Using neuroimaging to detect awareness in disorders of consciousness

The assessment of residual brain function in the vegetative state is extremely difficult and depends frequently on subjective interpretations of observed spontaneous and volitional behaviours. For those patients who retain peripheral motor function, rigorous behavioural assessment supported by structural imaging and electrophysiology is usually sufficient to establish a patient's level of wakefulness and awareness. However, it is becoming increasingly apparent that, in some patients, damage to the peripheral motor system may prevent overt responses to commands, even though the cognitive ability to perceive and understand such commands may remain intact. Advances in functional neuroimaging suggest a novel solution to this problem; in several recent cases, so-called activation studies have been used to identify residual cognitive function and even conscious awareness in patients who are assumed to be vegetative, yet retain cognitive abilities that have evaded detection using standard clinical methods.