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The Persistent Vegetative State: Evidence That the Lower Brain Survives Because Its Neurons Intrinsically Resist Ischemia

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Brain Function and Responsiveness in Disorders of Consciousness

Abstract

Global ischemia caused by heart attack, pulmonary failure, near-drowning or traumatic brain injury often damages the higher brain but not the brainstem, leading to a ‘persistent vegetative state’ where the patient is awake but not aware. Approximately 30,000 US patients are held captive in this condition but not a single research study has addressed how the lower brain is preferentially protected in these people. In the higher brain, ischemia elicits a profound anoxic depolarization (AD) causing neuronal dysfunction and vasoconstriction within minutes. Might brainstem nuclei generate less damaging AD and so be more resilient? Here we compared neuronal resistance to acute injury induced by simulated ischemia in ‘higher’ brain (neocortex, hippocampus, striatum, thalamus and cerebellar cortex) versus ‘lower’ brain (hypothalamus and brainstem) in live slices from rat and mouse. Light transmittance (LT) imaging in response to 10 min of oxygen/glucose deprivation (OGD) revealed immediate and acutely damaging AD propagating through gray matter of higher regions. In adjacent lower brain nuclei, OGD-evoked AD caused little tissue injury. Whole-cell patch recordings from higher neurons under OGD revealed an immediate and irreversible loss of membrane potential (strong AD) that did not recover. In contrast lower neurons only slowly depolarized (weak AD) and then repolarized post-OGD. Two-photon microscopy confirmed non-recoverable swelling of cortical pyramidal neurons during OGD, while lower neurons appeared uninjured. All of the above responses were mimicked by bath exposure to 100 μM ouabain which inhibits the Na+/K+ pump or to 1–10 nM palytoxin which converts the pump into an open cationic channel. Our working hypothesis is that the Na+/K+ pump isoforms expressed in lower brain neurons confer resilience during ischemic stress and that higher brain ‘shutdown’ has evolutionary advantages.

Our studies show that, independent of blood supply, the Na+/K+ pump of higher neurons fails quickly and extensively during ischemia compared to naturally resilient hypothalamic and brainstem neurons. The selective survival of lower brain regions in patients who endure global ischemia will support a persistent vegetative state.

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Acknowledgments

Neuronal recordings were obtained by Dr. C. Devin Brisson as part of his doctoral thesis carried out in RDA’s laboratory. Thanks to Dr. Susan Boehnke for statistical advice.

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  1. Department of Biomedical and Molecular Sciences, Queen’s University, Kingston, ON, K7L-3N6, Canada

    R. David Andrew

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Correspondence to R. David Andrew .

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Editors and Affiliations

  1. Dept. of Psychology and Neurosurgery, University of California, L.A., Los Angeles, California, USA

    Martin M. Monti

  2. Dept of Neurosc, Ophthalmol and Genetics, University of Genova, Genova, Italy

    Walter G. Sannita

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Andrew, R.D. (2016). The Persistent Vegetative State: Evidence That the Lower Brain Survives Because Its Neurons Intrinsically Resist Ischemia. In: Monti, M., Sannita, W. (eds) Brain Function and Responsiveness in Disorders of Consciousness. Springer, Cham. https://doi.org/10.1007/978-3-319-21425-2_10

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