The vegetative state: prevalence, misdiagnosis, and treatment limitations

Effects of non-invasive brain stimulation on arousal and alertness among traumatic brain injury patients with disorders of consciousness or persistent vegetative State: a systematic review

INTRODUCTION

Traumatic brain injury (TBI) often leads to disorders of consciousness (DOC) or persistent vegetative state (PVS), characterized by impaired arousal and awareness. Non-invasive brain stimulation (NIBS) techniques have shown promise in modulating cortical excitability and potentially enhancing arousal and alertness in these patients. This systematic review aims to synthesize existing literature on the effects of NIBS on arousal and alertness among TBI patients with DOC or PVS.

METHODS

A systematic search was conducted across multiple databases for studies investigating the use of NIBS techniques such as transcranial magnetic stimulation (TMS) and transcranial direct current stimulation (tDCS) in TBI patients with DOC or PVS. Studies were included if they assessed changes in arousal or alertness following NIBS intervention. Data extraction and quality assessment were performed using predefined criteria.

RESULTS

A total of 11 studies with 475 patients (mean age 46.21 ± 12.31 years) met the inclusion criteria and were included in the review. The majority of studies utilized TMS or tDCS as the NIBS modality. Findings suggest that NIBS may lead to improvements in arousal and alertness among TBI patients with DOC or PVS. However, the magnitude and duration of these effects varied across studies.

CONCLUSION

Non-invasive brain stimulation shows promise as a potential intervention for enhancing arousal and alertness in TBI patients with DOC or PVS. Further well-controlled studies are warranted to elucidate optimal stimulation parameters, long-term effects, and potential synergies with other rehabilitation approaches.

Heart rate variability responses to personalized and non-personalized affective videos. A study on healthy subjects and patients with disorders of consciousness

Introduction

The diagnosis of patients with disorders of consciousness (DOC), including those in a minimally conscious state (MCS) and those with unresponsive wakefulness syndrome (UWS), remains a significant clinical challenge. Neurobehavioral assessment primarily relies on motor responses to commands, which are often difficult to interpret due to impaired comprehension and cognitive-motor dissociation, resulting in a high rate of misdiagnosis. While electrical, hemodynamic, and metabolic brain responses, combined with personalized stimuli, have shown promise in improving diagnosis, the role of cardiac activity-less intrusive and time-efficient-remains underexplored.

Methods

This study investigated heart rate variability (HRV) responses to personalized videos of acquaintances versus non-personalized videos of strangers. The study included 17 healthy subjects and 11 patients with DOC. Cardiac responses were recorded and analyzed to compare responses to different stimuli and to examine differences between the two groups.

Results

Healthy subjects exhibited significant differences in several HRV measures in response to both personalized and non-personalized stimuli, whereas patients with DOC did not demonstrate similar differences. Additionally, significant differences were observed in HRV measures between healthy subjects and patients with DOC.

Conclusion

These findings suggest impaired emotional processing in patients with DOC. Further exploration of these differences may enhance diagnostic approaches for this patient population, particularly through the integration of HRV-based measures.

Medical complications and advance medical decision-making in the minimally conscious state

OBJECTIVES

Medical complications occur frequently in MCS and influence advance medical decision-making. This study aimed to report on medical complications and advance medical decision-making in a nationwide group of MCS patients.

METHODS

In this descriptive cross-sectional study, clinical and advance medical decision-making characteristics were collected in a survey, completed by the treating physician.

RESULTS

The MCS population consisted of 32 patients: 65.6% traumatic etiology, 68.8% male. Patients had a median of five complications: hypertonia/spasticity (81.3%) and pneumonia (50.0%) occurred most frequently. Most patients had curative goals: three patients had a fully curative treatment scenarios, 29 a curative scenario with ≥ 1 treatment restrictions, two a palliative and two a symptomatic scenario. Conversations about advance medical decision-making were complicated by disputes with next of kin, inability to evaluate medical treatment because of medical instability, next of kin not being ready to discuss medical treatment, or a treatment scenario explicitly based on requests of next of kin.

CONCLUSION

Medical complications are common in MCS patients and advance medical decision making was complicated. This legitimates realization of specialized care across acute, post-acute and long-term care. Further longitudinal research into advance medical decision-making is recommended.

Survival and clinical characteristics of patients with disorders of consciousness in a developing country between 2002 and 2018

OBJECTIVE

Describe the survival, sociodemographic and clinical characteristics of subjects with disorders of consciousness in a reference rehabilitation center, in a developing country.

METHODS

Patients with disorders of consciousness (DoC) caused by acquired neurological injuries, admitted between the years 2002-2018 in a neurorehabilitation center. Extracted data covered demographics, clinical details, survival time, and discharge information. Cox proportional hazard model and Kaplan-Meier analysis were used to reveal, associations with survival.

RESULT

Out of 5064 neurological cases, 159 patients were diagnosed with DoC. The demographic data showed a male dominance (65%), with an average injury age of 42 years. The most common causes were traumatic (41%), anoxic (36%), and vascular (10%), with traffic accidents accounting for 71% of traumatic injuries. The study found that 75% of patients remained in a vegetative state (VS), and 25% in a minimally conscious state (MCS), with an average survival of 2110 days.

CONCLUSION

There were no significant differences in survival days between patients in MCS and VS. Patients with traumatic injuries showed a higher survival rate than those with non-traumatic injuries. Age and etiology were identified as factors associated with a higher risk of death.

Research hotspots and trends in the application of electroencephalography for assessment of disorders of consciousness: a bibliometric analysis

Objective

Disorders of consciousness (DoC) result from severe traumatic brain injury and hypoxia or ischemia of brain tissues, leading to impaired perceptual abilities. Electroencephalography (EEG) is a non-invasive and widely applicable technology used for assessing DoC. We aimed to identify the research hotspots in this field through a systematic analysis.

Methods

Relevant studies published from January 1, 2004 to December 31, 2023 were retrieved from the Web of Science Core Collection database. The data were analyzed and visualized using CiteSpace, VOSviewer, and SCImago Graphica.

Results

In total, 1,639 relevant publications were retrieved. The country with the highest number of publications was the United States, the most productive institution was Harvard University, the journal with the highest output was Clinical Neurophysiology, and the journal with the highest total number of citations was Neurology. The author with the most publications was Steven Laureys and the most common keyword was "vegetative state."

Conclusion

The field is undergoing rapid development, characterized by a proliferation of advanced technologies and an increased emphasis on international collaboration. The document offers an impartial perspective on the advancements of the research study for the benefit of the researchers.

Mortality of chronic disorders of consciousness in adults and adolescents - a retrospective community based study from Salzburg, Austria

Introduction

Epidemiological data on disorders of consciousness (DoC) is rare and very heterogeneous due to difficulties in case ascertainment and differences in health care pathways between countries. This study reports data on mortality and survival time for DoC patients in Salzburg, Austria.

Methods

All patients with DoC were registered in the health care region of Salzburg North, Austria between 2007 and 2022 and their death data retrieved from the Statistik Austria. The 1- and 5-year mortality was calculated, also in relation to several explanatory variables (age, sex, etiology, diagnosis, CRS-R score, improvement). Furthermore, the incidence, survival functions using the Kaplan-Meier estimator and a Cox-Regression were calculated.

Results

The mean annual incidence is 2.2 DoC/100.000 inhabitants in the Salzburg North region. The crude 1- and 5-year mortality rates were 25.9 and 55.1%, respectively, and the median survival of DoC patients based on the Kaplan-Meier estimator was 6.3 years. Moreover, the mortality was lower in women and in younger patients, those of traumatic etiology, and those with higher CRS-R scores, better diagnosis or an improvement of diagnosis until discharge from hospital.

Conclusion

This article gives a rare insight into epidemiological data on DoC and shows which factors influence the mortality of these patients. Moreover, it is the first community based study on mortality of DoC in Salzburg, Austria.

Altered Mental Status at the Extreme: Behavioral Evaluation of Disorders of Consciousness

Disorders of consciousness represent altered mental status at its most severe, comprising a continuum between coma, the vegetative state/unresponsive wakefulness syndrome, the minimally conscious state, and emergence from the minimally conscious state. Patients often transition between these levels throughout their recovery, and determining a patient's current level can be challenging, particularly in the acute care setting. Although healthcare providers have classically relied on a bedside neurological exam or the Glasgow Coma Scale to aid with assessment of consciousness, studies have identified multiple limitations of doing so. Neurobehavioral assessment measures, such as the Coma Recovery Scale-Revised, have been developed to address these shortcomings. Each behavioral metric has strengths as well as weaknesses when applied in the acute care setting. In this review, we appraise common assessment approaches, outline alternative measures for fine-tuning these assessments in the acute care setting, and highlight strategies for implementing these practices in an interdisciplinary manner.

Neuroimaging biomarkers for the diagnosis and prognosis of patients with disorders of consciousness

The progress in neuroimaging and electrophysiological techniques has shown substantial promise in improving the clinical assessment of disorders of consciousness (DOC). Through the examination of both stimulus-induced and spontaneous brain activity, numerous comprehensive investigations have explored variations in brain activity patterns among patients with DOC, yielding valuable insights for clinical diagnosis and prognostic purposes. Nonetheless, reaching a consensus on precise neuroimaging biomarkers for patients with DOC remains a challenge. Therefore, in this review, we begin by summarizing the empirical evidence related to neuroimaging biomarkers for DOC using various paradigms, including active, passive, and resting-state approaches, by employing task-based fMRI, resting-state fMRI (rs-fMRI), electroencephalography (EEG), and positron emission tomography (PET) techniques. Subsequently, we conducted a review of studies examining the neural correlates of consciousness in patients with DOC, with the findings holding potential value for the clinical application of DOC. Notably, previous research indicates that neuroimaging techniques have the potential to unveil covert awareness that conventional behavioral assessments might overlook. Furthermore, when integrated with various task paradigms or analytical approaches, this combination has the potential to significantly enhance the accuracy of both diagnosis and prognosis in DOC patients. Nonetheless, the stability of these neural biomarkers still needs additional validation, and future directions may entail integrating diagnostic and prognostic methods with big data and deep learning approaches.

A new ICT system coupling electromyography and coma recovery scale-revised to support the diagnostic process in disorders of consciousness

The Coma Recovery Scale-revised (CRS-r) is the gold standard for the behavioral assessment of patients with Disorders of Consciousness (DoCs). However, the misdiagnosis rate is around 40%. For this reason, recent guidelines suggested enhancing the assessment with neurophysiological measures: among these, surface electromyography (sEMG) represents a convenient bedside solution. This work presents the use of the STRIVEfc system, a wearable device that allows CRS-r administration while recording four sEMG signals. STRIVEfc was employed in 40 sessions on 33 DoCs patients and the sEMG was analyzed to look for voluntary and consistent over threshold (OT) muscular activities. Their duration, amplitude, and number were retained and compared between patients in Unresponsive Wakefulness Syndrome (UWS) and Minimally Conscious State (MCS), revealing more numerous and significantly longer OTs in the latter group. Lastly, the EMG information was exploited to enrich the behavioral assessment by building the instrumented CRS-r score (ICRS-r). In 9/16 UWS sessions, the ICRS-r score suggested a higher-level functioning, not translated into a behavioral response, compatible with MCS diagnosis. Overall, the use of STRIVEfc allows to reveal hidden muscular patterns not detectable by the clinician, thus improving the characterization of DoCs patient's functional capabilities and supporting the diagnostic process.

Meta-analysis of the diagnostic value of functional magnetic resonance imaging for distinguishing unresponsive wakefulness syndrome/vegetative state and minimally conscious state

Objective

Unresponsive wakefulness syndrome/vegetative state (UWS/VS) and minimally conscious state (MCS) are considered different clinical entities, but their differential diagnosis remains challenging. As a potential clinical tool, functional magnetic resonance imaging (fMRI) could detect residual awareness without the need for the patients' actual motor responses. This study aimed to investigate the diagnostic value of fMRI for distinguishing between UWS/VS and MCS through a meta-analysis of the existing studies.

Methods

We conducted a comprehensive search (from the database creation date to November. 2023) for relevant English articles on fMRI for the differential diagnosis of UWS/VS and MCS. The pooled sensitivity, specificity, positive likelihood ratio (LR+), negative likelihood ratio (LR-), summary receiver operating characteristic (SROC) curve, and area under the curve (AUC) were calculated to assess the diagnostic value of fMRI in distinguishing between UWS/VS and MCS. The statistical I 2 test was used to assess heterogeneity, and the source of heterogeneity was investigated by performing a meta-regression analysis. Publication bias was assessed using the Deeks funnel plot asymmetry test.

Results

Ten studies were included in the meta-analysis. The pooled sensitivity and specificity were 0.71 (95% CI 0.62-0.79) and 0.71 (95% CI 0.54-0.84), respectively. The fMRI for the differential diagnosis of UWS/VS and MCS has a moderate positive likelihood ratio (2.5) and a relatively low negative likelihood ratio (0.40). Additionally, SROC curves showed that the AUC was 0.76 (95% CI 0.72-0.80).

Conclusion

Functional magnetic resonance imaging has a good performance in the differential diagnosis of UWS/VS and MCS, and may provide a potential tool for evaluating the prognosis and guiding the rehabilitation therapy in patients with disorders of consciousness.

Acupuncture-assisted therapy for prolonged disorders of consciousness: study protocol for a randomized, conventional-controlled, assessor-and-statistician-blinded trial

Background

Acupuncture is a promising non-pharmaceutical complementary therapy in treating prolonged Disorders of consciousness (pDOC), but solid evidence to support its effectiveness and safety is still lacking. Thus, the purpose of this study is to investigate the efficacy and safety of acupuncture-assisted therapy for pDOC patients.

Methods

A single-center, prospective, randomized, conventional-controlled, assessor-and-statistician-blinded trial has been designed and is being conducted at West China Hospital of Sichuan University. A total of 110 participants will be randomly assigned to the experimental group and the control group in a 1:1 allocation ratio and evaluated using Coma Recovery Scale-Revised (CRS-R) at 8 a.m., 12 p.m., and 4 p.m. on 2 consecutive days before enrollment to determine the consciousness level. The experimental group will receive acupuncture combined with conventional treatment, while the control group will receive only conventional treatment during the trial observation period. The treatment duration of both groups will be 20 days. Among them, the frequency of acupuncture-assisted therapy is once a day, with 10 consecutive sessions followed by a day's rest for a total of 24 days. Data will be collected separately during baseline and after the final treatment. For data analysis, both Full Analysis Set (FAS) and Per Protocol Set (PPS) principles will be performed together by applying SPSS 27.0 software. The primary outcome measures are the changes of CRS-R before and after treatment, while the secondary outcome measures are the changes of Full Outline of Unresponsiveness Scale (FOUR), the changes of Nociception Coma Scale-Revised (NCS-R), the changes of Disability Rating Scale (DRS), the changes of Mismatch Negativity (MMN) and P300 before and after treatment, respectively.

Discussion

This trial aims to rationally assess the consciousness level from multiple 2 perspectives through subjective evaluation and objective detection by selecting several standardized clinical scales combined with Event-Related Potential (ERP) detection technology. In this way, we will be able to reduce the subjectivity of consciousness assessment and objectively evaluate the clinical efficacy of acupuncture-assisted therapy for pDOC. The study, if proven to be effective and safe enough, will provide a favorable evidence to guide medical decision-making choices and future researches.

Clinical trial registration

https://www.chictr.org.cn/, identifier ChiCTR2300076180.

Disorder of consciousness related pattern could distinguish minimally conscious state from unresponsive wakefulness syndrome: A F-18-FDG-PET study

BACKGROUND

Accurate evaluation of level of disorder of consciousness (DOC) is clinically challenging.

OBJECTIVE

This study aimed to establish a distinctive DOC-related pattern (DOCRP) for assessing disease severity and distinguishing unresponsive wakefulness syndrome (UWS) from minimally conscious state (MCS).

METHODS

Fifteen patients with DOC and eighteen health subjects with F-18-fluorodeoxyglucose (F-18-FDG) positron emission tomography (PET) were enrolled in this study. All patients were assessed by Coma Recovery Scale-Revised (CRS-R) and all individuals were randomly divided into two cohorts (Cohort A and B). DOCRP was identified in Cohort A and subsequently validated in Cohort B and A+B. We also assessed the discriminatory power of DOCRP between MCS and UWS.

RESULTS

The DOCRP was characterized bilaterally by relatively decreased metabolism in the medial and lateral frontal lobes, parieto-temporal lobes, cingulate gyrus and caudate, associated with relatively increased metabolism in the cerebellum and brainstem. DOCRP expression exhibited high accuracy in differentiating DOC patients from controls (P<0.0001, AUC=1.000), and furthermore could effectively distinguish MCS from UWS (P=0.037, AUC=0.821, sensitivity: 85.7 %, specificity: 75.0 %). Particularly in the subgroup of DOC patients survived global hypoxic-ischemic brain injury, DOCRP expression exhibited even better discriminatory power between MCS and UWS (P=0.046, AUC=1.000).

CONCLUSIONS

DOCRP might serve as an objective biomarker in distinguishing between UWS and MCS, especially in patients survived global hypoxic-ischemic brain injury.

TRIAL REGISTRATION NUMBER

ChiCTR2300073717 (Chinese clinical trial registry site, http://www.chictr.org).

Lateral frontoparietal effective connectivity differentiates and predicts state of consciousness in a cohort of patients with traumatic disorders of consciousness

Neuroimaging studies have suggested an important role for the default mode network (DMN) in disorders of consciousness (DoC). However, the extent to which DMN connectivity can discriminate DoC states-unresponsive wakefulness syndrome (UWS) and minimally conscious state (MCS)-is less evident. Particularly, it is unclear whether effective DMN connectivity, as measured indirectly with dynamic causal modelling (DCM) of resting EEG can disentangle UWS from healthy controls and from patients considered conscious (MCS+). Crucially, this extends to UWS patients with potentially "covert" awareness (minimally conscious star, MCS*) indexed by voluntary brain activity in conjunction with partially preserved frontoparietal metabolism as measured with positron emission tomography (PET+ diagnosis; in contrast to PET- diagnosis with complete frontoparietal hypometabolism). Here, we address this gap by using DCM of EEG data acquired from patients with traumatic brain injury in 11 UWS (6 PET- and 5 PET+) and in 12 MCS+ (11 PET+ and 1 PET-), alongside with 11 healthy controls. We provide evidence for a key difference in left frontoparietal connectivity when contrasting UWS PET- with MCS+ patients and healthy controls. Next, in a leave-one-subject-out cross-validation, we tested the classification performance of the DCM models demonstrating that connectivity between medial prefrontal and left parietal sources reliably discriminates UWS PET- from MCS+ patients and controls. Finally, we illustrate that these models generalize to an unseen dataset: models trained to discriminate UWS PET- from MCS+ and controls, classify MCS* patients as conscious subjects with high posterior probability (pp > .92). These results identify specific alterations in the DMN after severe brain injury and highlight the clinical utility of EEG-based effective connectivity for identifying patients with potential covert awareness.

Neuroimaging in Disorders of Consciousness and Recovery

There is a clinical need for more accurate diagnosis and prognostication in patients with disorders of consciousness (DoC). There are several neuroimaging modalities that enable detailed, quantitative assessment of structural and functional brain injury, with demonstrated diagnostic and prognostic value. Additionally, longitudinal neuroimaging studies have hinted at quantifiable structural and functional neuroimaging biomarkers of recovery, with potential implications for the management of DoC.

Prevalence of the Minimally Conscious State Among Institutionalized Patients in the Netherlands: A Nationwide Study

BACKGROUND AND OBJECTIVES

The minimally conscious state (MCS) is a prolonged disorder of consciousness (pDoC) and one of the most severe outcomes of acquired brain injury. Prevalence data are scarce. The aim of this study was to establish the nationwide point prevalence of institutionalized patients in MCS in the Netherlands.

METHODS

This was a descriptive cross-sectional study in which all 86 Dutch hospitals, all 5 specialized pDoC rehabilitation facilities, and all 274 nursing homes were asked whether they were treating patients with a pDoC on the point prevalence date of September 15, 2021. Each patient's legal representative provided informed consent for their inclusion. Patient level of consciousness was verified using the Coma Recovery Scale-Revised (CRS-R) in a single assessment session performed in the facility of residence by an experienced physician. Data on patient demographics, etiology, level of consciousness, facility of residence, and clinical status were collected from a questionnaire by the treating physician. The prevalence of institutionalized patients in MCS of per 100,000 members of the Dutch population was calculated, based on actual census data.

RESULTS

Seventy patients were reported to have a pDoC, of whom 6 were excluded. The level of consciousness was verified for 49 patients while for 15, it could not be verified. Of the patients verified, 38 had a pDoC, of whom 32 were in MCS (mean age 44.8 years, 68.8% male). The prevalence of institutionalized patients in MCS is 0.2-0.3 per 100,000 Dutch inhabitants. Traumatic brain injury was present in 21 of 32 patients (65.6%). Specialized pDoC rehabilitation was received by 17 of 32 patients (53%), with the rest admitted to nursing homes. The most frequent signs of consciousness on the CRS-R were visual pursuit, reproducible movement to command, and automatic motor response.

DISCUSSION

This nationwide study revealed a low prevalence of institutionalized patients in MCS in the Netherlands. These findings are now being used to organize pDoC care in this country.

Deep brain stimulation in disorders of consciousness: 10 years of a single center experience

Disorders of consciousness (DoC), namely unresponsive wakefulness syndrome (UWS) and minimally conscious state (MCS), represent severe conditions with significant consequences for patients and their families. Several studies have reported the regaining of consciousness in such patients using deep brain stimulation (DBS) of subcortical structures or brainstem nuclei. Our study aims to present the 10 years' experience of a single center using DBS as a therapy on a cohort of patients with DoC. Eighty Three consecutive patients were evaluated between 2011 and 2022; entry criteria consisted of neurophysiological and neurological evaluations and neuroimaging examinations. Out of 83, 36 patients were considered candidates for DBS implantation, and 32 patients were implanted: 27 patients had UWS, and five had MCS. The stimulation target was the centromedian-parafascicular complex in the left hemisphere in hypoxic brain lesion or the one better preserved in patients with traumatic brain injury. The level of consciousness was improved in seven patients. Three out of five MCS patients emerged to full awareness, with the ability to interact and communicate. Two of them can live largely independently. Four out of 27 UWS patients showed consciousness improvement with two patients emerging to full awareness, and the other two reaching MCS. In patients with DoC lasting longer than 12 months following traumatic brain injury or 6 months following anoxic-ischemic brain lesion, spontaneous recovery is rare. Thus, DBS of certain thalamic nuclei could be recommended as a treatment option for patients who meet neurological, neurophysiological and neuroimaging criteria, especially in earlier phases, before occurrence of irreversible musculoskeletal changes. Furthermore, we emphasize the importance of cooperation between centers worldwide in studies on the potentials of DBS in treating patients with DoC.

The Neurological Rehabilitation of Adults With Coma and Disorders of Consciousness

BACKGROUND

Severe quantitative disorders of consciousness (DoC) due to acute brain injury affect up to 47% of patients upon admission to intensive care and early rehabilitation units. Nevertheless, the rehabilitation of this vulnerable group of patients has not yet been addressed in any German-language guidelines and has only been studied in a small number of randomized clinical trials.

METHODS

In an S3 clinical practice guideline project, a systematic literature search was carried out for interventions that could improve consciousness in patients with coma, unresponsive wakefulness syndrome, or minimally conscious state after acute brain injury, and an evidence-based evaluation of these interventions was performed. Recommendations concerning diagnostic methods and medical ethics were issued by consensus.

RESULTS

Misdiagnoses are common in patients with DoC, with minimal consciousness often going unrecognized. Patients with DoC should, therefore, be repeatedly assessed with standardized instruments, particularly the Coma Recovery Scale-Revised. The literature search yielded 54 clinical trials, mostly of low quality; there were two randomized controlled clinical trials providing level 1 evidence. The best available evidence for the improvement of impaired consciousness is for the administration of amantadine (4 studies) and for anodal transcranial direct-current stimulation of the left dorsolateral prefrontal cortex in patients in the minimal conscious state (8 studies, 2 systematic reviews). Further important components of rehabilitation include positioning methods and sensory stimulation techniques such as music therapy.

CONCLUSION

For the first time, evidence-based German-language clinical practice guidelines have now become available for the neurological rehabilitation of patients with DoC.

Neuroimaging in Coma, Brain Death, and Related Conditions

Coma is a state of unresponsiveness to external stimuli, which can be secondary to a variety of CNS alterations affecting essential neuronal pathways, particularly the ascending reticular activating system. A comprehensive clinical evaluation is necessary for assessment of motor function and brainstem reflexes but is often insufficient for determination of the underlying etiology and extent of injury. Diagnostic brain imaging is typically needed for management and decision-making, particularly in acute settings where prompt diagnosis of reversible/treatable conditions is essential, as well as for prognostication. Understanding the pathophysiologic mechanisms leading to coma and comalike states and their imaging manifestations will enable selection of appropriate modalities and facilitate a clinically relevant interpretation. For evaluation of brain death, diagnostic imaging has a supportive role, and when indicated, selection of an ancillary diagnostic test is based on multiple factors, including susceptibility to confounding factors and specificity, in addition to safety, convenience, and availability.Learning objective: To describe the pathophysiology of alterations of consciousness and discuss the role of neuroimaging modalities in the evaluation of coma, brain death, and associated conditions

Whole body gestational donation

Whole body gestational donation offers an alternative means of gestation for prospective parents who wish to have children but cannot, or prefer not to, gestate. It seems plausible that some people would be prepared to consider donating their whole bodies for gestational purposes just as some people donate parts of their bodies for organ donation. We already know that pregnancies can be successfully carried to term in brain-dead women. There is no obvious medical reason why initiating such pregnancies would not be possible. In this paper, I explore the ethics of whole-body gestational donation. I consider a number of potential counter-arguments, including the fact that such donations are not life-saving and that they may reify the female reproductive body. I suggest if we are happy to accept organ donation in general, the issues raised by whole-body gestational donation are differences of degree rather than substantive new concerns. In addition, I identify some intriguing possibilities, including the use of male bodies-perhaps thereby circumventing some potential feminist objections.

Correction of Local Brain Temperature after Severe Brain Injury Using Hypothermia and Medical Microwave Radiometry (MWR) as Companion Diagnostics

The temperature of the brain can reflect the activity of its different regions, allowing us to evaluate the connections between them. A study involving 111 patients in a vegetative state or minimally conscious state used microwave radiometry to measure their cortical temperature. The patients were divided into a main group receiving a 10-day selective craniocerebral hypothermia (SCCH) procedure, and a control group receiving basic therapy and rehabilitation. The main group showed a significant improvement in consciousness level as measured by CRS-R assessment on day 14 compared to the control group. Temperature heterogeneity increased in patients who received SCCH, while remaining stable in the control group. The use of microwave radiometry to assess rehabilitation effectiveness and the inclusion of SCCH in rehabilitation programs appears to be a promising approach.

Prediction of voluntary movements of the upper extremities by resting state-brain regional glucose metabolism in patients with chronic severe brain injury: A pilot study

Confirmation of the exact voluntary movements of patients with disorder of consciousness following severe traumatic brain injury (TBI) is difficult because of the associated communication disturbances. In this pilot study, we investigated whether regional brain glucose metabolism assessed by ¹⁸ F-fluorodeoxyglucose positron emission tomography (FDG-PET) at rest could predict voluntary movement in severe TBI patients, particularly those with sufficient upper limb capacity to use communication devices. We visually and verbally instructed patients to clasp or open their hands. After video capture, three independent rehabilitation therapists determined whether the patients' movements were voluntary or involuntary. The results were compared with the standardized uptake value in the primary motor cortex, referring to the Penfield's homunculus, by resting state by FDG-PET imaged 1 year prior. Results showed that glucose uptake in the left (p = 0.0015) and right (p = 0.0121) proximal limb of the primary motor cortex, based on Penfield's homunculus on cerebral cartography, may reflect contralateral voluntary movement. Receiver operating characteristic curve analysis showed that a mean cutoff standardized uptake value of 5.47 ± 0.08 provided the best sensitivity and specificity for differentiating between voluntary and involuntary movements in each area. FDG-PET may be a useful and robust biomarker for predicting long-term recovery of motor function in severe TBI patients with disorders of consciousness.

Repetitive transcranial magnetic stimulation over the posterior parietal cortex improves functional recovery in nonresponsive patients: A crossover, randomized, double-blind, sham-controlled study

Background

Recent studies have shown that patients with disorders of consciousness (DoC) can benefit from repetitive transcranial magnetic stimulation (rTMS) therapy. The posterior parietal cortex (PPC) is becoming increasingly important in neuroscience research and clinical treatment for DoC as it plays a crucial role in the formation of human consciousness. However, the effect of rTMS on the PPC in improving consciousness recovery remains to be studied.

Method

We conducted a crossover, randomized, double-blind, sham-controlled clinical study to assess the efficacy and safety of 10 Hz rTMS over the left PPC in unresponsive patients. Twenty patients with unresponsive wakefulness syndrome were recruited. The participants were randomly divided into two groups: one group received active rTMS treatment for 10 consecutive days (n = 10) and the other group received sham treatment for the same period (n = 10). After a 10-day washout period, the groups crossed over and received the opposite treatment. The rTMS protocol involved the delivery of 2000 pulses/day at a frequency of 10 Hz, targeting the left PPC (P3 electrode sites) at 90% of the resting motor threshold. The primary outcome measure was the JFK Coma Recovery Scele-Revised (CRS-R), and evaluations were conducted blindly. EEG power spectrum assessments were also conducted simultaneously before and after each stage of the intervention.

Result

rTMS-active treatment resulted in a significant improvement in the CRS-R total score (F = 8.443, p = 0.009) and the relative alpha power (F = 11.166, p = 0.004) compared to sham treatment. Furthermore, 8 out of 20 patients classified as rTMS responders showed improvement and evolved to a minimally conscious state (MCS) as a result of active rTMS. The relative alpha power also significantly improved in responders (F = 26.372, p = 0.002) but not in non-responders (F = 0.704, p = 0.421). No adverse effects related to rTMS were reported in the study.

Conclusions

This study suggests that 10 Hz rTMS over the left PPC can significantly improve functional recovery in unresponsive patients with DoC, with no reported side effects.

Clinical trial registration

www.ClinicalTrials.gov, identifier: NCT05187000.

Post-Discharge Plight Of Patients With Chronic Disorders Of Consciousness: A Systematic Review Of Socioeconomic And Health Aspects

Objective — the presented study aims to systematize and structure significant information regarding the problems of patients with disorders of consciousness (DOC) and their families after discharge from the hospital, and to search for possible solutions. Material and Methods — to identify eligible studies, we searched the Medline database (via PubMed) for studies on socioeconomic and medical issues of patients with chronic DOC at the post-hospital stage of rehabilitation for the last 20 years. Results — we included 28 studies with 21 cohorts of patients from 7 different countries in our study. The components of informal caregiver burden and their impact on the quality of life were identified and systematized. These components include high physical load, high economic costs, vast time expenditures, strong emotional involvement, and a top level of expertise in caregiving, all of which are required from the relatives. Conclusion — It was affirmed, that the lack of healthcare system support was a major contributing factor to the overall burden. Our research also showed that delivering care without receiving information, advice, and training is extremely painful for family caregivers.

EEG-based Brain-Computer Interfaces for people with Disorders of Consciousness: Features and applications. A systematic review

Background

Disorders of Consciousness (DoC) are clinical conditions following a severe acquired brain injury (ABI) characterized by absent or reduced awareness, known as coma, Vegetative State (VS)/Unresponsive Wakefulness Syndrome (VS/UWS), and Minimally Conscious State (MCS). Misdiagnosis rate between VS/UWS and MCS is attested around 40% due to the clinical and behavioral fluctuations of the patients during bedside consciousness assessments. Given the large body of evidence that some patients with DoC possess "covert" awareness, revealed by neuroimaging and neurophysiological techniques, they are candidates for intervention with brain-computer interfaces (BCIs).

Objectives

The aims of the present work are (i) to describe the characteristics of BCI systems based on electroencephalography (EEG) performed on DoC patients, in terms of control signals adopted to control the system, characteristics of the paradigm implemented, classification algorithms and applications (ii) to evaluate the performance of DoC patients with BCI.

Methods

The search was conducted on Pubmed, Web of Science, Scopus and Google Scholar. The PRISMA guidelines were followed in order to collect papers published in english, testing a BCI and including at least one DoC patient.

Results

Among the 527 papers identified with the first run of the search, 27 papers were included in the systematic review. Characteristics of the sample of participants, behavioral assessment, control signals employed to control the BCI, the classification algorithms, the characteristics of the paradigm, the applications and performance of BCI were the data extracted from the study. Control signals employed to operate the BCI were: P300 (N = 19), P300 and Steady-State Visual Evoked Potentials (SSVEP; hybrid system, N = 4), sensorimotor rhythms (SMRs; N = 5) and brain rhythms elicited by an emotional task (N = 1), while assessment, communication, prognosis, and rehabilitation were the possible applications of BCI in DoC patients.

Conclusion

Despite the BCI is a promising tool in the management of DoC patients, supporting diagnosis and prognosis evaluation, results are still preliminary, and no definitive conclusions may be drawn; even though neurophysiological methods, such as BCI, are more sensitive to covert cognition, it is suggested to adopt a multimodal approach and a repeated assessment strategy.

Modulation of cerebral cortex activity by acupuncture in patients with prolonged disorder of consciousness: An fNIRS study

BACKGROUND AND OBJECTIVE

Acupuncture is a promising non-pharmacological therapy for patients with prolonged disorder of consciousness (PDOC); however, its underlying mechanism remains uncertain. This study aimed to reveal the modulatory effects of acupuncture on the cerebral cortex activity among patients with PDOC.

MATERIALS AND METHODS

Twenty-eight PDOC patients were randomly assigned to the treatment (n = 14) or control (n = 14) group. The treatment group received one session of acupuncture, while the control group received one session of sham acupuncture. All patients underwent evaluation of the functional connectivity and activation response of the dorsolateral prefrontal cortex (DLPFC), primary motor cortex (M1), and primary somatosensory cortex (S1) via functional near-infrared spectroscopy. We further explored the potential correlation of the consciousness level and activation response/functional connectivity with acupuncture.

RESULTS

Compared to the control group, a single session of acupuncture significantly tended to enhance resting-state functional connectivity (rsFC) in DLPFC-M1, DLPFC-M1, and S1-S1. And the activation level of the DLPFC (both sides) in the acupuncture group is significantly higher than those in sham acupuncture group. However, no significant correlation was found between the consciousness level and activation response/functional connectivity.

CONCLUSION

One session of acupuncture has a significant modulation of rsFC and activation in the DLPFC, M1, and S1 with PDOC patients. Acupuncture-evoked effect may have some functional significance in PDOC patients. This is an important step toward exploring the acupuncture effects on PDOC patients.

Educational challenges of family caregivers of vegetative state patients for home care preparedness: A qualitative content analysis

BACKGROUND

Patients with a vegetative state (VS) are completely dependent on caregivers in all physical aspects of their lives. Caring for such patients comes with a great deal of difficulty for family caregivers. As a result, family caregivers must be fully trained and prepared for this role. The present qualitative study was conducted to investigate the educational challenges faced by family caregivers of VS patients for home care preparedness.

MATERIALS AND METHODS

The present qualitative study was conducted through the conventional content analysis method from August 2020 to September 2021 in two provinces of Iran (Sistan and Baluchestan Province; and Razavi Khorasan Province). Fourteen family caregivers of patients in a VS were included in the study. Semi-structured and in-depth interviews were employed to collect data. The Graneheim and Lundman method was utilized to conduct the data analysis using MAXQDA2020 software. Data collection continued until data saturation and the identification of main categories.

RESULTS

As indicated by the data analysis, three categories of "unmet educational needs," "confused caregiver," and "searching for practical knowledge" which included 19 sub-categories described the experiences of family caregivers of patients in a VS concerning challenges they went through in preparation for patient care at home. Participants' experiences revealed that despite the inadequacy of educations provided by health-care providers on knowledge and skills required by family caregivers, they were committed to caring for the patient and trying to acquire the required knowledge.

CONCLUSION

Results indicated that inadequate education and the lack of family caregivers' contribution to caring for the patient in the VS during their stay in the hospital impedes their acquisition of adequate knowledge and skill to care for patients at home. Therefore, healthcare system policymakers should be planning to eliminate the educational barriers faced by family caregivers and expand the educational activities of hospitals' homecare centers to provide educational support of family caregivers after the patient's discharge.

Development of an Italian version of the functional communication measures and preliminary observations in patients with severe acquired brain injury and emerging from a prolonged disorder of consciousness

A proper assessment tool targeting communicative abilities in patients with severe acquired brain injury (sABI), and particularly for patients recovering from prolonged disorders of consciousness (pDoC), is lacking. The Functional Communication Measures (FCM) consists of a series of rating scales, ranging from 1 (least functional) to 7 (most functional), assessing cognitive requirements for communication and communicative abilities in patients with brain injury. Here we presented exploratory data concerning an Italian adaptation of FCM administered to patients with sABI. After the translation into Italian language, the FCM was blindly administered by 2 independent speech therapists to 19 patients (10 males; median age = 58; IQR = 25) admitted to neurorehabilitation unit after sABI with a level of cognitive functioning between 4 and 8. Two further patients who presented a pDoC after sABI and emerged from the minimally conscious state (a 64-year-old female and a 74-year-old female) were also evaluated by means of the FCM, the Coma Recovery Scale-Revised, and the Disability Rating Scale. Inter-rater agreement was almost perfect for attention, memory, and swallowing items, and substantial for communicative-augmentative communication, motor speech, spoken language expression, and spoken language comprehension. Importantly, in the two pDoC patients, the FCM identified two different functioning profiles in the attention, swallowing, motor speech, and spoken language expression scales, notwithstanding the two patients achieved the same scores on scales for functional disability and consciousness level. The FCM might be a promising and easy-to-administer tool to assess communicative functions in patients with sABI, independently from evaluation of functional disability.

Application of High-Tech Solution for Memory Assessment in Patients With Disorders of Consciousness

Testing cognitive function in patients after severe brain damage is a major clinical challenge. In the absence of both verbal and motor communication, tests commonly used to assess cognitive function are completely or partially undoable for disorders of consciousness patients. The study involved 12 patients with varying degrees of impaired consciousness due to brain damage, with no verbal and motor communication. Memory was assessed in study participants using oculography. Memory tasks were presented in four categories. The total percentage of correctly completed tasks obtained across the group was 39.58%. The most difficult tasks included category C.4 with tasks involving working memory. Regardless of the subjects' level of consciousness, there was no statistically significant difference in the percentage of correct responses obtained in subgroups distinguished by CRS-R score. Eye tracking technology can be successfully used in the assessment of cognitive function, particularly when eye movements are the only channel of communication in individuals after brain damage. We suggest that the cognitive functions of people after brain damage should be further analyzed using eye tracking.

Pain in Persons with Disorders of Consciousness

Pain and suffering in persons with disorders of consciousness (DoC) remain poorly understood, frequently unaddressed or inadequately addressed, and controversial on numerous levels. This narrative literature review will address a number of critical issues germane to pain and suffering in this challenging group of patients, providing an introductory overview of the topic, perspectives on current knowledge regarding pain pathoanatomy and pathophysiology, and a review of common pain generators and factors that can lead to the chronifcation of pain. Caveats on bedside pain assessment challenges, as well as electrophysiologic and neuroimaging findings in these patients, will also be explored. Pain management techniques, including non-pharmacological and pharmacological, will be reviewed. Ethical considerations in the context of pain and suffering in persons with disorders of consciousness will round out the review prior to our concluding comments.

Olfactory Stimulation and the Diagnosis of Patients With Disorders of Consciousness: A Double-Blind, Randomized Clinical Trial

OBJECTIVES

The aim of this study was to determine whether behavioral responses elicited by olfactory stimulation are a predictor of conscious behavioral response and prognosis of patients with disorders of consciousness (DOC).

METHODS

Twenty-three DOC patients (8 unresponsive wakefulness syndrome [UWS]; 15 minimally conscious state [MCS]) were recruited for this study in which 1-Octen-3-ol (familiar neutral odor) and pyridine were used to test odor behavioral responses, and water was used as an odorless stimulus. One rater presented the three odors in front of each patient's nose randomly, and another one videotaped all behavioral responses (e.g., pouting, wrinkling nose, slightly shaking head, frowning, etc.). Two independent raters, blind to the stimuli and the patient's diagnosis, gave the behavioral results according to the recorded videos. One-, 3-, and 6-month follow-up evaluations were conducted to obtain a good prognostic value.

RESULTS

All MCS patients showed behavioral responses to the 1-Octen-3-ol stimulus; nine MCS and one UWS showed olfactory emotional responses to the pyridine, and two MCS showed olfactory emotional responses to the water stimulus. The incidence of behavioral response was significantly higher using 1-Octen-3-ol than it was for water by McNemar test (p < 0.001), significantly higher using pyridine than it was for water (p < 0.01). The χ2 test results indicated that there were significant differences between MCS and UWS to 1-Octen-3-ol (p < 0.001). For MCS patients, the incidence of behavioral response was no different between using 1-Octen-3-ol and pyridine (p > 0.05). There was no significant relationship between the olfactory behavioral response and the improvement of consciousness based on the χ2 test analysis (p > 0.05).

CONCLUSION

Olfactory stimuli, especially for the familiar neutral odor, might be effective for eliciting a conscious behavioral response and estimating the clinical diagnosis of DOC patients.

CLINICAL TRIAL REGISTRATION

[https://clinicaltrials.gov/ct2/show/NCT03732092], [identifier NCT03732092].

Towards consensus on visual pursuit and visual fixation in patients with disorders of consciousness. A Delphi study

BACKGROUND

The aim of this Delphi study was to reach consensus about definition, operationalization and assessment of visual pursuit (VP) and visual fixation (VF).

METHODS

In a three-round international Delphi study, clinical and research experts on disorders of consciousness indicated their level of agreement on 87 statements using a 5-point Likert scale. Consensus for agreement was defined by a median of 5, an interquartile range (IQR) ≤ 1, and ≥ 80% indicating moderate or strong agreement.

RESULTS

Forty-three experts from three continents participated, 32 completed all three rounds. For VP, the consensus statements with the highest levels of agreement were on the term 'pursuit of a visual stimulus', the description 'ability to follow visually in horizontal and/or vertical plane', a duration > 2 s, tracking in horizontal and vertical planes, and a frequency of more than 2 times per assessment. For VF, consensus statements with the highest levels of agreement were on the term 'sustained VF', the description 'sustained fixation in response to a salient stimulus', a duration of > 2 s and a frequency of 2 or more times per assessment. The assessment factors with the highest levels of agreement were personalized stimuli, the use of eye tracking technology, a patient dependent time of assessment, sufficient environmental light, upright posture, and the necessity to exclude ocular/oculomotor problems.

CONCLUSION

This first international Delphi study on VP and VF in patients with disorders of consciousness provides provisional operational definitions and an overview of the most relevant assessment factors.

Residual implicit and explicit language abilities in patients with disorders of consciousness: A systematic review

Language assessment in post-comatose patients is difficult due to their limited behavioral repertoire; yet associated language deficits might lead to an underestimation of consciousness levels in unresponsive wakefulness syndrome (UWS) or minimally conscious state (MCS; -/+) diagnoses. We present a systematic review of studies from 2002 assessing residual language abilities with neuroimaging, electrophysiological or behavioral measures in patients with severe brain injury. Eighty-five articles including a total of 2278 patients were assessed for quality. The median percentages of patients showing residual implicit language abilities (i.e., cortical responses to specific words/sentences) were 33 % for UWS, 50 % for MCS- and 78 % for MCS + patients, whereas explicit language abilities (i.e., command-following using brain-computer interfaces) were reported in 20 % of UWS, 33 % of MCS- and 50 % of MCS + patients. Cortical responses to verbal stimuli increased along with consciousness levels and the progressive recovery of consciousness after a coma was paralleled by the reappearance of both implicit and explicit language processing. This review highlights the importance of language assessment in patients with disorders of consciousness.

Incidence, causes and consequences of moderate and severe traumatic brain injury as determined by Abbreviated Injury Score in the Netherlands

Traumatic brain injury (TBI) is a leading cause of death and disability. Epidemiology seems to be changing. TBIs are increasingly caused by falls amongst elderly, whilst we see less polytrauma due to road traffic accidents (RTA). Data on epidemiology is essential to target prevention strategies. A nationwide retrospective cohort study was conducted. The Dutch National Trauma Database was used to identify all patients over 17 years old who were admitted to a hospital with moderate and severe TBI (AIS ≥ 3) in the Netherlands from January 2015 until December 2017. Subgroup analyses were done for the elderly and polytrauma patients. 12,295 patients were included in this study. The incidence of moderate and severe TBI was 30/100.000 person-years, 13% of whom died. Median age was 65 years and falls were the most common trauma mechanism, followed by RTAs. Amongst elderly, RTAs consisted mostly of bicycle accidents. Mortality rates were higher for elderly (18%) and polytrauma patients (24%). In this national database more elderly patients who most often sustained the injury due to a fall or an RTA were seen. Bicycle accidents were very frequent, suggesting prevention could be an important aspect in order to decrease morbidity and mortality.

Simplified evaluation of CONsciousness disorders (SECONDs) in individuals with severe brain injury: A validation study

BACKGROUND

The Coma Recovery Scale-Revised (CRS-R) is the gold standard to assess severely brain-injured patients with prolonged disorders of consciousness (DoC). However, the amount of time needed to complete this examination may limit its use in clinical settings.

OBJECTIVE

We aimed to validate a new faster tool to assess consciousness in individuals with DoC.

METHODS

This prospective validation study introduces the Simplified Evaluation of CONsciousness Disorders (SECONDs), a tool composed of 8 items: arousal, localization to pain, visual fixation, visual pursuit, oriented behaviors, command-following, and communication (both intentional and functional). A total of 57 individuals with DoC were assessed on 2 consecutive days by 3 blinded examiners: one CRS-R and one SECONDs were performed on 1 day, whereas 2 SECONDs were performed on the other day. A Mann-Whitney U test was used to compare the duration of administration of the SECONDs versus the CRS-R, and weighted Fleiss' kappa coefficients were used to assess inter-/intra-rater reliability as well as concurrent validity.

RESULTS

In the 57 participants, the SECONDs was about 2.5 times faster to administer than the CRS-R. The comparison of the CRS-R versus the SECONDs on the same day or the best of the 3 SECONDs led to "substantial" or "almost perfect" agreement (kappa coefficients ranging from 0.78 to 0.85). Intra-/inter-rater reliability also showed almost perfect agreement (kappa coefficients from 0.85 to 0.91 and 0.82 to 0.85, respectively).

CONCLUSIONS

The SECONDs appears to be a fast, reliable and easy-to-use scale to diagnose DoC and may be a good alternative to other scales in clinical settings where time constraints preclude a more thorough assessment.

Estimating the Minimal Number of Repeated Examinations for Random Responsiveness With the Coma Recovery Scale-Revised as an Example

Objective: The aim of this study was to develop a general method to estimate the minimal number of repeated examinations needed to detect patients with random responsiveness, given a limited rate of missed diagnosis.

Methods: Basic statistical theory was applied to develop the method. As an application, 100 patients with disorders of consciousness (DOC) were assessed with the Coma Recovery Scale–Revised (CRS-R). DOC patients were supposed to be examined for 13 times over 20 days, while anyone who was diagnosed as a minimally conscious state (MCS) in a round would no longer be examined in the subsequent rounds. To test the validation of this method, a series of the stochastic simulation was completed by computer software under all the conditions of possible combinations of three kinds of distributions for p, five values of p, and four sizes of the sample and repeated for 100 times.

Results: A series of formula was developed to estimate the probability of a positive response to a single examination given by a patient and the minimal number of successive examinations needed based on the numbers of patients detected in the first i (i =1, 2,.) rounds of repeated examinations. As applied to the DOC patients assessed with the CRS-R, with a rate of missed diagnosis < 0.0001, the estimate of the minimal number of examinations was six in traumatic brain injury patients and five in non-traumatic brain injury patients. The outcome of the simulation showed that this method performed well under various conditions possibly occurring in practice.

Interpretation: The method developed in this paper holds in theory and works well in application and stochastic simulation. It could be applied to any other kind of examinations for random responsiveness, not limited to CRS-R for detecting MCS; this should be validated in further research.

Persistent vegetative state: an overview

Background

Disorder of consciousness diagnosis, especially when is classified as persistent vegetative state (without misestimating the other diagnosis classifications), in the intensive care is an important diagnosis to evaluate and treat. Persistent vegetative state diagnosis is a challenge in the daily clinical practice because the diagnosis is made mainly based upon the clinical history and the patient behavior observation. There are some specific criteria for this diagnosis, and this could be very tricky when the physician is not well trained.

Main body

We made a literature review regarding the persistent vegetative state diagnosis, clinical features, management, prognosis, and daily medical practice challenges while considering the bioethical issues and the family perspective about the patient status. The objective of this overview is to provide updated information regarding this clinical state’s features while considering the current medical literature available.

Conclusions

Regardless of the currently available guidelines and literature, there is still a lot of what we do not know about the persistent vegetative state. There is a lack of evidence regarding the optimal diagnosis and even more, about how to expect a natural history of this disorder of consciousness. It is important to recall that the patients (despite of their altered mental state diagnosis) should always be treated to avoid some of the intensive care unit long-stance complications.

The prevalence and determinants of inappropriate sexual behaviour in people with acquired brain injury in nursing homes

AIMS

Establishing the prevalence of inappropriate sexual behaviour, concurrent challenging behaviours and the determinants of inappropriate sexual behaviour among patients with acquired brain injury ≤65 years of age in Dutch nursing homes.

DESIGN

Cross-sectional, observational study in acquired brain injury special care units spreads throughout the country.

METHODS

Nursing homes were recruited through the national expertise network for patients with severe acquired brain injury, regional brain injury teams and by searching the Internet. Patient characteristics were collected through digital questionnaires. Inappropriate sexual behaviour was assessed with the St. Andrews Sexual Behaviour Assessment, concurrent challenging behaviours with the NeuroPsychiatric Inventory-Nursing Home Version and the Cohen-Mansfield Agitation Inventory, cognition with the Mini-Mental State Examination and activities of daily living with the Disability Rating Scale. Psychotropic drug use was retrieved from the electronic prescription system. Associations between determinants and inappropriate sexual behaviour were examined using multilevel multivariate linear regression model analyses. Data collection started in June 2017 and ended in April 2019.

RESULTS

Of the 118 included patients, 38.1% had one or more inappropriate sexual behaviours. Verbal comments (30.1%) and non-contact behaviour (24.8%) were the most prevalent types of inappropriate sexual behaviour. Less severe behaviours were more common than more severe behaviours. The most frequent concurrent challenging behaviours were agitation, aggression and hyperactivity. Physical aggression was associated with more inappropriate sexual behaviour. Being married and pain were associated with less inappropriate sexual behaviour.

CONCLUSION

Inappropriate sexual behaviour is prevalent in patients with acquired brain injury ≤65 years of age residing in nursing homes.

IMPACT

Inappropriate sexual behaviour may have impact not only on the patients themselves but also on nursing staff. Insight into the magnitude, severity, course and concurrent challenging behaviours, sexuality and quality of life could give direction to the kind of interventions and education that is needed. The ultimate goal is to develop appropriate care for this vulnerable group of patients, specifically psychosocial interventions and appropriate use of psychotropic drugs.

The Timecourse of Electrophysiological Brain-Heart Interaction in DoC Patients

Disorders of Consciousness (DOC) are a spectrum of pathologies affecting one's ability to interact with the external world. Two possible conditions of patients with DOC are Unresponsive Wakefulness Syndrome/Vegetative State (UWS/VS) and Minimally Conscious State (MCS). Analysis of spontaneous EEG activity and the Heart Rate Variability (HRV) are effective techniques in exploring and evaluating patients with DOC. This study aims to observe fluctuations in EEG and HRV parameters in the morning/afternoon resting-state recording. The study enrolled 13 voluntary Healthy Control (HC) subjects and 12 DOC patients (7 MCS, 5 UWS/VS). EEG and EKG were recorded. PSDalpha, PSDtheta powerband, alpha-blocking, alpha/theta of the EEG, Complexity Index (CI) and SDNN of EKG were analyzed. Higher values of PSDalpha, alpha-blocking, alpha/theta and CI values and lower values of PSD theta characterized HC individuals in the morning with respect to DOC patients. In the afternoon, we detected a significant difference between groups in the CI, PSDalpha, PSDtheta, alpha/theta and SDNN, with lower PSDtheta value for HC. CRS-R scores showed a strong correlation with recorded parameters mainly during evaluations in the morning. Our finding put in evidence the importance of the assessment, as the stimulation of DOC patients in research for behavioural response, in the morning.

Neural Tracking of Sound Rhythms Correlates With Diagnosis, Severity, and Prognosis of Disorders of Consciousness

Effective diagnosis and prognosis of patients with disorders of consciousness (DOC) provides a basis for family counseling, decision-making, and the design of rehabilitation programs. However, effective and objective bedside evaluation is a challenging problem. In this study, we explored electroencephalography (EEG) response tracking sound rhythms as potential neural markers for DOC evaluation. We analyzed the responses to natural speech and tones modulated at 2 and 41 Hz. At the population level, patients with positive outcomes (DOC-P) showed higher cortical synchronization to modulated tones at 41 Hz compared with patients with negative outcomes (DOC-N). At the individual level, phase coherence to modulated tones at 41 Hz was significantly correlated with Coma Recovery Scale-Revised (CRS-R) and Glasgow Outcome Scale-Extended (GOS-E) scores. Furthermore, SVM classifiers, trained using phase coherences in higher frequency bands or combination of the low frequency aSSR and speech tracking responses, performed very well in diagnosis and prognosis of DOC. These findings show that EEG response to auditory rhythms is a potential tool for diagnosis, severity, and prognosis of DOC.

Toward a global and reproducible science for brain imaging in neurotrauma: the ENIGMA adult moderate/severe traumatic brain injury working group

The global burden of mortality and morbidity caused by traumatic brain injury (TBI) is significant, and the heterogeneity of TBI patients and the relatively small sample sizes of most current neuroimaging studies is a major challenge for scientific advances and clinical translation. The ENIGMA (Enhancing NeuroImaging Genetics through Meta-Analysis) Adult moderate/severe TBI (AMS-TBI) working group aims to be a driving force for new discoveries in AMS-TBI by providing researchers world-wide with an effective framework and platform for large-scale cross-border collaboration and data sharing. Based on the principles of transparency, rigor, reproducibility and collaboration, we will facilitate the development and dissemination of multiscale and big data analysis pipelines for harmonized analyses in AMS-TBI using structural and functional neuroimaging in combination with non-imaging biomarkers, genetics, as well as clinical and behavioral measures. Ultimately, we will offer investigators an unprecedented opportunity to test important hypotheses about recovery and morbidity in AMS-TBI by taking advantage of our robust methods for large-scale neuroimaging data analysis. In this consensus statement we outline the working group's short-term, intermediate, and long-term goals.

Intensive neurorehabilitation for patients with prolonged disorders of consciousness: protocol of a mixed-methods study focusing on outcomes, ethics and impact

BACKGROUND

Prolonged disorders of consciousness (PDOC) are amongst the severest sequelae of acquired brain injury. Evidence regarding epidemiology and rehabilitation outcomes is scarce. These knowledge gaps and psychological distress in families of PDOC patients may complicate clinical decision-making. The complex PDOC care and associated moral dilemmas result in high workload in healthcare professionals. Since 2019, all PDOC patients in the Netherlands have access to intensive neurorehabilitation up to 2 years post-injury provided by one rehabilitation center and four specialized nursing homes. Systematic monitoring of quantitative rehabilitation data within this novel chain of care is done in a study called DOCTOR. The optimization of tailored PDOC care, however, demands a better understanding of the impact of PDOC on patients, their families and healthcare professionals and their views on rehabilitation outcomes, end-of-life decisions and quality of dying. The True Outcomes of PDOC (TOPDOC) study aims to gain insight in the qualitative outcomes of PDOC rehabilitation and impact of PDOC on patients, their families and healthcare professionals.

METHODS

Nationwide multicenter prospective cohort study in the settings of early and prolonged intensive neurorehabilitation with a two-year follow-up period, involving three study populations: PDOC patients > 16 years, patients' family members and healthcare professionals involved in PDOC care. Families' and healthcare professionals' views on quality of rehabilitation outcomes, end-of-life decisions and dying will be qualitatively assessed using comprehensive questionnaires and in-depth interviews. Ethical dilemmas will be explored by studying moral deliberations. The impact of providing care to PDOC patients on healthcare professionals will be studied in focus groups.

DISCUSSION

To our knowledge, this is the first nationwide study exploring quality of outcomes, end-of-life decisions and dying in PDOC patients and the impact of PDOC in a novel chain of care spanning the first 24 months post-injury in specialized rehabilitation and nursing home settings. Newly acquired knowledge in TOPDOC concerning quality of outcomes in PDOC rehabilitation, ethical aspects and the impact of PDOC will enrich quantitative epidemiological knowledge and outcomes arising from DOCTOR. Together, these projects will contribute to the optimization of centralized PDOC care providing support to PDOC patients, families and healthcare professionals.

Life satisfaction in families with a child in an Unresponsive Wakefulness Syndrome

Background

The article examines life conditions in families living together with a child in an Unresponsive Wakefulness Syndrome (UWS). Such families experience severe stress at financial, logistical, and existential level.

Methods

We investigated a large sample of families living with a UWS child (comprising 13% of the total population) and compared these families with families without a chronically ill child. A set of four questionnaires aimed to evaluate life conditions entails a total of 204 items. One of the questionnaires was developed by the corresponding author specifically for this study. The questionnaires were positively accepted by the persons concerned and permitted us to test six specific hypotheses.

Results

Life satisfaction (LS) in families with a UWS child was significantly lower than in control families. LS was significantly affected by external situational factors (everyday support, home visits, support by a doctor, nursing service, health insurance, etc.). Self-management skills were on average lower in families with a UWS child than in controls. These skills strongly and directly correlated with LS. Further, LS was not significantly related to the acceptance of feelings and negatively correlated with the floods of emotions. The relationship with the own child was equally satisfactory in families with and without a UWS child indicating that the families regard their UWS child as a full family member.

Conclusions

The data show that happy life is possible in families living together with a UWS child. They further specify conditions for satisfactory life under multiple highly severe challenges. Personal self-management skills, coping strategies, and resilience, as well as outside social support, appear to be critical factors.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12887-021-02549-8.

Visual fixation in disorders of consciousness: Development of predictive models to support differential diagnosis

The visual fixation represents a doubtful behavioral sign to discriminate Vegetative from Minimally Conscious State (MCS). To disentangle its meaning, we fitted univariate and multivariable logistic regression models matching different neurophysiological and neuroimaging data of 54 patients with Disorders of Consciousness to select the best model predicting which visual performance (visual blink or pursuit) was shown by patients and the best predictors set. The best models found highlighted the importance of the structural MRI and the visual evoked potentials data in predicting visual pursuit. Then, a qualitative pilot test was made on four patients showing visual fixation revealing that the obtained models correctly predict whether the patients' visual performance could support/correlate to a cognitively mediated behavior. The present pilot models could help clinicians to evaluate if the visual fixation response can support the MCS diagnosis.

Neural reactivity parameters of awareness predetermine one-year survival in patients with disorders of consciousness

Objective: The current investigation evaluated the sensitivity of neural-reactivity markers of awareness versus standard clinical assessments in predicting 1-year survival in nonresponsive-awake patients with disorders of consciousness (DOC).Methods: Pre-attentive auditory mismatch-negativity (MMN) event-related potentials (ERP's), globally induced electroencephalography (EEG) spectral power following verbal command, and clinical parameters were assessed. The study included 10 patients with DOC with mixed etiology and 10 healthy controls (HC) at baseline. The clinical status of patients with DOC was reassessed after 1 year.Results: Unlike baseline clinical assessment scores, baseline MMN amplitudes of non-survivors and induced theta-power following verbal-command clearly distinguished the non-surviving patients versus surviving patients. Baseline MMN peak-amplitude latencies in survivors with DOC were significantly related to clinical outcome over a 1-year period.Conclusion: Current findings underscore the increased sensitivity of EEG-reactivity markers of awareness versus standard clinical scores in predicting 1-year clinical outcome and survival in patients with DOC. Further longitudinal research in larger DOC samples is needed to confirm the prognostic-reliability, and validity of neural reactivity parameters of awareness in patients with DOC. Current finding may have implications for clinical care and medical-legal decisions in unresponsive-awake patients, and could assist clinicians to predict their survival up to 1 year from admission.

Addressing Pain for a Proper Rehabilitation Process in Patients With Severe Disorders of Consciousness

Consciousness constitutes a fundamental prerequisite in the individual appraisal and experience of pain. In the same way, a person needs to be able to report on pain perception. Patients who suffered a severe brain injury with disorders of consciousness (DOC) represent a spectrum of pathologies affecting patients' capacity to interact with the external world. In these patients, the most relevant aspects in response to pain are physiologic and behavioral. The treatments and management of pain are challenging issues in these patients, arising serious ethical concerns and bringing emotional load among medical staff, caregivers, and relatives. In this review, we report the importance of having a correct pain management in DOC patients, to individuate the best pharmacological treatment that can make the difference in detecting a behavioral response, indicative of a change in the level of consciousness, and in planning a more effective rehabilitative approach.

Outcome registry of early intensive neurorehabilitation in patients with disorders of consciousness: study protocol of a prospective cohort study

BACKGROUND

Prolonged disorders of consciousness (PDOC) may occur after severe brain injury. Two diagnostic entities are distinguished within PDOC: unresponsive wakefulness syndrome (UWS, previously known as vegetative state) and minimally conscious state (MCS). Patients with PDOC may benefit from early intensive neurorehabilitation (EIN). In the Netherlands, the EIN programme is provided by one designated expert rehabilitation centre and forms the starting point of a dedicated chain of specialised rehabilitation and care for this group. This study project, called DOCTOR: Disorders of Consciousness; Treatment and Outcomes Registry, sets up a registry and systematically investigates multiple short- and long-term outcomes of patients with PDOC who receive EIN.

METHODS

Single-centre prospective cohort study with a 2-year follow-up period. Patients with PDOC due to acute brain injury who receive EIN, aged 16 years and older are included. Measurements will take place at start EIN, in week 5, 10, and at discharge from the EIN programme (duration = max 14 weeks) and at week 28, 40, 52, and 104 after admission to the EIN programme, following patients through the health-care chain. Outcome measures are the changes over time in level of consciousness, using the Coma Recovery Scale-Revised; the frequency and type of medical complications; the mortality rate; level of disability, including the level of motor, cognitive, behavioural and emotional functioning; participation; and quality of life. Secondary outcomes include self-efficacy of caregivers, caregivers' strain and cost-effectiveness of the programme.

DISCUSSION

The DOCTOR study will provide insight in the recovery patterns and predictors of recovery for multiple outcomes in PDOC patients after following EIN. The results of the study will enable us to benchmark and improve EIN and the organisation of the health-care chain, both for patients with PDOC and for their families.

TRIAL REGISTRATION

Netherlands Trial Register, NL 8138 . Retrospectively registered 6 November 2019.