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  • Updated 05.14.2024
  • Released 05.19.2004
  • Expires For CME 05.14.2027

Locked-in syndrome



“Locked-in” syndrome describes patients who are awake and conscious but selectively “de-efferented,” with no means of producing speech or moving their facial muscles or limbs. They are aware and perceive normally but are effectively locked in their own bodies, unable to communicate except possibly by blinking or eye movements. Locked-in syndrome typically results from a lesion in the brainstem, classically in the ventral pons. In this article, the author discusses the presentation, etiology, prognosis, diagnostic evaluation, and management of locked-in syndrome. Updates focus on the progress in brain-computer interfaces for communication and functionality of these patients.

Key points

• Locked-in syndrome is a de-efferented state characterized by quadriplegia and paralysis of the lower cranial nerves.

• Patients retain consciousness and can classically communicate by vertical eye movements and eye blinking.

• The most common etiology is atherothrombotic occlusion of the basilar artery resulting in ischemia of the ventral pons.

• Advances in technology, such as brain-computer interfaces, are allowing for improved communication for patients with locked-in syndrome.

Historical note and terminology

In 1875, French physician Camille Darolles, an intern supervised by François Damaschino (1840-1889), gave the first accurate clinical and pathological report of a complete or total case of locked-in syndrome, which lasted only for a few hours before the patient's death (24; 32; 122). Darolles presented the case at a monthly meeting of the Société Anatomique de Paris chaired by Jean-Martin Charcot (1825-1893).

New York neurologists Fred Plum (1924-2010) and Jerome Posner (1932-) first introduced the term in 1983, and they described the syndrome as “a state in which selective supranuclear motor de-efferentation produces paralysis of all four limbs and the last cranial nerves without interfering with consciousness” (98).

The famous case of Jean-Dominique Bauby (1952-1997) provides a patient’s perspective of locked-in syndrome following a devastating brainstem stroke. Despite being locked in, Bauby “dictated” his memoir to Claude Mendibil by the laborious method of blinking when the correct letter was reached by a person slowly reciting the alphabet over and over again. The book includes vivid depictions of the insensitivity of some healthcare providers toward a severely disabled person (as well as his outspoken reactions to such treatment) (09; 66). Bauby died suddenly 2 days after publication the of his book, The Diving Bell and the Butterfly (09). The book was later adapted for a critically acclaimed film of the same name.

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