Is eye opening really significant?
How significant is it that Rep. Gabrielle Giffords opened her left eye? According to at least one expert, it's very significant.
Vivek Deshmukh, director of cerebrovascular neurosurgery at the Providence Brain Institute in Portland, Ore., said Thursday that a brain-injury patient's ability to open his or her eyes in response to hearing someone's voice is a crucial indication that the patient's level of consciousness is improving.
"It's very significant," Deshmukh said in a telephone interview. "It's not as significant as her following commands. That was the distinction that allows us to know she comprehends speech. But opening her eyes is one more step in her recovery."
Aside from the ability to respond to commands, doctors assessing brain injury patients often first test to see whether the patients open their eyes in response to pain, he said.
"If you don't open you eyes in response to any stimulation, that's the deepest level of coma. If she opens her eyes in response to pain, that suggests slightly more response. If you open them in response to voice, that's even more awareness. The best yet is opening them spontaneously," Deshmukh said.
Some brain injury patients open their eyes months after being in a coma but never regain much awareness because they have suffered too much brain damage. But when someone opens their eyes in the acute period soon after the injury, that implies that they have retained a higher level of functioning, Deshmukh said.
"In the acute period, eye opening is very significant," he said. "In someone like her, who in just a few days after injury is opening her eyes and following commands, it is a much better prognostic indicator of recovery. It's less meaningful when it happens three or six months later."
Now that Giffords is opening her left eye (the right one was injured in the shooting and is bandaged), that suggests that she may have recovered enough to make it safe to wean her off her breathing tube, he said. Doctors earlier this week said they were keeping the breathing tube in place to prevent complications, such as pneumonia. But Deshmukh said Giffords's ability to open her eye suggests she may have enough consciousness to control her ability to swallow and breath on her own.
"She's reached the stage now where if she is opening her eyes in response to voice and following commands, now we're looking at, 'When will the breathing tube come out?' The combination should lead them to consider weaning the ventilator now that she's outside the window for brain swelling," he said.
"If patients aren't opening their eyes, their level of consciousness is suppressed enough that she can't cough out secretions. That can lead to pneumonia. Now that she's opening her eyes, that intimates she is aware enough to protect her own airways and initiate and maintain her own breaths," he said.
Another expert said he was not surprised by the development, given the previous reports of Giffords's ability to respond to commands.
"We know her brain stem is working and we know the core of her brain is working. In that light, I would say this is to be expected," said Arthur Kobrine, a professor of neurosurgery at Georgetown University Hospital who treated Jim Brady, who suffered a gunshot wound to the head during the 1981 assassination attempt on President Ronald Reagan. "It really means they are backing away from sedation and allowing her to wake up. It's more or less confirmation that her brain stem is working."
A key question is how much vision Giffords has, which will be determined by how much damage the bullet did to the part of her left brain involved in vision, Kobrine said. She may be left with only half a field of vision in each eye, he said. The part of the brain involved in vision on the left side controls the right half of the field of vision in each eye.
"We don't know whether she sees or how well she sees," he said.
Beyond her ability to see, doctors will look for other signs that will indicate her condition and prognosis, including whether she can follow objects with her eyes and whether she turns to notice people when they walk in the room, according to Zachary Levine, director of Functional Neurosurgery at Washington Hospital Center.
"That means the part of the brain that involves interaction in a complex way is functioning," he said.
But doctors will not really be able to assess her condition until the breathing tube is removed and they can begin detailed testing, such as her ability to stick out her tongue, speak and read, Levine said.
"These are all ways to assess her higher function," he said.
This post has been updated.
| January 13, 2011; 1:04 PM ET
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