猫持续性植物状态模型制作及其相关基础与治疗研究
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摘要
引起持续性植物状态(Petsistent vegetative state，PVS)的原因很多，其中脑损伤引起的PVS最常见，脑干损伤又是脑损伤中引起PVS的主要原因。由于传统观念认为PVS病程长、疗效差、预后不好，许多医务人员及患者家属对PVS的治疗态度不十分积极，在该方面的研究也无重大突破，其原因之一是有关PVS的基础研究难度大。
动物模型的建立是基础研究的先决条件。近年来，有关PVS动物模型的报道或因为重复性差，或因为与临床上PVS病情相差较远而无法推广。本实验首先运用颞枕硬膜外水囊法制作脑干伤PVS模型，并在此基础上对PVS动物模型进行一系列相关的基础与治疗研究。
第一部分 猫持续性植物状态模型的制作
本实验采用杂种猫200只，体重约2.26±0.39kg，随机分为正常对照(10只)、假手术处理(10只)和PVS组(180只)。正常组除麻醉外不行任何手术处理，假手组只开颅，不致脑损伤，PVS组于矢状缝
右侧旁开1 .5厘米，人字缝右侧向前0.5厘米处切开头皮、颗肌达颅骨，
牙科钻钻一骨窗，骨窗大小约IXI厘米，将硬脑膜与颅骨内板分离达中
颅凹底，并置入橡胶水囊，注入生理盐水约0.5一2毫升。观察到猫同
侧瞳孔增大而对侧瞳孔未变大为准，维持囊内压力。缝合颗肌及头皮，
无菌纱布包扎，6小时后去除气囊。术后将猫放入动物房，保持呼吸道
通，常规护理和喂养。术中、术后记录猫的瞳孔、颅内压、呼吸、心率
和血压等，并对术后的神经反射等进行观察。
依照1996年我国中华医学会急救分会意识障碍小组在南京制定的
持续性植物状态的标准，根据动物的特点稍加改变为本实验的标准。模
型制作结果为:
1.模型猫PVS观察时间平均为56天;
2.成功制作PVS猫66只，成功率为36.7%(66/180);
3.死亡111只，死亡率为62%(111/180);
4.并发症发生143次，发生率为79.4%(143/l 80)，常见并发症
为误吸、颅内出血、麻醉过度、癫痈等。
结论:本实验采用硬膜外水囊的方法，类似临床上硬膜外血肿的
发病机制，即颅内高压、脑移位引起脑庙，导致中脑等损伤而引起昏迷
一持续性植物状态的发生。同其它方法制作的PVS模型相比，本模型成
功率较高，与临床相似，有苏醒可能，能对其进行相关基础与治疗研究。
本模型制作相对简单，重复性较好，利于推广。是一种比较理想的持续
性植物状态动物模型。
第二部分猫持续性植物状态的相关基础研究
随机选择由本实验采用硬膜外水囊方法制作的“持续性植物状态
猫”(10只)，假手术对照组(10只)，正常对照组(10只)，用高效
液相色谱电化学检测器法检测各组动物脑脊液、血液中多巴胺含量变
化，用免疫组化的方法对动物中脑的多巴胺神经元进行形态学研究，并
对各组的脑电图(EEG)、体感诱发电位(SEP)进行检测以及对动物头
颅进行CT和MRI检查等。结果发现:
1、持续性植物状态猫脑脊液中多巴胺的含量(83.34士21.21)普遍
降低，与正常对照组(150.22士25.32)相比相差显著(P(0.01):PVS猫
血液中多巴胺的含量(17.12士3.25)也明显降低，与对照组(95.37士22.34)
相比相差显著(P(0.01)，(单位:pg/ml)。
2、与正常对照组相比，PVS猫伤侧中脑TH免疫染色阳性细胞数明
显减少，细胞形态也较小。表明中脑多巴胺能神经细胞受损，多巴胺合
成减少。
3、EEG显示:在PVS状态中，a波、6波和e波增加，日波显著减
少，表明PVS猫脑皮质功能受损。
4、SEP显示:在PVS状态中，多数猫为H或111，提示脑干神经功能
受损。
5、CT和MR工显示:球囊对脑组织明显压迫，中线异位，脑干受压。
结论:本实验对“Pvs猫”的脑脊液、血液中多巴胺检测结果表
明:多巴胺含量普遍降低，与其对照组相比相差显著。经DAB法显色的
抗TH免疫组化染色切片上可见，损伤侧的TH阳性细胞明显少于对照组;
EEG显示Q波、6波和。波增加，p波显著减少，SEP检查表明多数猫为
H或m，提示尸VS猫大脑皮层和脑干功能受损。CT和MRI检查发现:
球囊对脑组织明显压迫，中线移位，脑干受压。
第三部分中西医结合对猫持续性植物状态模型的治疗
作用
随机选择由本实验采用硬膜外水囊注射法制作的“持续性植物状
态猫”50只，随机分为PVS组(10只)、治疗对照组(10只)、中药治
疗组(10只)、西药治疗组(10只)和中西医治疗组(10只)。PVS组
不给任何药物治疗。治疗对照组给等剂量生理盐水。药物治疗组，西药
物组:应用美多巴及嗅隐亭。开始剂量为:美多巴每次为Zmg/kg体重，
澳隐亭每次为0.02mg/kg体重，每日3次，以后每周增量(美多巴为
Zmg/kg体重，漠隐亭为0.OZmg/kg体重)。在治疗过程中意识好转，神
经功能改善后，维持该用量2周，然后逐渐减量，减量的剂量、时间与
加量时相同。中药物组给神经再通口服液，剂量为0.sml/kg体重，每
日3次。中西医结合治疗组同时给美多巴、澳隐亭和神经再通口服液。
药物治疗时间共为2月。所有组其他喂养方法和相同。对每组动物在治
疗后抽取脑脊液和血液进行多巴胺的测定，对治疗后的模型进行免疫组
化研究。
经过两个月的治疗?
There are many causes for persistent vegetative state (PVS).The brain injury, especially brain stem injury, is the most common cause resulted in the PVS. According to the traditional concepts , the course of PVS is longer. The curative effect and prognosis are not so good. So,some medical workers and families are not very active in treating PVS. That is the reasons why the study on PVS has not been made a great breakthrough so far.
The establishment of the models of PVS is a prerequisite to the experimental study. In the recent y ears, the reports on the models of PVS couldn't been popularized because of the poor replication or of the great difference between the conditions of the clinical patients and the experimental studies. In this experiment, a model of brain stem injury is initial established by filling water into the a rubber sac between epidural and cranium.
Part I The establishment of the models of PVS in cats
200 cross-breed cats weighing about 2.26?.39Kg each used in this experiment were divided randomly into normal control group (10 cats), sham-operation group (10 cats) and PVS group (180 cats). The cats were treated with nothing except the anaesthesia in the normal control group. The sham-operation groups were only made a cranium hole with a diameter of 1 x1 cm2. In PVS groups,the skin and temporalis were cut and made a cramium hole with 1x1 cm2 diameter on the right side of 1.5 cm sagittal suture and 0.5 cm before the lambdoid suture. A rubber sac was put into the area of temporal-occipital, which located at the middle cranial fossa.
The rubber sac was poured into water with amout of 0.5~2ml untill the right pupil was enlarged for 6 hours.The brain stem was injuried by the high pressure rubber sac with water.The sacs were removed 6hours later. After the surgery, the cats were put into the animal house. The animals keep at the respiratory tracts being unobstructed and normal nursing and feeding. The pupils, intracranial pressure, respiration, heart rate, and blood pressure etc were monitered during and after the operation, and the postoperative neural reflection was examined.
The standards of PVS evaluated according the basis of 1996 Chineses acute medical association. And we used this standard was modified according to the characteristics of the cats. The results of establishing the models:
1 The models was lasted 56 days averagely;
2 66 cats were successfully induced the PVS, and the success rate was 36.7% (66/180);
3 The death rate was 62% (111/180);
4 The incidence rate of complications was 79.4%(143/180),and the common complications were mistake-suck-in,intracranial hemorrhage,over-anesthesia and epliepsy ,et al;
Conclusion:
The PVS model induced with rubber water sac in the experiment has
the similar pathogenesis of epidural hematoma in the clinic condition. The mechanism of this model may associated with increased intracranial pressure and brain stem shift, which resulted in the brain herniation,injury the mesencephalon and eventully long time coma-PVS. Compared with other models, this one has a high success rate, possible palinesthesia, easy replication,simple establishment and similarity both the clinical conditions of the patients and the experiment. This model can be used in studies for basis experiment and treatment.
Part II the relative basis studies on the models of PVS in cats
30 cats were^used in this part of experiment. It includes normal control group(10 cats), pseudo-operation group (10 cats) and PVS groups(10 cats) produced by our experiment. The levels of DA in cerebrospinal fluid and serum were detected with high-performance-liquid-chromatography and electric-chemical-detector (HPLG-ECD) in the cats.The morphologic change of dopaminergic neurons in mesencephalon were studied with immunohistochemicaly method for tyrosine hydroxylase (TH), and the animals were momitored by EEG ^ SEP, CT and MRI.
Results:
1.The level of DAin cerebrospinal fluid (83.34+21.21) in PVS cats was evadent
动物模型的建立是基础研究的先决条件。近年来，有关PVS动物模型的报道或因为重复性差，或因为与临床上PVS病情相差较远而无法推广。本实验首先运用颞枕硬膜外水囊法制作脑干伤PVS模型，并在此基础上对PVS动物模型进行一系列相关的基础与治疗研究。
第一部分 猫持续性植物状态模型的制作
本实验采用杂种猫200只，体重约2.26±0.39kg，随机分为正常对照(10只)、假手术处理(10只)和PVS组(180只)。正常组除麻醉外不行任何手术处理，假手组只开颅，不致脑损伤，PVS组于矢状缝
右侧旁开1 .5厘米，人字缝右侧向前0.5厘米处切开头皮、颗肌达颅骨，
牙科钻钻一骨窗，骨窗大小约IXI厘米，将硬脑膜与颅骨内板分离达中
颅凹底，并置入橡胶水囊，注入生理盐水约0.5一2毫升。观察到猫同
侧瞳孔增大而对侧瞳孔未变大为准，维持囊内压力。缝合颗肌及头皮，
无菌纱布包扎，6小时后去除气囊。术后将猫放入动物房，保持呼吸道
通，常规护理和喂养。术中、术后记录猫的瞳孔、颅内压、呼吸、心率
和血压等，并对术后的神经反射等进行观察。
依照1996年我国中华医学会急救分会意识障碍小组在南京制定的
持续性植物状态的标准，根据动物的特点稍加改变为本实验的标准。模
型制作结果为:
1.模型猫PVS观察时间平均为56天;
2.成功制作PVS猫66只，成功率为36.7%(66/180);
3.死亡111只，死亡率为62%(111/180);
4.并发症发生143次，发生率为79.4%(143/l 80)，常见并发症
为误吸、颅内出血、麻醉过度、癫痈等。
结论:本实验采用硬膜外水囊的方法，类似临床上硬膜外血肿的
发病机制，即颅内高压、脑移位引起脑庙，导致中脑等损伤而引起昏迷
一持续性植物状态的发生。同其它方法制作的PVS模型相比，本模型成
功率较高，与临床相似，有苏醒可能，能对其进行相关基础与治疗研究。
本模型制作相对简单，重复性较好，利于推广。是一种比较理想的持续
性植物状态动物模型。
第二部分猫持续性植物状态的相关基础研究
随机选择由本实验采用硬膜外水囊方法制作的“持续性植物状态
猫”(10只)，假手术对照组(10只)，正常对照组(10只)，用高效
液相色谱电化学检测器法检测各组动物脑脊液、血液中多巴胺含量变
化，用免疫组化的方法对动物中脑的多巴胺神经元进行形态学研究，并
对各组的脑电图(EEG)、体感诱发电位(SEP)进行检测以及对动物头
颅进行CT和MRI检查等。结果发现:
1、持续性植物状态猫脑脊液中多巴胺的含量(83.34士21.21)普遍
降低，与正常对照组(150.22士25.32)相比相差显著(P(0.01):PVS猫
血液中多巴胺的含量(17.12士3.25)也明显降低，与对照组(95.37士22.34)
相比相差显著(P(0.01)，(单位:pg/ml)。
2、与正常对照组相比，PVS猫伤侧中脑TH免疫染色阳性细胞数明
显减少，细胞形态也较小。表明中脑多巴胺能神经细胞受损，多巴胺合
成减少。
3、EEG显示:在PVS状态中，a波、6波和e波增加，日波显著减
少，表明PVS猫脑皮质功能受损。
4、SEP显示:在PVS状态中，多数猫为H或111，提示脑干神经功能
受损。
5、CT和MR工显示:球囊对脑组织明显压迫，中线异位，脑干受压。
结论:本实验对“Pvs猫”的脑脊液、血液中多巴胺检测结果表
明:多巴胺含量普遍降低，与其对照组相比相差显著。经DAB法显色的
抗TH免疫组化染色切片上可见，损伤侧的TH阳性细胞明显少于对照组;
EEG显示Q波、6波和。波增加，p波显著减少，SEP检查表明多数猫为
H或m，提示尸VS猫大脑皮层和脑干功能受损。CT和MRI检查发现:
球囊对脑组织明显压迫，中线移位，脑干受压。
第三部分中西医结合对猫持续性植物状态模型的治疗
作用
随机选择由本实验采用硬膜外水囊注射法制作的“持续性植物状
态猫”50只，随机分为PVS组(10只)、治疗对照组(10只)、中药治
疗组(10只)、西药治疗组(10只)和中西医治疗组(10只)。PVS组
不给任何药物治疗。治疗对照组给等剂量生理盐水。药物治疗组，西药
物组:应用美多巴及嗅隐亭。开始剂量为:美多巴每次为Zmg/kg体重，
澳隐亭每次为0.02mg/kg体重，每日3次，以后每周增量(美多巴为
Zmg/kg体重，漠隐亭为0.OZmg/kg体重)。在治疗过程中意识好转，神
经功能改善后，维持该用量2周，然后逐渐减量，减量的剂量、时间与
加量时相同。中药物组给神经再通口服液，剂量为0.sml/kg体重，每
日3次。中西医结合治疗组同时给美多巴、澳隐亭和神经再通口服液。
药物治疗时间共为2月。所有组其他喂养方法和相同。对每组动物在治
疗后抽取脑脊液和血液进行多巴胺的测定，对治疗后的模型进行免疫组
化研究。
经过两个月的治疗?
There are many causes for persistent vegetative state (PVS).The brain injury, especially brain stem injury, is the most common cause resulted in the PVS. According to the traditional concepts , the course of PVS is longer. The curative effect and prognosis are not so good. So,some medical workers and families are not very active in treating PVS. That is the reasons why the study on PVS has not been made a great breakthrough so far.
The establishment of the models of PVS is a prerequisite to the experimental study. In the recent y ears, the reports on the models of PVS couldn't been popularized because of the poor replication or of the great difference between the conditions of the clinical patients and the experimental studies. In this experiment, a model of brain stem injury is initial established by filling water into the a rubber sac between epidural and cranium.
Part I The establishment of the models of PVS in cats
200 cross-breed cats weighing about 2.26?.39Kg each used in this experiment were divided randomly into normal control group (10 cats), sham-operation group (10 cats) and PVS group (180 cats). The cats were treated with nothing except the anaesthesia in the normal control group. The sham-operation groups were only made a cranium hole with a diameter of 1 x1 cm2. In PVS groups,the skin and temporalis were cut and made a cramium hole with 1x1 cm2 diameter on the right side of 1.5 cm sagittal suture and 0.5 cm before the lambdoid suture. A rubber sac was put into the area of temporal-occipital, which located at the middle cranial fossa.
The rubber sac was poured into water with amout of 0.5~2ml untill the right pupil was enlarged for 6 hours.The brain stem was injuried by the high pressure rubber sac with water.The sacs were removed 6hours later. After the surgery, the cats were put into the animal house. The animals keep at the respiratory tracts being unobstructed and normal nursing and feeding. The pupils, intracranial pressure, respiration, heart rate, and blood pressure etc were monitered during and after the operation, and the postoperative neural reflection was examined.
The standards of PVS evaluated according the basis of 1996 Chineses acute medical association. And we used this standard was modified according to the characteristics of the cats. The results of establishing the models:
1 The models was lasted 56 days averagely;
2 66 cats were successfully induced the PVS, and the success rate was 36.7% (66/180);
3 The death rate was 62% (111/180);
4 The incidence rate of complications was 79.4%(143/180),and the common complications were mistake-suck-in,intracranial hemorrhage,over-anesthesia and epliepsy ,et al;
Conclusion:
The PVS model induced with rubber water sac in the experiment has
the similar pathogenesis of epidural hematoma in the clinic condition. The mechanism of this model may associated with increased intracranial pressure and brain stem shift, which resulted in the brain herniation,injury the mesencephalon and eventully long time coma-PVS. Compared with other models, this one has a high success rate, possible palinesthesia, easy replication,simple establishment and similarity both the clinical conditions of the patients and the experiment. This model can be used in studies for basis experiment and treatment.
Part II the relative basis studies on the models of PVS in cats
30 cats were^used in this part of experiment. It includes normal control group(10 cats), pseudo-operation group (10 cats) and PVS groups(10 cats) produced by our experiment. The levels of DA in cerebrospinal fluid and serum were detected with high-performance-liquid-chromatography and electric-chemical-detector (HPLG-ECD) in the cats.The morphologic change of dopaminergic neurons in mesencephalon were studied with immunohistochemicaly method for tyrosine hydroxylase (TH), and the animals were momitored by EEG ^ SEP, CT and MRI.
Results:
1.The level of DAin cerebrospinal fluid (83.34+21.21) in PVS cats was evadent
引文
1 Latronico, -N; Alongi, -S; Guarneri, -B et al. Approach to the patient in vegetative state. Part Ⅰ: diagnosis. Minerva-Anestesiol. 2000 Apt: 66(4): 225-31
1 Latronico, -N; Antonini, -L; Taricco, -M et al. Approach to the patient in vegetative state. Part Ⅱ: differential diagnosis. Minerva-Anestesiol. 2000 Apr; 66(4): 233-40
2 Latronico, -N; Alongi, -S; Facchi, -E et al. Approach to the patient in vegetative state. Part Ⅲ: prognosis. Minerva-Anestesiol. 2000 Apt; 66(4): 241-8
3 Martinelli, -G. Vegetative state. Practice guideline for its diagnosis and treatment. Hinerva-Anestesiol. 2000 Apr; 66(4): 173-5
4 李金彩，肖华，姜云峰等。中西医结合治疗醒状昏迷患者的临床观察。中国中西医结合杂志 2000；20(11)
5 Xiao Hua, Lj Jincai, Xuqiang, et al. Observation of Medorba, Bromocriptine and Chinese prescription on consciousness recover of patients with persistent vegrtative states. MODERN REHABILITATION (现代康复). 2001; 5(10):147
6 江弘，李玉著，郑文济，等。延长性昏迷的颅脑损伤动物模型。中国临床神经外科杂志，2000，5：60-62．
7 段云祥，郑文济，段国升。持续性植物状态。中华神经外科杂志，1995，11：365-366．
8 张国瑾；王传民；丁新生。中国持续性植物状态的诊断标准及评分量表。中国急救医学 1996+．10．25；19(10)：632-633
9 Jenneet B, Plum F. Pertistent vegetative state after brain damage: a syndrome in search of a name. Lancet, 1972;1:734-735
10 ANA Committee on Ethnical Affairs. Pertistent vegetative state: report of the American Neurological Association Committee of
Ethnical Affairs. Ann Neurol. 1993:33:386-390
11 Ohta T,Yamashita S, Ozaki T, et al. "Vegetative syndrome" :it's definition. Traumatology 1975;6:166-174
12 肖华、张卫兵、李金彩主编。内科疾病与昏迷。第一版，北京：现代出版 社。2000：215-219。
13 Dubroja,-I; Valent,-S; Miklic,-P; Kesak,-D. Outcome of post-traumatic unawareness persisting for more than a month. J-Neurol-Neurosurg-Psychiatry. 1995 Apr; 58(4) : 465-6
14 Heindl,-U-T; Laub,-M-C.Outcome of persistent vegetative state following hypoxic or traumatic brain injury in children and adolescents. Neuropediatrics. 1996 Apr; 27(2) : 94-100
15 Katayama,-Y; Tsubokawa,-T; Yamamoto,-T et al. Characterization and modification of brain activity with deep brain stimulation in patients in a persistent vegetative state: pain-related late positive component of cerebral evoked potential. Pacing-Clin-Electrophysiol. 1991 Jan; 14(1) : 116-20
16 Grossman,-P; Hagel,-K. Post-traumatic apallic syndrome following head injury. Part 2: Treatment. Disabil-Rehabil. 1996 Feb; 18(2) : 57-68
17 Inoue,-M; Nakase,-H; Hirabayashi,-H et al. Effect of stimulation of the dorsal aspect of the cervical spinal cord on local cerebral blood flow and EEG in the cat. Neurol-Res. 2000 Jun; 22(4) : 386-92
18 Zafonte,-R-D; Watanabe,-T; Mann,-N-R. Amantadine: a potential treatment for the minimally conscious state. Brain-Tnj. 1998 Jul; 12(7) : 617-21
19 Matsuda,-W; Sugimoto,-K; Sato,-N; Watanabe,-T; Yanaka.-K; Matsumura,-A; Nose,-T . A case of primary brain-stem injury recovered from persistent vegetative state after L-dopa ministration. No-To-Shinkei. 1999 Dec;
20 Hayashi,-N The brain hypothermia therapy for prevention of
vegetation after severe brain injury. Nippon-Geka-Gakkai-Zasshi. 1999 Jul; 100(7) : 443-8
1 Latronico, -N; Antonini, -L; Taricco, -M et al. Approach to the patient in vegetative state. Part Ⅱ: differential diagnosis. Minerva-Anestesiol. 2000 Apr; 66(4): 233-40
2 Latronico, -N; Alongi, -S; Facchi, -E et al. Approach to the patient in vegetative state. Part Ⅲ: prognosis. Minerva-Anestesiol. 2000 Apt; 66(4): 241-8
3 Martinelli, -G. Vegetative state. Practice guideline for its diagnosis and treatment. Hinerva-Anestesiol. 2000 Apr; 66(4): 173-5
4 李金彩，肖华，姜云峰等。中西医结合治疗醒状昏迷患者的临床观察。中国中西医结合杂志 2000；20(11)
5 Xiao Hua, Lj Jincai, Xuqiang, et al. Observation of Medorba, Bromocriptine and Chinese prescription on consciousness recover of patients with persistent vegrtative states. MODERN REHABILITATION (现代康复). 2001; 5(10):147
6 江弘，李玉著，郑文济，等。延长性昏迷的颅脑损伤动物模型。中国临床神经外科杂志，2000，5：60-62．
7 段云祥，郑文济，段国升。持续性植物状态。中华神经外科杂志，1995，11：365-366．
8 张国瑾；王传民；丁新生。中国持续性植物状态的诊断标准及评分量表。中国急救医学 1996+．10．25；19(10)：632-633
9 Jenneet B, Plum F. Pertistent vegetative state after brain damage: a syndrome in search of a name. Lancet, 1972;1:734-735
10 ANA Committee on Ethnical Affairs. Pertistent vegetative state: report of the American Neurological Association Committee of
Ethnical Affairs. Ann Neurol. 1993:33:386-390
11 Ohta T,Yamashita S, Ozaki T, et al. "Vegetative syndrome" :it's definition. Traumatology 1975;6:166-174
12 肖华、张卫兵、李金彩主编。内科疾病与昏迷。第一版，北京：现代出版 社。2000：215-219。
13 Dubroja,-I; Valent,-S; Miklic,-P; Kesak,-D. Outcome of post-traumatic unawareness persisting for more than a month. J-Neurol-Neurosurg-Psychiatry. 1995 Apr; 58(4) : 465-6
14 Heindl,-U-T; Laub,-M-C.Outcome of persistent vegetative state following hypoxic or traumatic brain injury in children and adolescents. Neuropediatrics. 1996 Apr; 27(2) : 94-100
15 Katayama,-Y; Tsubokawa,-T; Yamamoto,-T et al. Characterization and modification of brain activity with deep brain stimulation in patients in a persistent vegetative state: pain-related late positive component of cerebral evoked potential. Pacing-Clin-Electrophysiol. 1991 Jan; 14(1) : 116-20
16 Grossman,-P; Hagel,-K. Post-traumatic apallic syndrome following head injury. Part 2: Treatment. Disabil-Rehabil. 1996 Feb; 18(2) : 57-68
17 Inoue,-M; Nakase,-H; Hirabayashi,-H et al. Effect of stimulation of the dorsal aspect of the cervical spinal cord on local cerebral blood flow and EEG in the cat. Neurol-Res. 2000 Jun; 22(4) : 386-92
18 Zafonte,-R-D; Watanabe,-T; Mann,-N-R. Amantadine: a potential treatment for the minimally conscious state. Brain-Tnj. 1998 Jul; 12(7) : 617-21
19 Matsuda,-W; Sugimoto,-K; Sato,-N; Watanabe,-T; Yanaka.-K; Matsumura,-A; Nose,-T . A case of primary brain-stem injury recovered from persistent vegetative state after L-dopa ministration. No-To-Shinkei. 1999 Dec;
20 Hayashi,-N The brain hypothermia therapy for prevention of
vegetation after severe brain injury. Nippon-Geka-Gakkai-Zasshi. 1999 Jul; 100(7) : 443-8