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Patients with completely locked-in syndrome are conscious and alert, even though they have lost the ability to control their muscles.1 These patients require a communication channel independent of the motor system. EEG-based brain–computer interfaces (BCIs) are an available communication aid, but aside from the intensive training that most of them demand, not all patients achieve proficiency in EEG control. Here we report an alternative method to re-establish communication in a 46-year-old woman with ALS. At the time of the study, she had been diagnosed with ALS for more than 5 years and had been artificially ventilated and fed for 3 years. For 12 months before this study, she was completely locked in, showing no signs of voluntary motor control including eye movements (measured with electro-oculogram) and external sphincter activity (measured with an anal electromyography electrode). Before entering the locked-in state, the patient requested continuation of life support from her family. The family insisted on respecting the patient's will beyond the locked-in state. EEG responses derived from auditory event–related paradigms indicated preserved cognitive functions,2 which, together with the experiment described below, excludes persistent vegetative state. Prior to this experiment, the patient participated in BCI training as described elsewhere,3 which was terminated after 6 months without success. Because of this …
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