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The diagnosis and differential diagnosis of (persistent) vegetative state, (P)VS, requires special expertise and experience (1). Recently, the term (P)VS has been substituted by the medical term Unresponsive Wakefulness Syndrome (UWS), as correctly mentioned by the authors (2). Our aim should be to reduce the unacceptably high rate of misdiagnosis in patients with (P)VS (37–43%) by improving quality management. One can only agree with the statement that above all the diagnosis of VS (UWS) is based on a qualified and standardized clinical neurological examination. Semantically, VS (UWS) and minimally conscious state (MCS) denote two functional transitory syndromes which can be clearly differentiated based on clinical findings. The reliability and validity of the German Coma Remission Scale (KRS) in identifying coma, PVS and MCS in early neurological rehabilitation has convinced specialists, health insurers and politicians (German Social Insurance Code (SGB) IX). With regard to the studies analyzed in the article, we had wished for a more adequate critical discussion on the evaluation and evidence of the way the respective neurological examination procedures were applied and what this meant for the rate of misdiagnosis. Have our recommendations of the European VS guidelines been followed in those studies (1)? Our recommendations have not been discussed in the review (2). Evidence-based, bed-side examination techniques were not mentioned. We recommended a 3-year further training program in a specialized department for VS patients. This qualification has been shown to provide medical-neurological expertise and to reduce the rate of misdiagnosis of VS by precisely allocating the typical symptoms observed with this transitory functional syndrome to the correct diagnosis. Supplementary tables on etiology, the clinical picture of full-blown VS (UWS) and clinical dynamics during the stages of regression are missing (3); these have been compiled with modifications in our guidelines (1) and continue to be valid. In UWS and MCS, not only neurotraumatologists are especially interested in the prognostic relevance of the cause, location and extent of the underlying brain damage and its functional changes over time, apart from patient age. Additional information about functional imaging is provided by Zakharova et al. (4).

DOI: 10.3238/arztebl.2015.0680a

Prof. Prof. h.c. mult. Dr. med. Dr. h.c. Klaus R.H. von Wild
Neurochirurgie, Neurorehabilitation, Medizinische Fakulät der WW-Universität Münster, kvw@neurosci.de

Prof. emer. Dr. Dr. hc. mult. Franz Gerstenbrand
Neurologie und Psychiatrie, Wien

Prof. Alexander Potapov, MD. PhD
Neurosurgery
The BURDENKO Neurosurgery Institute,
Moscow RUSSIA

Conflict of interest statement
The authors declare that no conflict of interest exists.

1.
von Wild, K, Gerstenbrand F, Dolce G, et al.: Guidelines for quality management of apallic syndrome/vegetative state. Eur J Trauma Emerg Surg 2007; 3: 268–92 CrossRef
2.
Bender A, Jox RJ, Grill E, Straube A, Lulé D: Persistent vegetative state and minimally conscious state—a systematic review and meta-analysis of diagnostic procedures. Dtsch Arztebl Int 2015; 112: 235–42 VOLLTEXT
3.
Gerstenbrand F: The symptomatology of the apallic syndrome. In: Dalle Ore G, Gerstenbrand F (eds.): Theapallic syndrome. Heidelberg, New York 1977: 14–21 CrossRef MEDLINE
4.
Zakharova N, Kornienko V, Potapov A, Pronin I: Neuroimaging of traumatic brain injury. Cham, Heidelberg, New York, Dordrecht, London: Springer 2014: 69–123 CrossRef CrossRef
1.von Wild, K, Gerstenbrand F, Dolce G, et al.: Guidelines for quality management of apallic syndrome/vegetative state. Eur J Trauma Emerg Surg 2007; 3: 268–92 CrossRef
2.Bender A, Jox RJ, Grill E, Straube A, Lulé D: Persistent vegetative state and minimally conscious state—a systematic review and meta-analysis of diagnostic procedures. Dtsch Arztebl Int 2015; 112: 235–42 VOLLTEXT
3.Gerstenbrand F: The symptomatology of the apallic syndrome. In: Dalle Ore G, Gerstenbrand F (eds.): Theapallic syndrome. Heidelberg, New York 1977: 14–21 CrossRef MEDLINE
4.Zakharova N, Kornienko V, Potapov A, Pronin I: Neuroimaging of traumatic brain injury. Cham, Heidelberg, New York, Dordrecht, London: Springer 2014: 69–123 CrossRef CrossRef

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