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Farg H, Elnakib A, Gebreil A, Alksas A, van Bogaert E, Mahmoud A, Khalil A, Ghazal M, Abou El-Ghar M, El-Baz A, Contractor S. Diagnostic value of PET imaging in clinically unresponsive patients. Br J Radiol 2024; 97:283-291. [PMID: 38308033 DOI: 10.1093/bjr/tqad040] [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: 01/18/2023] [Revised: 07/27/2023] [Accepted: 11/21/2023] [Indexed: 02/04/2024] Open
Abstract
Rapid advancements in the critical care management of acute brain injuries have facilitated the survival of numerous patients who may have otherwise succumbed to their injuries. The probability of conscious recovery hinges on the extent of structural brain damage and the level of metabolic and functional cerebral impairment, which remain challenging to assess via laboratory, clinical, or functional tests. Current research settings and guidelines highlight the potential value of fluorodeoxyglucose-PET (FDG-PET) for diagnostic and prognostic purposes, emphasizing its capacity to consistently illustrate a metabolic reduction in cerebral glucose uptake across various disorders of consciousness. Crucially, FDG-PET might be a pivotal tool for differentiating between patients in the minimally conscious state and those in the unresponsive wakefulness syndrome, a persistent clinical challenge. In patients with disorders of consciousness, PET offers utility in evaluating the degree and spread of functional disruption, as well as identifying irreversible neural damage. Further, studies that capture responses to external stimuli can shed light on residual or revived brain functioning. Nevertheless, the validity of these findings in predicting clinical outcomes calls for additional long-term studies with larger patient cohorts suffering from consciousness impairment. Misdiagnosis of conscious illnesses during bedside clinical assessments remains a significant concern. Based on the clinical research settings, current clinical guidelines recommend PET for diagnostic and/or prognostic purposes. This review article discusses the clinical categories of conscious disorders and the diagnostic and prognostic value of PET imaging in clinically unresponsive patients, considering the known limitations of PET imaging in such contexts.
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Affiliation(s)
- Hashim Farg
- Radiology Department, Urology and Nephrology Center, Mansoura University, 35516 Mansoura, Egypt
| | - Ahmed Elnakib
- BioImaging Lab, Bioengineering Department, University of Louisville, Louisville, KY 40292, United States
| | - Ahmad Gebreil
- BioImaging Lab, Bioengineering Department, University of Louisville, Louisville, KY 40292, United States
| | - Ahmed Alksas
- BioImaging Lab, Bioengineering Department, University of Louisville, Louisville, KY 40292, United States
| | - Eric van Bogaert
- Department of Radiology, University of Louisville, Louisville, KY 40202, United States
| | - Ali Mahmoud
- BioImaging Lab, Bioengineering Department, University of Louisville, Louisville, KY 40292, United States
| | - Ashraf Khalil
- College of Technological Innovation, Zayed University, Abu Dhabi 4783, United Arab Emirates
| | - Mohammed Ghazal
- Electrical, Computer, and Biomedical Engineering Department, Abu Dhabi University, Abu Dhabi 59911, United Arab Emirates
| | - Mohamed Abou El-Ghar
- Radiology Department, Urology and Nephrology Center, Mansoura University, 35516 Mansoura, Egypt
| | - Ayman El-Baz
- BioImaging Lab, Bioengineering Department, University of Louisville, Louisville, KY 40292, United States
| | - Sohail Contractor
- Department of Radiology, University of Louisville, Louisville, KY 40202, United States
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Xu LB, Hampton S, Fischer D. Neuroimaging in Disorders of Consciousness and Recovery. Phys Med Rehabil Clin N Am 2024; 35:51-64. [PMID: 37993193 DOI: 10.1016/j.pmr.2023.06.017] [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] [Indexed: 11/24/2023]
Abstract
There is a clinical need for more accurate diagnosis and prognostication in patients with disorders of consciousness (DoC). There are several neuroimaging modalities that enable detailed, quantitative assessment of structural and functional brain injury, with demonstrated diagnostic and prognostic value. Additionally, longitudinal neuroimaging studies have hinted at quantifiable structural and functional neuroimaging biomarkers of recovery, with potential implications for the management of DoC.
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Affiliation(s)
- Linda B Xu
- Department of Neurology, University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA 19104, USA.
| | - Stephen Hampton
- Department of Physical Medicine and Rehabilitation, University of Pennsylvania, 1800 Lombard Street, Philadelphia, PA 19146, USA
| | - David Fischer
- Department of Neurology, University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA 19104, USA.
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3
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Usami N, Asano Y, Ikegame Y, Takei H, Yamada Y, Yano H, Shinoda J. Cerebral Glucose Metabolism in Patients with Chronic Disorders of Consciousness. Can J Neurol Sci 2023; 50:719-729. [PMID: 36200558 DOI: 10.1017/cjn.2022.301] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE To measure regional cerebral metabolic rate of glucose (CMRGlu) in patients with chronic disorders of consciousness (DOCs) using 18F-fluorodeoxyglucose positron emission tomography (FDG-PET). METHODS This retrospective cohort study examined 50 patients (mean age: 40.9 ± 20.1 years) with traumatic brain injury (TBI)-induced chronic DOCs [minimally conscious state (MCS)+, n = 20; MCS-, n = 15 and vegetative state (VS), n = 15]. We measured FDG-PET-based CMRGlu values in 12 regions of both brain hemispheres and compared those among MCS+, MCS - and VS patients. RESULTS In both hemispheres, the regional CMRGlu reduced with consciousness deterioration in 11 of 12 regions (91.7%). In seven right hemisphere regions, CMRGlu values were markedly higher in MCS+ patients than in MCS- patients. Furthermore, CMRGlu was suggestively higher in the left occipital region in MCS- patients than in VS patients. CONCLUSION Functional preservation in the left occipital region in patients with chronic DOCs might reflect an awareness of external environments, whereas extensive functional preservation in the right cerebral hemisphere might reflect communication motivation.
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Affiliation(s)
- Noriko Usami
- Chubu Medical Center for Prolonged Traumatic Brain Injury, Gifu, Japan
- Department of Clinical Brain Sciences, Gifu University Graduate School of Medicine, Gifu, Japan
| | - Yoshitaka Asano
- Chubu Medical Center for Prolonged Traumatic Brain Injury, Gifu, Japan
- Department of Clinical Brain Sciences, Gifu University Graduate School of Medicine, Gifu, Japan
| | - Yuka Ikegame
- Chubu Medical Center for Prolonged Traumatic Brain Injury, Gifu, Japan
| | - Hiroaki Takei
- Chubu Medical Center for Prolonged Traumatic Brain Injury, Gifu, Japan
| | - Yuichi Yamada
- Chubu Medical Center for Prolonged Traumatic Brain Injury, Gifu, Japan
| | - Hirohito Yano
- Chubu Medical Center for Prolonged Traumatic Brain Injury, Gifu, Japan
- Department of Clinical Brain Sciences, Gifu University Graduate School of Medicine, Gifu, Japan
| | - Jun Shinoda
- Chubu Medical Center for Prolonged Traumatic Brain Injury, Gifu, Japan
- Department of Clinical Brain Sciences, Gifu University Graduate School of Medicine, Gifu, Japan
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Chen C, Han J, Zheng S, Zhang X, Sun H, Zhou T, Hu S, Yan X, Wang C, Wang K, Hu Y. Dynamic Changes of Brain Activity in Different Responsive Groups of Patients with Prolonged Disorders of Consciousness. Brain Sci 2022; 13:brainsci13010005. [PMID: 36671987 PMCID: PMC9856292 DOI: 10.3390/brainsci13010005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2022] [Revised: 12/07/2022] [Accepted: 12/12/2022] [Indexed: 12/24/2022] Open
Abstract
As medical technology continues to improve, many patients diagnosed with brain injury survive after treatments but are still in a coma. Further, multiple clinical studies have demonstrated recovery of consciousness after transcranial direct current stimulation. To identify possible neurophysiological mechanisms underlying disorders of consciousness (DOCs) improvement, we examined the changes in multiple resting-state EEG microstate parameters after high-definition transcranial direct current stimulation (HD-tDCS). Because the left dorsolateral prefrontal cortex is closely related to consciousness, it is often chosen as a stimulation target for tDCS treatment of DOCs. A total of 21 patients diagnosed with prolonged DOCs were included in this study, and EEG microstate analysis of resting state EEG datasets was performed on all patients before and after interventions. Each of them underwent 10 anodal tDCS sessions of the left dorsolateral prefrontal cortex over 5 consecutive working days. According to whether the clinical manifestations improved, DOCs patients were divided into the responsive (RE) group and the non-responsive (N-RE) group. The dynamic changes of resting state EEG microstate parameters were also analyzed. After multiple HD-tDCS interventions, the duration and coverage of class C microstates in the RE group were significantly increased. This study also found that the transition between microstates A and C increased, while the transition between microstates B and D decreased in the responsive group. However, these changes in EEG microstate parameters in the N-RE group have not been reported. Our findings suggest that EEG neural signatures have the potential to assess consciousness states and that improvement in the dynamics of brain activity was associated with the recovery of DOCs. This study extends our understanding of the neural mechanism of DOCs patients in consciousness recovery.
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Affiliation(s)
- Chen Chen
- Department of Neurology, The First Affiliated Hospital of Anhui Medical University, Hefei 230032, China
- Collaborative Innovation Center of Neuropsychiatric Disorders and Mental Health, Hefei 230032, China
- Anhui Province Key Laboratory of Cognition and Neuropsychiatric Disorders, Hefei 230032, China
- The School of Mental Health and Psychological Sciences, Anhui Medical University, Hefei 230032, China
| | - Jinying Han
- Department of Neurology, The First Affiliated Hospital of Anhui Medical University, Hefei 230032, China
- Collaborative Innovation Center of Neuropsychiatric Disorders and Mental Health, Hefei 230032, China
- Anhui Province Key Laboratory of Cognition and Neuropsychiatric Disorders, Hefei 230032, China
- The School of Mental Health and Psychological Sciences, Anhui Medical University, Hefei 230032, China
| | - Shuang Zheng
- Department of Neurology, The First Affiliated Hospital of Anhui Medical University, Hefei 230032, China
- Collaborative Innovation Center of Neuropsychiatric Disorders and Mental Health, Hefei 230032, China
- Anhui Province Key Laboratory of Cognition and Neuropsychiatric Disorders, Hefei 230032, China
- The School of Mental Health and Psychological Sciences, Anhui Medical University, Hefei 230032, China
| | - Xintong Zhang
- Department of Neurology, The First Affiliated Hospital of Anhui Medical University, Hefei 230032, China
- Collaborative Innovation Center of Neuropsychiatric Disorders and Mental Health, Hefei 230032, China
- Anhui Province Key Laboratory of Cognition and Neuropsychiatric Disorders, Hefei 230032, China
- The School of Mental Health and Psychological Sciences, Anhui Medical University, Hefei 230032, China
| | - Haibo Sun
- The First Clinical College of Anhui Medical University, Hefei 230032, China
| | - Ting Zhou
- Department of Neurology, The Second Affiliated Hospital of Anhui University of Chinese Medicine, Hefei 230001, China
| | - Shunyin Hu
- Department of Neurorehabilitation, Hefei Anhua Trauma Rehabilitation Hospital, Hefei 230011, China
| | - Xiaoxiang Yan
- Department of Neurology, The First Affiliated Hospital of Anhui Medical University, Hefei 230032, China
| | - Changqing Wang
- Department of Neurology, The First Affiliated Hospital of Anhui Medical University, Hefei 230032, China
| | - Kai Wang
- Department of Neurology, The First Affiliated Hospital of Anhui Medical University, Hefei 230032, China
- Collaborative Innovation Center of Neuropsychiatric Disorders and Mental Health, Hefei 230032, China
- Anhui Province Key Laboratory of Cognition and Neuropsychiatric Disorders, Hefei 230032, China
- The School of Mental Health and Psychological Sciences, Anhui Medical University, Hefei 230032, China
- Hefei Comprehensive National Science Center, Institute of Artificial Intelligence, Hefei 230032, China
| | - Yajuan Hu
- Department of Neurology, The First Affiliated Hospital of Anhui Medical University, Hefei 230032, China
- Collaborative Innovation Center of Neuropsychiatric Disorders and Mental Health, Hefei 230032, China
- Anhui Province Key Laboratory of Cognition and Neuropsychiatric Disorders, Hefei 230032, China
- The School of Mental Health and Psychological Sciences, Anhui Medical University, Hefei 230032, China
- Correspondence: ; Tel.: +139-5691-2105
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Qureshi AY, Stevens RD. Mapping the Unconscious Brain: Insights From Advanced Neuroimaging. J Clin Neurophysiol 2022; 39:12-21. [PMID: 34474430 DOI: 10.1097/wnp.0000000000000846] [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: 01/18/2023] Open
Abstract
SUMMARY Recent advances in neuroimaging have been a preeminent factor in the scientific effort to unravel mechanisms of conscious awareness and the pathophysiology of disorders of consciousness. In the first part of this review, we selectively discuss operational models of consciousness, the biophysical signal that is measured using different imaging modalities, and knowledge on disorders of consciousness that has been gleaned with each neuroimaging modality. Techniques considered include diffusion-weighted imaging, diffusion tensor imaging, different types of nuclear medicine imaging, functional MRI, magnetoencephalography, and the combined transcranial magnetic stimulation-electroencephalography approach. In the second part of this article, we provide an overview of how advanced neuroimaging can be leveraged to support neurological prognostication, the use of machine learning to process high-dimensional imaging data, potential applications in clinical practice, and future directions.
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Affiliation(s)
- Abid Y Qureshi
- Department of Neurology, University of Kansas Medical Center, Kansas City, Missouri, U.S.A.; and
| | - Robert D Stevens
- Departments of Anesthesiology and Critical Care, Neurology, Radiology, and Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, U.S.A
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Candia-Rivera D, Annen J, Gosseries O, Martial C, Thibaut A, Laureys S, Tallon-Baudry C. Neural Responses to Heartbeats Detect Residual Signs of Consciousness during Resting State in Postcomatose Patients. J Neurosci 2021; 41:5251-5262. [PMID: 33758019 PMCID: PMC8211547 DOI: 10.1523/jneurosci.1740-20.2021] [Citation(s) in RCA: 35] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2020] [Revised: 01/12/2021] [Accepted: 01/14/2021] [Indexed: 11/21/2022] Open
Abstract
The neural monitoring of visceral inputs might play a role in first-person perspective (i.e., the unified viewpoint of subjective experience). In healthy participants, how the brain responds to heartbeats, measured as the heartbeat-evoked response (HER), correlates with perceptual, bodily, and self-consciousness. Here we show that HERs in resting-state EEG data distinguishes between postcomatose male and female human patients (n = 68, split into training and validation samples) with the unresponsive wakefulness syndrome and in patients in a minimally conscious state with high accuracy (random forest classifier, 87% accuracy, 96% sensitivity, and 50% specificity in the validation sample). Random EEG segments not locked to heartbeats were useful to predict unconsciousness/consciousness, but HERs were more accurate, indicating that HERs provide specific information on consciousness. HERs also led to more accurate classification than heart rate variability. HER-based consciousness scores correlate with glucose metabolism in the default-mode network node located in the right superior temporal sulcus, as well as with the right ventral occipitotemporal cortex. These results were obtained when consciousness was inferred from brain glucose met`abolism measured with positron emission topography. HERs reflected the consciousness diagnosis based on brain metabolism better than the consciousness diagnosis based on behavior (Coma Recovery Scale-Revised, 77% validation accuracy). HERs thus seem to capture a capacity for consciousness that does not necessarily translate into intentional overt behavior. These results confirm the role of HERs in consciousness, offer new leads for future bedside testing, and highlight the importance of defining consciousness and its neural mechanisms independently from behavior.
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Affiliation(s)
- Diego Candia-Rivera
- Laboratoire de Neurosciences Cognitives et Computationnelles, Département d'Etudes Cognitives, École Normale Supérieure, INSERM, Université PSL, 75005 Paris, France
| | - Jitka Annen
- GIGA-Consciousness, Coma Science Group, University of Liège, 4000 Liège, Belgium
- Centre du Cerveau, University Hospital of Liège, 4000 Liège, Belgium
| | - Olivia Gosseries
- GIGA-Consciousness, Coma Science Group, University of Liège, 4000 Liège, Belgium
- Centre du Cerveau, University Hospital of Liège, 4000 Liège, Belgium
| | - Charlotte Martial
- GIGA-Consciousness, Coma Science Group, University of Liège, 4000 Liège, Belgium
- Centre du Cerveau, University Hospital of Liège, 4000 Liège, Belgium
| | - Aurore Thibaut
- GIGA-Consciousness, Coma Science Group, University of Liège, 4000 Liège, Belgium
- Centre du Cerveau, University Hospital of Liège, 4000 Liège, Belgium
| | - Steven Laureys
- GIGA-Consciousness, Coma Science Group, University of Liège, 4000 Liège, Belgium
- Centre du Cerveau, University Hospital of Liège, 4000 Liège, Belgium
| | - Catherine Tallon-Baudry
- Laboratoire de Neurosciences Cognitives et Computationnelles, Département d'Etudes Cognitives, École Normale Supérieure, INSERM, Université PSL, 75005 Paris, France
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Wang Z, Mascarenhas C, Jia X. Positron Emission Tomography After Ischemic Brain Injury: Current Challenges and Future Developments. Transl Stroke Res 2020; 11:628-642. [PMID: 31939060 PMCID: PMC7347441 DOI: 10.1007/s12975-019-00765-0] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2019] [Revised: 11/22/2019] [Accepted: 12/04/2019] [Indexed: 12/19/2022]
Abstract
Positron emission tomography (PET) is widely used in clinical and animal studies, along with the development of diverse tracers. The biochemical characteristics of PET tracers may help uncover the pathophysiological consequences of cardiac arrest (CA) and ischemic stroke, which include cerebral ischemia and reperfusion, depletion of oxygen and glucose, and neuroinflammation. PubMed was searched for studies of the application of PET for "cardiac arrest," "ischemic stroke," and "targeted temperature management." Available studies were included and classified according to the biochemical properties involved and metabolic processes of PET tracers, and were summarized. The mechanisms of ischemic brain injuries were investigated by PET with various tracers to elucidate the pathological process from the initial decrease of cerebral blood flow (CBF) to the subsequent abnormalities in energy and oxygen metabolism, to the monitoring of inflammation. In general, the trends of cerebral blood flow and oxygen metabolism after ischemic attack are not unidirectional but closely related to the time point of injury and recovery. Glucose metabolism after injury showed significant differences in different brain regions whereas global cerebral metabolic rate of glucose (CMRglc) declined. PET monitoring of neuroinflammation shows comparable efficacy to immunostaining. The technology of PET targeting in brain metabolism and the development of tracers provide new tools to track and evaluate the brain's pathological changes after ischemic brain injury. Despite no existing evidence for an available PET-based prediction method, discoveries of new tracers are expected to provide more possibilities for the whole field.
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Affiliation(s)
- Zhuoran Wang
- Department of Critical Care Medicine, Zhongnan Hospital of Wuhan University, Wuhan, 43007, China
- Department of Neurosurgery, University of Maryland School of Medicine, 10 South Pine Street, MSTF Building 823, Baltimore, MD, 21201, USA
| | - Conrad Mascarenhas
- Department of Neurosurgery, University of Maryland School of Medicine, 10 South Pine Street, MSTF Building 823, Baltimore, MD, 21201, USA
| | - Xiaofeng Jia
- Department of Neurosurgery, University of Maryland School of Medicine, 10 South Pine Street, MSTF Building 823, Baltimore, MD, 21201, USA.
- Department of Orthopedics, University of Maryland School of Medicine, Baltimore, MD, 21201, USA.
- Department of Anatomy and Neurobiology, University of Maryland School of Medicine, Baltimore, MD, 21201, USA.
- Department of Biomedical Engineering, Johns Hopkins University School of Medicine, Baltimore, MD, 21205, USA.
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, 21205, USA.
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Bai Y, Xia X, Wang Y, He J, Li X. Electroencephalography quadratic phase self-coupling correlates with consciousness states and restoration in patients with disorders of consciousness. Clin Neurophysiol 2019; 130:1235-1242. [PMID: 31163368 DOI: 10.1016/j.clinph.2019.04.710] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2018] [Revised: 03/27/2019] [Accepted: 04/09/2019] [Indexed: 11/17/2022]
Abstract
OBJECTIVE The objective of this study was to explore the role for quadratic phase coupling within electroencephalography (EEG) oscillations in the diagnosis of consciousness and consciousness restoration for disorders of consciousness (DOC). METHODS Fifty-one DOC patients were enrolled in this study. For each patient, a Coma Recovery Scale-Revised (CRS-R) score and 20-min resting-state EEG were recorded. Consciousness recovery was assessed with a CRS-R score at a three-month follow-up. Twenty healthy subjects were included as controls. General harmonic wavelet transform-based bicoherence was used to quantify the quadratic phase coupling characteristics of the EEG oscillations. RESULTS Quadratic phase self-coupling (QPSC) at the delta (QPSC_delta), theta (QPSC_theta) and alpha (QPSC_alpha) bands were closely correlated with patient CRS-R scores. Particularly, the QPSC_theta value could significantly differentiate between vegetative state (VS) patients, minimally conscious state (MCS) patients and healthy control subjects. As compared to VS patients, patients with MCS had a lower QPSC_theta value on the left as well as a higher QPSC_alpha value in right frontal regions. The frontal QPSC_theta value showed significant differences between recovered and unrecovered patients. CONCLUSION QPSC characteristics could differentiate between consciousness states and show a predictive ability for the recovery of consciousness in DOC patients. SIGNIFICANCE Changes in QPSC accompany consciousness injury and restoration in DOC patients. A QPSC assessment is helpful in the diagnosis and prognosis of DOC patients.
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Affiliation(s)
- Yang Bai
- Department of Basic Medical Science, School of Medicine, Hangzhou Normal University, Hangzhou, Zhejiang 311121, China; International Vegetative State and Consciousness Science Institute, Hangzhou Normal University, Hangzhou, Zhejiang 311121, China
| | - Xiaoyu Xia
- Department of Neurosurgery, PLA Army General Hospital, Beijing 100700, China
| | - Yong Wang
- Institute of Electrical Engineering, Yanshan University, Qinhuangdao 066004, China
| | - Jianghong He
- Department of Neurosurgery, PLA Army General Hospital, Beijing 100700, China
| | - Xiaoli Li
- State Key Laboratory of Cognitive Neuroscience and Learning & IDG/McGovern Institute for Brain Research, Beijing Normal University, Beijing 100875, China.
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Kotchoubey B, Pavlov YG. A Systematic Review and Meta-Analysis of the Relationship Between Brain Data and the Outcome in Disorders of Consciousness. Front Neurol 2018; 9:315. [PMID: 29867725 PMCID: PMC5954214 DOI: 10.3389/fneur.2018.00315] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2018] [Accepted: 04/20/2018] [Indexed: 12/29/2022] Open
Abstract
A systematic search revealed 68 empirical studies of neurophysiological [EEG, event-related brain potential (ERP), fMRI, PET] variables as potential outcome predictors in patients with Disorders of Consciousness (diagnoses Unresponsive Wakefulness Syndrome [UWS] and Minimally Conscious State [MCS]). Data of 47 publications could be presented in a quantitative manner and systematically reviewed. Insufficient power and the lack of an appropriate description of patient selection each characterized about a half of all publications. In more than 80% studies, neurologists who evaluated the patients' outcomes were familiar with the results of neurophysiological tests conducted before, and may, therefore, have been influenced by this knowledge. In most subsamples of datasets, effect size significantly correlated with its standard error, indicating publication bias toward positive results. Neurophysiological data predicted the transition from UWS to MCS substantially better than they predicted the recovery of consciousness (i.e., the transition from UWS or MCS to exit-MCS). A meta-analysis was carried out for predictor groups including at least three independent studies with N > 10 per predictor per improvement criterion (i.e., transition to MCS versus recovery). Oscillatory EEG responses were the only predictor group whose effect attained significance for both improvement criteria. Other perspective variables, whose true prognostic value should be explored in future studies, are sleep spindles in the EEG and the somatosensory cortical response N20. Contrary to what could be expected on the basis of neuroscience theory, the poorest prognostic effects were shown for fMRI responses to stimulation and for the ERP component P300. The meta-analytic results should be regarded as preliminary given the presence of numerous biases in the data.
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Affiliation(s)
- Boris Kotchoubey
- Institute of Medical Psychology, University of Tübingen, Tübingen, Germany
| | - Yuri G Pavlov
- Institute of Medical Psychology, University of Tübingen, Tübingen, Germany.,Department of Psychology, Ural Federal University, Yekaterinburg, Russia
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Kiani M, Abbasi M, Ahmadi M, Salehi B. Organ Transplantation in Iran; Current State and Challenges with a View on Ethical Consideration. J Clin Med 2018; 7:E45. [PMID: 29510570 PMCID: PMC5867571 DOI: 10.3390/jcm7030045] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2017] [Revised: 02/23/2018] [Accepted: 02/27/2018] [Indexed: 12/31/2022] Open
Abstract
Organ transplantation is a new issue in medical science. It is an important achievement and a sign of the progression and ability of medical centers around the world. Governments, populations, the medical community and people involved in culture, art, and media all have a decisive role in the culture of organ donation, which is the only way to guarantee that the healthy organs of a brain-dead person can continue to work and save the lives of people in need of organ transplantation. The brain death phenomenon and its possible application in organ transplantation, while offering new hope for the salvation of a number of patients, has led to many ethical, cultural, and legal issues. Ethical issues in organ transplantation are very complicated due to many social factors such as religion, culture, and traditions of the affected communities. The ethical and legal points of removing organs from the body of a living or cadaveric source, the definition of brain death, the moral and legal conditions of the donor and the recipient, and the financial relationship between them and many others, are all critical issues in organ transplantation. While there may be no available explicit solution to these issues, they should be rigorously considered by the experts. Efforts to systematically eliminate barriers and solve problems in organ transplantation, can not only reduce the costs of maintaining brain-dead patients and encourage patients that need organ transplantation but can also prevent immoral and illegal activities. In this paper, we have reviewed the most important and current challenges in organ transplantation with a view to the ethical considerations, and we have suggested some strategies to extend it in Iran.
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Affiliation(s)
- Mehrzad Kiani
- Department of Medical Ethics, Faculty of Traditional Medicine, Shahid Beheshti University of Medical Sciences, Tehran 1985717443, Iran.
| | - Mahmoud Abbasi
- Medical Ethics and Law Research Center, Shahid Beheshti University of Medical Sciences, Tehran 1985717443, Iran.
| | - Mehdi Ahmadi
- Razi Vaccine and Serum Research Institute (RVSRI), Agricultural Research, Education and Extension Organization (AREEO), Karaj 3197619751, Iran.
| | - Bahare Salehi
- Medical Ethics and Law Research Center, Shahid Beheshti University of Medical Sciences, Tehran 1985717443, Iran.
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11
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Annen J, Heine L, Ziegler E, Frasso G, Bahri M, Di Perri C, Stender J, Martial C, Wannez S, D'ostilio K, Amico E, Antonopoulos G, Bernard C, Tshibanda F, Hustinx R, Laureys S. Function-structure connectivity in patients with severe brain injury as measured by MRI-DWI and FDG-PET. Hum Brain Mapp 2018; 37:3707-3720. [PMID: 27273334 DOI: 10.1002/hbm.23269] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2016] [Revised: 04/12/2016] [Accepted: 05/16/2016] [Indexed: 02/05/2023] Open
Abstract
A vast body of literature exists showing functional and structural dysfunction within the brains of patients with disorders of consciousness. However, the function (fluorodeoxyglucose FDG-PET metabolism)-structure (MRI-diffusion-weighted images; DWI) relationship and how it is affected in severely brain injured patients remains ill-defined. FDG-PET and MRI-DWI in 25 severely brain injured patients (19 Disorders of Consciousness of which 7 unresponsive wakefulness syndrome, 12 minimally conscious; 6 emergence from minimally conscious state) and 25 healthy control subjects were acquired here. Default mode network (DMN) function-structure connectivity was assessed by fractional anisotropy (FA) and metabolic standardized uptake value (SUV). As expected, a profound decline in regional metabolism and white matter integrity was found in patients as compared with healthy subjects. Furthermore, a function-structure relationship was present in brain-damaged patients between functional metabolism of inferior-parietal, precuneus, and frontal regions and structural integrity of the frontal-inferiorparietal, precuneus-inferiorparietal, thalamo-inferioparietal, and thalamofrontal tracts. When focusing on patients, a stronger relationship between structural integrity of thalamo-inferiorparietal tracts and thalamic metabolism in patients who have emerged from the minimally conscious state as compared with patients with disorders of consciousness was found. The latter finding was in line with the mesocircuit hypothesis for the emergence of consciousness. The findings showed a positive function-structure relationship within most regions of the DMN. Hum Brain Mapp 37:3707-3720, 2016. © 2016 Wiley Periodicals, Inc.
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Affiliation(s)
- J Annen
- Cyclotron Research Centre, University of Liège, Liège, Belgium.,Coma Science Group, GIGA Consciousness, University of Liège, Liège, Belgium.,University Hospital of Liège, Liège, Belgium
| | - L Heine
- Cyclotron Research Centre, University of Liège, Liège, Belgium.,Coma Science Group, GIGA Consciousness, University of Liège, Liège, Belgium.,University Hospital of Liège, Liège, Belgium
| | - E Ziegler
- Cyclotron Research Centre, University of Liège, Liège, Belgium
| | - G Frasso
- Faculty of Social Sciences, Quantitative Methods for Social Sciences, University of Liège, Liège, Belgium
| | - M Bahri
- Cyclotron Research Centre, University of Liège, Liège, Belgium
| | - C Di Perri
- Cyclotron Research Centre, University of Liège, Liège, Belgium.,Coma Science Group, GIGA Consciousness, University of Liège, Liège, Belgium
| | - J Stender
- University of Copenhagen, Copenhagen, Denmark
| | - C Martial
- Cyclotron Research Centre, University of Liège, Liège, Belgium.,Coma Science Group, GIGA Consciousness, University of Liège, Liège, Belgium.,University Hospital of Liège, Liège, Belgium
| | - S Wannez
- Cyclotron Research Centre, University of Liège, Liège, Belgium.,Coma Science Group, GIGA Consciousness, University of Liège, Liège, Belgium.,University Hospital of Liège, Liège, Belgium
| | - K D'ostilio
- Headache Research Unit, University of Liège, Liège, Belgium
| | - E Amico
- Cyclotron Research Centre, University of Liège, Liège, Belgium.,Coma Science Group, GIGA Consciousness, University of Liège, Liège, Belgium
| | - G Antonopoulos
- Cyclotron Research Centre, University of Liège, Liège, Belgium.,Coma Science Group, GIGA Consciousness, University of Liège, Liège, Belgium
| | - C Bernard
- University Hospital of Liège, Liège, Belgium
| | - F Tshibanda
- University Hospital of Liège, Liège, Belgium
| | - R Hustinx
- University Hospital of Liège, Liège, Belgium
| | - S Laureys
- Cyclotron Research Centre, University of Liège, Liège, Belgium. .,Coma Science Group, GIGA Consciousness, University of Liège, Liège, Belgium. .,University Hospital of Liège, Liège, Belgium.
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12
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Golkowski D, Merz K, Mlynarcik C, Kiel T, Schorr B, Lopez-Rolon A, Lukas M, Jordan D, Bender A, Ilg R. Simultaneous EEG–PET–fMRI measurements in disorders of consciousness: an exploratory study on diagnosis and prognosis. J Neurol 2017; 264:1986-1995. [DOI: 10.1007/s00415-017-8591-z] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2017] [Revised: 08/08/2017] [Accepted: 08/08/2017] [Indexed: 12/28/2022]
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13
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Transcranial parenchymal sonography in patients with Chronic Disorders of Consciousness: Association with neuroimaging data, and beyond. Conscious Cogn 2017; 52:32-38. [PMID: 28460271 DOI: 10.1016/j.concog.2017.04.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2017] [Revised: 04/05/2017] [Accepted: 04/17/2017] [Indexed: 10/19/2022]
Abstract
Differential diagnosis of patients with Chronic Disorders of Consciousness (DoC) is rather challenging, owing to the lack of objective approaches highlighting residual awareness. Sophisticated functional neuroimaging have provided high diagnostic value, but their application in the clinical setting is limited due to their relative complexity, cost, availability and poor collaboration of persons with DoC. By using a specific ultrasound-based methodology, namely Transcranial B-mode Parenchymal Sonography (TCS), it is possible to obtain images of the main parenchymal brain structures. We assessed the TCS abnormalities in three patients with DoC, demonstrating widespread alterations of brain parenchyma morphology that matched to MRI findings and were associated with the degree of consciousness disorders. Thus, TCS might represent a valuable tool for routine assessment and follow-up of brain structures functioning of patients with DoC, potentially helping in differential diagnosis and prognosis.
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14
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Keller I, Garbacenkaite R. Neurofeedback in three patients in the state of unresponsive wakefulness. Appl Psychophysiol Biofeedback 2016; 40:349-56. [PMID: 26159769 DOI: 10.1007/s10484-015-9296-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Some severely brain injured patients remain unresponsive, only showing reflex movements without any response to command. This syndrome has been named unresponsive wakefulness syndrome (UWS). The objective of the present study was to determine whether UWS patients are able to alter their brain activity using neurofeedback (NFB) technique. A small sample of three patients received a daily session of NFB for 3 weeks. We applied the ratio of theta and beta amplitudes as a feedback variable. Using an automatic threshold function, patients heard their favourite music whenever their theta/beta ratio dropped below the threshold. Changes in awareness were assessed weekly with the JFK Coma Recovery Scale-Revised for each treatment week, as well as 3 weeks before and after NFB. Two patients showed a decrease in their theta/beta ratio and theta-amplitudes during this period. The third patient showed no systematic changes in his EEG activity. The results of our study provide the first evidence that NFB can be used in patients in a state of unresponsive wakefulness.
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Affiliation(s)
- Ingo Keller
- Schoen Klinik Bad Aibling, Kolbermoorer Strasse 72, 83043, Bad Aibling, Germany.
| | - Ruta Garbacenkaite
- Clinical Neuropsychology Unit and Outpatient Service, Saarland University, Saarbruecken, Germany
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15
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Towards a method to differentiate chronic disorder of consciousness patients' awareness: The Low-Resolution Brain Electromagnetic Tomography Analysis. J Neurol Sci 2016; 368:178-83. [PMID: 27538628 DOI: 10.1016/j.jns.2016.07.016] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2016] [Revised: 07/01/2016] [Accepted: 07/08/2016] [Indexed: 01/18/2023]
Abstract
Assessing residual signs of awareness in patients suffering from chronic disorders of consciousness (DOC) is a challenging issue. DOC patient behavioral assessment is often doubtful since some individuals may retain covert traces of awareness; thus, some Unresponsive Wakefulness Syndrome (UWS) patients may be misdiagnosed. The aim of our study was to explore possible differences between the source powers within poly-modal cortices to differentiate Minimally Conscious State (MCS) from UWS. To this end, we recorded an electroencephalogram (EEG) during awake resting state and performed a Low-Resolution Brain Electromagnetic Tomography (LORETA), which is a 3D source localization method allowing the visualization of the most probable neuroanatomical generators of EEG differences. MCS and UWS patients showed significant variations concerning the frontal source power of delta-band, frontal and parietal of theta, parietal and occipital of alpha, central of beta, and parietal of gamma, in correlation with the Coma Recovery Scale-Revised (CRS-R) score. The alpha-band was the most significant LORETA data correlating with the consciousness level. In addition, we observed a significant correlation between central beta-peaks and the motor abilities and a dissociation between theta and gamma bands within parietal regions. Our findings suggest that LORETA analysis may be useful in DOC differential diagnosis since distinct neurophysiological correlates in some UWS patients could be used to assess deeper the residual cerebral activity of brain areas responsible for covert awareness.
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16
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Gosseries O, Pistoia F, Charland-Verville V, Carolei A, Sacco S, Laureys S. The Role of Neuroimaging Techniques in Establishing Diagnosis, Prognosis and Therapy in Disorders of Consciousness. Open Neuroimag J 2016; 10:52-68. [PMID: 27347265 PMCID: PMC4894918 DOI: 10.2174/1874440001610010052] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2016] [Revised: 04/06/2016] [Accepted: 04/11/2016] [Indexed: 12/30/2022] Open
Abstract
Non-communicative brain damaged patients raise important clinical and scientific issues. Here, we review three major pathological disorders of consciousness: coma, the unresponsive wakefulness syndrome and the minimally conscious state. A number of clinical studies highlight the difficulty in making a correct diagnosis in patients with disorders of consciousness based only on behavioral examinations. The increasing use of neuroimaging techniques allows improving clinical characterization of these patients. Recent neuroimaging studies using positron emission tomography, functional magnetic resonance imaging, electroencephalography and transcranial magnetic stimulation can help assess diagnosis, prognosis, and therapeutic treatment. These techniques, using resting state, passive and active paradigms, also highlight possible dissociations between consciousness and responsiveness, and are facilitating a more accurate understanding of brain function in this challenging population.
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Affiliation(s)
- Olivia Gosseries
- Coma Science Group, GIGA, University of Liege, Liege, Belgium; Department of Psychology and Psychiatry, University of Wisconsin, Madison, WI, United-States
| | - Francesca Pistoia
- Department of Biotechnological and Applied Clinical Sciences, Neurological Institute, University of L'Aquila, L'Aquila, Italy
| | | | - Antonio Carolei
- Department of Biotechnological and Applied Clinical Sciences, Neurological Institute, University of L'Aquila, L'Aquila, Italy
| | - Simona Sacco
- Department of Biotechnological and Applied Clinical Sciences, Neurological Institute, University of L'Aquila, L'Aquila, Italy
| | - Steven Laureys
- Coma Science Group, GIGA, University of Liege, Liege, Belgium
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Liu Z, Zhou Y, Yi R, He J, Yang Y, Luo L, Dai Y, Luo X. Quantitative research into the deconditioning of hemodynamic to disorder of consciousness carried out using transcranial Doppler ultrasonography and photoplethysmography obtained via finger-transmissive absorption. Neurol Sci 2016; 37:547-55. [PMID: 26758709 PMCID: PMC4819775 DOI: 10.1007/s10072-015-2429-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2015] [Accepted: 11/23/2015] [Indexed: 11/06/2022]
Abstract
In this study, transcranial Doppler ultrasonography (TCD) and photoplethysmography (PPG) have been utilized, through the observation of peripheral and cerebrovascular hemodynamic changes of the disorder of consciousness (DOC) patients, measured on clinical behavior scale of Coma Recovery Score-Revised (CRS-R) to obesrve their diagnostic value in evaluation of DOC patients. TCD ultrasound was used to evaluate the flow velocity and waveform patterns of middle cerebral artery (MCA), while PPG infrared signals were utilized to assess the peripheral circulation as a mean of measuring cardiovascular activities. The research was carried out on a sample of 36 individuals, of which 16 met the DOC criteria and 20 were healthy individuals. Each person in the patients groups was assessed by the CRS-R. The velocity of middle cerebral artery in tested patients in a whole cardiac cycle, detected by TCD, decreased comparing with normal values. The values of pulsatility index (PI) of the MCA increased in patients groups comparing with normal. Through binary variables correlation analysis, we found that the PI of the left MCA of TCD of the patients significantly inversely correlated with their motor subscore, included in their CRS-R in the level of α = 0.05 (Pearson’s product-moment correlation coefficient = −0.556, p = 0.025). The values of photoplethysmographic augmentation index (PAI) that were detected by PPG increased comparing with normal. Finally, using binary variables correlation analysis we found the significant inverse correlation between the PAI of PPG and the mean velocity of the left MCA of the TCD in the level of α = 0.05 (Pearson’s product-moment correlation coefficient = −0.377, p = 0.022) in all the groups. The results of this study revealed a specific relationship between PI and PAI in the DOC patients. That relationship can potentially be exploited to enhance the capabilities in early assessment of the deconditioning of the DOC patients’ cardiovascular system and its influence on their cerebral vascular system. Ultimately, the dependency discovered can assist in predicting the tendency of the prognosis of the DOC patients in clinic.
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Affiliation(s)
- Zhen Liu
- Department of Neurosurgery, No. 263 Clinical Department of Beijing Army General Hospital, Beijing, 101149, China.
| | - Yan Zhou
- Department of Internal Medicine, TongZhou Maternal and Child Health Hospital of Beijing, Beijing, 100000, China
| | - Rui Yi
- Department of Neurosurgery, Beijing Army General Hospital, Beijing, 100700, China
| | - Jianghong He
- Department of Neurosurgery, Beijing Army General Hospital, Beijing, 100700, China
| | - Yi Yang
- Department of Neurosurgery, Beijing Army General Hospital, Beijing, 100700, China
| | - Li Luo
- Department of Neurosurgery, Beijing Army General Hospital, Beijing, 100700, China
| | - Yiwu Dai
- Department of Neurosurgery, Beijing Army General Hospital, Beijing, 100700, China
| | - Xiaomin Luo
- Healthcare Department, Beijing Genomics Institute, Shenzhen, 518083, China
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18
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Hannawi Y, Lindquist MA, Caffo BS, Sair HI, Stevens RD. Resting brain activity in disorders of consciousness: a systematic review and meta-analysis. Neurology 2015; 84:1272-80. [PMID: 25713001 DOI: 10.1212/wnl.0000000000001404] [Citation(s) in RCA: 98] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
Abstract
OBJECTIVE To quantitatively synthesize results from neuroimaging studies that evaluated patterns of resting functional activity in patients with disorders of consciousness (DOC). METHODS We performed a systematic review and coordinate-based meta-analysis of studies published up to May 2014. Studies were included if they compared resting-state functional neuroimaging data acquired in patients with DOC (coma, minimally conscious state, emergence from minimally conscious state, or vegetative state) with a group of healthy controls. Coordinate-based meta-analysis was performed in studies that included voxel-based comparisons at the whole-brain level and if analysis was accomplished with data-driven approaches. RESULTS A total of 36 studies (687 patients, 637 healthy controls) were included in the systematic review. Reported DOC were vegetative state (43.2%), coma (23.4%), minimally conscious state (22.8%), and emergence from minimally conscious state (1.6%); the most common etiologies of DOC were traumatic brain injury (37.7%) and anoxic brain injury (36.9%). Functional neuroimaging was accomplished using fMRI (16 studies), PET (15 studies), SPECT (4 studies), and both PET and SPECT in one study. Meta-analysis in 13 studies (272 patients, 259 healthy controls) revealed consistently reduced activity in patients with DOC in bilateral medial dorsal nucleus of the thalamus, left cingulate, posterior cingulate, precuneus, and middle frontal and medial temporal gyri. CONCLUSIONS In patients with DOC evaluated in the resting state, functional neuroimaging indicates markedly reduced activity within midline cortical and subcortical sites, anatomical structures that have been linked to the default-mode network. Studies are needed to determine the relation between activation (and coherence) within these structures and the emergence of conscious awareness.
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Affiliation(s)
- Yousef Hannawi
- From the Departments of Anesthesiology and Critical Care Medicine (Y.H., R.D.S.), Neurology (Y.H., R.D.S.), Radiology (H.I.S., R.D.S.), and Neurosurgery (R.D.S.), Johns Hopkins University School of Medicine, Baltimore; and Department of Biostatistics (M.A.L., B.S.C.), Johns Hopkins Bloomberg School of Public Health, Baltimore, MD.
| | - Martin A Lindquist
- From the Departments of Anesthesiology and Critical Care Medicine (Y.H., R.D.S.), Neurology (Y.H., R.D.S.), Radiology (H.I.S., R.D.S.), and Neurosurgery (R.D.S.), Johns Hopkins University School of Medicine, Baltimore; and Department of Biostatistics (M.A.L., B.S.C.), Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Brian S Caffo
- From the Departments of Anesthesiology and Critical Care Medicine (Y.H., R.D.S.), Neurology (Y.H., R.D.S.), Radiology (H.I.S., R.D.S.), and Neurosurgery (R.D.S.), Johns Hopkins University School of Medicine, Baltimore; and Department of Biostatistics (M.A.L., B.S.C.), Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Haris I Sair
- From the Departments of Anesthesiology and Critical Care Medicine (Y.H., R.D.S.), Neurology (Y.H., R.D.S.), Radiology (H.I.S., R.D.S.), and Neurosurgery (R.D.S.), Johns Hopkins University School of Medicine, Baltimore; and Department of Biostatistics (M.A.L., B.S.C.), Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Robert D Stevens
- From the Departments of Anesthesiology and Critical Care Medicine (Y.H., R.D.S.), Neurology (Y.H., R.D.S.), Radiology (H.I.S., R.D.S.), and Neurosurgery (R.D.S.), Johns Hopkins University School of Medicine, Baltimore; and Department of Biostatistics (M.A.L., B.S.C.), Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
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19
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Stender J, Kupers R, Rodell A, Thibaut A, Chatelle C, Bruno MA, Gejl M, Bernard C, Hustinx R, Laureys S, Gjedde A. Quantitative rates of brain glucose metabolism distinguish minimally conscious from vegetative state patients. J Cereb Blood Flow Metab 2015; 35:58-65. [PMID: 25294128 PMCID: PMC4294395 DOI: 10.1038/jcbfm.2014.169] [Citation(s) in RCA: 68] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2014] [Revised: 08/11/2014] [Accepted: 09/03/2014] [Indexed: 12/20/2022]
Abstract
The differentiation of the vegetative or unresponsive wakefulness syndrome (VS/UWS) from the minimally conscious state (MCS) is an important clinical issue. The cerebral metabolic rate of glucose (CMRglc) declines when consciousness is lost, and may reveal the residual cognitive function of these patients. However, no quantitative comparisons of cerebral glucose metabolism in VS/UWS and MCS have yet been reported. We calculated the regional and whole-brain CMRglc of 41 patients in the states of VS/UWS (n=14), MCS (n=21) or emergence from MCS (EMCS, n=6), and healthy volunteers (n=29). Global cortical CMRglc in VS/UWS and MCS averaged 42% and 55% of normal, respectively. Differences between VS/UWS and MCS were most pronounced in the frontoparietal cortex, at 42% and 60% of normal. In brainstem and thalamus, metabolism declined equally in the two conditions. In EMCS, metabolic rates were indistinguishable from those of MCS. Ordinal logistic regression predicted that patients are likely to emerge into MCS at CMRglc above 45% of normal. Receiver-operating characteristics showed that patients in MCS and VS/UWS can be differentiated with 82% accuracy, based on cortical metabolism. Together these results reveal a significant correlation between whole-brain energy metabolism and level of consciousness, suggesting that quantitative values of CMRglc reveal consciousness in severely brain-injured patients.
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Affiliation(s)
- Johan Stender
- 1] Department of Neuroscience and Pharmacology, University of Copenhagen, Copenhagen, Denmark [2] Cyclotron Research Centre and Neurology Department, University and University Hospital of Liège, Liège, Belgium
| | - Ron Kupers
- Department of Neuroscience and Pharmacology, University of Copenhagen, Copenhagen, Denmark
| | - Anders Rodell
- 1] Department of Nuclear Medicine and PET Centre, Aarhus University Hospital, Aarhus, Denmark [2] Centre for Advanced Imaging, University of Queensland, Brisbane, Australia
| | - Aurore Thibaut
- Cyclotron Research Centre and Neurology Department, University and University Hospital of Liège, Liège, Belgium
| | - Camille Chatelle
- Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Marie-Aurélie Bruno
- Cyclotron Research Centre and Neurology Department, University and University Hospital of Liège, Liège, Belgium
| | - Michael Gejl
- 1] Centre for Advanced Imaging, University of Queensland, Brisbane, Australia [2] Department of Biomedicine-Pharmacology, Aarhus University, Aarhus, Denmark
| | - Claire Bernard
- Department of Nuclear Medicine, University Hospital of Liège, Liège, Belgium
| | - Roland Hustinx
- Department of Nuclear Medicine, University Hospital of Liège, Liège, Belgium
| | - Steven Laureys
- Cyclotron Research Centre and Neurology Department, University and University Hospital of Liège, Liège, Belgium
| | - Albert Gjedde
- 1] Department of Neuroscience and Pharmacology, University of Copenhagen, Copenhagen, Denmark [2] Department of Neurology, McGill University, Montréal, Québec, Canada [3] Department of Radiology and Radiological Science, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
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20
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Shulman RG, Hyder F, Rothman DL. Insights from neuroenergetics into the interpretation of functional neuroimaging: an alternative empirical model for studying the brain's support of behavior. J Cereb Blood Flow Metab 2014; 34:1721-35. [PMID: 25160670 PMCID: PMC4269754 DOI: 10.1038/jcbfm.2014.145] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2014] [Revised: 06/12/2014] [Accepted: 07/21/2014] [Indexed: 02/05/2023]
Abstract
Functional neuroimaging measures quantitative changes in neurophysiological parameters coupled to neuronal activity during observable behavior. These results have usually been interpreted by assuming that mental causation of behavior arises from the simultaneous actions of distinct psychological mechanisms or modules. However, reproducible localization of these modules in the brain using functional magnetic resonance imaging (MRI) and positron emission tomography (PET) imaging has been elusive other than for sensory systems. In this paper, we show that neuroenergetic studies using PET, calibrated functional magnetic resonance imaging (fMRI), (13)C magnetic resonance spectroscopy, and electrical recordings do not support the standard approach, which identifies the location of mental modules from changes in brain activity. Of importance in reaching this conclusion is that changes in neuronal activities underlying the fMRI signal are many times smaller than the high ubiquitous, baseline neuronal activity, or energy in resting, awake humans. Furthermore, the incremental signal depends on the baseline activity contradicting theoretical assumptions about linearity and insertion of mental modules. To avoid these problems, while making use of these valuable results, we propose that neuroimaging should be used to identify observable brain activities that are necessary for a person's observable behavior rather than being used to seek hypothesized mental processes.
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Affiliation(s)
- Robert G Shulman
- Magnetic Resonance Research Center, Yale University, New Haven, Connecticut, USA
| | - Fahmeed Hyder
- Magnetic Resonance Research Center, Yale University, New Haven, Connecticut, USA
- Departments of Diagnostic Radiology, Yale University, New Haven, Connecticut, USA
- Biomedical Engineering, Yale University, New Haven, Connecticut, USA
- Quantitative Neuroscience with Magnetic Resonance Core Center, Yale University, New Haven, Connecticut, USA
| | - Douglas L Rothman
- Magnetic Resonance Research Center, Yale University, New Haven, Connecticut, USA
- Departments of Diagnostic Radiology, Yale University, New Haven, Connecticut, USA
- Biomedical Engineering, Yale University, New Haven, Connecticut, USA
- Quantitative Neuroscience with Magnetic Resonance Core Center, Yale University, New Haven, Connecticut, USA
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21
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Stender J, Gosseries O, Bruno MA, Charland-Verville V, Vanhaudenhuyse A, Demertzi A, Chatelle C, Thonnard M, Thibaut A, Heine L, Soddu A, Boly M, Schnakers C, Gjedde A, Laureys S. Diagnostic precision of PET imaging and functional MRI in disorders of consciousness: a clinical validation study. Lancet 2014; 384:514-22. [PMID: 24746174 DOI: 10.1016/s0140-6736(14)60042-8] [Citation(s) in RCA: 301] [Impact Index Per Article: 30.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND Bedside clinical examinations can have high rates of misdiagnosis of unresponsive wakefulness syndrome (vegetative state) or minimally conscious state. The diagnostic and prognostic usefulness of neuroimaging-based approaches has not been established in a clinical setting. We did a validation study of two neuroimaging-based diagnostic methods: PET imaging and functional MRI (fMRI). METHODS For this clinical validation study, we included patients referred to the University Hospital of Liège, Belgium, between January, 2008, and June, 2012, who were diagnosed by our unit with unresponsive wakefulness syndrome, locked-in syndrome, or minimally conscious state with traumatic or non-traumatic causes. We did repeated standardised clinical assessments with the Coma Recovery Scale-Revised (CRS-R), cerebral (18)F-fluorodeoxyglucose (FDG) PET, and fMRI during mental activation tasks. We calculated the diagnostic accuracy of both imaging methods with CRS-R diagnosis as reference. We assessed outcome after 12 months with the Glasgow Outcome Scale-Extended. FINDINGS We included 41 patients with unresponsive wakefulness syndrome, four with locked-in syndrome, and 81 in a minimally conscious state (48=traumatic, 78=non-traumatic; 110=chronic, 16=subacute). (18)F-FDG PET had high sensitivity for identification of patients in a minimally conscious state (93%, 95% CI 85-98) and high congruence (85%, 77-90) with behavioural CRS-R scores. The active fMRI method was less sensitive at diagnosis of a minimally conscious state (45%, 30-61) and had lower overall congruence with behavioural scores (63%, 51-73) than PET imaging. (18)F-FDG PET correctly predicted outcome in 75 of 102 patients (74%, 64-81), and fMRI in 36 of 65 patients (56%, 43-67). 13 of 41 (32%) of the behaviourally unresponsive patients (ie, diagnosed as unresponsive with CRS-R) showed brain activity compatible with (minimal) consciousness (ie, activity associated with consciousness, but diminished compared with fully conscious individuals) on at least one neuroimaging test; 69% of these (9 of 13) patients subsequently recovered consciousness. INTERPRETATION Cerebral (18)F-FDG PET could be used to complement bedside examinations and predict long-term recovery of patients with unresponsive wakefulness syndrome. Active fMRI might also be useful for differential diagnosis, but seems to be less accurate. FUNDING The Belgian National Funds for Scientific Research (FNRS), Fonds Léon Fredericq, the European Commission, the James McDonnell Foundation, the Mind Science Foundation, the French Speaking Community Concerted Research Action, the University of Copenhagen, and the University of Liège.
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Affiliation(s)
- Johan Stender
- Coma Science Group, Cyclotron Research Center and Neurology Department, University and University Hospital of Liège, Liège, Belgium; Department of Neuroscience and Pharmacology, University of Copenhagen, Copenhagen, Denmark
| | - Olivia Gosseries
- Coma Science Group, Cyclotron Research Center and Neurology Department, University and University Hospital of Liège, Liège, Belgium
| | - Marie-Aurélie Bruno
- Coma Science Group, Cyclotron Research Center and Neurology Department, University and University Hospital of Liège, Liège, Belgium
| | - Vanessa Charland-Verville
- Coma Science Group, Cyclotron Research Center and Neurology Department, University and University Hospital of Liège, Liège, Belgium
| | - Audrey Vanhaudenhuyse
- Coma Science Group, Cyclotron Research Center and Neurology Department, University and University Hospital of Liège, Liège, Belgium
| | - Athena Demertzi
- Coma Science Group, Cyclotron Research Center and Neurology Department, University and University Hospital of Liège, Liège, Belgium
| | - Camille Chatelle
- Coma Science Group, Cyclotron Research Center and Neurology Department, University and University Hospital of Liège, Liège, Belgium
| | - Marie Thonnard
- Coma Science Group, Cyclotron Research Center and Neurology Department, University and University Hospital of Liège, Liège, Belgium
| | - Aurore Thibaut
- Coma Science Group, Cyclotron Research Center and Neurology Department, University and University Hospital of Liège, Liège, Belgium
| | - Lizette Heine
- Coma Science Group, Cyclotron Research Center and Neurology Department, University and University Hospital of Liège, Liège, Belgium
| | - Andrea Soddu
- Brain and Mind Institute, Physics and Astronomy Department, University of Western Ontario, London ON, Canada
| | - Mélanie Boly
- Coma Science Group, Cyclotron Research Center and Neurology Department, University and University Hospital of Liège, Liège, Belgium
| | - Caroline Schnakers
- Coma Science Group, Cyclotron Research Center and Neurology Department, University and University Hospital of Liège, Liège, Belgium
| | - Albert Gjedde
- Department of Neuroscience and Pharmacology, University of Copenhagen, Copenhagen, Denmark
| | - Steven Laureys
- Coma Science Group, Cyclotron Research Center and Neurology Department, University and University Hospital of Liège, Liège, Belgium.
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Gosseries O, Zasler ND, Laureys S. Recent advances in disorders of consciousness: Focus on the diagnosis. Brain Inj 2014; 28:1141-50. [PMID: 25099018 DOI: 10.3109/02699052.2014.920522] [Citation(s) in RCA: 89] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Affiliation(s)
- Olivia Gosseries
- Coma Science Group, Cyclotron Research Centre and Neurology Department, University and University Hospital of Liege , Liege , Belgium
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23
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Hahn DK, Geocadin RG, Greer DM. Quality of evidence in studies evaluating neuroimaging for neurologic prognostication in adult patients resuscitated from cardiac arrest. Resuscitation 2014; 85:165-72. [DOI: 10.1016/j.resuscitation.2013.10.031] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2013] [Revised: 10/17/2013] [Accepted: 10/29/2013] [Indexed: 11/25/2022]
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Abstract
Clinical audits have suggested up to 40% of patients with disorders of consciousness may be misdiagnosed, in part, due to the highly subjective process of determining, from a patient's behaviour, whether they retain awareness of self or environment. To address this problem, objective neuroimaging methods, such as positron emission tomography and functional magnetic resonance imaging have been explored. Using these techniques, paradigms, which do not require the patient to move or speak, can be used to determine a patient's level of residual cognitive function. Indeed, visual discrimination, speech comprehension and even the ability to respond to command have been demonstrated in some patients who are assumed to be vegetative on the basis of standard behavioural assessments. Functional neuroimaging is now increasingly considered to be a very useful and necessary addition to the clinical assessment process, where there is concern about the accuracy of the diagnosis and the possibility that residual cognitive function has remained undetected. In this essay, the latest neuroimaging findings are reviewed, the limitations and caveats pertaining to interpretation are outlined and the necessary developments, before neuroimaging becomes a standard component of the clinical assessment are discussed.
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Morrison LJ, Neumar RW, Zimmerman JL, Link MS, Newby LK, McMullan PW, Hoek TV, Halverson CC, Doering L, Peberdy MA, Edelson DP. Strategies for improving survival after in-hospital cardiac arrest in the United States: 2013 consensus recommendations: a consensus statement from the American Heart Association. Circulation 2013; 127:1538-63. [PMID: 23479672 DOI: 10.1161/cir.0b013e31828b2770] [Citation(s) in RCA: 213] [Impact Index Per Article: 19.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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Mindsight: diagnostics in disorders of consciousness. Crit Care Res Pract 2012; 2012:624724. [PMID: 23213492 PMCID: PMC3505640 DOI: 10.1155/2012/624724] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2012] [Revised: 04/30/2012] [Accepted: 07/08/2012] [Indexed: 12/20/2022] Open
Abstract
Diagnosis of patients with disorders of consciousness (comprising coma, vegetative state/unresponsive wakefulness syndrome, and minimally conscious state) has long been dependent on unstandardized behavioral tests. The arrival of standardized behavioral tools, and especially the Coma Recovery Scale revised, uncovered a high rate of misdiagnosis. Ancillary techniques, such as brain imaging and electrophysiological examinations, are ever more often being deployed to aid in the search for remaining consciousness. They are used to look for brain activity patterns similar to those found in healthy controls. The development of portable and cheaper devices will make these techniques more widely available.
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Laureys S, Schiff ND. Coma and consciousness: Paradigms (re)framed by neuroimaging. Neuroimage 2012; 61:478-91. [PMID: 22227888 DOI: 10.1016/j.neuroimage.2011.12.041] [Citation(s) in RCA: 227] [Impact Index Per Article: 18.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2011] [Accepted: 12/15/2011] [Indexed: 01/18/2023] Open
Affiliation(s)
- Steven Laureys
- Coma Science Group, Cyclotron Research Centre and Neurology Department, University and University Hospital of Liège, 4000 Liège, Belgium.
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28
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Abstract
Awake but not aware: This puzzling dissociation of the two central elements of consciousness defines the vegetative state. Traditionally, this condition has been believed to imply a brain with preserved hypothalamic and brainstem autonomic functions but with no capacity for cortical cognitive processes. As is discussed in this review, over a 20-year span neuroimaging techniques have clearly demonstrated that this characterization of patients in a vegetative state is incorrect. Contrary to the initial belief, the "vegetative" brain can retain several high-level aspects of cognitive functions, across sensory modalities, including language processing and learning dynamics. Nonetheless, the residual cognitive functions observed in vegetative patients might reflect intact but functionally disconnected cortical modules that do not give rise to the subjective feeling of phenomenological awareness.
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Affiliation(s)
- Martin M Monti
- Department of Psychology, University of California, Los Angeles, Los Angeles, California 90095, USA.
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29
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Liu AA, Voss HU, Dyke JP, Heier LA, Schiff ND. Arterial spin labeling and altered cerebral blood flow patterns in the minimally conscious state. Neurology 2011; 77:1518-23. [PMID: 21940616 DOI: 10.1212/wnl.0b013e318233b229] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To use arterial spin labeling (ASL) to compare cerebral blood flow (CBF) patterns in minimally conscious state (MCS) patients with those in normal controls in an observational study design. METHODS Subjects meeting MCS criteria and normal controls were identified. A pseudocontinuous ASL sequence was performed with subjects and controls in the resting awake state. Multiple CBF values for 10 predetermined regions of interest were sampled and average CBF was calculated and compared between controls and subjects. RESULTS Ten normal controls were identified, with ages ranging from 26 to 54 years. Four subjects met the MCS criteria and received an ASL study, with one patient receiving a second study at a later date. Subjects ranged in age from 19 to 58 years and had traumatic brain injury, stroke, or hypoxic-ischemic encephalopathy. Regional CBF for controls ranged from 21.6 to 57.2 mL/100 g/min, with a pattern of relatively increased blood flow posteriorly including the posterior cingulate, parietal, and occipital cortices. CBF patterns for MCS subjects showed greater variability (from 7.7 to 33.1 mL/100 g/min), demonstrating globally decreased CBF in gray matter compared with that in normal controls, especially in the medial prefrontal and midfrontal regions. In the one subject studied longitudinally, global CBF values increased over time, which correlated with clinical improvement. CONCLUSIONS We identified globally decreased CBF and a selective reduction of CBF within the medial prefrontal and midfrontal cortical regions as well as gray matter in MCS patients. ASL may serve as an adjunctive method to assess functional reserve in patients recovering from severe brain injuries.
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Affiliation(s)
- A A Liu
- Beth Israel Deaconess-Harvard University, 330 Brookline Avenue, Boston, MA 02215, USA.
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30
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Abstract
Advances in resuscitation and critical care management have resulted in the survival of many patients despite severe brain damage. These patients may remain in coma or in vegetative state. The probability of recovery of conscious function is dependent on the extent of structural brain damage, which is difficult to assess by clinical, laboratory or functional tests. Positron emission tomography (PET) of 18F-fluordeoxyglucose (FDG) can be used to investigate metabolic and functional impairment of the brain. In acute vegetative state (AVS, duration <1 month), overall glucose utilization was significantly reduced in comparison with age-matched controls. In a few cases with locked-in syndrome, cortical metabolism was in the normal range. 11C-Flumazenil (FMZ) measures the density of benzodiazepine receptors (BZRs) and thereby furnishes an estimate of neuronal integrity. PET with this tracer demonstrated a considerable reduction in BZRs in cortical areas, but indicated that the cerebellum was spared from neuronal loss. The comparison of FDG- and FMZ-PET findings in AVS demonstrates that alterations of cerebral glucose consumption do not represent mere functional inactivation, but also irreversible structural damage. In some cases with minimally conscious state, auditory stimuli with emotional valence induced more brain activation (investigated by H215O-PET) than meaningless noise; such studies can be used to detect residual cortical function. To improve prognostication of chances for recovery, a combination of functional activation studies and assessment of the extent of neuronal damage might be the optimal procedure and should be tested in larger cohorts of patients with comatose states of different severity.
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Affiliation(s)
- W-D Heiss
- WDH Foundation, Max Planck Institute for Neurological Research, Köln, Germany.
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31
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Deakin CD, Morrison LJ, Morley PT, Callaway CW, Kerber RE, Kronick SL, Lavonas EJ, Link MS, Neumar RW, Otto CW, Parr M, Shuster M, Sunde K, Peberdy MA, Tang W, Hoek TLV, Böttiger BW, Drajer S, Lim SH, Nolan JP. Part 8: Advanced life support: 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science with Treatment Recommendations. Resuscitation 2011; 81 Suppl 1:e93-e174. [PMID: 20956032 DOI: 10.1016/j.resuscitation.2010.08.027] [Citation(s) in RCA: 167] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
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Peberdy MA, Callaway CW, Neumar RW, Geocadin RG, Zimmerman JL, Donnino M, Gabrielli A, Silvers SM, Zaritsky AL, Merchant R, Vanden Hoek TL, Kronick SL. Part 9: Post–Cardiac Arrest Care. Circulation 2010; 122:S768-86. [DOI: 10.1161/circulationaha.110.971002] [Citation(s) in RCA: 1034] [Impact Index Per Article: 73.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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Morrison LJ, Deakin CD, Morley PT, Callaway CW, Kerber RE, Kronick SL, Lavonas EJ, Link MS, Neumar RW, Otto CW, Parr M, Shuster M, Sunde K, Peberdy MA, Tang W, Hoek TLV, Böttiger BW, Drajer S, Lim SH, Nolan JP, Adrie C, Alhelail M, Battu P, Behringer W, Berkow L, Bernstein RA, Bhayani SS, Bigham B, Boyd J, Brenner B, Bruder E, Brugger H, Cash IL, Castrén M, Cocchi M, Comadira G, Crewdson K, Czekajlo MS, Davies SR, Dhindsa H, Diercks D, Dine CJ, Dioszeghy C, Donnino M, Dunning J, El Sanadi N, Farley H, Fenici P, Feeser VR, Foster JA, Friberg H, Fries M, Garcia-Vega FJ, Geocadin RG, Georgiou M, Ghuman J, Givens M, Graham C, Greer DM, Halperin HR, Hanson A, Holzer M, Hunt EA, Ishikawa M, Ioannides M, Jeejeebhoy FM, Jennings PA, Kano H, Kern KB, Kette F, Kudenchuk PJ, Kupas D, La Torre G, Larabee TM, Leary M, Litell J, Little CM, Lobel D, Mader TJ, McCarthy JJ, McCrory MC, Menegazzi JJ, Meurer WJ, Middleton PM, Mottram AR, Navarese EP, Nguyen T, Ong M, Padkin A, Ferreira de Paiva E, Passman RS, Pellis T, Picard JJ, Prout R, Pytte M, Reid RD, Rittenberger J, Ross W, Rubertsson S, Rundgren M, Russo SG, Sakamoto T, Sandroni C, Sanna T, Sato T, Sattur S, Scapigliati A, Schilling R, Seppelt I, Severyn FA, Shepherd G, Shih RD, Skrifvars M, Soar J, Tada K, Tararan S, Torbey M, Weinstock J, Wenzel V, Wiese CH, Wu D, Zelop CM, Zideman D, Zimmerman JL. Part 8: Advanced Life Support. Circulation 2010; 122:S345-421. [DOI: 10.1161/circulationaha.110.971051] [Citation(s) in RCA: 250] [Impact Index Per Article: 17.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Bruno MA, Soddu A, Demertzi A, Laureys S, Gosseries O, Schnakers C, Boly M, Noirhomme Q, Thonnard M, Chatelle C, Vanhaudenhuyse A. Disorders of consciousness: Moving from passive to resting state and active paradigms. Cogn Neurosci 2010; 1:193-203. [DOI: 10.1080/17588928.2010.485677] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Lull N, Noé E, Lull JJ, García-Panach J, Chirivella J, Ferri J, López-Aznar D, Sopena P, Robles M. Voxel-based statistical analysis of thalamic glucose metabolism in traumatic brain injury: Relationship with consciousness and cognition. Brain Inj 2010; 24:1098-107. [DOI: 10.3109/02699052.2010.494592] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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36
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Metabolismo talámico y situación neurológica tras un traumatismo craneoencefálico. Estudio mediante PET-FDG y morfometría basada en vóxel. Neurologia 2010. [DOI: 10.1016/s0213-4853(10)70006-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
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Lull N, Noé E, Lull J, García-Panach J, García-Martí G, Chirivella J, Ferri J, Sopena R, de La Cueva L, Robles M. Thalamic metabolism and neurological outcome after traumatic brain injury. A voxel-based morphometric FDG-PET study. NEUROLOGÍA (ENGLISH EDITION) 2010. [DOI: 10.1016/s2173-5808(10)70034-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/15/2022] Open
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Abstract
The three conditions that are traditionally defined as disorders of consciousness are the comatose state, the minimally conscious state and the vegetative state. Thirty years after the phrase was coined, the definition and management of patients in vegetative states continue to provoke debate. Recent advances in neuroimaging have cast doubt on the assertion that these patients are completely unaware of their environment. This article presents a case report and review of disorders of consciousness, their definition, prognosis and ethical issues in the management of patients.
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Affiliation(s)
- Justin Healy
- Justin Healy Medical Student, University of Manchester
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39
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Giacino JT, Schnakers C, Rodriguez-Moreno D, Kalmar K, Schiff N, Hirsch J. Behavioral assessment in patients with disorders of consciousness: gold standard or fool's gold? PROGRESS IN BRAIN RESEARCH 2009; 177:33-48. [PMID: 19818893 DOI: 10.1016/s0079-6123(09)17704-x] [Citation(s) in RCA: 130] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
In the absence of "hard" neurophysiologic markers, the burden of proof for establishing conscious awareness in individuals who sustain severe brain injury lies in behavioral assessment. Because behavior represents indirect evidence of consciousness, reliance on behavioral markers presents significant challenges and may lead to misdiagnosis. Detection of conscious awareness is confounded by numerous factors including fluctuations in arousal level, difficulty differentiating reflexive or involuntary movement from intentional behavior, underlying sensory and motor impairments, and medication side effects. When an ambiguous behavior is observed, the onus falls to the clinician to determine where along the continuum of unconsciousness to consciousness, it lies. This paper (1) summarizes the current diagnostic criteria for coma, the vegetative state, and the minimally conscious state, (2) describes current behavioral assessment methods, (3) discusses the limitations of behavioral assessment techniques, (4) reviews recent applications of functional neuroimaging in the assessment of patients with disorders of consciousness, and (5) concludes with a case study that illustrates the disparity between behavioral and functional neuroimaging findings that may be encountered in this population.
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Coleman MR, Bekinschtein T, Monti MM, Owen AM, Pickard JD. A multimodal approach to the assessment of patients with disorders of consciousness. PROGRESS IN BRAIN RESEARCH 2009; 177:231-48. [PMID: 19818905 DOI: 10.1016/s0079-6123(09)17716-6] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Unlike other neurological conditions, the heterogeneous pathology linked to disorders of consciousness currently excludes a distinction between the vegetative and minimally conscious states based upon pathological presentation. The clinical assessment is therefore made on the basis of the patient's clinical history and exhibited behaviour. This creates a particular challenge for the clinician who has to decide whether a certain behaviour, which might be inconsistent or incomplete, reflects a conscious or an unconscious process. In an alarmingly high number of cases, identified during clinical audit, this decision process has been shown to be particularly fallible. The behavioural assessment is not only highly subjective, but also dependent upon the ability of the patient to move or speak; it is the only way someone can demonstrate they are aware. To address this problem we propose a multimodal approach, which integrates objective tools, such as electrophysiology and functional brain imaging, with traditional behavioural scales. Together this approach informs the clinical decision process and resolves many of the dilemmas faced by clinicians interpreting solely behavioural indices. This approach not only provides objective information regarding the integrity of residual cognitive function, but also removes the dependency on the patient to move or speak by using specially designed paradigms that do not require a motor output in order to reveal awareness of self or environment. To demonstrate this approach we describe the case of BW, who sustained a traumatic brain injury seven months prior to investigation. BW was admitted to a five-day assessment programme, which implemented our multimodal approach. On behavioural assessment BW demonstrated evidence of orientation and visual pursuit. However, he showed no response to written or verbal command, despite holding command cards and scanning text. Electrophysiology confirmed that he retained a preserved neural axis supporting vision and hearing, and suggested some evidence that he was able to create a basic memory trace. A hierarchical fMRI auditory paradigm suggested he was able to perceive sound and speech, but revealed no evidence of speech comprehension or ability to respond to command. This was corroborated in the visual modality using a hierarchical paradigm demonstrating that he was able to perceive motion, objects and faces, but retained no evidence of being able to respond to command. We briefly review work by other teams advocating the use of brain imaging and electrophysiology and discuss the steps that are now required in order to create an international standard for the assessment of persons with impaired consciousness after brain injury.
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Affiliation(s)
- M R Coleman
- Impaired Consciousness Research Group, Wolfson Brain Imaging Centre, University of Cambridge, UK.
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41
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Brain function in physiologically, pharmacologically, and pathologically altered states of consciousness. Int Anesthesiol Clin 2008; 46:131-46. [PMID: 18617821 DOI: 10.1097/aia.0b013e318181a8b3] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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Leon-Carrion J, Martin-Rodriguez JF, Damas-Lopez J, Barroso y Martin JM, Dominguez-Morales MR. Brain function in the minimally conscious state: a quantitative neurophysiological study. Clin Neurophysiol 2008; 119:1506-14. [PMID: 18486547 DOI: 10.1016/j.clinph.2008.03.030] [Citation(s) in RCA: 52] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2007] [Revised: 02/22/2008] [Accepted: 03/19/2008] [Indexed: 10/22/2022]
Abstract
OBJECTIVE To explore possible EEG power spectrum and coherence differences between patients in minimally conscious state (MCS) and patients with severe neurocognitive disorders (SND), who show signs of awareness. We also try to find EEG cortical sources that differentiate between both conditions using LORETA source analysis. METHODS We studied 16 patients with traumatic brain injury (7 MCS, 9 SND; aged 18-49) and compared EEG power spectra, coherence, and LORETA sources at rest for both groups. RESULTS EEG power spectra revealed significant differences in the delta range of both conditions. Patients in MCS showed a notably increased power in this band, compared to SND patients. LORETA analysis showed that posterior sources of delta and theta frequencies had higher amplitude in MCS patients than in SND patients. Regarding fast frequencies, lower source magnitudes in temporal and frontal lobes were found for MCS patients. CONCLUSIONS Our results stress the importance of fronto-temporal-parietal associative cortices within the "awareness-regions" model. Our results also suggest a relation between excess of slow wave activity and diminished level of awareness in brain injury population. SIGNIFICANCE Neurophysiological correlates in brain damaged patients who are severely impaired could be used to assess the integrity of brain areas responsible for awareness.
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Affiliation(s)
- J Leon-Carrion
- Human Neuropsychology Laboratory, School of Psychology, Department of Experimental Psychology, C/Camilo José Cela s/n, University of Seville, Seville, Spain.
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46
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Giacino JT, Hirsch J, Schiff N, Laureys S. Functional neuroimaging applications for assessment and rehabilitation planning in patients with disorders of consciousness. Arch Phys Med Rehabil 2007; 87:S67-76. [PMID: 17140882 DOI: 10.1016/j.apmr.2006.07.272] [Citation(s) in RCA: 96] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2006] [Revised: 07/24/2006] [Accepted: 07/24/2006] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To describe the theoretic framework, design, and potential clinical applications of functional neuroimaging protocols in patients with disorders of consciousness. DATA SOURCES Recent published literature and authors' own work. STUDY SELECTION Studies using functional neuroimaging techniques to investigate cognitive processing in patients diagnosed with vegetative and minimally conscious state. DATA EXTRACTION Not applicable. DATA SYNTHESIS Positron-emission tomography activation studies suggest that the vegetative state represents a global disconnection syndrome in which higher order association cortices are functionally disconnected from primary cortical areas. In contrast, patterns of activation in functional magnetic resonance imaging studies of patients in the minimally conscious state show preservation of large-scale cortical networks associated with language and visual processing. CONCLUSIONS Novel applications of functional neuroimaging in patients with disorders of consciousness may aid in differential diagnosis, prognostic assessment and identification of pathophysiologic mechanisms. Improvements in patient characterization may, in turn, provide new opportunities for restoration of function through interventional neuromodulation.
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Affiliation(s)
- Joseph T Giacino
- JFK Johnson Rehabilitation Institute, and New Jersey Neuroscience Institute, JFK Medical Center, Edison, NJ 08818, USA.
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47
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Abstract
Advances in neuroimaging techniques hold significant promise for improving understanding of disorders of consciousness arising from severe brain injuries. We review neuroimaging studies of the vegetative state (VS) and minimally conscious state (MCS), and findings in an unusual case of late emergence from MCS. Multimodal neuroimaging studies using positron emission tomography techniques, functional magnetic resonance imaging, and quantitative electroencephalography and magnetoencephalography quantify variations of residual cerebral activity across these patient populations. The results suggest models to distinguish the pathophysiologic basis of VS and MCS. Less clear are potential brain mechanisms underlying late recovery of communication in rare MCS patients. Diffusion tensor magnetic resonance imaging studies and recent experimental findings suggest that structural remodeling of the brain following severe injury may play a role in late functional recoveries. More generally, relatively long time courses of recovery following severe brain injury emphasize the need to develop markers for identifying patients who may harbor potential for further meaningful recovery. Introduction of neuroimaging into the clinical evaluation process will require developing frameworks for longitudinal assessments of cerebral function. Although limited in number, available studies already provide important insights into underlying brain mechanisms that may help guide development of such assessment strategies.
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Affiliation(s)
- Nicholas D Schiff
- Department of Neurology and Neuroscience, Weill Medical College of Cornell University, New York, NY 10021, USA.
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48
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Abstract
We review the emerging applications of functional and structural neuroimaging techniques for the assessment of patients with disorders of consciousness. Measurements of brain function from patients in the vegetative state (VS) and minimally conscious state (MCS) are compared, and a conceptual organization is developed that suggests models of brain mechanisms associated with different functional levels of recovery. We emphasize developing strategies to place complex brain injuries on a more equal footing using global and regional quantification of resting or activated brain activity using functional imaging techniques alongside more detailed structural assessments of neuronal integrity and axonal connectivity now available. Preliminary studies from several investigative groups suggest that some MCS patients may harbor a functional reserve in the form of recruitable cerebral networks. These findings support developing systematic characterizations of the severely injured brain and suggest that some patients may benefit from improved diagnostic assessments.
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Affiliation(s)
- Nicholas D Schiff
- Laboratory of Cognitive Neuromodulation, Department of Neurology and Neuroscience, Weill Medical College of Cornell University, New York, New York 10021, USA.
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49
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Abstract
The vegetative state and the minimally conscious state are disorders of consciousness that can be acute and reversible or chronic and irreversible. Diffuse lesions of the thalami, cortical neurons, or the white-matter tracts that connect them cause the vegetative state, which is wakefulness without awareness. Functional imaging with PET and functional MRI shows activation of primary cortical areas with stimulation, but not of secondary areas or distributed neural networks that would indicate awareness. Vegetative state has a poor prognosis for recovery of awareness when present for more than a year in traumatic cases and for 3 months in non-traumatic cases. Patients in minimally conscious state are poorly responsive to stimuli, but show intermittent awareness behaviours. Indeed, findings of preliminary functional imaging studies suggest that some patients could have substantially intact awareness. The outcomes of minimally conscious state are variable. Stimulation treatments have been disappointing in vegetative state but occasionally improve minimally conscious state. Treatment decisions for patients in vegetative state or minimally conscious state should follow established ethical and legal principles and accepted practice guidelines of professional medical specialty societies.
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50
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Beuthien-Baumann B, Holthoff VA, Rudolf J. Functional imaging of vegetative state applying single photon emission tomography and positron emission tomography. Neuropsychol Rehabil 2006; 15:276-82. [PMID: 16350971 DOI: 10.1080/09602010443000290] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
Nuclear medicine techniques, such as single photon emission tomography (SPECT) and positron emission tomography (PET) have been applied in patients in a vegetative state to investigate brain function in a non-invasive manner. Parameters investigated include glucose metabolism, perfusion at rest, variations of regional perfusion after stimulation, and benzodiazepine receptor density. Compared to controls, patients in a vegetative state show a substantial reduction of glucose metabolism and perfusion. While patients post-anoxia exhibit a rather homogenous cortical reduction of glucose metabolism, patients after head trauma often show severe cortical and sub-cortical reductions at the site of primary trauma. To distinguish reduced glucose metabolism due to neuronal inactivation from neuronal loss, flumazenil-PET, an indicator of benzodiazepine receptor density, could add valuable information on the extent of brain damage. Activation studies focus on the evaluation of residual brain network, looking for processing in secondary projection fields. So far the predictive strength concerning possible recovery for the individual patient is limited, and PET and SPECT are not routine procedures in the assessment of patients in a vegetative state.
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