equipment needed for such patients to communicate, said Prof Ng.

aprilc@sph.com.sg