38. fMRI reveals cognitive and emotional processing in a long-term comatose patient—S. Eickhoff 1,2, M. Dafotakis 1, C. Gref-kes 1,3, T. Stöcker 1,4, J.N. Shah 1,4, K. Zilles 1,2,4, M. Siebler 5

(1 Forschungszentrum Jülich, Institut für Neurowissenschaftenund Biophysik – Medizin (INB 3), Jülich, Germany, 2 Heinrich-Heine-Universität, Vogt Institut für Hirnforschung, Düsseldorf,Germany, 3 Max-Planck-Institut für neurologische Forschung,Köln, Germany, 4 Brain Imaging Center West (BICW), Jülich, Ger-many, 5 Heinrich-Heine-Universität, Neurologische Klinik, Düs-seldorf, Germany)

History: At the age of 38, an otherwise healthy mother of twochildren was admitted to hospital with a Glasgow coma scale(GCS) of 4 following closed head injury. Diagnostics revealed trau-matic subarachnoid haemorrhage and right-sided space-occupyingparenchymal haematoma; treated by craniotomy and haematomaresection. Without ever regaining consciousness, opening her eyesor showing other than stereotypic left arm movements, she wastransferred to a nursing home. 35 months later, the patient was pre-sented for further evaluation using functional magnetic resonanceimaging (fMRI).

Clinical status: Examination revealed a GCS of 5 and a grade IVcoma on the Grady Coma Scale. When the permanently closed eye-lids were lifted, the eyes showed horizontal deconjugation with var-iable abduction of either eye. The right pupil was wider and stoodslightly higher (skew deviation). Vestibulo-ocular reflex testing andcaloric irrigation indicated a bilateral internuclear ophthalmoplegia.Stereotypical masticatory movements, non-habituating snout, pal-mo-mental and (strong) grasp reflexes were present. Spastic tetrapa-resis was more pronounced on the lower extremity and on the rightside with hypertonic contractures. Particularly when the patient wasmanipulated, stereotype movements of the left arm and hand werevisible.

fMRI methods: Three sensory paradigms were tested twice twomonths apart [Visual stimulation by full-field flicker light; auditorystimulation by non-emotional words; brushing the right or leftforearm] using a block design. During the second examination,we furthermore investigated responses to speech of varying famil-iarity (the patient’s children, longstanding close friends, unknownperson) and content (addressing the patient directly, stating boththe speaker’s and patient’s name, or uttering random non-emo-tional words). All six conditions (3 speakers � 2 contents) werepresented 20 times each in a pseudorandomised order using ablock design.

fMRI results: SPM5 analysis revealed robust activation of audi-tory, visual and somatosensory cortices by sensory stimulation(P < 0.05, FWE corrected). Additionally, presentation of auditorywords also activated Broca’s area (left BA 44). Stronger response dur-ing speech directed to the patient as compared to neutral phrases,and a speaker-dependent modulation thereof, was detected in theleft amygdala and the right anterior superior temporal sulcus. Inboth regions, children’s’ voices elicited the strongest activity fol-lowed by her friends, while the response to the unknown voicewas significantly smaller. Regardless of the speaker, addressing thepatient resulted in significantly larger activations in these regions(Figs. 1 and 2).

Implications: This case highlights the potential of neuroimagingto contribute to the evaluation of comatose patients by revealingcognitive and emotional capabilities not previously accessible. Thedetection of differentiated cortical processing, even in a patient withsuch poor clinical status, should bring about a reconsideration of theway these patients are cared for and relative’s claims of ‘‘communi-cation’’. Moreover, assessment of residual cortical function by fMRImay help identifying patients who have the highest prospective tobenefit from interventional treatment (e.g., deep brain stimulation).

Finally, there might be a long-term potential for communication viabrain-computer interfaces arising from this study and precedingobservations in PVS patients.

doi:10.1016/j.clinph.2008.07.039

39. Adaptation of the cortical motor network following hetero-topic hand replantation probed by fMRI and effective connec-tivity analysis—S. Eickhoff 1,2, M. Dafotakis 1, C. Grefkes 1,3, J.N.Shah 1,4, K. Zilles 1,2,4, H. Piza-Katzer 5 (1 Forschungszentrum

Fig. 1.

Fig. 2.

Society Proceedings / Clinical Neurophysiology 120 (2009) e9–e88 e19