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Little is known about the brain and states of consciousness – but recent studies may give grounds for hope in unresponsive patients.
If a person suffers a severe brain injury and lands in intensive care in a coma, doctors and relatives will ask whether the patient has regained consciousness yet.
They often ask the injured person to move their hand, say, and if the patient fails to do so, they often assume the patient is still in such a deep coma that they are not aware of anything.
But this may not necessarily be true, studies show. About 15 per cent to 20 per cent of patients are thinking cognitively even if they make no outward response when addressed, research studies have shown.

The latest study, published in the New England Journal of Medicine, says this actually applies to around 25 per cent of patients.
“Some patients with severe brain injuries do not appear to process their outside world,” says lead study author Yelena Bodien from Massachusetts General Hospital’s Centre for Neurotechnology and Neurorehabilitation.
“However, when they are examined using advanced techniques such as functional magnetic resonance imaging (fMRI) and electroencephalography (EEG), we can detect brain activity that suggests otherwise.”
The scientists examined patients with severe brain injuries from the US and Europe who were involved in road accidents with traumatic brain injury, or had a stroke, or were resuscitated after cardiac arrest.
While their brains were scanned in tests, they were given instructions, such as “imagine opening and closing your hand”. They were also asked to imagine they were taking part in a sport.

Of the 241 patients studied who were lying in bed and showed no externally visible reaction, tests showed 60 of them still followed the instructions internally for several minutes. That means the group was attentive, understood language and had a short-term memory, the authors say.
The international study, conducted over a period of several years, is important, says Julian Bösel, spokesman for the Neurological Intensive Care Medicine Commission of the German Society of Neurology (DGN), as it includes the largest patient group to date, was carried out at six medical centres, and has recorded the phenomenon more systematically than usual.
But it raises a central ethical question, namely whether therapy should be continued, he says.
Severe brain injuries often cause an impairment of consciousness. A coma is a state of complete unconsciousness, where patients do not open their eyes, even in response to pain stimuli.
There are other degrees and levels of partial consciousness, such as a minimally conscious state, or when patients occasionally open their eyes and have distinct sleep-wake phases, even if they are unresponsive.
People in intensive care units and rehabilitation wards should always be treated as if they are aware of something. You talk to them and treat them with respect
Frank Erbguth, president of the German Brain Foundation
These can last for days, weeks, months or even years.
“In certain constellations, studies such as the present one could provide an opportunity to examine more of these patients with EEG and observe them over a longer period of time,” says Bösel.
We can deduce from this that, when in doubt, certain patients should be given more time, he says. However, it is unclear whether special therapies help such people.
For some time now, attempts have been made to achieve something with behavioural therapies, medication or other procedures, but mostly without resounding or lasting success.
A Massachusetts General Hospital team is also using modern technology to probe these questions, testing brain-computer interfaces to connect the brains of patients with computers so that they can communicate with each other.

But the latest study does not tell us anything wholly new, in the view of Frank Erbguth, president of the German Brain Foundation.
“It is clear that the phenomenon exists,” he says. However, just because electrical patterns or active regions in the brain are measured does not mean that these people really have a higher form of consciousness, he says, adding that the fMRI or EEG of anaesthetised people shows similar levels of consciousness.
Both scientists agree on the way patients should be handled, however.
“People in intensive care units and rehabilitation wards should always be treated as if they are aware of something. You talk to them and treat them with respect, as they already are today,” says Erbguth.
So how high is the rate of people who show cognitive abilities but lack behavioural signs? The study authors and the German scientists agree it is difficult to make definitive statements on this.

In the new study, the tests were not standardised, and the patients were selected.
“Also the causes of brain damage that were summarised here were completely different,” says Erbguth.
But the percentage figures from studies like this one show that “we should be aware that perhaps even more patients with impaired consciousness are aware of what is going on around them than we thought”, says Bösel.
It is still common in many places for comatose patients to be spoken to at the bedside as if they were not there, he says.
“But many carers do a really good job, greeting the patient, introducing themselves and telling them what they are doing with them.”
That is an approach that everyone should take to heart, including doctors on ward rounds and visitors, he says.
Do not address frightening or upsetting topics while beside the patient, however. “We stand at the bedside and don’t know that much about what’s really going on in the patient’s head,” says Bösel.
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