A 6-year-old boy, previously experiencing normal development and without any significant medical, family, or social history, suffered severe traumatic brain injury (TBI), diffuse axonal injury (DAI), and atlanto-occipital dislocation with accompanying severe cervical (C1)-level spinal cord and bulbo-medullary injury (as depicted in Figures 2, 3), which is often considered fatal. Furthermore, the patient experienced cardiac arrest. Upon admission, he was in a state of acute flaccid coma with closed eyes and showed no response to stimuli, exhibiting only sluggish reactivity in one pupil. This condition was observed on the first day of hospitalization. Although the initial prognosis indicated a futile and terminal state, for which it was expected that he may progress to brain death, the decision to continue life support was made as the parents were undergoing their hospitalization. Consequently, a comprehensive assessment of multimodal brain networks was conducted, leading to therapy and further testing. Miraculously, the patient survived and now possesses communication and cognitive abilities comparable to his chronological age, despite being quadriplegic.
On day 2 (d2), antiseizure medication treatment was initiated based on rs-fMRI findings, which detected rs-SOZ suggestive of epileptogenic activity in deep brain regions that were not observed on cvEEG monitoring conducted during that period. Task-fMRI performed on d2 showed no reactivity initially but demonstrated activation in response to commands on d10, indicating command-following (CMD), despite the patient being in a coma according to bedside examinations. Consequently, network improvement was first detected through rs-fMRI and task-fMRI, a significant 17 days prior to the patient regaining consciousness, which became evident on day 27 when he exhibited facial and eye movements in response to commands, despite his quadriplegia. Before d10, the option of WLST was presented to the family, but they declined following the discovery of CMD, as described in a recently published interview.
During further hospital care, amantadine was administered from d11 to d19. However, it was discontinued due to family concerns regarding its unclear benefits, particularly considering the patient's covert consciousness. Unfortunately, on d72, newly developing hydrocephalus was identified and likely contributed to deterioration in consciousness. The patient experienced subsequent recovery following the emergent placement of an external ventricular drain (EVD). Later, at 8 years of age, the patient is attending grade-appropriate academic classes, able to communicate orally, and has intermittent recovery of urinary continence. However, there has been only mild improvement in quadriplegia.
The primary conclusion drawn from this case is that rs-fMRI can detect potential epileptogenic signals that may be suppressing brain network activity. Following treatment and repeated testing, confirmed command-following (CMD) can be identified, as initially suggested by rs-fMRI and confirmed by task-fMRI. These findings have significant implications for the consideration of WLST, representing unique advancements in the field of pediatrics with ABI.