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Pupillo E, Magnoni A, Tinti L, Sassi S, Monti A, Barbieri J, Millul A, Aldeghi MR, Bianchi E. Vegetative state in two Italian residential facilities: study of prognosis for subjects and related caregivers. Neurol Sci 2025:10.1007/s10072-025-08205-8. [PMID: 40304935 DOI: 10.1007/s10072-025-08205-8] [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: 02/26/2025] [Accepted: 04/21/2025] [Indexed: 05/02/2025]
Abstract
BACKGROUND Vegetative state (VS) is a severe disturbance of consciousness, often caused by cerebral insults, with limited long-term prognosis data. STUDY OBJECTIVE to provide a detailed picture of a cohort of patients treated at 2 long-term care facilities in Lombardy starting from 2014. METHODS Multicentric observational study. Subjects who met the diagnostic criteria for VS were admitted. A caregiver was identified for each patient and filled two questionnaires to evaluate quality of life (SF-36) and need for psychological support (FSQ-30). RESULTS The study included 146 patients (median age: 61.8 years at admission, 60.4 at the event that caused VS). Non-traumatic cerebral hemorrhage was the leading cause of VS (41%), followed by traumatic (19%) and anoxic brain injury (17%), and ischemic stroke (6.8%). The cumulative mortality was 10% at 1 year, 24% at 2 years, 43% at 5 years, 69% at 10 years, and 88% at 15 years after the event that caused VS, with age (HR 1.03) and ischemic stroke (HR 2.86) as risk factors. Among 24 caregivers, 50% had FSQ-30 score suggesting recommended psychological support (R area), 33% were in the SR area (strongly recommended), and 13% in the U area (urgent need). Females had worse FSQ-30 and SF-36 scores than males, particularly in the mental health index (median 60 vs. 74) and mental component scale (45.3 vs. 53.2). CONCLUSIONS Hemorrhages were found to be the most common cause of VS, differing from previous studies that identified trauma as the primary cause. Caregivers exhibited significant psychological distress.
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Affiliation(s)
- Elisabetta Pupillo
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Via Mario Negri 2, Milano, Italy.
| | - Andrea Magnoni
- Cooperativa La Meridiana, Viale Cesare Battisti, 86, Monza, Italy
| | - Lorenzo Tinti
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Via Mario Negri 2, Milano, Italy
| | - Serena Sassi
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Via Mario Negri 2, Milano, Italy
| | - Ambrogio Monti
- Cooperativa La Meridiana, Viale Cesare Battisti, 86, Monza, Italy
| | - Jessica Barbieri
- Cooperativa La Meridiana, Viale Cesare Battisti, 86, Monza, Italy
| | - Andrea Millul
- Istituti Riuniti Airoldi e Muzzi, Via Airoldi e Muzzi 2, Lecco, Italy
| | | | - Elisa Bianchi
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Via Mario Negri 2, Milano, Italy
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Murtaugh B, Olson DM, Badjatia N, Lewis A, Aiyagari V, Sharma K, Creutzfeldt CJ, Falcone GJ, Shapiro-Rosenbaum A, Zink EK, Suarez JI, Silva GS. Caring for Coma after Severe Brain Injury: Clinical Practices and Challenges to Improve Outcomes: An Initiative by the Curing Coma Campaign. Neurocrit Care 2025; 42:325-333. [PMID: 39433705 DOI: 10.1007/s12028-024-02116-w] [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] [Received: 05/16/2024] [Accepted: 08/22/2024] [Indexed: 10/23/2024]
Abstract
Severe brain injury can result in disorders of consciousness (DoC), including coma, vegetative state/unresponsive wakefulness syndrome, and minimally conscious state. Improved emergency and trauma medicine response, in addition to expanding efforts to prevent premature withdrawal of life-sustaining treatment, has led to an increased number of patients with prolonged DoC. High-quality bedside care of patients with DoC is key to improving long-term functional outcomes. However, there is a paucity of DoC-specific evidence guiding clinicians on efficacious bedside care that can promote medical stability and recovery of consciousness. This Viewpoint describes the state of current DoC bedside care and identifies knowledge and practice gaps related to patient care with DoC collated by the Care of the Patient in Coma scientific workgroup as part of the Neurocritical Care Society's Curing Coma Campaign. The gap analysis identified and organized domains of bedside care that could affect patient outcomes: clinical expertise, assessment and monitoring, timing of intervention, technology, family engagement, cultural considerations, systems of care, and transition to the post-acute continuum. Finally, this Viewpoint recommends future research and education initiatives to address and improve the care of patients with DoC.
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Affiliation(s)
- Brooke Murtaugh
- Department of Rehabilitation Programs, Madonna Rehabilitation Hospitals, Lincoln, NE, 68506, USA.
| | - DaiWai M Olson
- Department of Neurology and Neurological Surgery, University of Texas Southwestern, Dallas, TX, 75390, USA
| | - Neeraj Badjatia
- Department of Neurology, University of Maryland School of Medicine, Baltimore, MD, 21201, USA
| | - Ariane Lewis
- Departments of Neurology and Neurosurgery, New York University Langone Medical Center, New York, NY, 10016, USA
| | - Venkatesh Aiyagari
- Department of Neurology and Neurological Surgery, University of Texas Southwestern, Dallas, TX, 75390, USA
| | - Kartavya Sharma
- Department of Neurology and Neurological Surgery, University of Texas Southwestern, Dallas, TX, 75390, USA
| | | | - Guido J Falcone
- Department of Neurology, Yale Medicine, New Haven, CT, 06519, USA
| | | | - Elizabeth K Zink
- Johns Hopkins University School of Medicine, Baltimore, MD, 21201, USA
| | - Jose I Suarez
- Johns Hopkins University School of Medicine, Baltimore, MD, 21201, USA
| | - Gisele Sampaio Silva
- Department of Neurology and Neurosurgery Federal University of São Paulo, Universidade Federal De Sao Paulo, and Hospital Israelita Albert Einstein, São Paulo, Brazil
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3
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Yang H, Huang W, Wen W, Long S, Zhang Y, Chi X, Luo D. The impact of frequency-specific music stimulation on consciousness in patients with disorders of consciousness. Front Neurol 2025; 16:1506261. [PMID: 40070671 PMCID: PMC11893416 DOI: 10.3389/fneur.2025.1506261] [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: 10/04/2024] [Accepted: 02/05/2025] [Indexed: 03/14/2025] Open
Abstract
Objective This study aimed to evaluate the effects of frequency-specific music stimulation on the awareness and brain connectivity in patients with disorders of consciousness (DOC). Methods A total of 25 DOC patients were exposed to auditory stimulation through music at varying frequencies (low: <0.5 Hz, middle: 0.5 Hz-3.5 kHz, high: >3.5 kHz). Brain responses were assessed using Functional Near-Infrared Spectroscopy (fNIRS) to monitor objective markers of brain activity. The analysis focused on effective connectivity and coupling strength (CS) values in response to different frequency stimulations, targeting regions such as the motor and somatosensory cortices. Results The mean age of the patients was 49.4 years, with an average coma duration of 1.96 months. While no significant differences were observed in general brain arousal across different frequency stimuli, notable differences in effective connectivity were identified. High-frequency stimulation resulted in significantly higher CS values in the right primary motor cortex (p < 0.05), while middle-frequency stimulation showed significant effects in the right primary somatosensory cortex (p = 0.016). Conclusion The findings suggest that middle- and high-frequency music stimulation may enhance effective connectivity in specific brain regions, potentially contributing to the rehabilitation of DOC patients. These results indicate that frequency-specific music could stimulate motor networks and areas associated with autobiographical memory, highlighting its therapeutic potential in promoting awareness in this patient population.
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Affiliation(s)
- Haitao Yang
- The First Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Wenhao Huang
- The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Wei Wen
- Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Shoufeng Long
- The Second Clinical College of Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Yujie Zhang
- Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Xiangfeng Chi
- Guangdong No. 2 Hospital of Traditional Chinese Medicine, Guangzhou, China
| | - Daihong Luo
- Beijing University of Chinese Medicine Shenzhen Hospital (Longgang), Shenzhen, China
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4
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Burns JD, Lerner DP. Neural Decoding, Disorders of Consciousness, and the Hard Consciousness Problem. Neurology 2025; 104:e213354. [PMID: 39883907 DOI: 10.1212/wnl.0000000000213354] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2024] [Accepted: 12/02/2024] [Indexed: 02/01/2025] Open
Affiliation(s)
- Joseph D Burns
- Division of Neurocritical Care, Department of Neurology, Lahey Hospital and Medical Center, Burlington, MA, and UMass Chan Medical School, Worcester, MA; and
| | - David P Lerner
- Division of Neurocritical Care, Department of Neurology, SUNY Downstate Medical Center and One Brooklyn Health, Brooklyn, NY
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5
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Claassen J, Kondziella D, Young MJ. Covert consciousness in critical care. Intensive Care Med 2025; 51:173-176. [PMID: 39831997 DOI: 10.1007/s00134-024-07722-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2024] [Accepted: 10/30/2024] [Indexed: 01/22/2025]
Affiliation(s)
- Jan Claassen
- Department of Neurology, Columbia University Medical Center, New York Presbyterian Hospital, New York, NY, USA.
| | - Daniel Kondziella
- Department of Neurology, Department of Clinical Medicine, Rigshospitalet, Copenhagen University Hospital &, University of Copenhagen, Copenhagen, Denmark
| | - Michael J Young
- Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
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6
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Biyani S, Chang H, Shah VA. Neurologic prognostication in coma and disorders of consciousness. HANDBOOK OF CLINICAL NEUROLOGY 2025; 207:237-264. [PMID: 39986724 DOI: 10.1016/b978-0-443-13408-1.00017-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/24/2025]
Abstract
Coma and disorders of consciousness (DoC) are clinical syndromes primarily resulting from severe acute brain injury, with uncertain recovery trajectories that often necessitate prolonged supportive care. This imposes significant socioeconomic burdens on patients, caregivers, and society. Predicting recovery in comatose patients is a critical aspect of neurocritical care, and while current prognostication heavily relies on clinical assessments, such as pupillary responses and motor movements, which are far from precise, contemporary prognostication has integrated more advanced technologies like neuroimaging and electroencephalogram (EEG). Nonetheless, neurologic prognostication remains fraught with uncertainty and significant inaccuracies and is impacted by several forms of prognostication biases, including self-fulfilling prophecy bias, affective forecasting, and clinician treatment biases, among others. However, neurologic prognostication in patients with disorders of consciousness impacts life-altering decisions including continuation of treatment interventions vs withdrawal of life-sustaining therapies (WLST), which have a direct influence on survival and recovery after severe acute brain injury. In recent years, advancements in neuro-monitoring technologies, artificial intelligence (AI), and machine learning (ML) have transformed the field of prognostication. These technologies have the potential to process vast amounts of clinical data and identify reliable prognostic markers, enhancing prediction accuracy in conditions such as cardiac arrest, intracerebral hemorrhage, and traumatic brain injury (TBI). For example, AI/ML modeling has led to the identification of new states of consciousness such as covert consciousness and cognitive motor dissociation, which may have important prognostic significance after severe brain injury. This chapter reviews the evolving landscape of neurologic prognostication in coma and DoC, highlights current pitfalls and biases, and summarizes the integration of clinical examination, neuroimaging, biomarkers, and neurophysiologic tools for prognostication in specific disease states. We will further discuss the future of neurologic prognostication, focusing on the integration of AI and ML techniques to deliver more individualized and accurate prognostication, ultimately improving patient outcomes and decision-making process in neurocritical care.
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Affiliation(s)
- Shubham Biyani
- Departments of Neurology, Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Henry Chang
- Department of Neurology, TriHealth Hospital, Cincinnati, OH, United States
| | - Vishank A Shah
- Departments of Neurology, Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, United States.
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7
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Blain-Moraes S, Sarwal A, Hemphill JC. The Curing Coma Campaign: A platform for advancing science and clinical care worldwide. HANDBOOK OF CLINICAL NEUROLOGY 2025; 207:265-280. [PMID: 39986725 DOI: 10.1016/b978-0-443-13408-1.00005-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/24/2025]
Abstract
Recovery from coma or impaired consciousness is often the central issue in acute neurologic conditions such as traumatic brain injury, hypoxic-ischemic brain injury, stroke, and central nervous system infections. Recent advances in the science underpinning acute disorders of consciousness (DoC) have also served to highlight further scientific gaps and the lack of a coordinated approach to improving care for these patients. The Curing Coma Campaign (CCC) was initiated by the Neurocritical Care Society in 2019 as a platform to bring together the scientific, clinical, and public communities to cohesively address this issue. Comprised of various modules and working groups focused on aspects including fundamental science, prospective clinical studies, ethics, care of the coma patient, and engagement and community, initial efforts of the CCC have ranged from developing strategies for biomarker development to creating World Coma Day as an opportunity for widespread interaction. To achieve the goal of relevance across different geographic and resourced environments, the CCC implemented specific considerations to ensure equity and generalizability. These include international representation of patients in research studies, attention to assessments and interventions that can be implemented in resource-limited settings, and recognition of the impact of culture on the care of DoC patients.
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Affiliation(s)
- Stefanie Blain-Moraes
- School of Physical and Occupational Therapy, McGill University, Montreal, QC, Canada
| | - Aarti Sarwal
- Deparrtment of Neurology, Wake Forest University School of Medicine, Winston-Salem, NC, United States
| | - J Claude Hemphill
- Department of Neurology, University of California, San Francisco, San Francisco, CA, United States.
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8
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Grønlund EW, Lindberg U, Fisher PM, Othman MH, Amiri M, Sølling C, Nielsen RD, Capion T, Ciochon UM, Hauerberg J, Sigurdsson ST, Thomsen G, Knudsen GM, Kjaergaard J, Larsen VA, Møller K, Hansen AE, Kondziella D. Arterial Spin Labeling Magnetic Resonance Imaging for Acute Disorders of Consciousness in the Intensive Care Unit. Neurocrit Care 2024; 41:1027-1037. [PMID: 38918338 PMCID: PMC11599417 DOI: 10.1007/s12028-024-02031-0] [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: 03/05/2024] [Accepted: 05/31/2024] [Indexed: 06/27/2024]
Abstract
BACKGROUND To investigate patients with disorders of consciousness (DoC) for residual awareness, guidelines recommend quantifying glucose brain metabolism using positron emission tomography. However, this is not feasible in the intensive care unit (ICU). Cerebral blood flow (CBF) assessed by arterial spin labeling magnetic resonance imaging (ASL-MRI) could serve as a proxy for brain metabolism and reflect consciousness levels in acute DoC. We hypothesized that ASL-MRI would show compromised CBF in coma and unresponsive wakefulness states (UWS) but relatively preserved CBF in minimally conscious states (MCS) or better. METHODS We consecutively enrolled ICU patients with acute DoC and categorized them as being clinically unresponsive (i.e., coma or UWS [≤ UWS]) or low responsive (i.e., MCS or better [≥ MCS]). ASL-MRI was then acquired on 1.5 T or 3 T. Healthy controls were investigated with both 1.5 T and 3 T ASL-MRI. RESULTS We obtained 84 ASL-MRI scans from 59 participants, comprising 36 scans from 35 patients (11 women [31.4%]; median age 56 years, range 18-82 years; 24 ≤ UWS patients, 12 ≥ MCS patients; 32 nontraumatic brain injuries) and 48 scans from 24 healthy controls (12 women [50%]; median age 50 years, range 21-77 years). In linear mixed-effects models of whole-brain cortical CBF, patients had 16.2 mL/100 g/min lower CBF than healthy controls (p = 0.0041). However, ASL-MRI was unable to discriminate between ≤ UWS and ≥ MCS patients (whole-brain cortical CBF: p = 0.33; best hemisphere cortical CBF: p = 0.41). Numerical differences of regional CBF in the thalamus, amygdala, and brainstem in the two patient groups were statistically nonsignificant. CONCLUSIONS CBF measurement in ICU patients using ASL-MRI is feasible but cannot distinguish between the lower and the upper ends of the acute DoC spectrum. We suggest that pilot testing of diagnostic interventions at the extremes of this spectrum is a time-efficient approach in the continued quest to develop DoC neuroimaging markers in the ICU.
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Affiliation(s)
- Elisabeth Waldemar Grønlund
- Department of Neurology, Copenhagen University Hospital - Rigshospitalet, Blegdamsvej 9, 2100, Copenhagen, Denmark
| | - Ulrich Lindberg
- Functional Imaging Unit, Department of Clinical Physiology and Nuclear Medicine, Copenhagen University Hospital - Rigshospitalet, Glostrup, Denmark
| | - Patrick M Fisher
- Neurobiology Research Unit, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
- Department of Drug Design and Pharmacology, University of Copenhagen, Copenhagen, Denmark
| | - Marwan H Othman
- Department of Neurology, Copenhagen University Hospital - Rigshospitalet, Blegdamsvej 9, 2100, Copenhagen, Denmark
| | - Moshgan Amiri
- Department of Neurology, Copenhagen University Hospital - Rigshospitalet, Blegdamsvej 9, 2100, Copenhagen, Denmark
| | - Christine Sølling
- Department of Neuroanaesthesiology, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Rune Damgaard Nielsen
- Department of Neuroanaesthesiology, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Tenna Capion
- Department of Neurosurgery, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Urszula Maria Ciochon
- Department of Radiology, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - John Hauerberg
- Department of Neurosurgery, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Sigurdur Thor Sigurdsson
- Department of Neuroanaesthesiology, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Gerda Thomsen
- Neurobiology Research Unit, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Gitte Moos Knudsen
- Department of Neurology, Copenhagen University Hospital - Rigshospitalet, Blegdamsvej 9, 2100, Copenhagen, Denmark
- Neurobiology Research Unit, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Jesper Kjaergaard
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
- Department of Cardiology, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Vibeke Andrée Larsen
- Department of Radiology, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Kirsten Møller
- Department of Neuroanaesthesiology, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Adam Espe Hansen
- Department of Radiology, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Daniel Kondziella
- Department of Neurology, Copenhagen University Hospital - Rigshospitalet, Blegdamsvej 9, 2100, Copenhagen, Denmark.
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark.
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Buowari DY, Ikpae BE. Causes and Outcome of Unconsciousness in the Accident and Emergency Department of the University of Port Harcourt Teaching Hospital. Niger Med J 2024; 65:984-994. [PMID: 39877513 PMCID: PMC11770643 DOI: 10.60787/nmj.v65i6.579] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2025] Open
Abstract
Background Unconsciousness occurs when a patient enters a sleeplike state but cannot be aroused, and it is not due to physiological drowsiness. It is a common presentation in the Accident and Emergency Department (A&E), and a burden to the emergency physician especially when the cause is unknown. The cause of coma may be trauma or non-trauma related. There is a shortage of data on the aetiology and outcome of unconsciousness in developing countries including Nigeria. Methodology This cross-sectional study investigates 765 unconscious patients using convenience sampling from September 2023 to June 2024 at the A&E of the University of Port Harcourt Teaching Hospital. The World Health Organization emergency unit form was adapted for this study. Results The total population of this study is 765, 55.16% males and 44.84% females. A majority of the cases 81.83% were not related to trauma. The commonest causes of unconsciousness were stroke, diabetic complications & emergencies, traumatic brain injury, metastatic neoplasm, HIV AIDs related disease and hypertensive emergency. Most of the patients 494(64.58%) died while in A&E, 116 (15.16%) were transferred to the ward and 56 (7.58%) were discharged against medical advice. Conclusion Unconscious patients are a challenge in the emergency room. Stroke and diabetic emergencies are the commonest causes of non-trauma-related aetiologies while traumatic brain injury is the most common cause of trauma-related aetiology of unconsciousness.
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Affiliation(s)
- Dabota Yvonne Buowari
- Department of Accident and Emergency, University of Port Harcourt Teaching Hospital, Port Harcourt, Nigeria
| | - Barile Edward Ikpae
- Department of Accident and Emergency, University of Port Harcourt Teaching Hospital, Port Harcourt, Nigeria
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Sharma K, Deco G, Solodkin A. The localization of coma. Cogn Neuropsychol 2024:1-20. [PMID: 39471280 DOI: 10.1080/02643294.2024.2420406] [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: 08/28/2023] [Revised: 10/08/2024] [Accepted: 10/17/2024] [Indexed: 11/01/2024]
Abstract
Coma and disorders of consciousness (DoC) are common manifestations of acute severe brain injuries. Research into their neuroanatomical basis can be traced from Hippocrates to the present day. Lesions causing DoC have traditionally been conceptualized as decreasing "alertness" from damage to the ascending arousal system, and/or, reducing level of "awareness" due to structural or functional impairment of large-scale brain networks. Within this framework, pharmacological and neuromodulatory interventions to promote recovery from DoC have hitherto met with limited success. This is partly due to inter-individual heterogeneity of brain injury patterns, and an incomplete understanding of brain network properties that characterize consciousness. Advances in multiscale computational modelling of brain dynamics have opened a unique opportunity to explore the causal mechanisms of brain activity at the biophysical level. These models can provide a novel approach for selection and optimization of potential interventions by simulation of brain network dynamics individualized for each patient.
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Affiliation(s)
- Kartavya Sharma
- Neurocritical care division, Departments of Neurology & Neurosurgery, University of Texas Southwestern Medical Center, Dallas, TX, USA
- Peter O'Donnell Jr. Brain Institute, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Gustavo Deco
- Computational Neuroscience Group, Center for Brain and Cognition, Universitat Pompeu Fabra, Barcelona, Spain
- Institució Catalana de la Recerca i Estudis Avançats (ICREA), Barcelona, Spain
| | - Ana Solodkin
- Department of Neuroscience, School of Behavioral and Brain Sciences, University of Texas at Dallas, Dallas, TX, USA
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11
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Silva GS. A Comprehensive Insight into Coma Prevalence in Chilean Critical Care Units. Neurocrit Care 2024; 41:324-325. [PMID: 38671313 DOI: 10.1007/s12028-024-01987-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2024] [Accepted: 03/20/2024] [Indexed: 04/28/2024]
Affiliation(s)
- Gisele Sampaio Silva
- Universidade Federal de São Paulo, São Paulo, Brazil.
- Hospital Israelita Albert Einstein, Avenida Albert Einstein, 627, Suíte 218, São Paulo, SP, 05652-900, Brazil.
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12
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Duarte S, Ou Z, Cao M, Cho SM, Thakor NV, Ritzl EK, Geocadin RG. High frequency oscillations may improve somatosensory evoked potential detection of good outcomes in disorders of consciousness secondary to acute neurologic injury. Resuscitation 2024; 203:110377. [PMID: 39187152 DOI: 10.1016/j.resuscitation.2024.110377] [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] [Received: 07/16/2024] [Revised: 08/19/2024] [Accepted: 08/20/2024] [Indexed: 08/28/2024]
Abstract
BACKGROUND Somatosensory evoked potentials (SEPs) are highly specific predictors of poor prognosis in hypoxic-ischemic coma when cortical responses (N20s) are absent. However, bilateral N20 presence is nonspecific for good outcomes. High-frequency oscillations (HFOs) in the SEP waveform predict neurologic recovery in animals, but clinical applications are poorly understood. We sought to develop a clinical measure of HFOs to potentially improve detection of good outcomes in coma. MATERIALS AND METHODS We collected SEP waveform data from all comatose inpatients (GCS<=8) who underwent neurologic prognostication from 2020 to 2022 at Johns Hopkins Hospital. We developed a novel measure - HFO evoked to spontaneous ratios (HFO-ESRs) - and applied this to those patients with bilaterally present N20s using both standard univariate classification and cubic kernal vector machine (SVM) models to predict the last documented in-hospital Glasgow Coma Scale (GCS) prior to discharge or death. RESULTS Of 58 total patients, 34 (58.6%) had bilaterally present N20s. Of these, 14 had final GCS>=9, and 20 had final GCS<=8. Mean age was 52 (+/- 17) years, 20.1% female. Etiologies of coma were primarily global hypoxic-ischemic brain injury (79.4%), intracranial hemorrhage (11.8%), and traumatic brain injury (2.9%). In univariate classification, the addition of averaged HFO-ESRs to bilaterally present N20s predicted final GCS>=9 with 68% specificity. The SVM model further improved specificity to 85%. CONCLUSIONS In this pilot investigation, we developed a novel clinical measure of SEP HFOs. Incorporation of this measure may improve the specificity of the SEP to predict in-hospital GCS outcomes in coma, but requires further validation in specific neurologic injuries and with longitudinal outcomes.
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Affiliation(s)
- Siena Duarte
- Department of Neurology - Division of Neurocritical Care, University of California, San Francisco, USA.
| | - Ze Ou
- Medical Scientist Training Program, Washington University in St. Louis School of Medicine, St. Louis, MO 63110, USA.
| | - Mingfeng Cao
- Department of Biomedical Engineering, Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA.
| | - Sung-Min Cho
- Departments of Neurology, Anesthesiology, Critical Care Medicine and Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA.
| | - Nitish V Thakor
- Department of Biomedical Engineering, Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA.
| | - Eva K Ritzl
- Department of Neurology, Mass General Brigham, Boston, MA, USA.
| | - Romergryko G Geocadin
- Departments of Neurology, Anesthesiology, Critical Care Medicine and Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA.
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13
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Egawa S, Ader J, Claassen J. Recovery of consciousness after acute brain injury: a narrative review. J Intensive Care 2024; 12:37. [PMID: 39327599 PMCID: PMC11425956 DOI: 10.1186/s40560-024-00749-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2024] [Accepted: 09/01/2024] [Indexed: 09/28/2024] Open
Abstract
BACKGROUND Disorders of consciousness (DoC) are frequently encountered in both, acute and chronic brain injuries. In many countries, early withdrawal of life-sustaining treatments is common practice for these patients even though the accuracy of predicting recovery is debated and delayed recovery can be seen. In this review, we will discuss theoretical concepts of consciousness and pathophysiology, explore effective strategies for management, and discuss the accurate prediction of long-term clinical outcomes. We will also address research challenges. MAIN TEXT DoC are characterized by alterations in arousal and/or content, being classified as coma, unresponsive wakefulness syndrome/vegetative state, minimally conscious state, and confusional state. Patients with willful modulation of brain activity detectable by functional MRI or EEG but not by behavioral examination is a state also known as covert consciousness or cognitive motor dissociation. This state may be as common as every 4th or 5th patient without behavioral evidence of verbal command following and has been identified as an independent predictor of long-term functional recovery. Underlying mechanisms are uncertain but intact arousal and thalamocortical projections maybe be essential. Insights into the mechanisms underlying DoC will be of major importance as these will provide a framework to conceptualize treatment approaches, including medical, mechanical, or electoral brain stimulation. CONCLUSIONS We are beginning to gain insights into the underlying mechanisms of DoC, identifying novel advanced prognostication tools to improve the accuracy of recovery predictions, and are starting to conceptualize targeted treatments to support the recovery of DoC patients. It is essential to determine how these advancements can be implemented and benefit DoC patients across a range of clinical settings and global societal systems. The Curing Coma Campaign has highlighted major gaps knowledge and provides a roadmap to advance the field of coma science with the goal to support the recovery of patients with DoC.
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Affiliation(s)
- Satoshi Egawa
- Department of Neurology, Neurological Institute, Columbia University Medical Center, NewYork-Presbyterian Hospital, 177 Fort Washington Avenue, MHB 8 Center, Room 300, New York, NY, 10032, USA
- NewYork-Presbyterian Hospital, New York, NY, USA
| | - Jeremy Ader
- Department of Neurology, Neurological Institute, Columbia University Medical Center, NewYork-Presbyterian Hospital, 177 Fort Washington Avenue, MHB 8 Center, Room 300, New York, NY, 10032, USA
- NewYork-Presbyterian Hospital, New York, NY, USA
| | - Jan Claassen
- Department of Neurology, Neurological Institute, Columbia University Medical Center, NewYork-Presbyterian Hospital, 177 Fort Washington Avenue, MHB 8 Center, Room 300, New York, NY, 10032, USA.
- NewYork-Presbyterian Hospital, New York, NY, USA.
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14
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Othman MH, Olsen MH, Hansen KIT, Amiri M, Jensen HR, Nyholm B, Møller K, Kjaergaard J, Kondziella D. Covert Consciousness in Acute Brain Injury Revealed by Automated Pupillometry and Cognitive Paradigms. Neurocrit Care 2024; 41:218-227. [PMID: 38605221 PMCID: PMC11335945 DOI: 10.1007/s12028-024-01983-7] [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: 02/02/2024] [Accepted: 03/12/2024] [Indexed: 04/13/2024]
Abstract
BACKGROUND Identifying covert consciousness in intensive care unit (ICU) patients with coma and other disorders of consciousness (DoC) is crucial for treatment decisions, but sensitive low-cost bedside markers are missing. We investigated whether automated pupillometry combined with passive and active cognitive paradigms can detect residual consciousness in ICU patients with DoC. METHODS We prospectively enrolled clinically low-response or unresponsive patients with traumatic or nontraumatic DoC from ICUs of a tertiary referral center. Age-matched and sex-matched healthy volunteers served as controls. Patients were categorized into clinically unresponsive (coma or unresponsive wakefulness syndrome) or clinically low-responsive (minimally conscious state or better). Using automated pupillometry, we recorded pupillary dilation to passive (visual and auditory stimuli) and active (mental arithmetic) cognitive paradigms, with task-specific success criteria (e.g., ≥ 3 of 5 pupillary dilations on five consecutive mental arithmetic tasks). RESULTS We obtained 699 pupillometry recordings at 178 time points from 91 ICU patients with brain injury (mean age 60 ± 13.8 years, 31% women, and 49.5% nontraumatic brain injuries). Recordings were also obtained from 26 matched controls (59 ± 14.8 years, 38% women). Passive paradigms yielded limited distinctions between patients and controls. However, active paradigms enabled discrimination between different states of consciousness. With mental arithmetic of moderate complexity, ≥ 3 pupillary dilations were seen in 17.8% of clinically unresponsive patients and 50.0% of clinically low-responsive patients (odds ratio 4.56, 95% confidence interval 2.09-10.10; p < 0.001). In comparison, 76.9% healthy controls responded with ≥ 3 pupillary dilations (p = 0.028). Results remained consistent across sensitivity analyses using different thresholds for success. Spearman's rank analysis underscored the robust association between pupillary dilations during mental arithmetic and consciousness levels (rho = 1, p = 0.017). Notably, one behaviorally unresponsive patient demonstrated persistent command-following behavior 2 weeks before overt signs of awareness, suggesting prolonged cognitive motor dissociation. CONCLUSIONS Automated pupillometry combined with mental arithmetic can identify cognitive efforts, and hence covert consciousness, in ICU patients with acute DoC.
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Affiliation(s)
- Marwan H Othman
- Department of Neurology, Rigshospitalet, Copenhagen University Hospital, Inge Lehmanns Vej 8, 2100, Copenhagen, Denmark
| | - Markus Harboe Olsen
- Department of Neuroanesthesiology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Karen Irgens Tanderup Hansen
- Department of Neurology, Rigshospitalet, Copenhagen University Hospital, Inge Lehmanns Vej 8, 2100, Copenhagen, Denmark
- Faculty of Health Science, University of Southern Denmark, Odense, Denmark
| | - Moshgan Amiri
- Department of Neurology, Rigshospitalet, Copenhagen University Hospital, Inge Lehmanns Vej 8, 2100, Copenhagen, Denmark
| | - Helene Ravnholt Jensen
- Department of Neuroanesthesiology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Benjamin Nyholm
- Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Kirsten Møller
- Department of Neuroanesthesiology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Jesper Kjaergaard
- Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Daniel Kondziella
- Department of Neurology, Rigshospitalet, Copenhagen University Hospital, Inge Lehmanns Vej 8, 2100, Copenhagen, Denmark.
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark.
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15
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Amiri M, Raimondo F, Fisher PM, Cacic Hribljan M, Sidaros A, Othman MH, Zibrandtsen I, Bergdal O, Fabritius ML, Hansen AE, Hassager C, Højgaard JLS, Jensen HR, Knudsen NV, Laursen EL, Møller JE, Nersesjan V, Nicolic M, Sigurdsson ST, Sitt JD, Sølling C, Welling KL, Willumsen LM, Hauerberg J, Larsen VA, Fabricius ME, Knudsen GM, Kjærgaard J, Møller K, Kondziella D. Multimodal Prediction of 3- and 12-Month Outcomes in ICU Patients with Acute Disorders of Consciousness. Neurocrit Care 2024; 40:718-733. [PMID: 37697124 PMCID: PMC10959792 DOI: 10.1007/s12028-023-01816-z] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Accepted: 07/21/2023] [Indexed: 09/13/2023]
Abstract
BACKGROUND In intensive care unit (ICU) patients with coma and other disorders of consciousness (DoC), outcome prediction is key to decision-making regarding prognostication, neurorehabilitation, and management of family expectations. Current prediction algorithms are largely based on chronic DoC, whereas multimodal data from acute DoC are scarce. Therefore, the Consciousness in Neurocritical Care Cohort Study Using Electroencephalography and Functional Magnetic Resonance Imaging (i.e. CONNECT-ME; ClinicalTrials.gov identifier: NCT02644265) investigates ICU patients with acute DoC due to traumatic and nontraumatic brain injuries, using electroencephalography (EEG) (resting-state and passive paradigms), functional magnetic resonance imaging (fMRI) (resting-state) and systematic clinical examinations. METHODS We previously presented results for a subset of patients (n = 87) concerning prediction of consciousness levels in the ICU. Now we report 3- and 12-month outcomes in an extended cohort (n = 123). Favorable outcome was defined as a modified Rankin Scale score ≤ 3, a cerebral performance category score ≤ 2, and a Glasgow Outcome Scale Extended score ≥ 4. EEG features included visual grading, automated spectral categorization, and support vector machine consciousness classifier. fMRI features included functional connectivity measures from six resting-state networks. Random forest and support vector machine were applied to EEG and fMRI features to predict outcomes. Here, random forest results are presented as areas under the curve (AUC) of receiver operating characteristic curves or accuracy. Cox proportional regression with in-hospital death as a competing risk was used to assess independent clinical predictors of time to favorable outcome. RESULTS Between April 2016 and July 2021, we enrolled 123 patients (mean age 51 years, 42% women). Of 82 (66%) ICU survivors, 3- and 12-month outcomes were available for 79 (96%) and 77 (94%), respectively. EEG features predicted both 3-month (AUC 0.79 [95% confidence interval (CI) 0.77-0.82]) and 12-month (AUC 0.74 [95% CI 0.71-0.77]) outcomes. fMRI features appeared to predict 3-month outcome (accuracy 0.69-0.78) both alone and when combined with some EEG features (accuracies 0.73-0.84) but not 12-month outcome (larger sample sizes needed). Independent clinical predictors of time to favorable outcome were younger age (hazard ratio [HR] 1.04 [95% CI 1.02-1.06]), traumatic brain injury (HR 1.94 [95% CI 1.04-3.61]), command-following abilities at admission (HR 2.70 [95% CI 1.40-5.23]), initial brain imaging without severe pathological findings (HR 2.42 [95% CI 1.12-5.22]), improving consciousness in the ICU (HR 5.76 [95% CI 2.41-15.51]), and favorable visual-graded EEG (HR 2.47 [95% CI 1.46-4.19]). CONCLUSIONS Our results indicate that EEG and fMRI features and readily available clinical data predict short-term outcome of patients with acute DoC and that EEG also predicts 12-month outcome after ICU discharge.
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Affiliation(s)
- Moshgan Amiri
- Department of Neurology, Copenhagen University Hospital - Rigshospitalet, Blegdamsvej 9, 2100, Copenhagen, Denmark
| | - Federico Raimondo
- Brain and Behaviour, Institute of Neuroscience and Medicine, Research Center Jülich, Jülich, Germany
- Institute of Systems Neuroscience, Medical Faculty, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Patrick M Fisher
- Neurobiology Research Unit, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
- Department of Drug Design and Pharmacology, University of Copenhagen, Copenhagen, Denmark
| | - Melita Cacic Hribljan
- Department of Neurophysiology, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Annette Sidaros
- Department of Neurology, Copenhagen University Hospital - Rigshospitalet, Blegdamsvej 9, 2100, Copenhagen, Denmark
- Department of Neurophysiology, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Marwan H Othman
- Department of Neurology, Copenhagen University Hospital - Rigshospitalet, Blegdamsvej 9, 2100, Copenhagen, Denmark
| | - Ivan Zibrandtsen
- Department of Neurology, Copenhagen University Hospital - Rigshospitalet, Blegdamsvej 9, 2100, Copenhagen, Denmark
- Department of Neurophysiology, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Ove Bergdal
- Department of Neurosurgery, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Maria Louise Fabritius
- Department of Neuroanaesthesiology, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Adam Espe Hansen
- Department of Radiology, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Christian Hassager
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
- Department of Cardiology, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Joan Lilja S Højgaard
- Department of Neurology, Copenhagen University Hospital - Rigshospitalet, Blegdamsvej 9, 2100, Copenhagen, Denmark
| | - Helene Ravnholt Jensen
- Department of Neuroanaesthesiology, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Niels Vendelbo Knudsen
- Department of Neuroanaesthesiology, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Emilie Lund Laursen
- Department of Neurology, Copenhagen University Hospital - Rigshospitalet, Blegdamsvej 9, 2100, Copenhagen, Denmark
| | - Jacob E Møller
- Department of Cardiology, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Vardan Nersesjan
- Biological and Precision Psychiatry, Copenhagen Research Center for Mental Health, Copenhagen University Hospital, Copenhagen, Denmark
| | - Miki Nicolic
- Department of Neurophysiology, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Sigurdur Thor Sigurdsson
- Department of Neuroanaesthesiology, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Jacobo D Sitt
- Institut du Cerveau - Paris Brain Institute, Inserm, Centre nationl de la recherche scientifique, Assistance Publique - Hôpitaux de Paris, Sorbonne Université, Hôpital de La Pitié Salpêtrière, Paris, France
| | - Christine Sølling
- Department of Neuroanaesthesiology, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Karen Lise Welling
- Department of Neuroanaesthesiology, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Lisette M Willumsen
- Department of Neurosurgery, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - John Hauerberg
- Department of Neurosurgery, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Vibeke Andrée Larsen
- Department of Radiology, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Martin Ejler Fabricius
- Department of Neurophysiology, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Gitte Moos Knudsen
- Neurobiology Research Unit, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Jesper Kjærgaard
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
- Department of Cardiology, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Kirsten Møller
- Department of Neuroanaesthesiology, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Daniel Kondziella
- Department of Neurology, Copenhagen University Hospital - Rigshospitalet, Blegdamsvej 9, 2100, Copenhagen, Denmark.
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark.
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Abstract
In this article, we discuss the taxonomy associated with the four major disorders of consciousness (DoC): coma, vegetative state or unresponsive wakefulness syndrome, minimally conscious state, and post-traumatic confusional state. We briefly review the history of each disorder and then provide operational definitions and diagnostic criteria for each one. We rely heavily on recently released practice guidelines and, where appropriate, identify knowledge gaps and discuss future directions to advance DoC research and practice.
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Affiliation(s)
- Katherine Golden
- School of Health & Rehabilitation Sciences, MGH Institute of Health Professions, 36 1st Avenue, Boston, MA 02129, USA
| | - Yelena G Bodien
- Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, 300 1st Avenue, Charlestown, MA, 02129, USA; Center for Neurotechnology and Neurorecovery, Department of Neurology, Massachusetts General Hospital and Harvard Medical School, 55 Fruit Street, Boston, MA 02114, USA; Department of Physical Medicine and Rehabilitation, Harvard Medical School, 25 Shattuck Street, Boston, MA, USA
| | - Joseph T Giacino
- Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, 300 1st Avenue, Charlestown, MA, 02129, USA; Center for Neurotechnology and Neurorecovery, Department of Neurology, Massachusetts General Hospital and Harvard Medical School, 55 Fruit Street, Boston, MA 02114, USA.
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17
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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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18
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Tinti L, Lawson T, Molteni E, Kondziella D, Rass V, Sharshar T, Bodien YG, Giacino JT, Mayer SA, Amiri M, Muehlschlegel S, Venkatasubba Rao CP, Vespa PM, Menon DK, Citerio G, Helbok R, McNett M. Research considerations for prospective studies of patients with coma and disorders of consciousness. Brain Commun 2024; 6:fcae022. [PMID: 38344653 PMCID: PMC10853976 DOI: 10.1093/braincomms/fcae022] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Revised: 01/04/2024] [Accepted: 01/26/2024] [Indexed: 03/02/2024] Open
Abstract
Disorders of consciousness are neurological conditions characterized by impaired arousal and awareness of self and environment. Behavioural responses are absent or are present but fluctuate. Disorders of consciousness are commonly encountered as a consequence of both acute and chronic brain injuries, yet reliable epidemiological estimates would require inclusive, operational definitions of the concept, as well as wider knowledge dissemination among involved professionals. Whereas several manifestations have been described, including coma, vegetative state/unresponsive wakefulness syndrome and minimally conscious state, a comprehensive neurobiological definition for disorders of consciousness is still lacking. The scientific literature is primarily observational, and studies-specific aetiologies lead to disorders of consciousness. Despite advances in these disease-related forms, there remains uncertainty about whether disorders of consciousness are a disease-agnostic unitary entity with a common mechanism, prognosis or treatment response paradigm. Our knowledge of disorders of consciousness has also been hampered by heterogeneity of study designs, variables, and outcomes, leading to results that are not comparable for evidence synthesis. The different backgrounds of professionals caring for patients with disorders of consciousness and the different goals at different stages of care could partly explain this variability. The Prospective Studies working group of the Neurocritical Care Society Curing Coma Campaign was established to create a platform for observational studies and future clinical trials on disorders of consciousness and coma across the continuum of care. In this narrative review, the author panel presents limitations of prior observational clinical research and outlines practical considerations for future investigations. A narrative review format was selected to ensure that the full breadth of study design considerations could be addressed and to facilitate a future consensus-based statement (e.g. via a modified Delphi) and series of recommendations. The panel convened weekly online meetings from October 2021 to December 2022. Research considerations addressed the nosographic status of disorders of consciousness, case ascertainment and verification, selection of dependent variables, choice of covariates and measurement and analysis of outcomes and covariates, aiming to promote more homogeneous designs and practices in future observational studies. The goal of this review is to inform a broad community of professionals with different backgrounds and clinical interests to address the methodological challenges imposed by the transition of care from acute to chronic stages and to streamline data gathering for patients with disorders of consciousness. A coordinated effort will be a key to allow reliable observational data synthesis and epidemiological estimates and ultimately inform condition-modifying clinical trials.
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Affiliation(s)
- Lorenzo Tinti
- Department of Neuroscience, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Milan 20156, Italy
| | - Thomas Lawson
- Critical Care, The Ohio State University Wexner Medical Center, Columbus, OH 43210, USA
| | - Erika Molteni
- Biomedical Engineering Department, School of Biomedical Engineering and Imaging Sciences, King’s College London, London SE1 7EU, UK
| | - Daniel Kondziella
- Department of Neurology, Rigshospitalet, Copenhagen University Hospital, Copenhagen 2100, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen 2200, Denmark
| | - Verena Rass
- Department of Neurology, Neuro-Intensive Care Unit, Medical University of Innsbruck, Innsbruck 6020, Austria
| | - Tarek Sharshar
- Neuro-Intensive Care Medicine, Anaesthesiology and ICU Department, GHU-Psychiatry and Neurosciences, Pole Neuro, Sainte-Anne Hospital, Institute of Psychiatry and Neurosciences of Paris, INSERM U1266, Université Paris Cité, Paris 75006, France
| | - Yelena G Bodien
- Department of Neurology, Harvard Medical School, Massachusetts General Hospital, Boston, MA 02114, USA
- Department of Physical Medicine and Rehabilitation, Harvard Medical School, Spaulding Rehabilitation Hospital, Charlestown, MA 02129, USA
| | - Joseph T Giacino
- Department of Physical Medicine and Rehabilitation, Harvard Medical School, Spaulding Rehabilitation Hospital, Charlestown, MA 02129, USA
| | - Stephan A Mayer
- Department of Neurology, New York Medical College, Valhalla, NY 10595, USA
- Department of Neurosurgery, New York Medical College, Valhalla, NY 10595, USA
| | - Moshgan Amiri
- Department of Neurology, Rigshospitalet, Copenhagen University Hospital, Copenhagen 2100, Denmark
| | - Susanne Muehlschlegel
- Department of Neurology and Anesthesiology/Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA
| | - Chethan P Venkatasubba Rao
- Division of Vascular Neurology and Neurocritical Care, Baylor College of Medicine and CHI Baylor St Luke’s Medical Center, Houston, TX 77030, USA
| | - Paul M Vespa
- Department of Neurology, David Geffen School of Medicine at UCLA, Los Angeles, CA 90095, USA
- Department of Neurosurgery, David Geffen School of Medicine at UCLA, Los Angeles, CA 90095, USA
| | - David K Menon
- Division of Anaesthesia, University of Cambridge, Cambridge CB2 1TN, UK
| | - Giuseppe Citerio
- NeuroIntensive Care, IRCSS Fondazione San Gerardo dei Tintori, Monza 20900, Italy
- School of Medicine and Surgery, Università Milano Bicocca, Milan 20854, Italy
| | - Raimund Helbok
- Department of Neurology, Neuro-Intensive Care Unit, Medical University of Innsbruck, Innsbruck 6020, Austria
- Department of Neurology, Johannes Kepler University, Linz 4040, Austria
| | - Molly McNett
- College of Nursing, The Ohio State University, Columbus, OH 43210, USA
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19
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Othman MH, Møller K, Kjaergaard J, Kondziella D. Detecting signatures of consciousness in acute brain injury after stimulation with apomorphine and methylphenidate: protocol for a placebo-controlled, randomized, cross-over study. BMJ Neurol Open 2024; 6:e000584. [PMID: 38268756 PMCID: PMC10806905 DOI: 10.1136/bmjno-2023-000584] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2023] [Accepted: 12/04/2023] [Indexed: 01/26/2024] Open
Abstract
Introduction Acute brain injury can lead to states of decreased consciousness, that is, disorder of consciousness (DoC). Detecting signs of consciousness early is vital for DoC management in the intensive care unit (ICU), neurorehabilitation and long-term prognosis. Our primary objective is to investigate the potential of pharmacological stimulant therapies in eliciting signs of consciousness among unresponsive or low-responsive acute DoC patients. Methods In a placebo-controlled, randomised, cross-over setting, we evaluate the effect of methylphenidate and apomorphine in 50 DoC patients with acute traumatic or non-traumatic brain injury admitted to the ICU. Patients are examined before and after administration of the trial drugs using (1) neurobehavioural scales to determine the clinical level of consciousness, (2) automated pupillometry to record pupillary responses as a signature for awareness and (3) near-infrared spectroscopy combined with electroencephalography to record neurovascular coupling as a measure for cortical activity. Primary outcomes include pupillary dilations and increase in cortical activity during passive and active paradigms. Ethics The study has been approved by the ethics committee (Journal-nr: H-21022096) and follows the principles of the Declaration of Helsinki. It is deemed to pose minimal risks and to hold a significant potential to improve treatment options for DoC patients. If the stimulants are shown to enhance cortical modulation of pupillary function and neurovascular coupling, this would warrant a large multicentre trial to evaluate their clinical impact. Dissemination Results will be available on EudraCT, clinicaltrialsregister.eu and published in an international peer-reviewed journal. Trial registration number EudraCT Number: 2021-001453-31.
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Affiliation(s)
- Marwan H Othman
- Department of Neurology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Kirsten Møller
- Department of Neuroanesthesiology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Jesper Kjaergaard
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
- Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Daniel Kondziella
- Department of Neurology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
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20
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Lewis A, Young MJ, Rohaut B, Jox RJ, Claassen J, Creutzfeldt CJ, Illes J, Kirschen M, Trevick S, Fins JJ. Ethics Along the Continuum of Research Involving Persons with Disorders of Consciousness. Neurocrit Care 2023; 39:565-577. [PMID: 36977963 PMCID: PMC11023737 DOI: 10.1007/s12028-023-01708-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2022] [Accepted: 02/23/2023] [Indexed: 03/30/2023]
Abstract
Interest in disorders of consciousness (DoC) has grown substantially over the past decade and has illuminated the importance of improving understanding of DoC biology; care needs (use of monitoring, performance of interventions, and provision of emotional support); treatment options to promote recovery; and outcome prediction. Exploration of these topics requires awareness of numerous ethics considerations related to rights and resources. The Curing Coma Campaign Ethics Working Group used its expertise in neurocritical care, neuropalliative care, neuroethics, neuroscience, philosophy, and research to formulate an informal review of ethics considerations along the continuum of research involving persons with DoC related to the following: (1) study design; (2) comparison of risks versus benefits; (3) selection of inclusion and exclusion criteria; (4) screening, recruitment, and enrollment; (5) consent; (6) data protection; (7) disclosure of results to surrogates and/or legally authorized representatives; (8) translation of research into practice; (9) identification and management of conflicts of interest; (10) equity and resource availability; and (11) inclusion of minors with DoC in research. Awareness of these ethics considerations when planning and performing research involving persons with DoC will ensure that the participant rights are respected while maximizing the impact and meaningfulness of the research, interpretation of outcomes, and communication of results.
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Affiliation(s)
- Ariane Lewis
- NYU Langone Medical Center, 530 First Avenue, Skirball-7R, New York, NY, 10016, USA.
| | - Michael J Young
- Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Benjamin Rohaut
- Inserm, CNRS, APHP - Hôpital de la Pitié Salpêtrière, Paris Brain Institute - ICM, DMU Neuroscience, Sorbonne University, Paris, France
| | - Ralf J Jox
- Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Jan Claassen
- New York Presbyterian Hospital, Columbia University, New York, NY, USA
| | - Claire J Creutzfeldt
- Harborview Medical Center, Seattle, WA, USA
- University of Washington, Seattle, WA, USA
- Cambia Palliative Care Center of Excellence, Seattle, WA, USA
| | - Judy Illes
- University of British Columbia, Vancouver, BC, Canada
| | | | | | - Joseph J Fins
- Weill Cornell Medical College, New York, NY, USA
- Yale Law School, New Haven, CT, USA
- Rockefeller University, New York, NY, USA
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Franzova E, Shen Q, Doyle K, Chen JM, Egbebike J, Vrosgou A, Carmona JC, Grobois L, Heinonen GA, Velazquez A, Gonzales IJ, Egawa S, Agarwal S, Roh D, Park S, Connolly ES, Claassen J. Injury patterns associated with cognitive motor dissociation. Brain 2023; 146:4645-4658. [PMID: 37574216 PMCID: PMC10629765 DOI: 10.1093/brain/awad197] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Revised: 04/14/2023] [Accepted: 05/28/2023] [Indexed: 08/15/2023] Open
Abstract
In unconscious appearing patients with acute brain injury, wilful brain activation to motor commands without behavioural signs of command following, known as cognitive motor dissociation (CMD), is associated with functional recovery. CMD can be detected by applying machine learning to EEG recorded during motor command presentation in behaviourally unresponsive patients. Identifying patients with CMD carries clinical implications for patient interactions, communication with families, and guidance of therapeutic decisions but underlying mechanisms of CMD remain unknown. By analysing structural lesion patterns and network level dysfunction we tested the hypothesis that, in cases with preserved arousal and command comprehension, a failure to integrate comprehended motor commands with motor outputs underlies CMD. Manual segmentation of T2-fluid attenuated inversion recovery and diffusion weighted imaging sequences quantifying structural injury was performed in consecutive unresponsive patients with acute brain injury (n = 107) who underwent EEG-based CMD assessments and MRI. Lesion pattern analysis was applied to identify lesion patterns common among patients with (n = 21) and without CMD (n = 86). Thalamocortical and cortico-cortical network connectivity were assessed applying ABCD classification of power spectral density plots and weighted pairwise phase consistency (WPPC) to resting EEG, respectively. Two distinct structural lesion patterns were identified on MRI for CMD and three for non-CMD patients. In non-CMD patients, injury to brainstem arousal pathways including the midbrain were seen, while no CMD patients had midbrain lesions. A group of non-CMD patients was identified with injury to the left thalamus, implicating possible language comprehension difficulties. Shared lesion patterns of globus pallidus and putamen were seen for a group of CMD patients, which have been implicated as part of the anterior forebrain mesocircuit in patients with reversible disorders of consciousness. Thalamocortical network dysfunction was less common in CMD patients [ABCD-index 2.3 (interquartile range, IQR 2.1-3.0) versus 1.4 (IQR 1.0-2.0), P < 0.0001; presence of D 36% versus 3%, P = 0.0006], but WPPC was not different. Bilateral cortical lesions were seen in patients with and without CMD. Thalamocortical disruption did not differ for those with CMD, but long-range WPPC was decreased in 1-4 Hz [odds ratio (OR) 0.8; 95% confidence interval (CI) 0.7-0.9] and increased in 14-30 Hz frequency ranges (OR 1.2; 95% CI 1.0-1.5). These structural and functional data implicate a failure of motor command integration at the anterior forebrain mesocircuit level with preserved thalamocortical network function for CMD patients with subcortical lesions. Amongst patients with bilateral cortical lesions preserved cortico-cortical network function is associated with CMD detection. These data may allow screening for CMD based on widely available structural MRI and resting EEG.
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Affiliation(s)
- Eva Franzova
- Department of Neurology, Columbia University Medical Center, NewYork-Presbyterian Hospital, New York, NY, USA
| | - Qi Shen
- Department of Neurology, Columbia University Medical Center, NewYork-Presbyterian Hospital, New York, NY, USA
| | - Kevin Doyle
- Department of Neurology, Columbia University Medical Center, NewYork-Presbyterian Hospital, New York, NY, USA
| | - Justine M Chen
- Department of Neurology, Columbia University Medical Center, NewYork-Presbyterian Hospital, New York, NY, USA
| | - Jennifer Egbebike
- Department of Neurology, Columbia University Medical Center, NewYork-Presbyterian Hospital, New York, NY, USA
| | - Athina Vrosgou
- Department of Neurology, Columbia University Medical Center, NewYork-Presbyterian Hospital, New York, NY, USA
| | - Jerina C Carmona
- Department of Neurology, Columbia University Medical Center, NewYork-Presbyterian Hospital, New York, NY, USA
| | - Lauren Grobois
- Department of Neurology, Columbia University Medical Center, NewYork-Presbyterian Hospital, New York, NY, USA
| | - Gregory A Heinonen
- Department of Neurology, Columbia University Medical Center, NewYork-Presbyterian Hospital, New York, NY, USA
| | - Angela Velazquez
- Department of Neurology, Columbia University Medical Center, NewYork-Presbyterian Hospital, New York, NY, USA
| | | | - Satoshi Egawa
- Department of Neurology, Columbia University Medical Center, NewYork-Presbyterian Hospital, New York, NY, USA
| | - Sachin Agarwal
- Department of Neurology, Columbia University Medical Center, NewYork-Presbyterian Hospital, New York, NY, USA
| | - David Roh
- Department of Neurology, Columbia University Medical Center, NewYork-Presbyterian Hospital, New York, NY, USA
| | - Soojin Park
- Department of Neurology, Columbia University Medical Center, NewYork-Presbyterian Hospital, New York, NY, USA
| | - E Sander Connolly
- Department of Neurological Surgery, Columbia University Medical Center, NewYork-Presbyterian Hospital, New York, NY, USA
| | - Jan Claassen
- Department of Neurology, Columbia University Medical Center, NewYork-Presbyterian Hospital, New York, NY, USA
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22
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Presciutti AM, Woodworth E, Rochon E, Neale M, Motta M, Piazza J, Vranceanu AM, Hwang DYG. A Mindfulness-Based Resiliency Program for Caregivers of Patients With Severe Acute Brain Injury Transitioning Out of Critical Care: Protocol for an Open Pilot Trial. JMIR Res Protoc 2023; 12:e50860. [PMID: 37878376 PMCID: PMC10632918 DOI: 10.2196/50860] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Accepted: 09/27/2023] [Indexed: 10/26/2023] Open
Abstract
BACKGROUND Caregivers of patients with severe acute brain injuries (SABI) that lead to coma and require intensive care unit (ICU) treatment often experience chronic emotional distress. To address this need, we developed the Coma Family (COMA-F) program, a mindfulness-based resiliency intervention for these caregivers. OBJECTIVE We will conduct an open pilot trial of COMA-F (National Institutes of Health Stage IA). Here we describe our study protocol and proposed intervention content. METHODS We will enroll 15 caregivers of patients with SABIs during their loved one's hospital course from 3 enrollment centers. A clinical psychologist will deliver the COMA-F intervention (6 sessions) over Zoom (Zoom Video Communications, Inc) or in person. We will iterate COMA-F after each caregiver completes the intervention and an exit interview. English-speaking adults who have emotional distress confirmed by the clinical team and are the primary caregivers of a patient with SABI are eligible. The adult patient must have been admitted to the neuro-ICU for SABI and (1) have had a Glasgow Coma Scale score below 9 while not intubated or an inability to follow meaningful commands while intubated at any point during their hospitalization for >24 hours due to SABI; (2) will be undergoing either tracheostomy or percutaneous endoscopic or surgical gastrostomy tube placement or have already received one or both; and (3) have a prognosis of survival >3 months. We will identify eligible caregivers through screening patients' medical records and through direct referrals from clinicians in the neuro-ICU. During the intervention we will teach caregivers mind-body and resilience skills, including deep breathing, mindfulness, meditation, dialectical thinking, acceptance, cognitive restructuring, effective communication, behavioral activation, and meaning-making. Caregivers will complete self-report assessments (measures of emotional distress and resilience) before and after the intervention. Primary outcomes are feasibility (recruitment, quantitative measures, adherence, and therapist fidelity) and acceptability (treatment satisfaction, credibility, and expectancy). We will conduct brief qualitative exit interviews to gather feedback on refining the program and study procedures. We will examine frequencies and proportions to determine feasibility and acceptability and will analyze qualitative exit interview data using thematic analysis. We will also conduct 2-tailed t tests to explore signals of improvement in emotional distress and treatment targets. We will then conduct an explanatory-sequential mixed methods analysis to integrate quantitative and qualitative data to refine the COMA-F manual and study procedures. RESULTS This study has been approved by the institutional review board at 1 of the 3 enrollment centers (2023P000536), with approvals at the other 2 centers pending. We anticipate that the study will be completed by late 2024. CONCLUSIONS We will use our findings to refine the COMA-F intervention and prepare for a feasibility randomized controlled trial. TRIAL REGISTRATION ClinicalTrials.gov NCT05761925; https://clinicaltrials.gov/study/NCT05761925. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) PRR1-10.2196/50860.
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Affiliation(s)
- Alexander Mattia Presciutti
- Department of Psychiatry, Center for Health Outcomes and Interdisciplinary Research, Massachusetts General Hospital, Boston, MA, United States
- Department of Psychiatry, Harvard Medical School, Boston, MA, United States
| | - Emily Woodworth
- Department of Psychiatry, Center for Health Outcomes and Interdisciplinary Research, Massachusetts General Hospital, Boston, MA, United States
| | - Elizabeth Rochon
- Department of Psychiatry, Center for Health Outcomes and Interdisciplinary Research, Massachusetts General Hospital, Boston, MA, United States
| | - Molly Neale
- Department of Neurology, Division of Neurocritical Care, University of North Carolina School of Medicine, Chapel Hill, NC, United States
| | - Melissa Motta
- Program in Trauma, Department of Neurology, University of Maryland School of Medicine, Baltimore, MD, United States
| | - Joseph Piazza
- Program in Trauma, Department of Neurology, University of Maryland School of Medicine, Baltimore, MD, United States
| | - Ana-Maria Vranceanu
- Department of Psychiatry, Center for Health Outcomes and Interdisciplinary Research, Massachusetts General Hospital, Boston, MA, United States
- Department of Psychiatry, Harvard Medical School, Boston, MA, United States
| | - David Yi-Gin Hwang
- Department of Neurology, Division of Neurocritical Care, University of North Carolina School of Medicine, Chapel Hill, NC, United States
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23
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Steinberg A, Fischhoff B. Cognitive Biases and Shared Decision Making in Acute Brain Injury. Semin Neurol 2023; 43:735-743. [PMID: 37793424 DOI: 10.1055/s-0043-1775596] [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: 10/06/2023]
Abstract
Many patients hospitalized after severe acute brain injury are comatose and require life-sustaining therapies. Some of these patients make favorable recoveries with continued intensive care, while others do not. In addition to providing medical care, clinicians must guide surrogate decision makers through high-stakes, emotionally charged decisions about whether to continue life-sustaining therapies. These consultations require clinicians first to assess a patient's likelihood of recovery given continued life-sustaining therapies (i.e., prognosticate), then to communicate that prediction to surrogates, and, finally, to elicit and interpret the patient's preferences. At each step, both clinicians and surrogates are vulnerable to flawed decision making. Clinicians can be imprecise, biased, and overconfident when prognosticating after brain injury. Surrogates can misperceive the choice and misunderstand or misrepresent a patient's wishes, which may never have been communicated clearly. These biases can undermine the ability to reach choices congruent with patients' preferences through shared decision making (SDM). Decision science has extensively studied these biases. In this article, we apply that research to improving SDM for patients who are comatose after acute brain injury. After introducing SDM and the medical context, we describe principal decision science results as they relate to neurologic prognostication and end-of-life decisions, by both clinicians and surrogates. Based on research regarding general processes that can produce imprecise, biased, and overconfident prognoses, we propose interventions that could improve SDM, supporting clinicians and surrogates in making these challenging decisions.
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Affiliation(s)
- Alexis Steinberg
- Department of Critical Care Medicine, Neurology, and Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Baruch Fischhoff
- Department of Engineering and Public Policy, Institute for Politics and Strategy, Carnegie Mellon University, Pittsburgh, Pennsylvania
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24
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Sanz LR, Laureys S, Gosseries O. Towards modern post-coma care based on neuroscientific evidence. Int J Clin Health Psychol 2023; 23:100370. [PMID: 36817874 PMCID: PMC9932483 DOI: 10.1016/j.ijchp.2023.100370] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2022] [Accepted: 01/12/2023] [Indexed: 02/05/2023] Open
Abstract
Background Understanding the mechanisms underlying human consciousness is pivotal to improve the prognostication and treatment of severely brain-injured patients. Consciousness remains an elusive concept and the identification of its neural correlates is an active subject of research, however recent neuroscientific advances have allowed scientists to better characterize disorders of consciousness. These breakthroughs question the historical nomenclature and our current management of post-comatose patients. Method This review examines the contribution of consciousness neurosciences to the current clinical management of severe brain injury. It investigates the major impact of consciousness disorders on healthcare systems, the scientific frameworks employed to identify their neural correlates and how evidence-based data from neuroimaging research have reshaped the landscape of post-coma care in recent years. Results Our increased ability to detect behavioral and neurophysiological signatures of consciousness has led to significant changes in taxonomy and clinical practice. We advocate for a multimodal framework for the management of severely brain-injured patients based on precision medicine and evidence-based decisions, integrating epidemiology, health economics and neuroethics. Conclusions Major progress in brain imaging and clinical assessment have opened the door to a new era of post-coma care based on standardized neuroscientific evidence. We highlight its implications in clinical applications and call for improved collaborations between researchers and clinicians to better translate findings to the bedside.
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Affiliation(s)
- Leandro R.D. Sanz
- Coma Science Group, GIGA Consciousness, University of Liège, Liège, Belgium
- Centre du Cerveau, University Hospital of Liège, Liège, Belgium
| | - Steven Laureys
- Coma Science Group, GIGA Consciousness, University of Liège, Liège, Belgium
- Centre du Cerveau, University Hospital of Liège, Liège, Belgium
- Joint International Research Unit on Consciousness, CERVO Brain Research Centre, CIUSS, Laval University, Québec, Canada
| | - Olivia Gosseries
- Coma Science Group, GIGA Consciousness, University of Liège, Liège, Belgium
- Centre du Cerveau, University Hospital of Liège, Liège, Belgium
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25
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Kreitzer N, Murtaugh B, Creutzfeldt C, Fins JJ, Manley G, Sarwal A, Dangayach N. Prognostic humility and ethical dilemmas after severe brain injury: Summary, recommendations, and qualitative analysis of Curing Coma Campaign virtual event proceedings. Front Hum Neurosci 2023; 17:1128656. [PMID: 37063099 PMCID: PMC10102639 DOI: 10.3389/fnhum.2023.1128656] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Accepted: 03/09/2023] [Indexed: 04/03/2023] Open
Abstract
BackgroundPatients with severe acute brain injuries (SABI) are at risk of living with long-term disability, frequent medical complications and high rates of mortality. Determining an individual patient’s prognosis and conveying this to family members/caregivers can be challenging. We conducted a webinar with experts in neurosurgery, neurocritical care, neuro-palliative care, neuro-ethics, and rehabilitation as part of the Curing Coma Campaign, which is supported by the Neurocritical Care Society. The webinar discussed topics focused on prognostic uncertainty, communicating prognosis to family members/caregivers, gaps within healthcare systems, and research infrastructure as it relates to patients experiencing SABI. The purpose of this manuscript is to describe the themes that emerged from this virtual discussion.MethodsA qualitative analysis of a webinar “Prognostic Humility and Ethical Dilemmas in Acute Brain Injury” was organized as part of the Neurocritical Care Society’s Curing Coma Campaign. A multidisciplinary group of experts was invited as speakers and moderators of the webinar. The content of the webinar was transcribed verbatim. Two qualitative researchers (NK and BM) read and re-read the transcription, and familiarized themselves with the text. The two coders developed and agreed on a code book, independently coded the transcript, and discussed any discrepancies. The transcript was analyzed using inductive thematic analysis of codes and themes that emerged within the expert discussion.ResultsWe coded 168 qualitative excerpts within the transcript. Two main themes were discussed: (1) the concept of prognostic uncertainty in the acute setting, and (2) lack of access to and evidence for quality rehabilitation and specialized continuum of care efforts specific to coma research. Within these two main themes, we found 5 sub-themes, which were broken down into 23 unique codes. The most frequently described code was the need for clinicians to acknowledge our own uncertainties when we discuss prognosis with families, which was mentioned 13 times during the webinar. Several strategies were described for speaking with surrogates of patients who have had a severe brain injury resulting in SABI. We also identified important gaps in the United States health system and in research to improve the care of patients with severe brain injuries.ConclusionAs a result of this webinar and expert discussion, authors identified and analyzed themes related to prognostic uncertainty with SABI. Recommendations were outlined for clinicians who engage with surrogates of patients with SABI to foster informed decisions for their loved one. Finally, recommendations for changes in healthcare systems and research support are provided in order to continue to propel SABI science forward to improve future prognostic certainty.
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Affiliation(s)
- Natalie Kreitzer
- Department of Emergency Medicine, University of Cincinnati, Cincinnati, OH, United States
- *Correspondence: Natalie Kreitzer,
| | - Brooke Murtaugh
- Brain Injury Program Manager, Department of Rehabilitation Programs, Madonna Rehabilitation Hospital, Lincoln, NE, United States
| | | | - Joseph J. Fins
- Division of Medical Ethics, Weill Cornell Medicine, New York, NY, United States
- Yale Law School, New Haven, CT, United States
| | - Geoff Manley
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, CA, United States
| | - Aarti Sarwal
- Department of Neurology, Wake Forest University, Winston-Salem, NC, United States
| | - Neha Dangayach
- Departments of Neurosurgery and Neurology, Icahn School of Medicine at Mount Sinai, New York, NY, United States
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26
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Claassen J. Beyond crystal balls: multimodal prediction of early recovery of consciousness. Brain 2023; 146:6-7. [PMID: 36508392 DOI: 10.1093/brain/awac434] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2022] [Accepted: 11/17/2022] [Indexed: 12/14/2022] Open
Abstract
This scientific commentary refers to ‘Multimodal prediction of residual consciousness in the intensive care unit: the CONNECT-ME study’ by Amiri et al. (https://doi.org/10.1093/brain/awac335).
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Affiliation(s)
- Jan Claassen
- Department of Neurology, Columbia University Medical Center, New York Presbyterian Hospital, New York, NY, USA
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27
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Schumm SN, Gabrieli D, Meaney DF. Plasticity impairment alters community structure but permits successful pattern separation in a hippocampal network model. Front Cell Neurosci 2022; 16:977769. [PMID: 36505514 PMCID: PMC9729278 DOI: 10.3389/fncel.2022.977769] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2022] [Accepted: 10/25/2022] [Indexed: 11/25/2022] Open
Abstract
Patients who suffer from traumatic brain injury (TBI) often complain of learning and memory problems. Their symptoms are principally mediated by the hippocampus and the ability to adapt to stimulus, also known as neural plasticity. Therefore, one plausible injury mechanism is plasticity impairment, which currently lacks comprehensive investigation across TBI research. For these studies, we used a computational network model of the hippocampus that includes the dentate gyrus, CA3, and CA1 with neuron-scale resolution. We simulated mild injury through weakened spike-timing-dependent plasticity (STDP), which modulates synaptic weights according to causal spike timing. In preliminary work, we found functional deficits consisting of decreased firing rate and broadband power in areas CA3 and CA1 after STDP impairment. To address structural changes with these studies, we applied modularity analysis to evaluate how STDP impairment modifies community structure in the hippocampal network. We also studied the emergent function of network-based learning and found that impaired networks could acquire conditioned responses after training, but the magnitude of the response was significantly lower. Furthermore, we examined pattern separation, a prerequisite of learning, by entraining two overlapping patterns. Contrary to our initial hypothesis, impaired networks did not exhibit deficits in pattern separation with either population- or rate-based coding. Collectively, these results demonstrate how a mechanism of injury that operates at the synapse regulates circuit function.
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Affiliation(s)
- Samantha N. Schumm
- Department of Bioengineering, School of Engineering and Applied Sciences, University of Pennsylvania, Philadelphia, PA, United States
| | - David Gabrieli
- Department of Bioengineering, School of Engineering and Applied Sciences, University of Pennsylvania, Philadelphia, PA, United States
| | - David F. Meaney
- Department of Bioengineering, School of Engineering and Applied Sciences, University of Pennsylvania, Philadelphia, PA, United States
- Department of Neurosurgery, Penn Center for Brain Injury and Repair, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
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