Bifocal extradural cortical stimulation-induced recovery of consciousness in the permanent post-traumatic vegetative state

Clinical diagnosis guidelines and neurorestorative treatment for chronic disorders of consciousness (2021 China version)

Chronic disorders of consciousness (DOC) include the vegetative state and the minimally consciousness state. The DOC diagnosis mainly relies on the evaluation of clinical behavioral scales, electrophysiological testing, and neuroimaging examinations. No specifically effective neurorestorative methods for chronic DOC currently exist. Any valuable exploration therapies of being able to repair functions and/or structures in the consciousness loop (e.g., drugs, hyperbaric medicines, noninvasive neurostimulation, sensory and environmental stimulation, invasive neuromodulation therapy, and cell transplantation) may become effective neurorestorative strategies for chronic DOC. In the viewpoint of Neurorestoratology, this guideline proposes the diagnostic and neurorestorative therapeutic suggestions and future exploration direction for this disease following the review of the existing treatment exploration achievements for chronic DOC.

Functional subdivisions of medial parieto-occipital cortex in humans and nonhuman primates using resting-state fMRI

Based on its diverse and wide-spread patterns of connectivity, primate posteromedial cortex (PMC) is well positioned to support roles in several aspects of sensory-, cognitive- and motor-related processing. Previous work in both humans and non-human primates (NHPs) using resting-state functional MRI (rs-fMRI) suggests that a subregion of PMC, the medial parieto-occipital cortex (mPOC), by virtue of its intrinsic functional connectivity (FC) with visual cortex, may only play a role in higher-order visual processing. Recent neuroanatomical tracer studies in NHPs, however, demonstrate that mPOC also has prominent cortico-cortical connections with several frontoparietal structures involved in movement planning and control, a finding consistent with increasing observations of reach- and grasp-related activity in the mPOC of both NHPs and humans. To reconcile these observations, here we used rs-fMRI data collected from both awake humans and anesthetized macaque monkeys to more closely examine and compare parcellations of mPOC across species and explore the FC patterns associated with these subdivisions. Seed-based and voxel-wise hierarchical cluster analyses revealed four broad spatially separated functional boundaries that correspond with graded differences in whole-brain FC patterns in each species. The patterns of FC observed are consistent with mPOC forming a critical hub of networks involved in action planning and control, spatial navigation, and working memory. In addition, our comparison between species indicates that while there are several similarities, there may be some species-specific differences in functional neural organization. These findings and the associated theoretical implications are discussed.

Persons and Evidence for Death: A Reply to Bulzacchelli

This article is a reply to Bulzacchelli's argument via two routes. First, I argue that Bulzacchelli has not clarified what he means by the two key terms in his argument: person and reduction. Second, and more importantly, I argue that Bulzacchelli's argument involves a contradiction. He seems to think that determining death on the basis of physiological evidence (i.e. the cessation of organismic functioning) is reductionistic. But he also endorses arguments against whole brain death (WBD) and those arguments maintain that because organ systems function (with external support) in the setting of WBD, the person still exists. But to say that the person still exists simply in virtue of organ systems still functioning is the very reduction Bulzacchelli intimates is a problem.

Effects of intrathecal baclofen therapy on motor and cognitive functions in a rat model of cerebral palsy

OBJECT

Cerebral palsy (CP) arises in the early stages of brain development and manifests as spastic paresis that is often associated with cognitive dysfunction. Available CP treatments are aimed at the management of spasticity and include botulinum toxin administration, selective dorsal rhizotomy, and intrathecal baclofen (ITB). In this study, the authors investigated whether the management of spasticity with ITB therapy affected motor function and whether the release of spasticity was associated with an improvement in intellectual function.

METHODS

Newborn Sprague-Dawley rats were divided into the following groups: control, CP model, and CP model with ITB therapy. For the CP model, postnatal Day 7 (P7) rats were exposed to hypoxic conditions (8% O(2)) for 150 minutes after ligation of the right common carotid artery. In the groups receiving ITB therapy, a spinal catheter was connected to an osmotic pump filled with baclofen and placed in the spinal subarachnoid space on P21 in the early group and on P35 in the late group. A daily dose of 12 μg of baclofen was continuously administered until P49, resulting in 28 days of therapy in the early group and 14 days in the late group. Changes in spasticity in the CP and CP with ITB treatment groups were confirmed by assessing the motor evoked potential in the plantar muscle.

RESULTS

In the CP group, the time required to complete a beam-walking test on P49 was significantly longer than that in the control and ITB treatment groups (4.15 ± 0.60 vs 2.10 ± 0.18 and 2.22 ± 0.22 seconds, respectively). Results of the beam-walking test are expressed as the mean ± SD. Radial arm maze performance on P49 indicated that spatial reference memory had significantly deteriorated in the CP group compared with controls (2.33 ± 0.87 vs 0.86 ± 0.90 points); moreover, working memory was also negatively affected by CP (0.78 ± 1.09 vs 0.14 ± 0.38 points). Results of the memory tests are expressed as the mean ± SE. These memory functions did not recover after ITB treatment.

CONCLUSIONS

Management of spasticity with ITB therapy improved the walking ability in the rat CP model. Intrathecal baclofen therapy-which reduces harmful sensory and motor stimulations caused by spasticity to more optimal levels-contributed to motor function recovery; however, it had no effect on intellectual recovery as assessed by memory performance in the rat CP model.

Neurotransmitters in disorders of consciousness and brain damage

Restorations from disorders of consciousness such as the minimally conscious state and the vegetative state have been achieved spontaneously or by pharmacological agents such as zolpidem, baclofen, dopaminergic agents and tricyclic antidepressants in some patients. Other restoration methods have included electric and magnetic nerve stimulation, oxygen, Kreb's cycle constituent substitution and axonal re-growth. Although apparently unrelated, these methods all influence neurotransmitter availability or production within the brain. This review proposes depleted neurotransmitter function as a cause for long term brain suppression and disorders of consciousness. It unifies fundamentally different treatment approaches and explores the restoration of neurotransmitter function as a common theme to improve brain function after brain damage.

Neuroimaging in disorders of consciousness: contributions to diagnosis and prognosis

Conventional assessment of the level of awareness that is retained by a patient with a disorder of consciousness following a brain injury is made on the basis of exhibited behaviors. This is particularly challenging for clinicians who must decide whether a certain behavior, which might be inconsistent or incomplete, reflects a conscious or an unconscious process. These assessments are not only highly subjective, but also dependent upon the ability of the patient to produce an appropriate motor response. Recent developments in neuroimaging techniques can provide a measure of the levels of awareness that these patients may retain, and importantly, they overcome the necessity for these patients to produce detectable movements by instead relying on their adopting appropriate ‘mind-sets’ as instructed by the task. In this article, we review recent advances in this field and discuss how they may accompany behavioral assessments in future in order to provide diagnostic and prognostic information.

Functional connectivity of the posteromedial cortex

As different areas within the PMC have different connectivity patterns with various cortical and subcortical regions, we hypothesized that distinct functional modules may be present within the PMC. Because the PMC appears to be the most active region during resting state, it has been postulated to play a fundamental role in the control of baseline brain functioning within the default mode network (DMN). Therefore one goal of this study was to explore which components of the PMC are specifically involved in the DMN. In a sample of seventeen healthy volunteers, we performed an unsupervised voxelwise ROI-based clustering based on resting state functional connectivity. Our results showed four clusters with different network connectivity. Each cluster showed positive and negative correlations with cortical regions involved in the DMN. Progressive shifts in PMC functional connectivity emerged from anterior to posterior and from dorsal to ventral ROIs. Ventral posterior portions of PMC were found to be part of a network implicated in the visuo-spatial guidance of movements, whereas dorsal anterior portions of PMC were interlinked with areas involved in attentional control. Ventral retrosplenial PMC selectively correlated with a network showing considerable overlap with the DMN, indicating that it makes essential contributions in self-referential processing, including autobiographical memory processing. Finally, ventral posterior PMC was shown to be functionally connected with a visual network.

The paper represents the first attempt to provide a systematic, unsupervised, voxelwise clustering of the human posteromedial cortex (PMC), using resting-state functional connectivity data. Moreover, a ROI-based parcellation was used to confirm the results.

Combination of diffusion tensor and functional magnetic resonance imaging during recovery from the vegetative state

BACKGROUND

The rate of recovery from the vegetative state (VS) is low. Currently, little is known of the mechanisms and cerebral changes that accompany those relatively rare cases of good recovery. Here, we combined functional magnetic resonance imaging (fMRI) and diffusion tensor imaging (DTI) to study the evolution of one VS patient at one month post-ictus and again twelve months later when he had recovered consciousness.

METHODS

fMRI was used to investigate cortical responses to passive language stimulation as well as task-induced deactivations related to the default-mode network. DTI was used to assess the integrity of the global white matter and the arcuate fasciculus. We also performed a neuropsychological assessment at the time of the second MRI examination in order to characterize the profile of cognitive deficits.

RESULTS

fMRI analysis revealed anatomically appropriate activation to speech in both the first and the second scans but a reduced pattern of task-induced deactivations in the first scan. In the second scan, following the recovery of consciousness, this pattern became more similar to that classically described for the default-mode network. DTI analysis revealed relative preservation of the arcuate fasciculus and of the global normal-appearing white matter at both time points. The neuropsychological assessment revealed recovery of receptive linguistic functioning by 12-months post-ictus.

CONCLUSIONS

These results suggest that the combination of different structural and functional imaging modalities may provide a powerful means for assessing the mechanisms involved in the recovery from the VS.