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Colomer C, Llorens R, Navarro MD, Noé E, Ferri J. Neurobehavioral Progress and Signs of Transition in Children With Prolonged Disorders of Consciousness: A Retrospective Longitudinal Study With the Coma Recovery Scale-Revised. Pediatr Neurol 2024; 155:187-192. [PMID: 38677241 DOI: 10.1016/j.pediatrneurol.2024.03.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Revised: 05/05/2023] [Accepted: 03/31/2024] [Indexed: 04/29/2024]
Abstract
BACKGROUND Research on disorders of consciousness in children is scarce and includes disparate and barely comparable participants and assessment instruments and therefore provides inconclusive information on the clinical progress and recovery in this population. This study retrospectively investigated the neurobehavioral progress and the signs of transition between states of consciousness in a group of children admitted to a rehabilitation program either with an unresponsive wakefulness syndrome (UWS) or in a minimally conscious state (MCS). METHODS Systematic weekly assessments were conducted with the Coma Recovery Scale-Revised (CRS-R) until emergence from MCS, discharge, or death. RESULTS Twenty-one children, nine admitted with a UWS and 12 admitted in an MCS, were included in the study. Four children with a UWS transitioned to an MCS with a CRS-R of 10 (9.2 to 12.2) by showing visual pursuit, visual fixation, or localization to noxious stimulation. Twelve children emerged from the MCS with a CRS-R of 20.5 (19 to 21.7). Children who emerged from the MCS had had a shorter time postinjury and higher CRS-R at admission, compared with those who did not emerge. CONCLUSIONS Almost half of the children who were admitted with a UWS transitioned to an MCS, and almost all who were admitted in an MCS emerged from this state. Children who emerged had shorter times since injury and higher scores on the CRS-R at admission, compared with those who did not emerge.
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Affiliation(s)
- Carolina Colomer
- IRENEA, Instituto de Rehabilitación Neurológica, Fundación Hospitales Vithas, València, Spain.
| | - Roberto Llorens
- IRENEA, Instituto de Rehabilitación Neurológica, Fundación Hospitales Vithas, València, Spain; Neurorehabilitation and Brain Research Group, Institute for Human-Centered Technology Research, Universitat Politècnica de València, València, Spain
| | - María Dolores Navarro
- IRENEA, Instituto de Rehabilitación Neurológica, Fundación Hospitales Vithas, València, Spain
| | - Enrique Noé
- IRENEA, Instituto de Rehabilitación Neurológica, Fundación Hospitales Vithas, València, Spain
| | - Joan Ferri
- IRENEA, Instituto de Rehabilitación Neurológica, Fundación Hospitales Vithas, València, Spain
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Giglio A, Reccius A, Regueira T, Carvajal C, Pedreros C, Pino M, Riquelme C, Aguilera S, Ferre A, Suarez JI. Coma Prevalence in Critical Care Units in Chile: Results of a Cross-Sectional Survey on World Coma Day. Neurocrit Care 2024:10.1007/s12028-024-01986-4. [PMID: 38649652 DOI: 10.1007/s12028-024-01986-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2023] [Accepted: 03/20/2024] [Indexed: 04/25/2024]
Abstract
BACKGROUND The purpose of this study was to assess the prevalence of coma among patients in critical care units in Chile. We also aimed to provide insight into the demographic characteristics, etiologies, and complications associated with coma. METHODS A single day cross-sectional study was conducted through a national survey of public and private hospitals with critical and intensive cardiac care units across Chile. Data were collected using an online questionnaire that contained questions regarding critically ill patients' information, demographic characteristics, etiology and duration of coma, medical complications, and support requirements. RESULTS A total of 84% of all health facilities answered, accounting for a total of 2,708 patients. The overall coma prevalence was 2.9%. The median age of the comatose patients was 61 years (interquartile range 50-72) and 66.2% were male. The median coma duration was five days (interquartile range 2-9). Cerebral hemorrhage was the most common etiology, followed by severe hypoxic-ischemic encephalopathy, acute ischemic stroke, and traumatic brain injury. A total of 48.1% of coma patients experienced acute and ongoing treatment complications, with pneumonia being the most common complication, and 97.4% required support during comatose management. CONCLUSIONS This study provides an overview of the prevalence of coma in Chilean critical and cardiac care units. Coma is a common condition. Comatose patients frequently experience medical complications during their hospitalization.
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Affiliation(s)
- Andrés Giglio
- Critical Care Department, Finis Terrae University, Pedro de Valdivia 1509 Providencia, Santiago, Chile.
- Critical Care Center, Clinica Las Condes Hospital, Estoril 450, Las Condes, Santiago, Chile.
| | - Andrés Reccius
- Critical Care Department, Finis Terrae University, Pedro de Valdivia 1509 Providencia, Santiago, Chile
- Critical Care Center, Clinica Las Condes Hospital, Estoril 450, Las Condes, Santiago, Chile
| | - Tomás Regueira
- Critical Care Unit, Clinica Santa María, Santiago, Chile
| | | | - Cesar Pedreros
- Critical Care Department, Finis Terrae University, Pedro de Valdivia 1509 Providencia, Santiago, Chile
- Critical Care Center, Clinica Las Condes Hospital, Estoril 450, Las Condes, Santiago, Chile
| | - Monserrat Pino
- Critical Care Center, Clinica Las Condes Hospital, Estoril 450, Las Condes, Santiago, Chile
| | - Carolina Riquelme
- Critical Care Center, Clinica Las Condes Hospital, Estoril 450, Las Condes, Santiago, Chile
| | - Sergio Aguilera
- Neurosurgery Department of Herminda Martin Hospital, Chillán, Chile
- Universidad de Valparaiso, Valparaiso, Chile
| | - Andrés Ferre
- Critical Care Department, Finis Terrae University, Pedro de Valdivia 1509 Providencia, Santiago, Chile
- Critical Care Center, Clinica Las Condes Hospital, Estoril 450, Las Condes, Santiago, Chile
| | - José Ignacio Suarez
- Neuroscience Critical Care Division, Departments of Neurology, and Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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Tangonan R, Lazaridis C. Evaluation and Management of Disorders of Consciousness in the Acute Care Setting. Phys Med Rehabil Clin N Am 2024; 35:79-92. [PMID: 37993195 DOI: 10.1016/j.pmr.2023.06.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2023]
Abstract
Acute disorders of consciousness (DOC) are impairments in arousal and awareness that occur within 28 days of an initial injury and can result from a variety of insults. These states range from coma, unresponsive wakefulness, covert consciousness, minimal consciousness, to confusional state. It is important to perform thorough, serial examinations with particular emphasis on the level of consciousness, brainstem reflexes, and motor responses. Evaluation of acute DOC includes laboratory tests, imaging, and electrophysiology testing. Prognostication in the acute phase of DOC must be done cautiously, using open, frequent communication with families, and by acknowledging significant multidimensional uncertainty.
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Affiliation(s)
- Ruth Tangonan
- Neurosciences Intensive Care Unit, Department of Neurology, University of Chicago Medicine and Biological Sciences, Chicago, IL, USA.
| | - Christos Lazaridis
- Neurosciences Intensive Care Unit, Department of Neurology, University of Chicago Medicine and Biological Sciences, Chicago, IL, USA; Department of Neurological Surgery, University of Chicago Medicine and Biological Sciences, Chicago, IL, USA
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Li Y, Gao J, Yang Y, Zhuang Y, Kang Q, Li X, Tian M, Lv H, He J. Temporal and spatial variability of dynamic microstate brain network in disorders of consciousness. CNS Neurosci Ther 2024; 30:e14641. [PMID: 38385681 PMCID: PMC10883110 DOI: 10.1111/cns.14641] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2023] [Revised: 01/17/2024] [Accepted: 02/01/2024] [Indexed: 02/23/2024] Open
Abstract
BACKGROUND Accurately diagnosing patients with the vegetative state (VS) and the minimally conscious state (MCS) reached a misdiagnosis of approximately 40%. METHODS A method combined microstate and dynamic functional connectivity (dFC) to study the spatiotemporal variability of the brain in disorders of consciousness (DOC) patients was proposed. Resting-state EEG data were obtained from 16 patients with MCS and 16 patients with VS. Mutual information (MI) was used to assess the EEG connectivity in each microstate. MI-based features with statistical differences were selected as the total feature subset (TFS), then the TFS was utilized to feature selection and fed into the classifier, obtaining the optimal feature subsets (OFS) in each microstate. Subsequently, an OFS-based MI functional connectivity network (MIFCN) was constructed in the cortex. RESULTS The group-average MI connectivity matrix focused on all channels revealed that all five microstates exhibited stronger information interaction in the MCS when comparing with the VS. While OFS-based MIFCN, which only focused on a few channels, revealed greater MI flow in VS patients than in MCS patients under microstates A, B, C, and E, except for microstate D. Additionally, the average classification accuracy of OFS in the five microstates was 96.2%. CONCLUSION Constructing features based on microstates to distinguish between two categories of DOC patients had effectiveness.
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Affiliation(s)
- Yaqian Li
- Key Laboratory of Cognitive Science of State Ethnic Affairs Commission, College of Biomedical EngineeringSouth‐Central Minzu UniversityWuhanChina
| | - Junfeng Gao
- Key Laboratory of Cognitive Science of State Ethnic Affairs Commission, College of Biomedical EngineeringSouth‐Central Minzu UniversityWuhanChina
| | - Ying Yang
- College of Foreign LanguagesWuhan University of TechnologyWuhanChina
| | - Yvtong Zhuang
- Department of Neurosurgery, Beijing Tiantan HospitalCapital Medical UniversityBeijingChina
| | - Qianruo Kang
- Key Laboratory of Cognitive Science of State Ethnic Affairs Commission, College of Biomedical EngineeringSouth‐Central Minzu UniversityWuhanChina
| | - Xiang Li
- Key Laboratory of Cognitive Science of State Ethnic Affairs Commission, College of Biomedical EngineeringSouth‐Central Minzu UniversityWuhanChina
| | - Min Tian
- Key Laboratory of Cognitive Science of State Ethnic Affairs Commission, College of Biomedical EngineeringSouth‐Central Minzu UniversityWuhanChina
| | - Haoan Lv
- Key Laboratory of Cognitive Science of State Ethnic Affairs Commission, College of Biomedical EngineeringSouth‐Central Minzu UniversityWuhanChina
| | - Jianghong He
- Department of Neurosurgery, Beijing Tiantan HospitalCapital Medical UniversityBeijingChina
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Piedade GS, Assumpcao de Monaco B, Guest JD, Cordeiro JG. Review of spinal cord stimulation for disorders of consciousness. Curr Opin Neurol 2023; 36:507-515. [PMID: 37889524 DOI: 10.1097/wco.0000000000001222] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2023]
Abstract
PURPOSE OF REVIEW High-cervical spinal cord stimulation can alter cortical activity and cerebral metabolism. These effects are potentially beneficial for disorders of consciousness. A better understanding of the effects of clinical application of stimulation is needed. We aimed to evaluate the existing literature to determine the state of available knowledge. We performed a literature review of clinical studies assessing cervical spinal cord epidural stimulation for disorders of consciousness. Only peer-reviewed articles reporting preoperative and postoperative clinical status were included. RECENT FINDINGS Nineteen studies were included. A total of 532 cases were reported, and 255 patients were considered responsive (47.9%). Considering only studies published after the definition of minimally conscious state (MCS) as an entity, 402 individuals in unresponsive wakefulness syndrome (UWS) and 113 in MCS were reported. Responsiveness to SCS was reported in 170 UWS patients (42.3%) and in 78 MCS cases (69.0%), although the criteria for responsiveness and outcome measures varied among publications. SUMMARY Cervical SCS yielded encouraging results in patients with disorders of consciousness and seems to be more effective in MCS. More extensive investigation is needed to understand its potential role in clinical practice.
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Affiliation(s)
| | | | - James D Guest
- Department of Neurosurgery, Jackson Memorial Hospital, University of Miami Miller School of Medicine, Miami
- The Miami Project to Cure Paralysis, Miller School of Medicine, Miami, Florida, USA
| | - Joacir Graciolli Cordeiro
- Department of Neurosurgery, Jackson Memorial Hospital, University of Miami Miller School of Medicine, Miami
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Nakamura Y, Shiozaki T, Ito H, Nakao S, Ogura H, Oda J. Long-Term Outcomes Over 20 Years in Persons With Persistent Disorders of Consciousness After Traumatic Brain Injury. Neurotrauma Rep 2023; 4:805-812. [PMID: 38028278 PMCID: PMC10664559 DOI: 10.1089/neur.2023.0080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2023] Open
Abstract
The long-term outcomes of patients with disorders of consciousness after traumatic brain injury (TBI) is unclear. We investigated the long-term outcomes over 20 years in patients who were in a persistent vegetative state (VS). We conducted a retrospective cohort study using a review of medical records and collected data by telephone and written interviews with patients and their families. We included patients who were treated for TBI at our hospital, between October 1996 and January 2003 and who were in a persistent VS, defined as a Disability Rating Scale (DRS) score of ≥22 at 1 month after TBI. The DRS was administered at 1 month, 6 months, 1 year, and then annually out to 20 years. We evaluated their clinical course until July 2021 with the DRS. We analyzed 35 patients in a persistent VS attributable to TBI. We were able to confirm the 20-year outcomes for 26 of the 35 patients (74%); at 20 years post-TBI, 19 (54%) patients were found to be deceased and 7 (20%) were alive. Over the 20-year study period, 23 of the 35 patients (65.7%) emerged from a persistent VS. Among the 35 patients in a persistent VS at 1 month post-TBI, 20 (57%) emerged from a persistent VS within 1 year, and 3 patients (8.6%) emerged from a persistent VS after more than a year after injury. DRS scores improved up to 9 years post-injury, whereas the change in DRS scores from 10 to 20 years post-injury was within ±1 point in all patients. We found that patients with persistent VS attributable to TBI may show improvement in functional disability up to 10 years post-injury. On the other hand, no substantial improvement in functional disability was observed after the 10th year.
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Affiliation(s)
- Youhei Nakamura
- Department of Traumatology and Acute Critical Medicine, Osaka University Graduate School of Medicine, Suita, Japan
| | - Tadahiko Shiozaki
- Department of Traumatology and Acute Critical Medicine, Osaka University Graduate School of Medicine, Suita, Japan
| | - Hiroshi Ito
- Department of Traumatology and Acute Critical Medicine, Osaka University Graduate School of Medicine, Suita, Japan
| | - Shunichiro Nakao
- Department of Traumatology and Acute Critical Medicine, Osaka University Graduate School of Medicine, Suita, Japan
| | - Hiroshi Ogura
- Department of Traumatology and Acute Critical Medicine, Osaka University Graduate School of Medicine, Suita, Japan
| | - Jun Oda
- Department of Traumatology and Acute Critical Medicine, Osaka University Graduate School of Medicine, Suita, Japan
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Murtaugh B, Shapiro Rosenbaum A. Clinical application of recommendations for neurobehavioral assessment in disorders of consciousness: an interdisciplinary approach. Front Hum Neurosci 2023; 17:1129466. [PMID: 37502093 PMCID: PMC10368884 DOI: 10.3389/fnhum.2023.1129466] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Accepted: 06/05/2023] [Indexed: 07/29/2023] Open
Abstract
Accurate diagnosis, prognosis, and subsequent rehabilitation care planning for persons with Disorders of Consciousness (DoC) has historically posed a challenge for neurological care professionals. Evidence suggests rates of misdiagnosis may be as high as 40% when informal beside evaluations are used to determine level of consciousness. The presence of myriad medical, neurological, functional (motor, sensory, cognitive) and environmental confounds germane to these conditions complicates behavioral assessment. Achieving diagnostic certainty is elusive but critical to inform care planning, clinical decision making, and prognostication. Standardized neurobehavioral rating scales has been shown to improve accuracy in distinguishing between coma, unresponsive wakefulness syndrome/vegetative state and minimally consciousness state as compared to informal assessment methods. Thus, these scales are currently recommended for use as the informal "gold standard" for diagnostic assessment in DoC. The following paper will present an evidence-based approach to neurobehavioral assessment for use in clinical practice. Strategies for optimizing assessment and aiding in identification and management of confounds that can limit diagnostic accuracy will be provided. Finally, clinical application of an interdisciplinary approach to identifying and managing confounds will be discussed and how assessment results can be used to identify trends in performance and guide prognostic counseling with families.
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Affiliation(s)
- Brooke Murtaugh
- Department of Rehabilitation Programs, Madonna Rehabilitation Hospitals, Lincoln, NE, United States
| | - Amy Shapiro Rosenbaum
- Department of Brain Injury Rehabilitation, Park Terrace Care Center, Queens, NY, United States
- TBI Model System, Icahn School of Medicine at Mount Sinai, New York, NY, United States
- Brainmatters Neuropsychological Services, PLLC, Plainview, NY, United States
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8
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Ma H, Fan S, Xu Z, Wan X, Yang Q, Yin Y, Wu X, Wu S, Zhang H, Ma C. Trigeminal nerve stimulation for prolonged disorders of consciousness: A randomized double-blind sham-controlled study. Brain Stimul 2023; 16:819-827. [PMID: 37182683 DOI: 10.1016/j.brs.2023.05.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Revised: 04/19/2023] [Accepted: 05/03/2023] [Indexed: 05/16/2023] Open
Abstract
BACKGROUND Trigeminal nerve stimulation (TNS) has been proposed as a promising intervention for coma awakening. However, the effect of TNS on patients with prolonged disorders of consciousness (pDoC) is still unclear. OBJECTIVE This study aimed to investigate the therapeutic effects of TNS in pDoC caused by stroke, trauma, and anoxia. METHODS A total of 60 patients (male =25, female =35) aged over 18 who were in a vegetative state or minimally conscious state were randomly assigned to the TNS (N = 30) or sham TNS (N = 30) groups. 4 weeks of intervention and a followed up for 8 weeks were performed. The Glasgow Coma Scale (GCS) and Coma Recovery Scale-Revised (CRS-R) scores as primary outcomes were assessed at baseline and at 2, 4, 8, and 12 weeks. RESULTS The score changes in the TNS group over time for CRS-R (2-week: mean difference = 0.9, 95% CI = [0.3, 1.5], P = 0.006; 4-week: 1.6, 95% CI = [0.8, 2.5], P < 0.001; 8-week: mean difference = 2.4, 95% CI = [1.3, 3.5], P < 0.001; 12-week: mean difference = 2.3, 95% CI = [1.1, 3.4], P < 0.001) and GCS (4-week: mean difference = 0.7, 95% CI = [0.3, 1.2], P = 0.002; 8-week: mean difference = 1.1, 95% CI = [0.6, 1.7], P < 0.001; 12-week: 1.1, 95% CI = [0.5, 1.7], P = 0.003) were higher than those in the sham group. 18-Fluorodeoxyglucose Positron Emission Tomography (FDG-PET) revealed that the metabolism of the right parahippocampal cortex, right precuneus, and bilateral middle cingulate cortex was significantly increased in TNS group. CONCLUSION The results of this study indicate that TNS could increase local brain metabolism and may promote functional recovery in patients with prolonged disorders of consciousness. REGISTRATION INFORMATION Name of the registry: Chinese Clinical Trial Registry. REGISTRATION NUMBER ChiCTR1900025573. The date that the study was submitted to a registry: 2019-09-01. The date when the first patient was enrolled was 2021-01-20.
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Affiliation(s)
- Haiyun Ma
- Department of Rehabilitation Medicine, Sun Yat-sen Memorial Hospital, Guangzhou, Guangdong, People's Republic of China
| | - Shengnuo Fan
- Department of Rehabilitation Medicine, Sun Yat-sen Memorial Hospital, Guangzhou, Guangdong, People's Republic of China
| | - Zhen Xu
- Department of Rehabilitation Medicine, Sun Yat-sen Memorial Hospital, Guangzhou, Guangdong, People's Republic of China
| | - Xiaoting Wan
- Department of Nuclear Medicine, Sun Yat-sen Memorial Hospital, Guangzhou, Guangdong, People's Republic of China
| | - Qian Yang
- Department of Rehabilitation Medicine, Sun Yat-sen Memorial Hospital, Guangzhou, Guangdong, People's Republic of China
| | - Yuping Yin
- Department of Nuclear Medicine, Sun Yat-sen Memorial Hospital, Guangzhou, Guangdong, People's Republic of China
| | - Xuemeng Wu
- Department of Rehabilitation Medicine, Sun Yat-sen Memorial Hospital, Guangzhou, Guangdong, People's Republic of China
| | - Shaoling Wu
- Department of Rehabilitation Medicine, Sun Yat-sen Memorial Hospital, Guangzhou, Guangdong, People's Republic of China.
| | - Hong Zhang
- Department of Nuclear Medicine, Sun Yat-sen Memorial Hospital, Guangzhou, Guangdong, People's Republic of China.
| | - Chao Ma
- Department of Rehabilitation Medicine, Sun Yat-sen Memorial Hospital, Guangzhou, Guangdong, People's Republic of China.
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Hyun C, Kim K, Lee S, Lee HH, Lee J. Quantitative evaluation of the consciousness level of patients in a vegetative state using virtual reality and an eye-tracking system: A single-case experimental design study. Neuropsychol Rehabil 2022; 32:2628-2645. [PMID: 34486951 DOI: 10.1080/09602011.2021.1974496] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
ABSTRACTIt is important to distinguish patients in a minimally conscious state (MCS) from patients in a vegetative state (VS) when assessing disorders of consciousness (DOC) as prognosis, selection of therapy, and drug treatment could differ accordingly. Clinical evaluation of a patient's eye movements, such as visual startle, visual fixation, and visual pursuit, provides valuable evidence but is often subject to misdiagnosis. To minimize such misdiagnosis caused by human judgment, a virtual reality (VR) technology-based quantitative assessment method with an eye-tracking system is proposed in this study. The new VR system presented 3 stimuli to 20 healthy participants, and visual response data were recorded to define valid responses to each stimulus. Further, the newly defined stimuli were presented to five chronic patients in VS, and the system classified three of them as showing visual fixations that could not be verified through clinical assessment beforehand. The proposed system, as verified through such experimentation, suggests quantitative and objective evaluation methods for examining three visual functions of patients with DOC.
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Affiliation(s)
- Cheolhwan Hyun
- Department of Rehabilitation Medicine, Konkuk University Medical Center and Konkuk University School of Medicine, Seoul, Korea
| | - Kyungmin Kim
- Department of Rehabilitation Medicine, Konkuk University Medical Center and Konkuk University School of Medicine, Seoul, Korea
| | - Soolim Lee
- Department of Rehabilitation Medicine, Konkuk University Medical Center and Konkuk University School of Medicine, Seoul, Korea
| | - Hyun Haeng Lee
- Department of Rehabilitation Medicine, Konkuk University Medical Center and Konkuk University School of Medicine, Seoul, Korea
| | - Jongmin Lee
- Department of Rehabilitation Medicine, Konkuk University Medical Center and Konkuk University School of Medicine, Seoul, Korea.,Research Institute of Medical Science, Konkuk University School of Medicine, Seoul, Korea
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Wu M, Luo B, Yu Y, Li X, Gao J, Li J, Sorger B, Riecke L. Rhythmic musical-electrical trigeminal nerve stimulation improves impaired consciousness. Neuroimage Clin 2022; 36:103170. [PMID: 36063757 PMCID: PMC9460811 DOI: 10.1016/j.nicl.2022.103170] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Revised: 07/27/2022] [Accepted: 08/23/2022] [Indexed: 12/14/2022]
Abstract
Accumulating evidence shows that consciousness is linked to neural oscillations in the thalamocortical system, suggesting that deficits in these oscillations may underlie disorders of consciousness (DOC). However, patient-friendly non-invasive treatments targeting this functional anomaly are still missing and the therapeutic value of oscillation restoration has remained unclear. We propose a novel approach that aims to restore DOC patients' thalamocortical oscillations by combining rhythmic trigeminal-nerve stimulation with comodulated musical stimulation ("musical-electrical TNS"). In a double-blind, placebo-controlled, parallel-group study, we recruited 63 patients with DOC and randomly assigned them to groups receiving gamma, beta, or sham musical-electrical TNS. The stimulation was applied for 40 min on five consecutive days. We measured patients' consciousness before and after the stimulation using behavioral indicators and neural responses to rhythmic auditory speech. We further assessed their outcomes one year later. We found that musical-electrical TNS reliably lead to improvements in consciousness and oscillatory brain activity at the stimulation frequency: 43.5 % of patients in the gamma group and 25 % of patients in the beta group showed an improvement of their diagnosis after being treated with the stimulation. This group of benefitting patients still showed more positive outcomes one year later. Moreover, patients with stronger behavioral benefits showed stronger improvements in oscillatory brain activity. These findings suggest that brain oscillations contribute to consciousness and that musical-electrical TNS may serve as a promising approach to improve consciousness and predict long-term outcomes in patients with DOC.
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Affiliation(s)
- Min Wu
- Department of Neurology & Brain Medical Centre, First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China,Department of Cognitive Neuroscience, Faculty of Psychology and Neuroscience, Maastricht University, Maastricht, Netherlands
| | - Benyan Luo
- Department of Neurology & Brain Medical Centre, First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China,Corresponding author.
| | - Yamei Yu
- Department of Neurology & Brain Medical Centre, First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Xiaoxia Li
- Department of Neurology & Brain Medical Centre, First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Jian Gao
- Hangzhou Mingzhou Brain Rehabilitation Hospital, Hangzhou, China
| | - Jingqi Li
- Hangzhou Mingzhou Brain Rehabilitation Hospital, Hangzhou, China
| | - Bettina Sorger
- Department of Cognitive Neuroscience, Faculty of Psychology and Neuroscience, Maastricht University, Maastricht, Netherlands
| | - Lars Riecke
- Department of Cognitive Neuroscience, Faculty of Psychology and Neuroscience, Maastricht University, Maastricht, Netherlands
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Osińska A, Rynkiewicz A, Binder M, Komendziński T, Borowicz A, Leszczyński A. Non-invasive Vagus Nerve Stimulation in Treatment of Disorders of Consciousness – Longitudinal Case Study. Front Neurosci 2022; 16:834507. [PMID: 35600632 PMCID: PMC9120963 DOI: 10.3389/fnins.2022.834507] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Accepted: 03/29/2022] [Indexed: 11/16/2022] Open
Abstract
Neuromodulatory electroceuticals such as vagus nerve stimulation have been recently gaining traction as potential rehabilitation tools for disorders of consciousness (DoC). We present a longitudinal case study of non-invasive auricular vagus nerve stimulation (taVNS) in a patient diagnosed with chronic unresponsive wakefulness syndrome (previously known as vegetative state). Over a period of 6 months we applied taVNS daily and regularly evaluated the patient’s behavioral outcomes using Coma Recovery Scale – Revised. We also took electrophysiological measures: resting state electroencephalography (EEG), heart rate (HR) and heart rate variability (HRV). All these methods revealed signs of improvement in the patient’s condition. The total CRS-R scores fluctuated but rose from 4 and 6 at initial stages to the heights of 12 and 13 in the 3rd and 5th month, which would warrant a change in diagnosis to a Minimally Conscious State. Scores obtained in a 2 months follow-up period, though, suggest this may not have been a lasting improvement. Behavioral signs of recovery are triangulated by EEG frequency spectrum profiles with re-emergence of a second oscillatory peak in the alpha range, which has been shown to characterize aware people. However, sustained spontaneous theta oscillations did not predictably diminish, which most likely reflects structural brain damage. ECG measures revealed a steady decrease in pre-stimulation HR combined with an increase in HRV-HR. This suggests a gradual withdrawal of sympathetic and an increase in parasympathetic control of the heart, which the previous literature has also linked with DoC improvements. Together, this study suggests that taVNS stimulation holds promise as a DoC treatment.
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Affiliation(s)
- Albertyna Osińska
- Faculty of Psychology, University of Warsaw, Warsaw, Poland
- *Correspondence: Albertyna Osińska,
| | - Andrzej Rynkiewicz
- Faculty of Psychology, University of Warsaw, Warsaw, Poland
- Andrzej Rynkiewicz,
| | - Marek Binder
- Institute of Psychology, Jagiellonian University, Kraków, Poland
| | - Tomasz Komendziński
- Department of Cognitive Science, Faculty of Humanities, Nicolaus Copernicus University in Toruń, Toruń, Poland
| | - Anna Borowicz
- Department of Cognitive Science, Faculty of Humanities, Nicolaus Copernicus University in Toruń, Toruń, Poland
| | - Antoni Leszczyński
- Department of Cognitive Science, Faculty of Humanities, Nicolaus Copernicus University in Toruń, Toruń, Poland
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Angerer M, Wilhelm FH, Liedlgruber M, Pichler G, Angerer B, Scarpatetti M, Blume C, Schabus M. Does the Heart Fall Asleep?—Diurnal Variations in Heart Rate Variability in Patients with Disorders of Consciousness. Brain Sci 2022; 12:brainsci12030375. [PMID: 35326331 PMCID: PMC8946070 DOI: 10.3390/brainsci12030375] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2022] [Revised: 03/03/2022] [Accepted: 03/06/2022] [Indexed: 02/04/2023] Open
Abstract
The current study investigated heart rate (HR) and heart rate variability (HRV) across day and night in patients with disorders of consciousness (DOC). We recorded 24-h electrocardiography in 26 patients with DOC (i.e., unresponsive wakefulness syndrome (UWS; n = 16) and (exit) minimally conscious state ((E)MCS; n = 10)). To examine diurnal variations, HR and HRV indices in the time, frequency, and entropy domains were computed for periods of clear day- (forenoon: 8 a.m.–2 p.m.; afternoon: 2 p.m.–8 p.m.) and nighttime (11 p.m.–5 a.m.). The results indicate that patients’ interbeat intervals (IBIs) were larger during the night than during the day, indicating HR slowing. The patients in UWS showed larger IBIs compared to the patients in (E)MCS, and the patients with non-traumatic brain injury showed lower HRV entropy than the patients with traumatic brain injury. Additionally, higher HRV entropy was associated with higher EEG entropy during the night. Thus, cardiac activity varies with a diurnal pattern in patients with DOC and can differentiate between patients’ diagnoses and etiologies. Moreover, the interaction of heart and brain appears to follow a diurnal rhythm. Thus, HR and HRV seem to mirror the integrity of brain functioning and, consequently, might serve as supplementary measures for improving the validity of assessments in patients with DOC.
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Affiliation(s)
- Monika Angerer
- Laboratory for Sleep, Cognition and Consciousness Research, Department of Psychology, University of Salzburg, 5020 Salzburg, Austria;
- Centre for Cognitive Neuroscience Salzburg (CCNS), University of Salzburg, 5020 Salzburg, Austria
| | - Frank H. Wilhelm
- Division of Clinical Psychology and Psychopathology, Department of Psychology, University of Salzburg, 5020 Salzburg, Austria; (F.H.W.); (M.L.)
| | - Michael Liedlgruber
- Division of Clinical Psychology and Psychopathology, Department of Psychology, University of Salzburg, 5020 Salzburg, Austria; (F.H.W.); (M.L.)
| | - Gerald Pichler
- Apallic Care Unit, Albert Schweitzer Hospital, Geriatric Health Care Centres of the City of Graz, 8020 Graz, Austria; (G.P.); (M.S.)
| | - Birgit Angerer
- Private Practice for General Medicine and Neurology, 8430 Leibnitz, Austria;
| | - Monika Scarpatetti
- Apallic Care Unit, Albert Schweitzer Hospital, Geriatric Health Care Centres of the City of Graz, 8020 Graz, Austria; (G.P.); (M.S.)
| | - Christine Blume
- Centre for Chronobiology, Psychiatric Hospital of the University of Basel, 4002 Basel, Switzerland;
- Transfaculty Research Platform Molecular and Cognitive Neurosciences, University of Basel, 4055 Basel, Switzerland
| | - Manuel Schabus
- Laboratory for Sleep, Cognition and Consciousness Research, Department of Psychology, University of Salzburg, 5020 Salzburg, Austria;
- Centre for Cognitive Neuroscience Salzburg (CCNS), University of Salzburg, 5020 Salzburg, Austria
- Correspondence:
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13
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Bagnato S. The role of plasticity in the recovery of consciousness. HANDBOOK OF CLINICAL NEUROLOGY 2022; 184:375-395. [PMID: 35034750 DOI: 10.1016/b978-0-12-819410-2.00020-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Disorders of consciousness (DOCs), i.e., coma, vegetative state, and minimally conscious state are the consequences of a severe brain injury that disrupts the brain ability to generate consciousness. Recovery from DOCs requires functional and structural changes in the brain. The sites where these plastic changes take place vary according to the pathophysiology of the DOC. The ascending reticular activating system of the brainstem and its complex connections with the thalamus and cortex are involved in the pathophysiology of coma. Subcortical structures, such as the striatum and globus pallidus, together with thalamocortical and corticothalamic projections, the basal forebrain, and several networks among different cortical areas are probably involved in vegetative and minimally conscious states. Some mechanisms of plasticity that allegedly operate in each of these sites to promote recovery of consciousness will be discussed in this chapter. While some mechanisms of plasticity work at a local level, others produce functional changes in complex neuronal networks, for example by entraining neuronal oscillations. The specific mechanisms of brain plasticity represent potential targets for future treatments aiming to restore consciousness in patients with severe DOCs.
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Affiliation(s)
- Sergio Bagnato
- Unit of Neurophysiology and Unit for Severe Acquired Brain Injuries, Rehabilitation Department, Giuseppe Giglio Foundation, Cefalù (PA), Italy.
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14
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Overbeek BUH, Lavrijsen JCM, van Gaal S, Kondziella D, Eilander HJ, Koopmans RTCM. Towards consensus on visual pursuit and visual fixation in patients with disorders of consciousness. A Delphi study. J Neurol 2022; 269:3204-3215. [PMID: 35001197 DOI: 10.1007/s00415-021-10905-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2021] [Revised: 11/10/2021] [Accepted: 11/11/2021] [Indexed: 10/19/2022]
Abstract
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.
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Affiliation(s)
- Berno U H Overbeek
- Department of Primary and Community Care, Radboud Institute of Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands. .,Kalorama, Beek Ubbergen, The Netherlands. .,Azora, Terborg, The Netherlands.
| | - Jan C M Lavrijsen
- Department of Primary and Community Care, Radboud Institute of Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Simon van Gaal
- Faculty of Social and Behavioural Sciences, Department of Psychology, University of Amsterdam, Amsterdam, The Netherlands
| | - Daniel Kondziella
- Department of Neurology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark.,Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Henk J Eilander
- Department of Primary and Community Care, Radboud Institute of Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Raymond T C M Koopmans
- Department of Primary and Community Care, Radboud Institute of Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands.,Center for Specialized Geriatric Care, Joachim en Anna, Nijmegen, The Netherlands
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Abstract
PURPOSE OF REVIEW In the study of brain-injured patients with disorders of consciousness (DoC), structural and functional MRI seek to provide insights into the neural correlates of consciousness, identify neurophysiologic signatures of covert consciousness, and identify biomarkers for recovery of consciousness. RECENT FINDINGS Cortical volume, white matter volume and integrity, and structural connectivity across many grey and white matter regions have been shown to vary with level of awareness in brain-injured patients. Resting-state functional connectivity (rs-FC) within and between canonical cortical networks also correlates with DoC patients' level of awareness. Stimulus-based and motor-imagery fMRI paradigms have identified some behaviorally unresponsive DoC patients with cortical processing and activation patterns that mirror healthy controls. Emerging techniques like dynamic rs-FC have begun to identify temporal trends in brain-wide connectivity that may represent novel neural correlates of consciousness. SUMMARY Structural and functional MRI will continue to advance our understanding of brain regions supporting human consciousness. Measures of regional and global white matter integrity and rs-FC in particular networks have shown significant improvement over clinical features in identifying acute and chronic DoC patients likely to recover awareness. As they are refined, functional MRI paradigms may additionally provide opportunities for interacting with behaviorally unresponsive patients.
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Nekrasova J, Kanarskii M, Borisov I, Pradhan P, Shunenkov D, Vorobiev A, Smirnova M, Pasko V, Petrova MV, Luginina E, Pryanikov I. One-Year Demographical and Clinical Indices of Patients with Chronic Disorders of Consciousness. Brain Sci 2021; 11:brainsci11050651. [PMID: 34065687 PMCID: PMC8156613 DOI: 10.3390/brainsci11050651] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2021] [Revised: 05/11/2021] [Accepted: 05/14/2021] [Indexed: 12/27/2022] Open
Abstract
This work aims to evaluate the prognostic value of the demographical and clinical data on long-term outcomes (up to 12 months) in patients with severe acquired brain injury with vegetative state/unresponsive wakefulness syndrome (VS/UWS/UWS) or a minimally conscious state (MCS). Patients (n = 211) with VS/UWS/UWS (n = 123) and MCS (n = 88) were admitted to the Federal Research and Clinical Center of Intensive Care Medicine and Rehabilitology after anoxic brain injury (n = 53), vascular lesions (n = 59), traumatic brain injury (n = 93), and other causes (n = 6). At the beginning of the 12-month study, younger age and a higher score by the Coma Recovery Scale-Revised (CRS-R) predicted a survival. However, no reliable markers of significant positive dynamics of consciousness were found. Based on the etiology, anoxic brain injury has the most unfavorable prognosis. For patients with vascular lesions, the first three months after injury have the most important prognostic value. No correlations were found between survival, increased consciousness, and gender. The demographic and clinical characteristics of patients with chronic DOC can be used to predict long-term mortality in patients with chronic disorders of consciousness. Further research should be devoted to finding reliable predictors of recovery of consciousness.
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Affiliation(s)
- Julia Nekrasova
- Department for the Study of Chronic Disorder of Consciousness, Federal Research and Clinical Center of Intensive Care Medicine and Rehabilitology, 107031 Moscow, Russia; (J.N.); (M.K.); (I.B.); (D.S.); (A.V.); (I.P.); (M.S.); (V.P.); (M.V.P.); (E.L.)
| | - Mikhail Kanarskii
- Department for the Study of Chronic Disorder of Consciousness, Federal Research and Clinical Center of Intensive Care Medicine and Rehabilitology, 107031 Moscow, Russia; (J.N.); (M.K.); (I.B.); (D.S.); (A.V.); (I.P.); (M.S.); (V.P.); (M.V.P.); (E.L.)
| | - Ilya Borisov
- Department for the Study of Chronic Disorder of Consciousness, Federal Research and Clinical Center of Intensive Care Medicine and Rehabilitology, 107031 Moscow, Russia; (J.N.); (M.K.); (I.B.); (D.S.); (A.V.); (I.P.); (M.S.); (V.P.); (M.V.P.); (E.L.)
| | - Pranil Pradhan
- Department for the Study of Chronic Disorder of Consciousness, Federal Research and Clinical Center of Intensive Care Medicine and Rehabilitology, 107031 Moscow, Russia; (J.N.); (M.K.); (I.B.); (D.S.); (A.V.); (I.P.); (M.S.); (V.P.); (M.V.P.); (E.L.)
- Correspondence: ; Tel.: +7-(977)-709-4468
| | - Denis Shunenkov
- Department for the Study of Chronic Disorder of Consciousness, Federal Research and Clinical Center of Intensive Care Medicine and Rehabilitology, 107031 Moscow, Russia; (J.N.); (M.K.); (I.B.); (D.S.); (A.V.); (I.P.); (M.S.); (V.P.); (M.V.P.); (E.L.)
| | - Alexey Vorobiev
- Department for the Study of Chronic Disorder of Consciousness, Federal Research and Clinical Center of Intensive Care Medicine and Rehabilitology, 107031 Moscow, Russia; (J.N.); (M.K.); (I.B.); (D.S.); (A.V.); (I.P.); (M.S.); (V.P.); (M.V.P.); (E.L.)
| | - Maria Smirnova
- Department for the Study of Chronic Disorder of Consciousness, Federal Research and Clinical Center of Intensive Care Medicine and Rehabilitology, 107031 Moscow, Russia; (J.N.); (M.K.); (I.B.); (D.S.); (A.V.); (I.P.); (M.S.); (V.P.); (M.V.P.); (E.L.)
| | - Vera Pasko
- Department for the Study of Chronic Disorder of Consciousness, Federal Research and Clinical Center of Intensive Care Medicine and Rehabilitology, 107031 Moscow, Russia; (J.N.); (M.K.); (I.B.); (D.S.); (A.V.); (I.P.); (M.S.); (V.P.); (M.V.P.); (E.L.)
| | - Marina V. Petrova
- Department for the Study of Chronic Disorder of Consciousness, Federal Research and Clinical Center of Intensive Care Medicine and Rehabilitology, 107031 Moscow, Russia; (J.N.); (M.K.); (I.B.); (D.S.); (A.V.); (I.P.); (M.S.); (V.P.); (M.V.P.); (E.L.)
- Department of Anestesiology-Reanimatology, People’s Friendship University of Russia, 117198 Moscow, Russia
| | - Elena Luginina
- Department for the Study of Chronic Disorder of Consciousness, Federal Research and Clinical Center of Intensive Care Medicine and Rehabilitology, 107031 Moscow, Russia; (J.N.); (M.K.); (I.B.); (D.S.); (A.V.); (I.P.); (M.S.); (V.P.); (M.V.P.); (E.L.)
| | - Igor Pryanikov
- Department for the Study of Chronic Disorder of Consciousness, Federal Research and Clinical Center of Intensive Care Medicine and Rehabilitology, 107031 Moscow, Russia; (J.N.); (M.K.); (I.B.); (D.S.); (A.V.); (I.P.); (M.S.); (V.P.); (M.V.P.); (E.L.)
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Behavioral signs of recovery from unresponsive wakefulness syndrome to emergence of minimally conscious state after severe brain injury. Ann Phys Rehabil Med 2021; 65:101534. [PMID: 33933691 DOI: 10.1016/j.rehab.2021.101534] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2020] [Revised: 03/02/2021] [Accepted: 03/16/2021] [Indexed: 11/22/2022]
Abstract
BACKGROUND A precise description of behavioral signs denoting transition from an unresponsive wakefulness syndrome/vegetative state (UWS/VS) to minimally conscious state (MCS) or emergence from MCS after severe brain injury is crucial for prognostic purposes. A few studies have attempted this goal but involved non-standardized instruments, limited temporal accuracy or samples or focused on patients with (sub)acute condition. OBJECTIVES We aimed to describe the behavioral signs that led to a change in diagnosis as well as the factors affecting this transition in a large sample of patients with chronic disorders of consciousness after severe brain injury. METHODS In this retrospective cohort study, patients in UWS/VS or MCS were assessed with the Coma Recovery Scale Revised (CRS-R) at 5 times within the 2 weeks after their admission to a neurorehabilitation center and then weekly until emergence from MCS, discharge or death. RESULTS Of the 185 patients included, 33 in UWS/VS and 45 in MCS transitioned to another state. Transition to MCS was mostly denoted by one behavioral sign (71%), predominantly visual fixation, followed by localization to noxious stimulation, and visual pursuit, and could be predicted by etiology, time post-injury and age. Emergence from MCS was characterized by one sign in 64% of patients and by 2 signs (functional communication and objects use) in the remaining patients and could be predicted by time post-injury and number of behavioral signs at admission. CONCLUSIONS Transition from UWS to MCS was predominantly signalled by visual fixation and could be predicted by etiology, time post-injury and age. Emergence from MCS was mostly signalled by one sign and could be predicted by time post-injury and number of behavioral signs at admission. Clinicians should pay particular attention to visual and motor subscales of the CRS-R to detect behavioral recovery after severe brain injury. Database registration. ClinicalTrials.gov: NCT04687397.
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Sattin D, Rossi Sebastiano D, Magnani FG, D'Incerti L, Marotta G, Benti R, Tirelli S, Bersano A, Duran D, Visani E, Ferraro S, Minati L, Nigri A, Rosazza C, Bianchi Marzoli S, Ciasca P, Carcagni A, Bruzzone MG, Franceschetti S, Leonardi M, Guido D. Visual fixation in disorders of consciousness: Development of predictive models to support differential diagnosis. Physiol Behav 2021; 230:113310. [PMID: 33412191 DOI: 10.1016/j.physbeh.2021.113310] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2020] [Revised: 12/29/2020] [Accepted: 12/30/2020] [Indexed: 12/13/2022]
Abstract
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.
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Affiliation(s)
- Davide Sattin
- Neurology, Public Health, Disability Unit - Coma Research Centre; Scientific Directorate, Fondazione IRCCS Istituto Neurologico Carlo Besta, Via Celoria 11, Milan, 20133, Italy.
| | - Davide Rossi Sebastiano
- Neurophysiology and Diagnostic Epileptology Unit - Fondazione IRCCS Istituto Neurologico Carlo Besta n, Via Celoria 11, Milan, 20133, Italy.
| | - Francesca Giulia Magnani
- Neurology, Public Health, Disability Unit - Coma Research Centre; Scientific Directorate, Fondazione IRCCS Istituto Neurologico Carlo Besta, Via Celoria 11, Milan, 20133, Italy.
| | - Ludovico D'Incerti
- Neuroradiology Unit, Fondazione IRCCS Istituto Neurologico Carlo Besta, Via Celoria 11, Milan, 20133, Italy.
| | - Giorgio Marotta
- Department of Nuclear Medicine, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via Francesco Sforza 35, Milan, 20122, Italy; Dipartimento di Studi Umanistici (DISTUM), Università degli Studi di Urbino Carlo Bo, Via Bramante, 17, 61029 Urbino PU.
| | - Riccardo Benti
- Department of Nuclear Medicine, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via Francesco Sforza 35, Milan, 20122, Italy.
| | - Simone Tirelli
- Neurology, Public Health, Disability Unit - Coma Research Centre; Scientific Directorate, Fondazione IRCCS Istituto Neurologico Carlo Besta, Via Celoria 11, Milan, 20133, Italy
| | - Anna Bersano
- Neurology Unit, UCV, Fondazione IRCCS Istituto Neurologico Carlo Besta, Via Celoria 11, Milan, 20133, Italy.
| | - Dunja Duran
- Neurophysiology and Diagnostic Epileptology Unit - Fondazione IRCCS Istituto Neurologico Carlo Besta n, Via Celoria 11, Milan, 20133, Italy.
| | - Elisa Visani
- Neurophysiology and Diagnostic Epileptology Unit - Fondazione IRCCS Istituto Neurologico Carlo Besta n, Via Celoria 11, Milan, 20133, Italy.
| | - Stefania Ferraro
- Neuroradiology Unit, Fondazione IRCCS Istituto Neurologico Carlo Besta, Via Celoria 11, Milan, 20133, Italy.
| | - Ludovico Minati
- Direzione Scientifica, Fondazione IRCCS Istituto Neurologico Carlo Besta, Via Celoria 11, Milan, 20133, Italy.
| | - Anna Nigri
- Neuroradiology Unit, Fondazione IRCCS Istituto Neurologico Carlo Besta, Via Celoria 11, Milan, 20133, Italy.
| | - Cristina Rosazza
- Neuroradiology Unit, Fondazione IRCCS Istituto Neurologico Carlo Besta, Via Celoria 11, Milan, 20133, Italy; Dipartimento di Studi Umanistici (DISTUM), Università degli Studi di Urbino Carlo Bo, Via Bramante, 17, 61029 Urbino PU.
| | - Stefania Bianchi Marzoli
- Neuro-Ophthalmology Center, IRCCS Istituto Auxologico Italiano, Scientific Institute Capitanio Hospital, via Mercalli, 28, Milan 20122, Italy.
| | - Paola Ciasca
- Neuro-Ophthalmology Center, IRCCS Istituto Auxologico Italiano, Scientific Institute Capitanio Hospital, via Mercalli, 28, Milan 20122, Italy.
| | - Antonella Carcagni
- Data Methods and Systems Statistical Laboratory, Department of Economics and Management, University of Brescia, Contrada Santa Chiara, 50, Brescia, 25122, Italy.
| | - Maria Grazia Bruzzone
- Neuroradiology Unit, Fondazione IRCCS Istituto Neurologico Carlo Besta, Via Celoria 11, Milan, 20133, Italy.
| | - Silvana Franceschetti
- Neurophysiology and Diagnostic Epileptology Unit - Fondazione IRCCS Istituto Neurologico Carlo Besta n, Via Celoria 11, Milan, 20133, Italy.
| | - Matilde Leonardi
- Neurology, Public Health, Disability Unit - Coma Research Centre; Scientific Directorate, Fondazione IRCCS Istituto Neurologico Carlo Besta, Via Celoria 11, Milan, 20133, Italy.
| | - Davide Guido
- Neurology, Public Health, Disability Unit - Coma Research Centre; Scientific Directorate, Fondazione IRCCS Istituto Neurologico Carlo Besta, Via Celoria 11, Milan, 20133, Italy.
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Boltzmann M, Schmidt SB, Gutenbrunner C, Krauss JK, Stangel M, Höglinger GU, Wallesch CW, Rollnik JD. The influence of the CRS-R score on functional outcome in patients with severe brain injury receiving early rehabilitation. BMC Neurol 2021; 21:44. [PMID: 33514337 PMCID: PMC7847163 DOI: 10.1186/s12883-021-02063-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2020] [Accepted: 01/19/2021] [Indexed: 11/10/2022] Open
Abstract
Background The aim of the study was to determine the role of the Coma Recovery Scale-Revised (CRS-R) in the prediction of functional status at the end of neurological early rehabilitative treatment. Methods Patients consecutively admitted to intensive or intermediate care units of a neurological rehabilitation center were enrolled in the study. Consciousness and functional status were assessed with the Coma Recovery Scale-Revised (CRS-R) and the Early Rehabilitation Barthel Index (ERBI), respectively. Both assessments were carried out weekly within the first month and at the end of early rehabilitation. Patient and clinical data were entered into a binary logistic regression model to predict functional status at discharge. Results 327 patients (112 females, 215 males) with a median age of 63 years (IQR = 53–75) and a median disease duration of 18 days (IQR = 12–28) were included. Most patients suffered from stroke (59 %), followed by traumatic brain injury (31 %), and hypoxic ischemic encephalopathy (10 %). Upon admission, 12 % were diagnosed as comatose, 31 % as unresponsive wakefulness syndrome (UWS), 35 % as minimally conscious state (MCS) and 22 % already emerged from MCS (eMCS). Of all patients undergoing complete early rehabilitative treatment (n = 180), 72 % showed improvements in level of consciousness (LOC). In this group, age, initial CRS-R score and gains in CRS-R score after four weeks independently predicted functional outcome at discharge. Conclusions The study confirms the relevance of the CRS-R score for functional outcome prediction. High CRS-R scores and young age facilitate functional improvements and increase the probability to continue treatment in subsequent rehabilitation phases. Moreover, results indicate that recovery might occur over a period of time that extends beyond acute care.
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Affiliation(s)
- Melanie Boltzmann
- Institute for Neurorehabilitative Research, Associated Institute of the Hannover Medical School, BDH-Clinic Hessisch Oldendorf, Hessisch Oldendorf, Germany.
| | - Simone B Schmidt
- Institute for Neurorehabilitative Research, Associated Institute of the Hannover Medical School, BDH-Clinic Hessisch Oldendorf, Hessisch Oldendorf, Germany
| | | | - Joachim K Krauss
- Department of Neurosurgery, Hannover Medical School, Hannover, Germany
| | - Martin Stangel
- Department of Neurology, Section of Clinical Neuroimmunology and Neurochemistry, Hannover Medical School, Hannover, Germany
| | | | | | - Jens D Rollnik
- Institute for Neurorehabilitative Research, Associated Institute of the Hannover Medical School, BDH-Clinic Hessisch Oldendorf, Hessisch Oldendorf, Germany
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When, How, and to What Extent Are Individuals with Unresponsive Wakefulness Syndrome Able to Progress? Neurobehavioral Progress. Brain Sci 2021; 11:brainsci11010126. [PMID: 33478033 PMCID: PMC7835897 DOI: 10.3390/brainsci11010126] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2020] [Revised: 01/09/2021] [Accepted: 01/15/2021] [Indexed: 01/21/2023] Open
Abstract
Accurate estimation of the neurobehavioral progress of patients with unresponsive wakefulness syndrome (UWS) is essential to anticipate their most likely clinical course and guide clinical decision making. Although different studies have described this progress and possible predictors of neurobehavioral improvement in these patients, they have methodological limitations that could restrict the validity and generalization of the results. This study investigates the neurobehavioral progress of 100 patients with UWS consecutively admitted to a neurorehabilitation center using systematic weekly assessments based on standardized measures, and the prognostic factors of changes in their neurobehavioral condition. Our results showed that, during the analyzed period, 34% of the patients were able to progress from UWS to minimally conscious state (MCS), 12% of the total sample (near one third from those who progressed to MCS) were able to emerge from MCS, and 10% of the patients died. Transition to MCS was mostly denoted by visual signs, which appeared either alone or in combination with motor signs, and was predicted by etiology and the score on the Coma Recovery Scale-Revised at admission with an accuracy of 75%. Emergence from MCS was denoted in the same proportion by functional communication and object use. Predictive models of emergence from MCS and mortality were not valid and the identified predictors could not be accounted for.
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21
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Naro A, Calabrò RS. Towards New Diagnostic Approaches in Disorders of Consciousness: A Proof of Concept Study on the Promising Use of Imagery Visuomotor Task. Brain Sci 2020; 10:brainsci10100746. [PMID: 33080823 PMCID: PMC7603054 DOI: 10.3390/brainsci10100746] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2020] [Revised: 10/08/2020] [Accepted: 10/14/2020] [Indexed: 12/16/2022] Open
Abstract
Background: advanced paraclinical approaches using functional neuroimaging and electroencephalography (EEG) allow identifying patients who are covertly aware despite being diagnosed as unresponsive wakefulness syndrome (UWS). Bedside detection of covert awareness employing motor imagery tasks (MI), which is a universally accepted clinical indicator of awareness in the absence of overt behavior, may miss some of these patients, as they could still have a certain level of awareness. We aimed at assessing covert awareness in patients with UWS using a visuomotor-guided motor imagery task (VMI) during EEG recording. Methods: nine patients in a minimally conscious state (MCS), 11 patients in a UWS, and 15 healthy individuals (control group—CG) were provided with an VMI (imagine dancing while watching a group dance video to command), a simple-MI (imagine squeezing their right hand to command), and an advanced-MI (imagine dancing without watching a group dance video to command) to detect command-following. We analyzed the command-specific EEG responses (event-related synchronization/desynchronization—ERS/ERD) of each patient, assessing whether these responses were appropriate, consistent, and statistically similar to those elicited in the CG, as reliable markers of motor imagery. Results: All patients in MCS, all healthy individuals and one patient in UWS repeatedly and reliably generated appropriate EEG responses to distinct commands of motor imagery with a classification accuracy of 60–80%. Conclusions: VMI outperformed significantly MI tasks. Therefore, patients in UWS may be still misdiagnosed despite a rigorous clinical assessment and an appropriate MI assessment. It is thus possible to suggest that motor imagery tasks should be delivered to patients with chronic disorders of consciousness in visuomotor-aided modality (also in the rehabilitation setting) to greatly entrain patient’s participation. In this regard, the EEG approach we described has the clear advantage of being cheap, portable, widely available, and objective. It may be thus considered as, at least, a screening tool to identify the patients who deserve further, advanced paraclinical approaches.
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22
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Abstract
INTRODUCTION New guidelines regarding the diagnosis of disorders of consciousness (DOC) (such as vegetative state and minimally conscious state) have recently been published by the American Academy of Neurology and the European Academy of Neurology. This follows an impressive number of prospective studies performed on DOC and recent multi-centric studies with larger sample size, which have gathered precious information on the recovery of cohort of patients through years and which now call for a better management of patients with DOC. AREAS COVERED This review will discuss recent updates on the clinical entities of DOC, the challenges for an accurate diagnosis and the last developments in diagnostic tools. EXPERT OPINION The authors will also discuss the impact of the new guidelines on their way of diagnosing patients and how diagnosis will most likely change in a near future.
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Affiliation(s)
- Caroline Schnakers
- Research Institute, Casa Colina Hospital and Centers for Healthcare , Pomona, CA, USA
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23
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Sattin D, Rossi Sebastiano D, D’Incerti L, Guido D, Marotta G, Benti R, Tirelli S, Magnani FG, Bersano A, Duran D, Ferraro S, Minati L, Nigri A, Rosazza C, Bianchi Marzoli S, Leonardi M. Visual behaviors in disorders of consciousness: Disentangling conscious visual processing by a multimodal approach. Eur J Neurosci 2020; 52:4345-4355. [DOI: 10.1111/ejn.14875] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2020] [Revised: 06/15/2020] [Accepted: 06/16/2020] [Indexed: 11/30/2022]
Affiliation(s)
- Davide Sattin
- Neurology, Public health, Disability Unit / Coma Research Centre Fondazione IRCCS Istituto Neurologico Carlo Besta Milan Italy
| | - Davide Rossi Sebastiano
- Neurophysiology and Diagnostic Epileptology Unit Fondazione IRCCS Istituto Neurologico Carlo Besta Milan Italy
| | - Ludovico D’Incerti
- Neuroradiology Unit Fondazione IRCCS Istituto Neurologico Carlo Besta Milan Italy
| | - Davide Guido
- Neurology, Public health, Disability Unit / Coma Research Centre Fondazione IRCCS Istituto Neurologico Carlo Besta Milan Italy
| | - Giorgio Marotta
- Department of Nuclear Medicine Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico Milan Italy
| | - Riccardo Benti
- Department of Nuclear Medicine Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico Milan Italy
| | - Simone Tirelli
- Neurology, Public health, Disability Unit / Coma Research Centre Fondazione IRCCS Istituto Neurologico Carlo Besta Milan Italy
| | - Francesca Giulia Magnani
- Neurology, Public health, Disability Unit / Coma Research Centre Fondazione IRCCS Istituto Neurologico Carlo Besta Milan Italy
| | - Anna Bersano
- Neurology Unit UCV Fondazione IRCCS Istituto Neurologico Carlo Besta Milan Italy
| | - Dunja Duran
- Neurophysiology and Diagnostic Epileptology Unit Fondazione IRCCS Istituto Neurologico Carlo Besta Milan Italy
| | - Stefania Ferraro
- Neuroradiology Unit Fondazione IRCCS Istituto Neurologico Carlo Besta Milan Italy
| | - Ludovico Minati
- Direzione Scientifica Fondazione IRCCS Istituto Neurologico Carlo Besta Milan Italy
| | - Anna Nigri
- Neuroradiology Unit Fondazione IRCCS Istituto Neurologico Carlo Besta Milan Italy
| | - Cristina Rosazza
- Neuroradiology Unit Fondazione IRCCS Istituto Neurologico Carlo Besta Milan Italy
- Dipartimento di Studi Umanistici (DISTUM) Università degli Studi di Urbino Carlo Bo Urbino PU Italy
| | - Stefania Bianchi Marzoli
- Neuro‐Ophthalmology Center IRCCS Istituto Auxologico Italiano, Scientific Institute Capitanio Hospital Milan Italy
| | - Matilde Leonardi
- Neurology, Public health, Disability Unit / Coma Research Centre Fondazione IRCCS Istituto Neurologico Carlo Besta Milan Italy
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Virtual Reality Based Cognitive Rehabilitation in Minimally Conscious State: A Case Report with EEG Findings and Systematic Literature Review. Brain Sci 2020; 10:brainsci10070414. [PMID: 32630179 PMCID: PMC7407378 DOI: 10.3390/brainsci10070414] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2020] [Revised: 06/22/2020] [Accepted: 06/23/2020] [Indexed: 12/14/2022] Open
Abstract
Chronic disorders of consciousness cause a total or partial and fluctuating unawareness of the surrounding environment. Virtual reality (VR) can be useful as a diagnostic and/or a neurorehabilitation tool, and its effects can be monitored by means of both clinical and electroencephalography (EEG) data recording of brain activity. We reported on the case of a 17-year-old patient with a disorder of consciousness (DoC) who was provided with VR training to improve her cognitive-behavioral outcomes, which were assessed using clinical scales (the Coma Recovery Scale-Revised, the Disability Rating Scale, and the Rancho Los Amigos Levels of Cognitive Functioning), as well as EEG recording, during VR training sessions. At the end of the training, significant improvements in both clinical and neurophysiological outcomes were achieved. Then, we carried out a systematic review of the literature to investigate the role of EEG and VR in the management of patients with DoC. A search on PubMed, Web of Science, Scopus, and Google Scholar databases was performed, using the keywords: “disorders of consciousness” and “virtual reality”, or “EEG”. The results of the literature review suggest that neurophysiological data in combination with VR could be useful in evaluating the reactions induced by different paradigms in DoC patients, helping in the differential diagnosis. In conclusion, the EEG plus VR approach used with our patient could be promising to define the most appropriate stimulation protocol, so as to promote a better personalization of the rehabilitation program. However, further clinical trials, as well as meta-analysis of the literature, are needed to be affirmative on the role of VR in patients with DoC.
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25
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Estraneo A, De Bellis F, Masotta O, Loreto V, Fiorenza S, Lo Sapio M, Trojano L. Demographical and clinical indices for long-term evolution of patients in vegetative or in minimally conscious state. Brain Inj 2019; 33:1633-1639. [DOI: 10.1080/02699052.2019.1658220] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Affiliation(s)
- A Estraneo
- Disorders of Consciousness Laboratory, Institute of Telese Terme, Maugeri Scientific and Clinical Institutes, IRCCS, Telese Terme (BN), Italy
- Department of Neurology, Santa Maria della Pietà General Hospital, Nola, Italy
| | - F De Bellis
- Disorders of Consciousness Laboratory, Institute of Telese Terme, Maugeri Scientific and Clinical Institutes, IRCCS, Telese Terme (BN), Italy
| | - O Masotta
- Disorders of Consciousness Laboratory, Institute of Telese Terme, Maugeri Scientific and Clinical Institutes, IRCCS, Telese Terme (BN), Italy
| | - V Loreto
- Disorders of Consciousness Laboratory, Institute of Telese Terme, Maugeri Scientific and Clinical Institutes, IRCCS, Telese Terme (BN), Italy
- Department of Neurology, Santa Maria della Pietà General Hospital, Nola, Italy
| | - S Fiorenza
- Disorders of Consciousness Laboratory, Institute of Telese Terme, Maugeri Scientific and Clinical Institutes, IRCCS, Telese Terme (BN), Italy
| | - M Lo Sapio
- Disorders of Consciousness Laboratory, Institute of Telese Terme, Maugeri Scientific and Clinical Institutes, IRCCS, Telese Terme (BN), Italy
| | - L Trojano
- Neuropsychology Lab., Department of Psychology, University of Campania 'Luigi Vanvitelli', Caserta, Italy
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Shinoda J, Nagamine Y, Kobayashi S, Odaki M, Oka N, Kinugasa K, Nakamura H, Ichida T, Miyashita R, Shima H, Hama T. Multidisciplinary attentive treatment for patients with chronic disorders of consciousness following severe traumatic brain injury in the NASVA of Japan. Brain Inj 2019; 33:1660-1670. [PMID: 31530028 DOI: 10.1080/02699052.2019.1667535] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Primary Objective: The aim of this study was to demonstrate the clinical outcomes of long-term multidisciplinary attentive treatment (MAT) in patients with chronic disorders of consciousness (DOC) due to severe traumatic brain injury (TBI) following automotive accidents.Research Design: Five hundred and ten patients (mean age: 40.4 years) were enrolled in this retrospective study.Methods and Procedures: Patients were provided MAT for one to several years in the eight medical facilities of the National Agency for Automotive Safety and Victims' Aid (NASVA) in Japan. Clinical status for consciousness, communication, and activities of daily living were evaluated using the NASVA grading system.Outcomes and results: Following MAT, NASVA scores at discharge were significantly improved compared to those at admission in every patient subgroup including sex, age, NASVA score, and association with/without hypoxic encephalopathy at admission. Younger age, shorter interval between injury and admission, and better neurocognitive function at admission were found to be significant and independent factors for a good prognosis.Conclusions: MAT can partially improve the cognitive and physical abilities of patients with chronic DOC. From the perspective of not only restoring a patient's daily life, but also reducing the caregiver's burden, this type of treatment program warrants more public attention.
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Affiliation(s)
- Jun Shinoda
- Chubu Medical Center for Prolonged Traumatic Dysfunction, Kizawa Memorial Hospital and Department of Clinical Brain Sciences, Gifu University Graduate School of Medicine, Minokamo, Gifu, Japan
| | - Yoshihide Nagamine
- Department of Neurosurgery, Kohnan Hospital, Tohoku Ryogo Center, Sendai, Japan
| | - Shigeki Kobayashi
- Rehabilitation Center for Traumatic Apallics Chiba, National Agency for Automotive Safety and Victims' Aid, Chiba, Japan
| | - Masaru Odaki
- Rehabilitation Center for Traumatic Apallics Chiba, National Agency for Automotive Safety and Victims' Aid, Chiba, Japan
| | - Nobuo Oka
- Rehabilitation Center for Traumatic Apallics Chiba, National Agency for Automotive Safety and Victims' Aid, Chiba, Japan
| | | | - Hirohiko Nakamura
- Department of Neurosurgery, Nakamura Memorial Hospital, Sapporo, Japan
| | - Takafumi Ichida
- NASVA Medi-care Section, Shonan-East General Hospital, Chigasaki, Kanagawa, Japan
| | - Ritsuko Miyashita
- NASVA Medi-care Section, Izumi-otsu Municipal Hospital, Izumi-Otsu, Osaka, Japan
| | - Hiroji Shima
- Department of Neurosurgery, St. Mary's Hospital, Kurume, Fukuoka, Japan
| | - Takashi Hama
- The National Agency for Automotive Safety and Victims' Aid (NASVA), Tokyo, Japan
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27
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Bareham CA, Allanson J, Roberts N, Hutchinson PJA, Pickard JD, Menon DK, Chennu S. Longitudinal assessments highlight long-term behavioural recovery in disorders of consciousness. Brain Commun 2019; 1:fcz017. [PMID: 31886461 PMCID: PMC6924536 DOI: 10.1093/braincomms/fcz017] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2019] [Revised: 08/13/2019] [Accepted: 08/25/2019] [Indexed: 11/30/2022] Open
Abstract
Accurate diagnosis and prognosis of disorders of consciousness is complicated by the variability amongst patients' trajectories. However, the majority of research and scientific knowledge in this field is based on cross-sectional studies. The translational gap in applying this knowledge to inform clinical management can only be bridged by research that systematically examines follow-up. In this study, we present findings from a novel longitudinal study of the long-term recovery trajectory of 39 patients, repeatedly assessed using the Coma Recovery Scale-Revised once every 3 months for 2 years, generating 185 assessments. Despite the expected inter-patient variability, there was a statistically significant improvement in behaviour over time. Further, improvements began approximately 22 months after injury. Individual variation in the trajectory of recovery was influenced by initial diagnosis. Patients with an initial diagnosis of unresponsive wakefulness state, who progressed to the minimally conscious state, did so at a median of 485 days following onset-later than 12-month period after which current guidelines propose permanence. Although current guidelines are based on the expectation that patients with traumatic brain injury show potential for recovery over longer periods than those with non-traumatic injury, we did not observe any differences between trajectories in these two subgroups. However, age was a significant predictor, with younger patients showing more promising recovery. Also, progressive increases in arousal contributed exponentially to improvements in behavioural awareness, especially in minimally conscious patients. These findings highlight the importance of indexing arousal when measuring awareness, and the potential for interventions to regulate arousal to aid long-term behavioural recovery in disorders of consciousness.
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Affiliation(s)
- Corinne A Bareham
- Department of Clinical Neurosciences, University of Cambridge, Cambridge CB2 0QQ, UK
| | - Judith Allanson
- Cambridge University Hospitals NHS Foundation Trust, Cambridge CB2 0QQ, UK
| | - Neil Roberts
- Sawbridgeworth Medical Services, Jacobs & Gardens Neuro Centres, Sawbridgeworth CM21 0HH, UK
| | - Peter J A Hutchinson
- Department of Clinical Neurosciences, University of Cambridge, Cambridge CB2 0QQ, UK
| | - John D Pickard
- Department of Clinical Neurosciences, University of Cambridge, Cambridge CB2 0QQ, UK
| | - David K Menon
- Division of Anaesthesia, University of Cambridge, Cambridge CB2 0QQ, UK
| | - Srivas Chennu
- Department of Clinical Neurosciences, University of Cambridge, Cambridge CB2 0QQ, UK
- School of Computing, University of Kent, Chatham Maritime, ME4 4AG, UK
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28
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Blume C, Angerer M, Raml M, Del Giudice R, Santhi N, Pichler G, Kunz AB, Scarpatetti M, Trinka E, Schabus M. Healthier rhythm, healthier brain? Integrity of circadian melatonin and temperature rhythms relates to the clinical state of brain-injured patients. Eur J Neurol 2019; 26:1051-1059. [PMID: 30770613 PMCID: PMC6766891 DOI: 10.1111/ene.13935] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2018] [Accepted: 02/12/2019] [Indexed: 11/30/2022]
Abstract
Background Healthy circadian rhythmicity has been suggested to relate to a better state of brain‐injured patients and to support the emergence of consciousness in patient groups characterized by a relative instability thereof such as patients with disorders of consciousness (DOC). Methods Going beyond earlier studies, a systems‐level perspective was adopted and, using multilevel modelling, the joint predictive value of three indices of circadian rhythm integrity derived from skin temperature variations, melatoninsulfate secretion, and physical activity (wrist actigraphy) patterns was evaluated for the behaviourally assessed state [Coma Recovery Scale ‐ Revised (CRS‐R) score] of DOC patients [13 unresponsive wakefulness syndrome; seven minimally conscious (exit) state]. Additionally, it was assessed in a subset of 16 patients whether patients’ behavioural repertoire (CRS‐R score) varied (i) with time of day or (ii) offset from the body temperature maximum (BTmax), i.e. when cognitive performance is expected to peak. Results The results reveal that better integrity of circadian melatoninsulfate and temperature rhythms relate to a richer behavioural repertoire. Moreover, higher CRS‐R scores are, by trend, related to assessments taking place at a later daytime or deviating less from the pre‐specified time of occurrence of BTmax. Conclusions In conclusion, the results suggest that therapeutic approaches aimed at improving circadian rhythms in brain‐injured patients are promising and should be implemented in hospitals or nursing homes. Beyond this, it might be helpful to schedule diagnostic procedures and therapies around the (pre‐assessed) BTmax (≈4 pm in healthy individuals) as this is when patients should be most responsive.
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Affiliation(s)
- C Blume
- Department of Psychology, University of Salzburg, Laboratory for Sleep, Cognition, and Consciousness Research, Salzburg, Austria.,University of Salzburg, Centre for Cognitive Neuroscience, Salzburg, Austria
| | - M Angerer
- Department of Psychology, University of Salzburg, Laboratory for Sleep, Cognition, and Consciousness Research, Salzburg, Austria
| | - M Raml
- Department of Psychology, University of Salzburg, Laboratory for Sleep, Cognition, and Consciousness Research, Salzburg, Austria
| | - R Del Giudice
- Department of Psychology, University of Salzburg, Laboratory for Sleep, Cognition, and Consciousness Research, Salzburg, Austria
| | - N Santhi
- Surrey Sleep Research Centre, Faculty of Health and Medical Sciences, University of Surrey, Guildford, UK
| | - G Pichler
- Geriatric Health Centres of the City of Graz, Albert Schweitzer Clinic, Apallic Care Unit, Graz, Austria
| | - A B Kunz
- Department of Neurology, Paracelsus Medical University, Christian Doppler Medical Center, Salzburg, Austria.,Gunther Ladurner Nursing Home, Salzburg, Austria
| | - M Scarpatetti
- Geriatric Health Centres of the City of Graz, Albert Schweitzer Clinic, Apallic Care Unit, Graz, Austria
| | - E Trinka
- University of Salzburg, Centre for Cognitive Neuroscience, Salzburg, Austria.,Department of Neurology, Paracelsus Medical University, Christian Doppler Medical Center, Salzburg, Austria
| | - M Schabus
- Department of Psychology, University of Salzburg, Laboratory for Sleep, Cognition, and Consciousness Research, Salzburg, Austria.,University of Salzburg, Centre for Cognitive Neuroscience, Salzburg, Austria
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29
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Formisano R, Contrada M, Ferri G, Schiattone S, Iosa M, Aloisi M. The Glasgow Outcome Scale Extended-Revised (GOSE-R) to include Minimally Conscious State in the Vegetative State/Unresponsive Wakefulness Syndrome category: a correlation with Coma Recovery Scale-Revised (CRS-R). Eur J Phys Rehabil Med 2018; 55:139-140. [PMID: 30376271 DOI: 10.23736/s1973-9087.18.05441-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
- Rita Formisano
- Post-Coma Unit, IRCCS Santa Lucia Foundation, Rome, Italy -
| | - Marianna Contrada
- Post-Coma Unit, IRCCS Santa Lucia Foundation, Rome, Italy.,Department of Behavioral Neuroscience, Sapienza University, Rome, Italy
| | - Giulia Ferri
- Post-Coma Unit, IRCCS Santa Lucia Foundation, Rome, Italy
| | | | - Marco Iosa
- Clinical Laboratory of Experimental Neurorehabilitation, IRCCS Santa Lucia Foundation, Rome, Italy
| | - Marta Aloisi
- Post-Coma Unit, IRCCS Santa Lucia Foundation, Rome, Italy
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D'amico F, Lancioni GE, Buonocunto F, Ricci C, Fiore P. Technology-aided leisure and communication support in extensive neuro-motor and communication impairments. Eur J Phys Rehabil Med 2018; 55:682-686. [PMID: 30370755 DOI: 10.23736/s1973-9087.18.05521-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Individuals with extensive neuro-motor impairment and lack of speech are known to remain fairly isolated and rely on others. Yet, there is only limited evidence as to how one can help them to reach a level of independence in relevant areas such as leisure and communication. This study assessed a program based on everyday technology to support leisure and communication engagement in six of those individuals. CASE REPORT The six cases (adults) were non-ambulatory and had no speech or functional active communication. Their neurological damage was due to extensive left hemispheric hemorrhagic or ischemic lesion and to critical illness polyneuropathy aggravating a condition of neonatal encephalopathy. A smartphone-based program was developed and successfully used to enable them to access leisure activities (e.g., listening to music) and communication (e.g., sending text messages or calling the caregiver). CLINICAL REHABILITATION IMPACT Cases like those presented in this study may reach independent and functional engagement if supported via specific, technology-aided intervention programs.
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Affiliation(s)
| | - Giulio E Lancioni
- Department of Neuroscience and Sense Organs, University of Bari, Bari, Italy -
| | | | - Carlo Ricci
- Salesian Pontificial University of Rome, Rome, Italy
| | - Pietro Fiore
- Department of Neuroscience and Sense Organs, University of Bari, Bari, Italy.,Physical and Rehabilitation Medicine, Bari Polyclinic, Bari, Italy
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31
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Yamaki T, Uchino Y, Henmi H, Kamezawa M, Hayakawa M, Uchida T, Ozaki Y, Onodera S, Oka N, Odaki M, Itou D, Kobayashi S. Increased brain glucose metabolism in chronic severe traumatic brain injury as determined by longitudinal 18F-FDG PET/CT. J Clin Neurosci 2018; 57:20-25. [PMID: 30172638 DOI: 10.1016/j.jocn.2018.08.052] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2018] [Revised: 08/20/2018] [Accepted: 08/21/2018] [Indexed: 10/28/2022]
Abstract
Little is known about changes in glucose metabolism in patients with chronic severe traumatic brain injury (sTBI). It remains to be elucidated how neurological manifestations of sTBI are associated with brain glucose metabolism during longitudinal follow-up. We show here that neurological manifestations are associated with changes of brain glucose metabolism by using two serial 18F-fluorodeoxyglucose positron emission tomography/computed tomography (18F-FDG PET/CT) images. In this longitudinal observational study, two serial 18F-FDG PET/CT images from each of 45 patients were analyzed for whole-brain maximum standardized uptake values (SUVmax). For clinical assessment, we applied two different scales: the coma recovery scale-revised and the original Chiba score with additional information regarding nutrition, excretion, facial expression, and position change of the patient's relative immobility and bedridden state. As a result, the increased FDG uptake group was associated with a high level of wakefulness (first PET, p = 0.04; second PET, p = 0.01) and small ventricular size (first PET, p = 0.01; second PET, p = 0.01). In addition, anticonvulsant withdrawal (p = 0.001), improvement of total Chiba score (p = 0.01), language expression (p = 0.03), position change (p = 0.03), and communication (p = 0.03) were accelerated in the increased FDG uptake group. Spearman's rank correlation coefficients of change in SUVmax and language expression between the first and second PET were 0.4 (p = 0.01). Our results indicate that chronic severe traumatic head injury patients have changed brain glucose metabolism.
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Affiliation(s)
- Tomohiro Yamaki
- Division of Neurosurgery, Rehabilitation Center for Traumatic Apallics Chiba, National Agency for Automotive Safety and Victims' Aid, 3-30-1 Isobe, Mihama-ku, Chiba-shi, Chiba 261-0012, Japan; Division of PET Imaging, Rehabilitation Center for Traumatic Apallics Chiba, National Agency for Automotive Safety and Victims' Aid, 3-30-1 Isobe, Mihama-ku, Chiba-shi, Chiba 261-0012, Japan.
| | - Yoshio Uchino
- Division of Neurosurgery, Rehabilitation Center for Traumatic Apallics Chiba, National Agency for Automotive Safety and Victims' Aid, 3-30-1 Isobe, Mihama-ku, Chiba-shi, Chiba 261-0012, Japan; Division of PET Imaging, Rehabilitation Center for Traumatic Apallics Chiba, National Agency for Automotive Safety and Victims' Aid, 3-30-1 Isobe, Mihama-ku, Chiba-shi, Chiba 261-0012, Japan.
| | - Haruko Henmi
- Division of PET Imaging, Rehabilitation Center for Traumatic Apallics Chiba, National Agency for Automotive Safety and Victims' Aid, 3-30-1 Isobe, Mihama-ku, Chiba-shi, Chiba 261-0012, Japan.
| | - Mizuho Kamezawa
- Division of PET Imaging, Rehabilitation Center for Traumatic Apallics Chiba, National Agency for Automotive Safety and Victims' Aid, 3-30-1 Isobe, Mihama-ku, Chiba-shi, Chiba 261-0012, Japan.
| | - Miyoko Hayakawa
- Division of PET Imaging, Rehabilitation Center for Traumatic Apallics Chiba, National Agency for Automotive Safety and Victims' Aid, 3-30-1 Isobe, Mihama-ku, Chiba-shi, Chiba 261-0012, Japan.
| | - Tomoki Uchida
- Division of PET Imaging, Rehabilitation Center for Traumatic Apallics Chiba, National Agency for Automotive Safety and Victims' Aid, 3-30-1 Isobe, Mihama-ku, Chiba-shi, Chiba 261-0012, Japan.
| | - Yoshihiro Ozaki
- Division of PET Imaging, Rehabilitation Center for Traumatic Apallics Chiba, National Agency for Automotive Safety and Victims' Aid, 3-30-1 Isobe, Mihama-ku, Chiba-shi, Chiba 261-0012, Japan.
| | - Shinji Onodera
- Division of PET Imaging, Rehabilitation Center for Traumatic Apallics Chiba, National Agency for Automotive Safety and Victims' Aid, 3-30-1 Isobe, Mihama-ku, Chiba-shi, Chiba 261-0012, Japan.
| | - Nobuo Oka
- Division of Neurosurgery, Rehabilitation Center for Traumatic Apallics Chiba, National Agency for Automotive Safety and Victims' Aid, 3-30-1 Isobe, Mihama-ku, Chiba-shi, Chiba 261-0012, Japan.
| | - Masaru Odaki
- Division of Neurosurgery, Rehabilitation Center for Traumatic Apallics Chiba, National Agency for Automotive Safety and Victims' Aid, 3-30-1 Isobe, Mihama-ku, Chiba-shi, Chiba 261-0012, Japan.
| | - Daisuke Itou
- Division of Neurosurgery, Rehabilitation Center for Traumatic Apallics Chiba, National Agency for Automotive Safety and Victims' Aid, 3-30-1 Isobe, Mihama-ku, Chiba-shi, Chiba 261-0012, Japan.
| | - Shigeki Kobayashi
- Division of Neurosurgery, Rehabilitation Center for Traumatic Apallics Chiba, National Agency for Automotive Safety and Victims' Aid, 3-30-1 Isobe, Mihama-ku, Chiba-shi, Chiba 261-0012, Japan.
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32
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Pain assessment with the revised nociception coma scale and outcomes of patients with unresponsive wakefulness syndrome: results from a pilot study. Neurol Sci 2018; 39:1073-1077. [DOI: 10.1007/s10072-018-3330-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2018] [Accepted: 03/16/2018] [Indexed: 01/31/2023]
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33
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Formisano R, Aloisi M, Ferri G, Schiattone S, Contrada M. The Glasgow Outcome Scale Extended-Revised (GOSE-R) to include minimally conscious state in the vegetative state category. J Neurol Sci 2018; 388:22. [PMID: 29627024 DOI: 10.1016/j.jns.2018.02.042] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2018] [Revised: 02/15/2018] [Accepted: 02/25/2018] [Indexed: 11/30/2022]
Affiliation(s)
- R Formisano
- Post-Coma Unit, IRCCS Santa Lucia Foundation, Rome, Italy.
| | - M Aloisi
- Post-Coma Unit, IRCCS Santa Lucia Foundation, Rome, Italy
| | - G Ferri
- Post-Coma Unit, IRCCS Santa Lucia Foundation, Rome, Italy
| | - S Schiattone
- Post-Coma Unit, IRCCS Santa Lucia Foundation, Rome, Italy
| | - M Contrada
- Post-Coma Unit, IRCCS Santa Lucia Foundation, Rome, Italy; Sapienza University of Rome, Italy
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Portaccio E, Morrocchesi A, Romoli AM, Hakiki B, Taglioli MP, Lippi E, Di Renzone M, Grippo A, Macchi C. Score on Coma Recovery Scale-Revised at admission predicts outcome at discharge in intensive rehabilitation after severe brain injury. Brain Inj 2018; 32:730-734. [DOI: 10.1080/02699052.2018.1440420] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Affiliation(s)
- Emilio Portaccio
- Intensive Rehabilitation Unit, IRCCS Don Gnocchi Foundation, Florence, Italy
- Intensive Rehabilitation Unit Study Group of the IRCCS Don Gnocchi Foundation, Italy
| | - Azzurra Morrocchesi
- Intensive Rehabilitation Unit, IRCCS Don Gnocchi Foundation, Florence, Italy
- Intensive Rehabilitation Unit Study Group of the IRCCS Don Gnocchi Foundation, Italy
| | - Anna Maria Romoli
- Intensive Rehabilitation Unit, IRCCS Don Gnocchi Foundation, Florence, Italy
- Intensive Rehabilitation Unit Study Group of the IRCCS Don Gnocchi Foundation, Italy
| | - Bahia Hakiki
- Intensive Rehabilitation Unit, IRCCS Don Gnocchi Foundation, Florence, Italy
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
- Intensive Rehabilitation Unit Study Group of the IRCCS Don Gnocchi Foundation, Italy
| | - Maria Pia Taglioli
- Intensive Rehabilitation Unit, IRCCS Don Gnocchi Foundation, Florence, Italy
- Intensive Rehabilitation Unit Study Group of the IRCCS Don Gnocchi Foundation, Italy
| | - Elena Lippi
- Intensive Rehabilitation Unit, IRCCS Don Gnocchi Foundation, Florence, Italy
- Intensive Rehabilitation Unit Study Group of the IRCCS Don Gnocchi Foundation, Italy
| | - Martina Di Renzone
- Intensive Rehabilitation Unit, IRCCS Don Gnocchi Foundation, Florence, Italy
- Intensive Rehabilitation Unit Study Group of the IRCCS Don Gnocchi Foundation, Italy
| | - Antonello Grippo
- Intensive Rehabilitation Unit, IRCCS Don Gnocchi Foundation, Florence, Italy
- Intensive Rehabilitation Unit Study Group of the IRCCS Don Gnocchi Foundation, Italy
| | - Claudio Macchi
- Intensive Rehabilitation Unit, IRCCS Don Gnocchi Foundation, Florence, Italy
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
- Intensive Rehabilitation Unit Study Group of the IRCCS Don Gnocchi Foundation, Italy
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Portaccio E, Morrocchesi A, Romoli AM, Hakiki B, Taglioli MP, Lippi E, Di Renzone M, Grippo A, Macchi C. Improvement on the Coma Recovery Scale-Revised During the First Four Weeks of Hospital Stay Predicts Outcome at Discharge in Intensive Rehabilitation After Severe Brain Injury. Arch Phys Med Rehabil 2018; 99:914-919. [PMID: 29428346 DOI: 10.1016/j.apmr.2018.01.015] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2017] [Revised: 01/11/2018] [Accepted: 01/13/2018] [Indexed: 12/01/2022]
Abstract
OBJECTIVES To evaluate the prognostic utility of serial assessment on the Coma Recovery Scale-Revised (CRS-R) during the first 4 weeks of intensive rehabilitation in patients surviving a severe brain injury. DESIGN Prospective cohort study. SETTING An intensive rehabilitation unit. PARTICIPANTS Patients (N=110) consecutively admitted to the intensive rehabilitation unit. Inclusion criteria were (1) a diagnosis of unresponsive wakefulness syndrome (UWS) or minimally conscious state (MCS) caused by an acquired brain injury, and (2) aged >18 years. INTERVENTIONS All patients underwent clinical evaluations using the Italian version of the CRS-R during the first month of hospital stay. MAIN OUTCOME MEASURES Behavioral classification on the CRS-R and the score on the Glasgow Outcome Scale (GOS) at final discharge. Patients transitioning from UWS to MCS or emergence from MCS (E-MCS), and from MCS to E-MCS were classified as patients with improved responsiveness (IR). RESULTS After a mean ± SD hospital stay of 5.3±2.7 months, 59 of 110 patients (53.6%) achieved IR. In the multivariable analysis, a higher CRS-R score change at week 4 (odds ratio =1.99; 95% confidence interval [CI], 1.49-2.66; P<.001) was the only significant predictor of IR at discharge. Fifty-three patients (48.2%) were classified as severely impaired at discharge (GOS=3). In the multivariable analysis, higher GOS scores were related to a higher CRS-R score at admission (B=.051; 95% CI, .027-.074; P<.001), a higher CRS-R score change at week 4 (B=.087; 95% CI, .064-.110; P<.001), and an absence of severe infections (B=-.477; 95% CI, -.778 to -.176; P=.002). CONCLUSIONS An improvement on the total CRS-R score and on different subscales across the first 4 weeks of inpatient rehabilitation discriminates patients who will have a better outcome at discharge, providing information for rehabilitation planning and for communication with patients and their caregivers.
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Affiliation(s)
| | | | | | - Bahia Hakiki
- IRCCS Don Gnocchi Foundation, Florence, Italy; University of Florence, Florence, Italy
| | | | - Elena Lippi
- IRCCS Don Gnocchi Foundation, Florence, Italy
| | | | | | - Claudio Macchi
- IRCCS Don Gnocchi Foundation, Florence, Italy; University of Florence, Florence, Italy
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Tan X, Gao J, Zhou Z, Wei R, Gong T, Wu Y, Liu K, He F, Wang J, Li J, Zhang X, Pan G, Luo B. Spontaneous Recovery from Unresponsive Wakefulness Syndrome to a Minimally Conscious State: Early Structural Changes Revealed by 7-T Magnetic Resonance Imaging. Front Neurol 2018; 8:741. [PMID: 29387037 PMCID: PMC5776100 DOI: 10.3389/fneur.2017.00741] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2017] [Accepted: 12/22/2017] [Indexed: 01/28/2023] Open
Abstract
Background Determining the early changes of brain structure that occur from vegetative state/unresponsive wakefulness syndrome (VS/UWS) to a minimally conscious state (MCS) is important for developing our understanding of the processes underlying disorders of consciousness (DOC), particularly during spontaneous recovery from severe brain damage. Objective This study used a multi-modal neuroimaging approach to investigate early structural changes during spontaneous recovery from VS/UWS to MCS. Methods The Coma Recovery Scale-Revised (CRS-R) score, 24-h electroencephalography (EEG), and ultra-high field 7-T magnetic resonance imaging were used to investigate a male patient with severe brain injury when he was in VS/UWS compared to MCS. Using white matter connectometry analysis, fibers in MCS were compared with the same fibers in VS/UWS. Whole-brain analysis was used to compare all fibers showing a 10% increase in density with each other as a population. Results Based on connectometry analysis, the number of fibers with increased density, and the magnitude of increase in MCS compared to VS/UWS, was greatest in the area of the temporoparietal junction (TPJ), and was mostly located in the right hemisphere. These results are in accordance with the active areas observed on 24-h EEG recordings. Moreover, analysis of different fibers across the brain, showing at least a 10% increase in density, revealed that altered white matter connections with higher discriminative weights were located within or across visual-related areas, including the cuneus_R, calcarine_R, occipital_sup_R, and occipital_mid_R. Furthermore, the temporal_mid_R, which is related to the auditory cortex, showed the highest increase in connectivity to other areas. This was consistent with improvements in the visual and auditory components of the CRS-R, which were greater than other improvements. Conclusion These results provide evidence to support the important roles for the TPJ and the visual and auditory sensory systems in the early recovery of a patient with severe brain injury. Our findings may facilitate a much deeper understanding of the mechanisms underlying conscious-related processes and enlighten treatment strategies for patients with DOC.
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Affiliation(s)
- Xufei Tan
- Department of Neurology and Brain Medical Centre, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Jian Gao
- Department of Rehabilitation, Hangzhou Hospital of Zhejiang CAPR, Hangzhou, China
| | - Zhen Zhou
- College of Computer Science and Technology, Zhejiang University, Hangzhou, China
| | - Ruili Wei
- Department of Neurology and Brain Medical Centre, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Ting Gong
- Center for Brain Imaging Science and Techonology, College of Biomedical Engineering and Instrumental Science, Zhejiang University, Hangzhou, China
| | - Yuqin Wu
- Department of Rehabilitation, Hangzhou Hospital of Zhejiang CAPR, Hangzhou, China
| | - Kehong Liu
- Department of Rehabilitation, Hangzhou Hospital of Zhejiang CAPR, Hangzhou, China
| | - Fangping He
- Department of Neurology and Brain Medical Centre, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Junyang Wang
- Department of Neurology and Brain Medical Centre, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Jingqi Li
- Department of Rehabilitation, Hangzhou Hospital of Zhejiang CAPR, Hangzhou, China
| | - Xiaotong Zhang
- Center for Brain Imaging Science and Techonology, College of Biomedical Engineering and Instrumental Science, Zhejiang University, Hangzhou, China.,Interdisciplinary Institute of Neuroscience and Technology, Qiushi Academy for Advanced Studies, Zhejiang University, Hangzhou, China
| | - Gang Pan
- College of Computer Science and Technology, Zhejiang University, Hangzhou, China
| | - Benyan Luo
- Department of Neurology and Brain Medical Centre, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China.,School of Medicine, Zhejiang University, and Collaborative Innovation Center for Brain Science, Hangzhou, China
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Conde V, Andreasen SH, Petersen TH, Larsen KB, Madsen K, Andersen KW, Akopian I, Madsen KH, Hansen CP, Poulsen I, Kammersgaard LP, Siebner HR. Alterations in the brain's connectome during recovery from severe traumatic brain injury: protocol for a longitudinal prospective study. BMJ Open 2017; 7:e016286. [PMID: 28615277 PMCID: PMC5541610 DOI: 10.1136/bmjopen-2017-016286] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
INTRODUCTION Traumatic brain injury (TBI) is considered one of the most pervasive causes of disability in people under the age of 45. TBI often results in disorders of consciousness, and clinical assessment of the state of consciousness in these patients is challenging due to the lack of behavioural responsiveness. Functional neuroimaging offers a means to assess these patients without the need for behavioural signs, indicating that brain connectivity plays a major role in consciousness emergence and maintenance. However, little is known regarding how changes in connectivity during recovery from TBI accompany changes in the level of consciousness. Here, we aim to combine cutting-edge neuroimaging techniques to follow changes in brain connectivity in patients recovering from severe TBI. METHODS AND ANALYSIS A multimodal, longitudinal assessment of 30 patients in the subacute stage after severe TBI will be made comprising an MRI session combined with electroencephalography (EEG), a positron emission tomography session and a transcranial magnetic stimulation (TMS) combined with EEG (TMS/EEG) session. A group of 20 healthy participants will be included for comparison. Four sessions for patients and two sessions for healthy participants will be planned. Data analysis techniques will focus on whole-brain, both data-driven and hypothesis-driven, connectivity measures that will be specific to the imaging modality. ETHICS AND DISSEMINATION The project has received ethical approval by the local ethics committee of the Capital Region of Denmark and by the Danish Data Protection. Results will be published as original research articles in peer-reviewed journals and disseminated in international conferences. None of the measurements will have any direct clinical impact on the patients included in the study but may benefit future patients through a better understanding of the mechanisms underlying the recovery process after TBI. TRIAL REGISTRATION NUMBER NCT02424656; PRE-RESULTS.
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Affiliation(s)
- Virginia Conde
- Danish Research Centre for Magnetic Resonance, Copenhagen University Hospital Hvidovre, Hvidovre, Denmark
| | - Sara Hesby Andreasen
- Danish Research Centre for Magnetic Resonance, Copenhagen University Hospital Hvidovre, Hvidovre, Denmark
- Department of Neurorehabilitation, Traumatic Brain Injury, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Tue Hvass Petersen
- Department of Neurorehabilitation, Traumatic Brain Injury, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Karen Busted Larsen
- Department of Neurorehabilitation, Traumatic Brain Injury, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Karine Madsen
- Department of Clinical Physiology and Nuclear Medicine, Centre for Functional and Diagnostic Imaging and Research, Copenhagen University Hospital Hvidovre, Hvidovre, Denmark
| | - Kasper Winther Andersen
- Danish Research Centre for Magnetic Resonance, Copenhagen University Hospital Hvidovre, Hvidovre, Denmark
| | - Irina Akopian
- Danish Research Centre for Magnetic Resonance, Copenhagen University Hospital Hvidovre, Hvidovre, Denmark
| | - Kristoffer Hougaard Madsen
- Danish Research Centre for Magnetic Resonance, Copenhagen University Hospital Hvidovre, Hvidovre, Denmark
- Section for Cognitive Systems, DTU Compute, Technical University of Denmark, Copenhagen, Denmark
| | - Christian Pilebæk Hansen
- Department of Neurorehabilitation, Traumatic Brain Injury, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Ingrid Poulsen
- Department of Neurorehabilitation, Traumatic Brain Injury, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Lars Peter Kammersgaard
- Department of Neurorehabilitation, Traumatic Brain Injury, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Hartwig Roman Siebner
- Danish Research Centre for Magnetic Resonance, Copenhagen University Hospital Hvidovre, Hvidovre, Denmark
- Department of Neurology, Copenhagen University Hospital Bispebjerg, Copenhagen, Denmark
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Wannez S, Gosseries O, Azzolini D, Martial C, Cassol H, Aubinet C, Annen J, Martens G, Bodart O, Heine L, Charland-Verville V, Thibaut A, Chatelle C, Vanhaudenhuyse A, Demertzi A, Schnakers C, Donneau AF, Laureys S. Prevalence of coma-recovery scale-revised signs of consciousness in patients in minimally conscious state. Neuropsychol Rehabil 2017; 28:1350-1359. [DOI: 10.1080/09602011.2017.1310656] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Affiliation(s)
- Sarah Wannez
- Coma Science Group, GIGA-Consciousness and Neurology Department, University of Liège, Liège, Belgium
| | - Olivia Gosseries
- Coma Science Group, GIGA-Consciousness and Neurology Department, University of Liège, Liège, Belgium
| | - Deborah Azzolini
- Coma Science Group, GIGA-Consciousness and Neurology Department, University of Liège, Liège, Belgium
| | - Charlotte Martial
- Coma Science Group, GIGA-Consciousness and Neurology Department, University of Liège, Liège, Belgium
| | - Helena Cassol
- Coma Science Group, GIGA-Consciousness and Neurology Department, University of Liège, Liège, Belgium
| | - Charlène Aubinet
- Coma Science Group, GIGA-Consciousness and Neurology Department, University of Liège, Liège, Belgium
| | - Jitka Annen
- Coma Science Group, GIGA-Consciousness and Neurology Department, University of Liège, Liège, Belgium
| | - Géraldine Martens
- Coma Science Group, GIGA-Consciousness and Neurology Department, University of Liège, Liège, Belgium
| | - Olivier Bodart
- Coma Science Group, GIGA-Consciousness and Neurology Department, University of Liège, Liège, Belgium
| | - Lizette Heine
- Coma Science Group, GIGA-Consciousness and Neurology Department, University of Liège, Liège, Belgium
| | - Vanessa Charland-Verville
- Coma Science Group, GIGA-Consciousness and Neurology Department, University of Liège, Liège, Belgium
| | - Aurore Thibaut
- Coma Science Group, GIGA-Consciousness and Neurology Department, University of Liège, Liège, Belgium
| | - Camille Chatelle
- Coma Science Group, GIGA-Consciousness and Neurology Department, University of Liège, Liège, Belgium
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, USA
| | - Audrey Vanhaudenhuyse
- Coma Science Group, GIGA-Consciousness and Neurology Department, University of Liège, Liège, Belgium
- Department of Algology, University Hospital of Liège, Liège, Belgium
| | - Athena Demertzi
- Coma Science Group, GIGA-Consciousness and Neurology Department, University of Liège, Liège, Belgium
| | - Caroline Schnakers
- Department of Neurosurgery, University of California, Los Angeles, USA
- Research Department, Casa Colina Hospital and Centers for Healthcare, Pomona, USA
| | | | - Steven Laureys
- Coma Science Group, GIGA-Consciousness and Neurology Department, University of Liège, Liège, Belgium
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Bagnato S, Boccagni C, Prestandrea C, Fingelkurts AA, Fingelkurts AA, Galardi G. Changes in Standard Electroencephalograms Parallel Consciousness Improvements in Patients With Unresponsive Wakefulness Syndrome. Arch Phys Med Rehabil 2016; 98:665-672. [PMID: 27794486 DOI: 10.1016/j.apmr.2016.09.132] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2016] [Revised: 09/19/2016] [Accepted: 09/30/2016] [Indexed: 10/20/2022]
Abstract
OBJECTIVE To identify changes in the standard electroencephalograms (EEGs) of patients with unresponsive wakefulness syndrome (UWS) who did or did not recover consciousness 6 months after admission to a rehabilitation department. DESIGN Prospective cohort study. SETTING Unit for severe acquired brain injuries. PARTICIPANTS Consecutive patients with UWS (N=28). INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES EEG amplitude (reduced or normal), dominant frequency (alpha, theta, or delta), and reactivity (absent or present) were scored at admission and 6 months later. The cumulative Amplitude-Frequency-Reactivity score was evaluated. Clinical assessments were made using the Coma Recovery Scale-Revised. RESULTS Sixteen (57.1%) of the 28 patients with UWS recovered consciousness after 6 months, while 12 patients (42.9%) did not recover consciousness. EEG improvements occurred in 14 patients with consciousness recovery (87.5%) and 2 patients without consciousness recovery (16.7%) only. Improvements in EEG dominant frequency (from the theta to the alpha band or from the delta to the theta band), reappearance of EEG reactivity, and Amplitude-Frequency-Reactivity score increase (P<.01) differentiated patients with consciousness improvement from those without consciousness improvement. Six months after admission for rehabilitation, patients with EEG improvements showed higher Coma Recovery Scale-Revised scores than did those without EEG changes (P<.01). CONCLUSIONS Most patients who emerge from UWS demonstrate improvement in basic EEG characteristics over time. EEG changes in patients with UWS may aid in the timely recognition of patients transitioning into a minimally conscious state.
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Affiliation(s)
- Sergio Bagnato
- Unit of Neurophysiology and Unit for Severe Acquired Brain Injuries, Rehabilitation Department, Giuseppe Giglio Foundation, Cefalù (PA), Italy.
| | - Cristina Boccagni
- Unit of Neurophysiology and Unit for Severe Acquired Brain Injuries, Rehabilitation Department, Giuseppe Giglio Foundation, Cefalù (PA), Italy
| | - Caterina Prestandrea
- Unit of Neurophysiology and Unit for Severe Acquired Brain Injuries, Rehabilitation Department, Giuseppe Giglio Foundation, Cefalù (PA), Italy
| | | | | | - Giuseppe Galardi
- Unit of Neurophysiology and Unit for Severe Acquired Brain Injuries, Rehabilitation Department, Giuseppe Giglio Foundation, Cefalù (PA), Italy
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