1
|
He Z, Lu R, Ge J, Guan Y, Chen Y, Liu G, Xie H, Bai Y, Wu Y, Wu J, Jia J. Disorder of consciousness related pattern could distinguish minimally conscious state from unresponsive wakefulness syndrome: A F-18-FDG-PET study. Brain Res Bull 2024; 215:111023. [PMID: 38964662 DOI: 10.1016/j.brainresbull.2024.111023] [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: 04/17/2024] [Revised: 06/26/2024] [Accepted: 06/28/2024] [Indexed: 07/06/2024]
Abstract
BACKGROUND Accurate evaluation of level of disorder of consciousness (DOC) is clinically challenging. OBJECTIVE This study aimed to establish a distinctive DOC-related pattern (DOCRP) for assessing disease severity and distinguishing unresponsive wakefulness syndrome (UWS) from minimally conscious state (MCS). METHODS Fifteen patients with DOC and eighteen health subjects with F-18-fluorodeoxyglucose (F-18-FDG) positron emission tomography (PET) were enrolled in this study. All patients were assessed by Coma Recovery Scale-Revised (CRS-R) and all individuals were randomly divided into two cohorts (Cohort A and B). DOCRP was identified in Cohort A and subsequently validated in Cohort B and A+B. We also assessed the discriminatory power of DOCRP between MCS and UWS. RESULTS The DOCRP was characterized bilaterally by relatively decreased metabolism in the medial and lateral frontal lobes, parieto-temporal lobes, cingulate gyrus and caudate, associated with relatively increased metabolism in the cerebellum and brainstem. DOCRP expression exhibited high accuracy in differentiating DOC patients from controls (P<0.0001, AUC=1.000), and furthermore could effectively distinguish MCS from UWS (P=0.037, AUC=0.821, sensitivity: 85.7 %, specificity: 75.0 %). Particularly in the subgroup of DOC patients survived global hypoxic-ischemic brain injury, DOCRP expression exhibited even better discriminatory power between MCS and UWS (P=0.046, AUC=1.000). CONCLUSIONS DOCRP might serve as an objective biomarker in distinguishing between UWS and MCS, especially in patients survived global hypoxic-ischemic brain injury. TRIAL REGISTRATION NUMBER ChiCTR2300073717 (Chinese clinical trial registry site, http://www.chictr.org).
Collapse
Affiliation(s)
- Zhijie He
- Department of Rehabilitation Medicine, Huashan Hospital, Fudan University, Shanghai, China
| | - Rongrong Lu
- Department of Rehabilitation Medicine, Huashan Hospital, Fudan University, Shanghai, China
| | - Jingjie Ge
- Department of Nuclear Medicine/PET Center, Huashan Hospital, Fudan University, Shanghai, China
| | - Yihui Guan
- Department of Nuclear Medicine/PET Center, Huashan Hospital, Fudan University, Shanghai, China
| | - Ying Chen
- Department of Rehabilitation Medicine, Huashan Hospital, Fudan University, Shanghai, China
| | - Gang Liu
- Department of Rehabilitation Medicine, Huashan Hospital, Fudan University, Shanghai, China
| | - Hongyu Xie
- Department of Rehabilitation Medicine, Huashan Hospital, Fudan University, Shanghai, China
| | - Yulong Bai
- Department of Rehabilitation Medicine, Huashan Hospital, Fudan University, Shanghai, China
| | - Yi Wu
- Department of Rehabilitation Medicine, Huashan Hospital, Fudan University, Shanghai, China
| | - Junfa Wu
- Department of Rehabilitation Medicine, Huashan Hospital, Fudan University, Shanghai, China.
| | - Jie Jia
- Department of Rehabilitation Medicine, Huashan Hospital, Fudan University, Shanghai, China; National Clinical Research Center for Aging and Medicine, Huashan Hospital, Fudan University, Shanghai, China; National Center for Neurological Disorders, Shanghai, China.
| |
Collapse
|
2
|
Hansen MJ. Modelling developments in consciousness within a multidimensional framework. Neurosci Conscious 2024; 2024:niae026. [PMID: 38895541 PMCID: PMC11184344 DOI: 10.1093/nc/niae026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2023] [Revised: 01/17/2024] [Accepted: 06/03/2024] [Indexed: 06/21/2024] Open
Abstract
A recent advancement in consciousness science has been the introduction of a multidimensional framework of consciousness. This framework has been applied to global states of consciousness, including psychedelic states and disorders of consciousness, and the consciousness of non-human animals. The multidimensional framework enables a finer parsing of both various states of consciousness and forms of animal consciousness, paving the way for new scientific investigations into consciousness. In this paper, the multidimensional model is expanded by constructing temporal profiles. This expansion allows for the modelling of changes in consciousness across the life cycles of organisms and the progression over time of disorders of consciousness. The result of this expansion is 2-fold: (i) it enables new modes of comparison, both across stages of development and across species; (ii) it proposes that more attention be given to the various types of fluctuations that occur in patients who are suffering from disorders of consciousness.
Collapse
Affiliation(s)
- Mads Jørgensen Hansen
- Department of Philosophy and History of Ideas, School of Culture and Society, Aarhus University, Aarhus 8000, Denmark
| |
Collapse
|
3
|
Kitano T, Giacino JT, Bodien Y, Waters A, Hioki D, Shinya J, Nakayama T, Ohgi S. Reliability and validation of the Japanese version of the coma recovery scale-revised (CRS-R). Brain Inj 2024; 38:249-259. [PMID: 38329043 DOI: 10.1080/02699052.2024.2309549] [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: 06/15/2022] [Accepted: 01/19/2024] [Indexed: 02/09/2024]
Abstract
PRIMARY OBJECTIVE This study aimed to verify the reliability and validity of the Japanese version of the Coma Recovery Scale-Revised (CRS-R). METHODS Subjects included 59 patients with disorders of consciousness (DOC) due to acquired brain injury. To validate test-retest reliability, Evaluator A assessed the CRS-R twice on the same day (A1, A2). To examine inter-rater reliability, Evaluators A (A2) and B (B) assessed the CRS-R without a time interval. To test concurrent validity, Evaluator A (A1) assessed the CRS-R, Japan Coma Scale (JCS), and the Glasgow Coma Scale (GCS) consecutively. To validate diagnostic accuracy, we evaluated the degree of agreement between A1 and A2 and between A2 and B in their diagnosis of DOC by CRS-R. RESULTS The test-retest (ρ = 0.92) and inter- (ρ = 0.98) reliability of CRS-R were excellent" and Concurrent validity of CRS-R with JCS (ρ = -0.82) and GCS (ρ = 0.92) were high. Results of DOC diagnosis were consistent for 48/59 cases (κ = 0.82) for A1 and A2 and for 54/59 cases (κ = 0.92) for A2 and B. CONLCUSION The Japanese version of the CRS-R may be as reliable and valid as the original English and other language versions.
Collapse
Affiliation(s)
- Takayuki Kitano
- Department of Rehabilitation, Hamamatsu Medical Center, Hamamatsu City, Shizuoka Prefecture, Japan
| | - Joseph T Giacino
- Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Charlestown, Massachusetts, USA
- Department of Physical Medicine and Rehabilitation, Harvard Medical School, Boston, Massachusetts, USA
| | - Yelena Bodien
- Department of Physical Medicine and Rehabilitation, Harvard Medical School, Boston, Massachusetts, USA
| | - Abigail Waters
- Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Charlestown, Massachusetts, USA
| | - Daichi Hioki
- Department of Rehabilitation, Hamamatsu Medical Center, Hamamatsu City, Shizuoka Prefecture, Japan
| | - Junko Shinya
- Department of Rehabilitation, Hamamatsu Medical Center, Hamamatsu City, Shizuoka Prefecture, Japan
| | - Teiji Nakayama
- Department of Neurosurgery, Hamamatsu Medical Center, Hamamatsu City, Shizuoka Prefecture, Japan
| | - Shohei Ohgi
- Faculty of Rehabilitation Studies, Seirei Christopher University, Hamamatsu City, Shizuoka Prefecture, Japan
| |
Collapse
|
4
|
Gong A, Wang Q, Guo Q, Yang Y, Chen X, Hu X, Zhang Y. Variability of large timescale functional networks in patients with disorders of consciousness. Front Neurol 2024; 15:1283140. [PMID: 38434205 PMCID: PMC10905795 DOI: 10.3389/fneur.2024.1283140] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2023] [Accepted: 01/24/2024] [Indexed: 03/05/2024] Open
Abstract
Objective Most brain function assessments for disorders of consciousness (DOC) utilized quantified characteristics, measured only once, ignoring the variation of patients' brain states. The study aims to investigate the brain activities of patients with DOC from a new perspective: variability of a large timescale functional network. Methods Forty-nine patients were enrolled in this study and performed a 1-week behavioral assessment. Subsequently, each patient received electroencephalography (EEG) recordings five times daily at 2-h intervals. Functional connectivity and networks were measured by weighted phase lag index and complex network parameters (characteristic path length, cluster coefficient, and betweenness centrality). The relative coefficient of variation (CV) of network parameters was measured to evaluate functional network variability. Results Functional networks of patients with vegetative state/unresponsive wakefulness syndrome (VS/UWS) showed significantly higher segregation (characteristic path length) and lower centrality (betweenness centrality) than emerging from the minimal conscious state (EMCS) and minimal conscious state (MCS), as well as lower integration (cluster coefficient) than MCS. The functional networks of VS/UWS patients consistently presented the highest variability in segregation and integration (i.e., highest CV values of characteristic path length and cluster coefficient) on a larger time scale than MCS and EMCS. Moreover, the CV values of characteristic path length and cluster coefficient showed a significant inverse correlation with the Coma Recovery Scale-Revised scores (CRS-R). The CV values of network betweenness centrality, particularly of the cento-parietal region, showed a positive correlation with the CRS-R. Conclusion The functional networks of VS/UWS patients present the most invariant segregation and integration but divergent centrality on the large time scale networks than MCS and EMCS. Significance The variations observed within large timescale functional networks significantly correlate with the degree of consciousness impairment. This finding augments our understanding of the neurophysiological mechanisms underpinning disorders of consciousness.
Collapse
Affiliation(s)
- Anjuan Gong
- Center for Cognition and Brain Disorders, The Affiliated Hospital of Hangzhou Normal University, Hangzhou, Zhejiang, China
| | - Qijun Wang
- Center for Cognition and Brain Disorders, The Affiliated Hospital of Hangzhou Normal University, Hangzhou, Zhejiang, China
| | - Qian Guo
- Hangzhou Normal University School of Nursing, Hangzhou, Zhejiang, China
| | - Ying Yang
- Hangzhou Normal University School of Nursing, Hangzhou, Zhejiang, China
| | - Xuewei Chen
- Hangzhou Normal University School of Nursing, Hangzhou, Zhejiang, China
| | - Xiaohua Hu
- Department of Rehabilitation Medicine, Armed Police Corps Hospital of Zhejiang Province, Hangzhou, Zhejiang, China
| | - Ying Zhang
- Center for Cognition and Brain Disorders, The Affiliated Hospital of Hangzhou Normal University, Hangzhou, Zhejiang, China
- Hangzhou Normal University School of Nursing, Hangzhou, Zhejiang, China
| |
Collapse
|
5
|
Huang L, Kang J, Zhong Y, Zhang J, Qiang M, Feng Z. A predictive model for awakening in patients with prolonged disorders of consciousness after craniocerebral injury. Medicine (Baltimore) 2024; 103:e36701. [PMID: 38215152 PMCID: PMC10783300 DOI: 10.1097/md.0000000000036701] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Accepted: 11/27/2023] [Indexed: 01/14/2024] Open
Abstract
This study aimed to develop and validate a nomogram to predict awakening at 1 year in patients with prolonged disorders of consciousness (pDOC). We retrospectively analyzed the data of 381 patients with pDOC at 2 centers. The data were randomly divided into training and validation sets using a ratio of 6:4. For the training set, univariate and multivariate logical regression analyses were used to identify the predictive variables. Receiver operating characteristic curves, calibration curves, and a decision curve analysis were utilized to assess the predictive accuracy, discriminative ability, and clinical utility of the model, respectively. The final model included age, Glasgow Coma Scale score, serum albumin level, and computed tomography midline shift, all of which had a significant effect on awakening after pDOC. For the 1-year awakening in the training set, the model had good discriminative power, with an area under the curve of 0.733 (95% confidence interval: 0.667-0.789). For the validation set, the area under the curve for 1-year awakening was 0.721 (95% confidence interval: 0.617-0.826). Model performance was good for both the training and validation sets according to calibration plots and decision curve analysis. We developed a precise, effective nomogram to assist clinicians in better assessing patients' outcomes, guiding clinical judgment, and personalizing the therapeutic process.
Collapse
Affiliation(s)
- Lianghua Huang
- First Department of Rehabilitation Medicine, Affiliated Hospital with Jiangxi University of Traditional Chinese Medicine, Nanchang, Jiangxi, P.R. China
- Department of Rehabilitation Medicine, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, P.R. China
| | - Junwei Kang
- Department of Rehabilitation Medicine, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, P.R. China
| | - Yuan Zhong
- Department of Rehabilitation Medicine, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, P.R. China
| | - Jieyuan Zhang
- First Clinical Medical School, Nanchang University, Nanchang, Jiangxi, P.R. China
| | - Mengxiang Qiang
- Department of Rehabilitation Medicine, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, P.R. China
| | - Zhen Feng
- Department of Rehabilitation Medicine, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, P.R. China
| |
Collapse
|
6
|
Cortese MD, Arcuri F, Vatrano M, Pioggia G, Cerasa A, Raso MG, Tonin P, Riganello F. Wessex Head Injury Matrix in Patients with Prolonged Disorders of Consciousness: A Reliability Study. Biomedicines 2023; 12:82. [PMID: 38255189 PMCID: PMC10813453 DOI: 10.3390/biomedicines12010082] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2023] [Revised: 12/22/2023] [Accepted: 12/27/2023] [Indexed: 01/24/2024] Open
Abstract
Introduction: The Wessex Head Injury Matrix (WHIM) was developed to assess patients with disorders of consciousness (DOC) and was tested in terms of inter-rater reliability (IRR) and test-retest reliability (TRR) in the year 2000. The American Congress of Rehabilitation and Medicine reported that IRR and TRR were unproven. We aim to assess the reliability of the WHIM in prolonged DOC patients (PDOC). Methods: A total of 51 PDOC patients (32 unresponsive wakefulness syndrome (UWS/VS) and 19 minimally conscious state (MCS)) who were hosted in a dedicated unit for long-term brain injury care were enrolled. The time from injury ranged from 182 to 3325 days. Two raters administered the Coma Recovery Scale-Revised (CRS-R) and the WHIM to test the IRR and TRR. The TRR was administered two weeks after the first assessment. Results: For the CRS-R, the agreement in IRR and TRR was perfect between the two raters. The agreement for the WHIM ranged from substantial to almost perfect for IRR and from fair to substantial for the TRR. Conclusions: The WHIM showed a strong IRR when administered by expert raters and strongly correlated with the CRS-R. This study provides further evidence of the psychometric qualities of the WHIM and the importance of its use in PDOC patients.
Collapse
Affiliation(s)
- Maria Daniela Cortese
- Research in Advanced Neurorehabilitation, S. Anna Institute, Via Siris, 11, 88900 Crotone, Italy; (M.D.C.); (F.A.); (M.V.); (A.C.); (P.T.)
| | - Francesco Arcuri
- Research in Advanced Neurorehabilitation, S. Anna Institute, Via Siris, 11, 88900 Crotone, Italy; (M.D.C.); (F.A.); (M.V.); (A.C.); (P.T.)
| | - Martina Vatrano
- Research in Advanced Neurorehabilitation, S. Anna Institute, Via Siris, 11, 88900 Crotone, Italy; (M.D.C.); (F.A.); (M.V.); (A.C.); (P.T.)
| | - Giovanni Pioggia
- Institute for Biomedical Research and Innovation (IRIB), National Research Council of Italy (CNR), 98100 Messina, Italy;
| | - Antonio Cerasa
- Research in Advanced Neurorehabilitation, S. Anna Institute, Via Siris, 11, 88900 Crotone, Italy; (M.D.C.); (F.A.); (M.V.); (A.C.); (P.T.)
- Institute for Biomedical Research and Innovation (IRIB), National Research Council of Italy (CNR), 98100 Messina, Italy;
| | - Maria Girolama Raso
- Research in Advanced Neurorehabilitation, S. Anna Institute, Via Siris, 11, 88900 Crotone, Italy; (M.D.C.); (F.A.); (M.V.); (A.C.); (P.T.)
| | - Paolo Tonin
- Research in Advanced Neurorehabilitation, S. Anna Institute, Via Siris, 11, 88900 Crotone, Italy; (M.D.C.); (F.A.); (M.V.); (A.C.); (P.T.)
| | - Francesco Riganello
- Research in Advanced Neurorehabilitation, S. Anna Institute, Via Siris, 11, 88900 Crotone, Italy; (M.D.C.); (F.A.); (M.V.); (A.C.); (P.T.)
| |
Collapse
|
7
|
Bodien YG, Vora I, Barra A, Chiang K, Chatelle C, Goostrey K, Martens G, Malone C, Mello J, Parlman K, Ranford J, Sterling A, Waters AB, Hirschberg R, Katz DI, Mazwi N, Ni P, Velmahos G, Waak K, Edlow BL, Giacino JT. Feasibility and Validity of the Coma Recovery Scale-Revised for Accelerated Standardized Testing: A Practical Assessment Tool for Detecting Consciousness in the Intensive Care Unit. Ann Neurol 2023; 94:919-924. [PMID: 37488068 PMCID: PMC10701693 DOI: 10.1002/ana.26740] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Revised: 07/11/2023] [Accepted: 07/15/2023] [Indexed: 07/26/2023]
Abstract
We developed and validated an abbreviated version of the Coma Recovery Scale-Revised (CRS-R), the CRS-R For Accelerated Standardized Testing (CRSR-FAST), to detect conscious awareness in patients with severe traumatic brain injury in the intensive care unit. In 45 consecutively enrolled patients, CRSR-FAST administration time was approximately one-third of the full-length CRS-R (mean [SD] 6.5 [3.3] vs 20.1 [7.2] minutes, p < 0.0001). Concurrent validity (simple kappa 0.68), test-retest (Mak's ρ = 0.76), and interrater (Mak's ρ = 0.91) reliability were substantial. Sensitivity, specificity, and accuracy for detecting consciousness were 81%, 89%, and 84%, respectively. The CRSR-FAST facilitates serial assessment of consciousness, which is essential for diagnostic and prognostic accuracy. ANN NEUROL 2023;94:919-924.
Collapse
Affiliation(s)
- Yelena G. Bodien
- Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Charlestown, MA
- Center for Neurotechnology and Neurorecovery, Department of Neurology, Massachusetts General Hospital and Harvard Medical School, Boston, MA
- Department of Physical Medicine and Rehabilitation, Harvard Medical School, Boston MA
| | - Isha Vora
- Department of Rehabilitation Sciences, MGH Institute of Health Professions, Boston, MA
| | - Alice Barra
- Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Charlestown, MA
- Coma GIGA Science Group, University of Liege, Liege, Belgium
| | - Kevin Chiang
- Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Camille Chatelle
- Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Charlestown, MA
- Coma GIGA Science Group, University of Liege, Liege, Belgium
| | - Kelsey Goostrey
- Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Charlestown, MA
| | - Geraldine Martens
- Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Charlestown, MA
- Coma GIGA Science Group, University of Liege, Liege, Belgium
- Department of Surgery, University of Montréal, Montréal, QC, Canada
| | - Christopher Malone
- Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Charlestown, MA
| | - Jennifer Mello
- Department of Speech-language and Swallowing, Massachusetts General Hospital, Boston, MA
| | - Kristin Parlman
- Department of Physical Therapy, Massachusetts General Hospital, Boston, MA
- Department of Occupational Therapy, Massachusetts General Hospital Boston, MA
| | - Jessica Ranford
- Department of Occupational Therapy, Massachusetts General Hospital Boston, MA
| | - Ally Sterling
- Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Charlestown, MA
| | - Abigail B. Waters
- Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Charlestown, MA
- Department of Clinical and Health Psychology, University of Florida, Gainesville, FL
| | - Ronald Hirschberg
- Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Charlestown, MA
- Department of Physical Medicine and Rehabilitation, Harvard Medical School, Boston MA
- Department of Physical Medicine and Rehabilitation, Massachusetts General Hospital, Boston, MA
| | - Douglas I. Katz
- Department of Neurology, Boston University Chobanian & Avedisian School of Medicine, Boston, MA; Encompass Health Braintree Rehabilitation, Braintree, MA
| | - Nicole Mazwi
- Department of Rehabilitation Medicine, University of Washington, Seattle, WA
| | - Pengsheng Ni
- Biostatistics & Epidemiology Data Analytic Center, Department of Health Law, Policy and Management, Boston University School of Public Health, Boston, MA, USA
| | - George Velmahos
- Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Karen Waak
- Department of Physical Therapy, Massachusetts General Hospital, Boston, MA
- Department of Occupational Therapy, Massachusetts General Hospital Boston, MA
| | - Brian L. Edlow
- Center for Neurotechnology and Neurorecovery, Department of Neurology, Massachusetts General Hospital and Harvard Medical School, Boston, MA
- Department of Physical Medicine and Rehabilitation, Harvard Medical School, Boston MA
- Athinoula A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital, Charlestown, MA
| | - Joseph T. Giacino
- Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Charlestown, MA
- Department of Physical Medicine and Rehabilitation, Harvard Medical School, Boston MA
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA
| |
Collapse
|
8
|
Alnagger N, Cardone P, Martial C, Laureys S, Annen J, Gosseries O. The current and future contribution of neuroimaging to the understanding of disorders of consciousness. Presse Med 2023; 52:104163. [PMID: 36796250 DOI: 10.1016/j.lpm.2022.104163] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Revised: 11/21/2022] [Accepted: 12/13/2022] [Indexed: 02/16/2023] Open
Abstract
Patients with disorders of consciousness (DoC) represent a group of severely brain-injured patients with varying capacities for consciousness in terms of both wakefulness and awareness. The current state-of-the-art for assessing these patients is through standardised behavioural examinations, but inaccuracies are commonplace. Neuroimaging and electrophysiological techniques have revealed vast insights into the relationships between neural alterations, andcognitive and behavioural features of consciousness in patients with DoC. This has led to the establishment of neuroimaging paradigms for the clinical assessment of DoC patients. Here, we review selected neuroimaging findings on the DoC population, outlining key findings of the dysfunction underlying DoC and presenting the current clinical utility of neuroimaging tools. We discuss that whilst individual brain areas play instrumental roles in generating and supporting consciousness, activation of these areas alone is not sufficient for conscious experience. Instead, for consciousness to arise, we need preserved thalamo-cortical circuits, in addition to sufficient connectivity between distinctly differentiated brain networks, underlined by connectivity both within, and between such brain networks. Finally, we present recent advances and future perspectives in computational methodologies applied to DoC, supporting the notion that progress in the science of DoC will be driven by a symbiosis of these data-driven analyses, and theory-driven research. Both perspectives will work in tandem to provide mechanistic insights contextualised within theoretical frameworks which ultimately inform the practice of clinical neurology.
Collapse
Affiliation(s)
- Naji Alnagger
- Coma Science Group, GIGA-Consciousness, University of Liège, Liège, Belgium; Centre du Cerveau(2), University Hospital of Liège, Liège, Belgium
| | - Paolo Cardone
- Coma Science Group, GIGA-Consciousness, University of Liège, Liège, Belgium; Centre du Cerveau(2), University Hospital of Liège, Liège, Belgium
| | - Charlotte Martial
- Coma Science Group, GIGA-Consciousness, University of Liège, Liège, Belgium; Centre du Cerveau(2), University Hospital of Liège, Liège, Belgium
| | - Steven Laureys
- Coma Science Group, GIGA-Consciousness, University of Liège, Liège, Belgium; Centre du Cerveau(2), University Hospital of Liège, Liège, Belgium; CERVO Research Center, Laval University, Quebec, Canada
| | - Jitka Annen
- Coma Science Group, GIGA-Consciousness, University of Liège, Liège, Belgium; Centre du Cerveau(2), University Hospital of Liège, Liège, Belgium
| | - Olivia Gosseries
- Coma Science Group, GIGA-Consciousness, University of Liège, Liège, Belgium; Centre du Cerveau(2), University Hospital of Liège, Liège, Belgium.
| |
Collapse
|
9
|
Gill-Thwaites HL, Elliott KE, Morrissey AM. LOCCATE: A tool to identify the diagnostic spectrum profile of motor function and functional communication responses for the individual with a prolonged disorder of consciousness. Neuropsychol Rehabil 2023; 33:48-68. [PMID: 34668462 DOI: 10.1080/09602011.2021.1981949] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Standardized neurobehavioural assessment tools (SNBATs) form a key aspect of diagnostic assessment for individuals with prolonged disorders of consciousness (PDOCs). Each SNBAT has different psychometric properties, operational definitions of behaviours, scoring systems and methods of administration. Selection and implementation of SNBATs varies within and between healthcare settings. Defining diagnostic and prognostic parameters requires collating multiple SNBAT results over time, which is problematic if several assessors and professions are involved. The Levels of Consciousness Calibration of Assessment Tools Evaluations (LOCCATE) is the first tool designed to calibrate the results of any recognized PDOC SNBAT. It also categorizes the diagnostic spectrum profile of both motor and communication responses into eight criteria of behaviours. Each criterion has up to three levels of reproducibility, ultimately producing a LOCCATE calibration score ranging from 1 to 27. A case study is presented to illustrate changes in LOCCATE scores over time, while an audit explores the tool's clinical utility. With current directives placing less emphasis on a PDOC diagnosis, there is now a greater need for a calibration tool such as LOCCATE to identify exactly what the individual can do and create an accurate trajectory as an evidence base to support clinical and best-interest decision-making.
Collapse
Affiliation(s)
- Helen L Gill-Thwaites
- Royal Hospital for Neuro-disability, London, UK.,Gill-Thwaites & Elliott Consultants, Hatfield, UK
| | | | - Anne-Marie Morrissey
- Discipline of Occupational Therapy, School of Allied Health, Health Research Institute, Ageing Research Centre, University of Limerick, Ireland
| |
Collapse
|
10
|
Galiotta V, Quattrociocchi I, D'Ippolito M, Schettini F, Aricò P, Sdoia S, Formisano R, Cincotti F, Mattia D, Riccio A. EEG-based Brain-Computer Interfaces for people with Disorders of Consciousness: Features and applications. A systematic review. Front Hum Neurosci 2022; 16:1040816. [PMID: 36545350 PMCID: PMC9760911 DOI: 10.3389/fnhum.2022.1040816] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2022] [Accepted: 11/17/2022] [Indexed: 12/11/2022] Open
Abstract
Background Disorders of Consciousness (DoC) are clinical conditions following a severe acquired brain injury (ABI) characterized by absent or reduced awareness, known as coma, Vegetative State (VS)/Unresponsive Wakefulness Syndrome (VS/UWS), and Minimally Conscious State (MCS). Misdiagnosis rate between VS/UWS and MCS is attested around 40% due to the clinical and behavioral fluctuations of the patients during bedside consciousness assessments. Given the large body of evidence that some patients with DoC possess "covert" awareness, revealed by neuroimaging and neurophysiological techniques, they are candidates for intervention with brain-computer interfaces (BCIs). Objectives The aims of the present work are (i) to describe the characteristics of BCI systems based on electroencephalography (EEG) performed on DoC patients, in terms of control signals adopted to control the system, characteristics of the paradigm implemented, classification algorithms and applications (ii) to evaluate the performance of DoC patients with BCI. Methods The search was conducted on Pubmed, Web of Science, Scopus and Google Scholar. The PRISMA guidelines were followed in order to collect papers published in english, testing a BCI and including at least one DoC patient. Results Among the 527 papers identified with the first run of the search, 27 papers were included in the systematic review. Characteristics of the sample of participants, behavioral assessment, control signals employed to control the BCI, the classification algorithms, the characteristics of the paradigm, the applications and performance of BCI were the data extracted from the study. Control signals employed to operate the BCI were: P300 (N = 19), P300 and Steady-State Visual Evoked Potentials (SSVEP; hybrid system, N = 4), sensorimotor rhythms (SMRs; N = 5) and brain rhythms elicited by an emotional task (N = 1), while assessment, communication, prognosis, and rehabilitation were the possible applications of BCI in DoC patients. Conclusion Despite the BCI is a promising tool in the management of DoC patients, supporting diagnosis and prognosis evaluation, results are still preliminary, and no definitive conclusions may be drawn; even though neurophysiological methods, such as BCI, are more sensitive to covert cognition, it is suggested to adopt a multimodal approach and a repeated assessment strategy.
Collapse
Affiliation(s)
- Valentina Galiotta
- Neuroelectric Imaging and Brain-Computer Interface Laboratory, Fondazione Santa Lucia (IRCCS), Rome, Italy,Department of Psychology, Sapienza University of Rome, Rome, Italy
| | - Ilaria Quattrociocchi
- Neuroelectric Imaging and Brain-Computer Interface Laboratory, Fondazione Santa Lucia (IRCCS), Rome, Italy,Department of Computer, Control, and Management Engineering “Antonio Ruberti”, Sapienza University of Rome, Rome, Italy
| | - Mariagrazia D'Ippolito
- Neuroelectric Imaging and Brain-Computer Interface Laboratory, Fondazione Santa Lucia (IRCCS), Rome, Italy,*Correspondence: Mariagrazia D'Ippolito
| | - Francesca Schettini
- Neuroelectric Imaging and Brain-Computer Interface Laboratory, Fondazione Santa Lucia (IRCCS), Rome, Italy,Servizio di Ausilioteca per la Riabilitazione Assistita con Tecnologia, Fondazione Santa Lucia (IRCCS), Rome, Italy
| | - Pietro Aricò
- Department of Computer, Control, and Management Engineering “Antonio Ruberti”, Sapienza University of Rome, Rome, Italy,Department of Molecular Medicine, Sapienza University of Rome, Rome, Italy,BrainSigns srl, Rome, Italy
| | - Stefano Sdoia
- Department of Psychology, Sapienza University of Rome, Rome, Italy
| | - Rita Formisano
- Neurorehabilitation 2 and Post-Coma Unit, Fondazione Santa Lucia (IRCCS), Rome, Italy
| | - Febo Cincotti
- Department of Computer, Control, and Management Engineering “Antonio Ruberti”, Sapienza University of Rome, Rome, Italy
| | - Donatella Mattia
- Neuroelectric Imaging and Brain-Computer Interface Laboratory, Fondazione Santa Lucia (IRCCS), Rome, Italy,Servizio di Ausilioteca per la Riabilitazione Assistita con Tecnologia, Fondazione Santa Lucia (IRCCS), Rome, Italy
| | - Angela Riccio
- Neuroelectric Imaging and Brain-Computer Interface Laboratory, Fondazione Santa Lucia (IRCCS), Rome, Italy,Servizio di Ausilioteca per la Riabilitazione Assistita con Tecnologia, Fondazione Santa Lucia (IRCCS), Rome, Italy
| |
Collapse
|
11
|
Hyun C, Kim K, Lee S, Lee HH, Lee J. Quantitative evaluation of the consciousness level of patients in a vegetative state using virtual reality and an eye-tracking system: A single-case experimental design study. Neuropsychol Rehabil 2022; 32:2628-2645. [PMID: 34486951 DOI: 10.1080/09602011.2021.1974496] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
ABSTRACTIt is important to distinguish patients in a minimally conscious state (MCS) from patients in a vegetative state (VS) when assessing disorders of consciousness (DOC) as prognosis, selection of therapy, and drug treatment could differ accordingly. Clinical evaluation of a patient's eye movements, such as visual startle, visual fixation, and visual pursuit, provides valuable evidence but is often subject to misdiagnosis. To minimize such misdiagnosis caused by human judgment, a virtual reality (VR) technology-based quantitative assessment method with an eye-tracking system is proposed in this study. The new VR system presented 3 stimuli to 20 healthy participants, and visual response data were recorded to define valid responses to each stimulus. Further, the newly defined stimuli were presented to five chronic patients in VS, and the system classified three of them as showing visual fixations that could not be verified through clinical assessment beforehand. The proposed system, as verified through such experimentation, suggests quantitative and objective evaluation methods for examining three visual functions of patients with DOC.
Collapse
Affiliation(s)
- Cheolhwan Hyun
- Department of Rehabilitation Medicine, Konkuk University Medical Center and Konkuk University School of Medicine, Seoul, Korea
| | - Kyungmin Kim
- Department of Rehabilitation Medicine, Konkuk University Medical Center and Konkuk University School of Medicine, Seoul, Korea
| | - Soolim Lee
- Department of Rehabilitation Medicine, Konkuk University Medical Center and Konkuk University School of Medicine, Seoul, Korea
| | - Hyun Haeng Lee
- Department of Rehabilitation Medicine, Konkuk University Medical Center and Konkuk University School of Medicine, Seoul, Korea
| | - Jongmin Lee
- Department of Rehabilitation Medicine, Konkuk University Medical Center and Konkuk University School of Medicine, Seoul, Korea.,Research Institute of Medical Science, Konkuk University School of Medicine, Seoul, Korea
| |
Collapse
|
12
|
Shen J, Tang S, Yan B, Xie D, Fang T, Chen L, Li G. Pain assessment during physiotherapy and noxious stimuli in patients with disorders of consciousness: A preliminary study. Front Integr Neurosci 2022; 16:962077. [PMID: 36159090 PMCID: PMC9492971 DOI: 10.3389/fnint.2022.962077] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2022] [Accepted: 08/22/2022] [Indexed: 12/03/2022] Open
Abstract
Objectives The primary purpose of this study is to determine whether patients with disorders of consciousness (DOC) (unresponsive wakefulness syndrome, UWS; minimally conscious state, MCS) experience pain during physiotherapy and noxious stimuli in a larger patient population. Materials and methods The patients’ level of consciousness was measured with the Coma Recovery Scale-Revised (CRS-R). Additionally, the Nociception Coma Scale-revised (NCS-R) was used to assess their pain response. The NCS-R total scores between UWS and MCS at baseline, physiotherapy and noxious stimulus were compared using the Mann-Whitney U test (Wilcoxon rank-sum test) and the Kruskal-Wallis H test with Bonferroni correction. Results The study enrolled 93 participants. There was a statistically significant difference in NCS-R total scores between the three conditions (H = 215.25, p < 0.001). At baseline, there was no statistically significant difference between MCS and UWS (U = 378, z = –1.35, p = 0.178). While there was a statistically significant difference between MCS and UWS during physiotherapy (U = 1,362, z = –3.06, p < 0.01) and under noxious stimuli (U = 5142.5, z = –11.22, p < 0.001). Conclusion Physiotherapy improved the activity responsiveness of DOC patients, and patients experienced less potential pain. However, some DOC patients, especially MCS patients, perceived pain under the noxious stimuli.
Collapse
|
13
|
Yelden K, James LM, Duport S, Kempny A, Farmer SF, Leff AP, Playford ED. A simple intervention for disorders of consciousness- is there a light at the end of the tunnel? Front Neurol 2022; 13:824880. [PMID: 35937075 PMCID: PMC9355643 DOI: 10.3389/fneur.2022.824880] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Accepted: 06/27/2022] [Indexed: 12/02/2022] Open
Abstract
Sleep is a physiological state necessary for memory processing, learning and brain plasticity. Patients with disorders of consciousness (DOC) show none or minimal sign of awareness of themselves or their environment but appear to have sleep-wake cycles. The aim of our study was to assess baseline circadian rhythms and sleep in patients with DOC; to optimize circadian rhythm using an intervention combining blue light, melatonin and caffeine, and to identify the impact of this intervention on brain function using event related potentials. We evaluated baseline circadian rhythms and sleep in 17 patients with DOC with 24-h polysomnography (PSG) and 4-hourly saliva melatonin measurements for 48 h. Ten of the 17 patients (5 female, age 30-71) were then treated for 5 weeks with melatonin each night and blue light and caffeine treatment in the mornings. Behavioral assessment of arousal and awareness [Coma recovery scale-revised (CRS-R)], 24-h polysomnography and 4-hourly saliva melatonin measurements, oddball mismatch negativity (MMN) and subject's own name (SON) experiments were performed twice at baseline and following intervention. Baseline sleep was abnormal in all patients. Cosinor analysis of saliva melatonin results revealed that averaged baseline % rhythmicity was low (M: 31%, Range: 13-66.4%, SD: 18.4). However, increase in % Melatonin Rhythm following intervention was statistically significant (p = 0.012). 7 patients showed improvement of CRS-R scores with intervention and this was statistically significant (p = 0.034). All the patients who had improvement of clinical scores also had statistically significant improvement of neurophysiological responses on MMN and SON experiments at group level (p = 0.001). Our study shows that sleep and circadian rhythms are severely deranged in DOC but optimization is possible with melatonin, caffeine and blue light treatment. Clinical and physiological parameters improved with this simple and inexpensive intervention. Optimization of sleep and circadian rhythms should be integrated into rehabilitation programs for people with DOC.
Collapse
Affiliation(s)
- Kudret Yelden
- Neurological Rehabilitation, Royal Hospital for Neuro-Disability, London, United Kingdom
- Department of Neuroscience, King's College Hospital, London, United Kingdom
- UCL Queen Square Institute of Neurology, University College London, London, United Kingdom
| | - Leon M. James
- Neurophysiology Department, Bupa Cromwell Hospital, London, United Kingdom
| | - Sophie Duport
- Research Department, Royal Hospital for Neuro-Disability, London, United Kingdom
| | - Agnieszka Kempny
- Research Department, Royal Hospital for Neuro-Disability, London, United Kingdom
| | - Simon F. Farmer
- UCL Queen Square Institute of Neurology, University College London, London, United Kingdom
- National Hospital for Neurology and Neurosurgery, University College London Hospital, London, United Kingdom
| | - Alex P. Leff
- UCL Queen Square Institute of Neurology, University College London, London, United Kingdom
- National Hospital for Neurology and Neurosurgery, University College London Hospital, London, United Kingdom
| | - E. Diane Playford
- UCL Queen Square Institute of Neurology, University College London, London, United Kingdom
- Warwick Medical School, University of Warwick, Coventry, United Kingdom
| |
Collapse
|
14
|
Effects of Acupuncture on Cortical Activation in Patients with Disorders of Consciousness: A Functional Near-Infrared Spectroscopy Study. EVIDENCE-BASED COMPLEMENTARY AND ALTERNATIVE MEDICINE 2022; 2022:5711961. [PMID: 35958938 PMCID: PMC9363174 DOI: 10.1155/2022/5711961] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/24/2022] [Revised: 06/12/2022] [Accepted: 06/28/2022] [Indexed: 11/17/2022]
Abstract
Background. Disorder of consciousness (DoC) is a clinical condition caused by severe brain damage. Some studies have reported that acupuncture, a traditional Chinese treatment, could facilitate the recovery of the patient’s consciousness. The therapeutic effects of acupuncture may be due to its modulation of facilitating cortex (PFC) activity, but it has not been greatly demonstrated. Objectives. We intended to observe the effects of acupuncture on prefrontal cortical activity, explore the potential correlation between cortical activation and the severity of DoC, and analyze the functional brain network connectivity to provide a theoretical basis for its application in clinical practice. Methods. Participants diagnosed with DoC were included in the study. Before the intervention, we assessed the patient’s state of consciousness using relevant scales, such as the Glasgow coma scale (GCS) and the coma recovery scale-revised (CRS-R). All patients received acupuncture manipulation with the functional near-infrared spectroscopy (fNIRS) system monitored. Result. A total of 16 subjects participated in our study. We observed that the concentration of oxygenated hemoglobin (HbO) in the PFC was increased during the acupuncture manipulation and declined during the resting state. Then, the connection strength of the left cerebral cortex was generally higher than that of the right. Finally, we observed only a weak difference in hemodynamic responses of PFC between the vegetative state (VS) and minimally conscious state (MCS) groups. However, the difference was not statistically significant. Conclusion. Our results indicated that acupuncture can increase the concentration of HbO in the PFC and strengthen the connection strength of the left cerebral cortex. However, our present study did not find a significant correlation between the cortical hemodynamic response and the severity of DoC.
Collapse
|
15
|
Xiao J, He Y, Yu T, Pan J, Xie Q, Cao C, Zheng H, Huang W, Gu Z, Yu Z, Li Y. Towards Assessment of Sound Localization in Disorders of Consciousness Using a Hybrid Audiovisual Brain-Computer Interface. IEEE Trans Neural Syst Rehabil Eng 2022; 30:1422-1432. [PMID: 35584066 DOI: 10.1109/tnsre.2022.3176354] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Behavioral assessment of sound localization in the Coma Recovery Scale-Revised (CRS-R) poses a significant challenge due to motor disability in patients with disorders of consciousness (DOC). Brain-computer interfaces (BCIs), which can directly detect brain activities related to external stimuli, may thus provide an approach to assess DOC patients without the need for any physical behavior. In this study, a novel audiovisual BCI system was developed to simulate sound localization evaluation in CRS-R. Specifically, there were two alternatively flashed buttons on the left and right sides of the graphical user interface, one of which was randomly chosen as the target. The auditory stimuli of bell sounds were simultaneously presented by the ipsilateral loudspeaker during the flashing of the target button, which prompted patients to selectively attend to the target button. The recorded electroencephalography data were analyzed in real time to detect event-related potentials evoked by the target and further to determine whether the target was attended to or not. A significant BCI accuracy for a patient implied that he/she had sound localization. Among eighteen patients, eleven and four showed sound localization in the BCI and CRS-R, respectively. Furthermore, all patients showing sound localization in the CRS-R were among those detected by our BCI. The other seven patients who had no sound localization behavior in CRS-R were identified by the BCI assessment, and three of them showed improvements in the second CRS-R assessment after the BCI experiment. Thus, the proposed BCI system is promising for assisting the assessment of sound localization and improving the clinical diagnosis of DOC patients.
Collapse
|
16
|
Hermann B, Sangaré A, Munoz-Musat E, Salah AB, Perez P, Valente M, Faugeras F, Axelrod V, Demeret S, Marois C, Pyatigorskaya N, Habert MO, Kas A, Sitt JD, Rohaut B, Naccache L. Importance, limits and caveats of the use of “disorders of consciousness” to theorize consciousness. Neurosci Conscious 2022; 2021:niab048. [PMID: 35369675 PMCID: PMC8966966 DOI: 10.1093/nc/niab048] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2021] [Revised: 12/21/2021] [Accepted: 01/27/2022] [Indexed: 11/13/2022] Open
Abstract
The clinical and fundamental exploration of patients suffering from disorders of consciousness (DoC) is commonly used by researchers both to test some of their key theoretical predictions and to serve as a unique source of empirical knowledge about possible dissociations between consciousness and cognitive and/or neural processes. For instance, the existence of states of vigilance free of any self-reportable subjective experience [e.g. “vegetative state (VS)” and “complex partial epileptic seizure”] originated from DoC and acted as a cornerstone for all theories by dissociating two concepts that were commonly equated and confused: vigilance and conscious state. In the present article, we first expose briefly the major achievements in the exploration and understanding of DoC. We then propose a synthetic taxonomy of DoC, and we finally highlight some current limits, caveats and questions that have to be addressed when using DoC to theorize consciousness. In particular, we show (i) that a purely behavioral approach of DoC is insufficient to characterize the conscious state of patients; (ii) that the comparison between patients in a minimally conscious state (MCS) and patients in a VS [also coined as unresponsive wakefulness syndrome (UWS)] does not correspond to a pure and minimal contrast between unconscious and conscious states and (iii) we emphasize, in the light of original resting-state positron emission tomography data, that behavioral MCS captures an important but misnamed clinical condition that rather corresponds to a cortically mediated state and that MCS does not necessarily imply the preservation of a conscious state.
Collapse
Affiliation(s)
| | - Aude Sangaré
- Brain institute-ICM, Inserm U1127, CNRS UMR 7225, Sorbonne Université, Paris 75013, France
- Department of Neurophysiology, AP-HP, Hôpital Pitié-Salpêtrière, Sorbonne Université, Paris 75006, France
| | - Esteban Munoz-Musat
- Brain institute-ICM, Inserm U1127, CNRS UMR 7225, Sorbonne Université, Paris 75013, France
| | - Amina Ben Salah
- Brain institute-ICM, Inserm U1127, CNRS UMR 7225, Sorbonne Université, Paris 75013, France
| | - Pauline Perez
- Brain institute-ICM, Inserm U1127, CNRS UMR 7225, Sorbonne Université, Paris 75013, France
| | - Mélanie Valente
- Brain institute-ICM, Inserm U1127, CNRS UMR 7225, Sorbonne Université, Paris 75013, France
- Department of Neurophysiology, AP-HP, Hôpital Pitié-Salpêtrière, Sorbonne Université, Paris 75006, France
| | - Frédéric Faugeras
- Department of Neurology, AP-HP, Hôpital Henri-Mondor-Albert Chenevier, Université Paris Est Creteil, Créteil 94 000, France
- Département d’Etudes Cognitives, École normale supérieure, PSL University, Paris 75005, France
- Inserm U955, Institut Mondor de Recherche Biomédicale, Equipe E01 NeuroPsychologie Interventionnelle, Créteil 94000, France
| | - Vadim Axelrod
- Gonda Multidisciplinary Brain Research Center, Bar-Ilan University, Ramat Gan 5290002, Israel
| | - Sophie Demeret
- Department of Neurology, Neuro-ICU, AP-HP, Hôpital Pitié-Salpêtrière, Sorbonne Université, Paris 75006, France
| | - Clémence Marois
- Department of Neurology, Neuro-ICU, AP-HP, Hôpital Pitié-Salpêtrière, Sorbonne Université, Paris 75006, France
| | - Nadya Pyatigorskaya
- Brain institute-ICM, Inserm U1127, CNRS UMR 7225, Sorbonne Université, Paris 75013, France
- Department of Neuroradiology, AP-HP, Hôpital Pitié-Salpêtrière, Sorbonne Université, Paris 75006, France
| | - Marie-Odile Habert
- Department of Nuclear Medicine, AP-HP, Pitié-Salpêtrière Hospital, Paris, France
- Laboratoire d’Imagerie Biomédicale, LIB, INSERM, CNRS, Sorbonne Université, Paris, France
| | - Aurélie Kas
- Department of Nuclear Medicine, AP-HP, Pitié-Salpêtrière Hospital, Paris, France
- Laboratoire d’Imagerie Biomédicale, LIB, INSERM, CNRS, Sorbonne Université, Paris, France
| | - Jacobo D Sitt
- Brain institute-ICM, Inserm U1127, CNRS UMR 7225, Sorbonne Université, Paris 75013, France
| | - Benjamin Rohaut
- Brain institute-ICM, Inserm U1127, CNRS UMR 7225, Sorbonne Université, Paris 75013, France
- Department of Neurology, Neuro-ICU, AP-HP, Hôpital Pitié-Salpêtrière, Sorbonne Université, Paris 75006, France
| | - Lionel Naccache
- Brain institute-ICM, Inserm U1127, CNRS UMR 7225, Sorbonne Université, Paris 75013, France
- Department of Neurophysiology, AP-HP, Hôpital Pitié-Salpêtrière, Sorbonne Université, Paris 75006, France
- Medical Intensive Care Unit, AP-HP, Hôpital Européen Georges Pompidou, Paris 75015, France
| |
Collapse
|
17
|
Goss AL, Creutzfeldt CJ. Prognostication, Ethical Issues, and Palliative Care in Disorders of Consciousness. Neurol Clin 2022; 40:59-75. [PMID: 34798975 PMCID: PMC8672806 DOI: 10.1016/j.ncl.2021.08.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Research advances in recent years have shown that some individuals with vegetative state or minimally conscious state can emerge to higher states of consciousness even years after injury. A minority of behaviorally unresponsive patients with vegetative state have also been shown to follow commands, or even communicate, using neuroimaging or electrophysiological techniques. These advances raise ethical questions that have important implications for clinical care. In this article, the authors argue that adopting a neuropalliative care approach can help clinicians provide ethical, compassionate care to these patients and their caregivers.
Collapse
Affiliation(s)
- Adeline L Goss
- Department of Neurology, University of California San Francisco, 505 Parnassus Avenue, Box 0114, San Francisco, CA 94143, USA.
| | - Claire J Creutzfeldt
- Department of Neurology, University of Washington, 325 Ninth Avenue, Seattle, WA 98104, USA
| |
Collapse
|
18
|
Porcaro C, Nemirovsky IE, Riganello F, Mansour Z, Cerasa A, Tonin P, Stojanoski B, Soddu A. Diagnostic Developments in Differentiating Unresponsive Wakefulness Syndrome and the Minimally Conscious State. Front Neurol 2022; 12:778951. [PMID: 35095725 PMCID: PMC8793804 DOI: 10.3389/fneur.2021.778951] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2021] [Accepted: 12/08/2021] [Indexed: 12/12/2022] Open
Abstract
When treating patients with a disorder of consciousness (DOC), it is essential to obtain an accurate diagnosis as soon as possible to generate individualized treatment programs. However, accurately diagnosing patients with DOCs is challenging and prone to errors when differentiating patients in a Vegetative State/Unresponsive Wakefulness Syndrome (VS/UWS) from those in a Minimally Conscious State (MCS). Upwards of ~40% of patients with a DOC can be misdiagnosed when specifically designed behavioral scales are not employed or improperly administered. To improve diagnostic accuracy for these patients, several important neuroimaging and electrophysiological technologies have been proposed. These include Positron Emission Tomography (PET), functional Magnetic Resonance Imaging (fMRI), Electroencephalography (EEG), and Transcranial Magnetic Stimulation (TMS). Here, we review the different ways in which these techniques can improve diagnostic differentiation between VS/UWS and MCS patients. We do so by referring to studies that were conducted within the last 10 years, which were extracted from the PubMed database. In total, 55 studies met our criteria (clinical diagnoses of VS/UWS from MCS as made by PET, fMRI, EEG and TMS- EEG tools) and were included in this review. By summarizing the promising results achieved in understanding and diagnosing these conditions, we aim to emphasize the need for more such tools to be incorporated in standard clinical practice, as well as the importance of data sharing to incentivize the community to meet these goals.
Collapse
Affiliation(s)
- Camillo Porcaro
- Department of Neuroscience and Padova Neuroscience Center (PNC), University of Padova, Padova, Italy
- Institute of Cognitive Sciences and Technologies (ISTC)–National Research Council (CNR), Rome, Italy
- Department of Information Engineering, Università Politecnica delle Marche, Ancona, Italy
- Centre for Human Brain Health, School of Psychology, University of Birmingham, Birmingham, United Kingdom
- *Correspondence: Camillo Porcaro ; orcid.org/0000-0003-4847-163X
| | - Idan Efim Nemirovsky
- Department of Physics and Astronomy, Brain and Mind Institute, University of Western Ontario, London, ON, Canada
| | - Francesco Riganello
- Sant'Anna Institute and Research in Advanced Neurorehabilitation (RAN), Crotone, Italy
| | - Zahra Mansour
- Department of Information Engineering, Università Politecnica delle Marche, Ancona, Italy
| | - Antonio Cerasa
- Sant'Anna Institute and Research in Advanced Neurorehabilitation (RAN), Crotone, Italy
- Institute for Biomedical Research and Innovation (IRIB), National Research Council, Messina, Italy
- Pharmacotechnology Documentation and Transfer Unit, Preclinical and Translational Pharmacology, Department of Pharmacy, Health Science and Nutrition, University of Calabria, Rende, Italy
| | - Paolo Tonin
- Sant'Anna Institute and Research in Advanced Neurorehabilitation (RAN), Crotone, Italy
| | - Bobby Stojanoski
- Faculty of Social Science and Humanities, University of Ontario Institute of Technology, Oshawa, ON, Canada
- Department of Psychology, Brain and Mind Institute, University of Western Ontario, London, ON, Canada
| | - Andrea Soddu
- Department of Physics and Astronomy, Brain and Mind Institute, University of Western Ontario, London, ON, Canada
| |
Collapse
|
19
|
Xu R, Spataro R, Allison BZ, Guger C. Brain-Computer Interfaces in Acute and Subacute Disorders of Consciousness. J Clin Neurophysiol 2022; 39:32-39. [PMID: 34474428 DOI: 10.1097/wnp.0000000000000810] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
SUMMARY Disorders of consciousness include coma, unresponsive wakefulness syndrome (also known as vegetative state), and minimally conscious state. Neurobehavioral scales such as coma recovery scale-revised are the gold standard for disorder of consciousness assessment. Brain-computer interfaces have been emerging as an alternative tool for these patients. The application of brain-computer interfaces in disorders of consciousness can be divided into four fields: assessment, communication, prediction, and rehabilitation. The operational theoretical model of consciousness that brain-computer interfaces explore was reviewed in this article, with a focus on studies with acute and subacute patients. We then proposed a clinically friendly guideline, which could contribute to the implementation of brain-computer interfaces in neurorehabilitation settings. Finally, we discussed limitations and future directions, including major challenges and possible solutions.
Collapse
Affiliation(s)
- Ren Xu
- Guger Technologies OG, Schiedlberg, Austria
| | - Rossella Spataro
- g.tec medical engineering GmbH, Schiedlberg, Austria
- IRCCS Centro Neurolesi Bonino Pulejo, Palermo, Italy; and
| | - Brendan Z Allison
- Cognitive Science Department, University of California San Diego, La Jolla, California, U.S.A
| | - Christoph Guger
- Guger Technologies OG, Schiedlberg, Austria
- g.tec medical engineering GmbH, Schiedlberg, Austria
| |
Collapse
|
20
|
da Conceição Teixeira L, Blacker D, Campos C, Garrett C, Duport S, Rocha NB. Repeated Clinical Assessment Using Sensory Modality Assessment and Rehabilitation Technique for Diagnosis in Prolonged Disorders of Consciousness. Front Hum Neurosci 2021; 15:728637. [PMID: 34924975 PMCID: PMC8671934 DOI: 10.3389/fnhum.2021.728637] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2021] [Accepted: 11/10/2021] [Indexed: 11/13/2022] Open
Abstract
Purpose: The recommended way to assess consciousness in prolonged disorders of consciousness is to observe the patient's responses to sensory stimulation. Multiple assessment sessions have to be completed in order to reach a correct diagnosis. There is, however, a lack of data on how many sessions are sufficient for validity and reliability. The aim of this study was to identify the number of Sensory Modality Assessment and Rehabilitation Technique (SMART) assessment sessions needed to reach a reliable diagnosis. A secondary objective was to identify which sensory stimulation modalities are more useful to reach a diagnosis. Materials and Methods: A retrospective analysis of all the adult patients (who received a SMART assessment) admitted to a specialist brain injury unit over the course of 4 years was conducted (n = 35). An independent rater analyzed the SMART levels for each modality and session and provided a suggestive diagnosis based on the highest SMART level per session. Results: For the vast majority of patients between 5 and 6 sessions was sufficient to reach the final clinical diagnosis. The visual, auditory, tactile, and motor function modalities were found to be more associated with the final diagnosis than the olfactory and gustatory modalities. Conclusion: These findings provide for the first time a rationale for optimizing the time spent on assessing patients using SMART.
Collapse
Affiliation(s)
- Liliana da Conceição Teixeira
- Center for Innovative Care and Health Technology, School of Health Sciences, Polytechnic of Leiria, Leiria, Portugal.,Center for Rehabilitation Research, School of Health, Polytechnic Institute of Porto, Porto, Portugal.,Faculty of Medicine, University of Porto, Porto, Portugal
| | - Danielle Blacker
- Occupational Therapy Department, Royal Hospital for Neuro-Disability, London, United Kingdom
| | - Carlos Campos
- Center for Rehabilitation Research, School of Health, Polytechnic Institute of Porto, Porto, Portugal.,Faculty of Medicine, University of Porto, Porto, Portugal.,Laboratory of Neuropsychophysiology, Faculty of Psychology and Educational Sciences, University of Porto, Porto, Portugal
| | | | - Sophie Duport
- Research Department, Royal Hospital for Neuro-Disability, London, United Kingdom
| | - Nuno Barbosa Rocha
- Center for Rehabilitation Research, School of Health, Polytechnic Institute of Porto, Porto, Portugal
| |
Collapse
|
21
|
Cortese MD, Arcuri F, Nemirovsky IE, Lucca LF, Tonin P, Soddu A, Riganello F. Nociceptive Response Is a Possible Marker of Evolution in the Level of Consciousness in Unresponsive Wakefulness Syndrome Patients. Front Neurosci 2021; 15:771505. [PMID: 34975378 PMCID: PMC8714733 DOI: 10.3389/fnins.2021.771505] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2021] [Accepted: 11/15/2021] [Indexed: 11/13/2022] Open
Abstract
The Nociception Coma Scale (NCS) and its revised version (NCS-R) were used to evaluate behavioral responses to pain in non-communicative patients. We hypothesized that if patients demonstrate changes to their NCS(-R) scores over time, their evolving behavioral abilities could indicate a forthcoming diagnostic improvement with the Coma Recovery Scale-Revised (CRS-R). Forty-three Vegetative State/Unresponsive Wakefulness Syndrome (VS/UWS) patients were enrolled in the study. The patients were assessed weekly using the CRS-R and NCS(-R) for four consecutive weeks. The first assessment was within 10 days after hospitalization. The assessments were performed between 09:30 and 11:30 AM in a room with constant levels of humidity, light and temperature, as well as an absence of transient noise. Noxious stimuli were administered using a Newton-meter, with pressure applied to the fingernail bed for a maximum of 5 s unless interrupted by a behavioral response from subjects. Seventeen patients demonstrated improvements in their level of consciousness, 13 of whom showed significant behavioral changes through the NCS(-R) before being diagnosed with a Minimally Conscious State (MCS) according to the CRS-R. The behavioral changes observed using the NCS(-R) corresponded to a high probability of observing an improvement from VS/UWS to MCS. To characterize the increased likelihood of this transition, our results present threshold scores of ≥5 for the NCS (accuracy 86%, sensitivity 87%, and specificity 86%) and ≥3 for the NCS-R (accuracy 77%, sensitivity 89%, and specificity 73%). In conclusion, a careful evaluation of responses to nociceptive stimuli in DOC patients could constitute an effective procedure in assessing their evolving conscious state.
Collapse
Affiliation(s)
- Maria Daniela Cortese
- Research in Advanced Neurorehabilitation (RAN), S. Anna Institute, Via Siris, Crotone, Italy
| | - Francesco Arcuri
- Research in Advanced Neurorehabilitation (RAN), S. Anna Institute, Via Siris, Crotone, Italy
| | - Idan E. Nemirovsky
- Department of Physics and Astronomy, Brain and Mind Institute, Western University, London, ON, Canada
| | - Lucia Francesca Lucca
- Research in Advanced Neurorehabilitation (RAN), S. Anna Institute, Via Siris, Crotone, Italy
| | - Paolo Tonin
- Research in Advanced Neurorehabilitation (RAN), S. Anna Institute, Via Siris, Crotone, Italy
| | - Andrea Soddu
- Department of Physics and Astronomy, Brain and Mind Institute, Western University, London, ON, Canada
| | - Francesco Riganello
- Research in Advanced Neurorehabilitation (RAN), S. Anna Institute, Via Siris, Crotone, Italy
| |
Collapse
|
22
|
Spontaneous eye blinking as a diagnostic marker in prolonged disorders of consciousness. Sci Rep 2021; 11:22393. [PMID: 34789832 PMCID: PMC8599689 DOI: 10.1038/s41598-021-01858-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2021] [Accepted: 11/01/2021] [Indexed: 11/26/2022] Open
Abstract
Clinical diagnosis of patients with prolonged disorders of consciousness is very challenging. As spontaneous eye blink rate (EBR) is reliably correlated with cognitive activity in healthy individuals, we investigated whether EBR could serve as a marker of patients' level of consciousness. We assessed ten patients in prolonged Vegetative State/Unresponsive Wakefulness Syndrome (VS/UWS; three females; mean age = 50.3 ± 17.8 years) and fourteen patients in Minimally Conscious State (MCS; three females; mean age = 52.9 ± 17.5 years) at their admission to a rehabilitation unit after the acute phase. During two separate 3-min rest conditions, we recorded patients' EBR by integrating on-line visual and off-line electro-oculographic count. We also assessed EBR during two auditory oddball tasks, i.e. passive listening and active counting of target tones in a sub-group of patients. EBR was significantly higher in MCS than in VS/UWS; moreover, EBR positively correlated with a validated index of responsiveness derived from the Coma Recovery Scale-Revised. Patients' mean EBR showed no significant differences within sessions and across experimental conditions of the oddball task, in both VS/UWS and MCS. Our findings suggest that, at least in the post-acute phase, observing patients' EBR for 3 min at rest could help to discriminate between VS/UWS and MCS, improving accuracy of clinical diagnosis.
Collapse
|
23
|
Treating Traumatic Brain Injuries with Electroceuticals: Implications for the Neuroanatomy of Consciousness. NEUROSCI 2021. [DOI: 10.3390/neurosci2030018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
According to the Centers for Disease Control and Prevention (CDC), traumatic brain injury (TBI) is the leading cause of loss of consciousness, long-term disability, and death in children and young adults (age 1 to 44). Currently, there are no United States Food and Drug Administration (FDA) approved pharmacological treatments for post-TBI regeneration and recovery, particularly related to permanent disability and level of consciousness. In some cases, long-term disorders of consciousness (DoC) exist, including the vegetative state/unresponsive wakefulness syndrome (VS/UWS) characterized by the exhibition of reflexive behaviors only or a minimally conscious state (MCS) with few purposeful movements and reflexive behaviors. Electroceuticals, including non-invasive brain stimulation (NIBS), vagus nerve stimulation (VNS), and deep brain stimulation (DBS) have proved efficacious in some patients with TBI and DoC. In this review, we examine how electroceuticals have improved our understanding of the neuroanatomy of consciousness. However, the level of improvements in general arousal or basic bodily and visual pursuit that constitute clinically meaningful recovery on the Coma Recovery Scale-Revised (CRS-R) remain undefined. Nevertheless, these advancements demonstrate the importance of the vagal nerve, thalamus, reticular activating system, and cortico-striatal-thalamic-cortical loop in the process of consciousness recovery.
Collapse
|
24
|
Riganello F, Vatrano M, Carozzo S, Russo M, Lucca LF, Ursino M, Ruggiero V, Cerasa A, Porcaro C. The Timecourse of Electrophysiological Brain-Heart Interaction in DoC Patients. Brain Sci 2021; 11:750. [PMID: 34198911 PMCID: PMC8228557 DOI: 10.3390/brainsci11060750] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2021] [Revised: 05/31/2021] [Accepted: 06/03/2021] [Indexed: 01/09/2023] Open
Abstract
Disorders of Consciousness (DOC) are a spectrum of pathologies affecting one's ability to interact with the external world. Two possible conditions of patients with DOC are Unresponsive Wakefulness Syndrome/Vegetative State (UWS/VS) and Minimally Conscious State (MCS). Analysis of spontaneous EEG activity and the Heart Rate Variability (HRV) are effective techniques in exploring and evaluating patients with DOC. This study aims to observe fluctuations in EEG and HRV parameters in the morning/afternoon resting-state recording. The study enrolled 13 voluntary Healthy Control (HC) subjects and 12 DOC patients (7 MCS, 5 UWS/VS). EEG and EKG were recorded. PSDalpha, PSDtheta powerband, alpha-blocking, alpha/theta of the EEG, Complexity Index (CI) and SDNN of EKG were analyzed. Higher values of PSDalpha, alpha-blocking, alpha/theta and CI values and lower values of PSD theta characterized HC individuals in the morning with respect to DOC patients. In the afternoon, we detected a significant difference between groups in the CI, PSDalpha, PSDtheta, alpha/theta and SDNN, with lower PSDtheta value for HC. CRS-R scores showed a strong correlation with recorded parameters mainly during evaluations in the morning. Our finding put in evidence the importance of the assessment, as the stimulation of DOC patients in research for behavioural response, in the morning.
Collapse
Affiliation(s)
- Francesco Riganello
- S.Anna Institute—Research in Advanced Neurorehabilitation, 88900 Crotone, Italy; (M.V.); (S.C.); (M.R.); (L.F.L.); (M.U.); (V.R.); (A.C.); (C.P.)
| | - Martina Vatrano
- S.Anna Institute—Research in Advanced Neurorehabilitation, 88900 Crotone, Italy; (M.V.); (S.C.); (M.R.); (L.F.L.); (M.U.); (V.R.); (A.C.); (C.P.)
| | - Simone Carozzo
- S.Anna Institute—Research in Advanced Neurorehabilitation, 88900 Crotone, Italy; (M.V.); (S.C.); (M.R.); (L.F.L.); (M.U.); (V.R.); (A.C.); (C.P.)
| | - Miriam Russo
- S.Anna Institute—Research in Advanced Neurorehabilitation, 88900 Crotone, Italy; (M.V.); (S.C.); (M.R.); (L.F.L.); (M.U.); (V.R.); (A.C.); (C.P.)
| | - Lucia Francesca Lucca
- S.Anna Institute—Research in Advanced Neurorehabilitation, 88900 Crotone, Italy; (M.V.); (S.C.); (M.R.); (L.F.L.); (M.U.); (V.R.); (A.C.); (C.P.)
| | - Maria Ursino
- S.Anna Institute—Research in Advanced Neurorehabilitation, 88900 Crotone, Italy; (M.V.); (S.C.); (M.R.); (L.F.L.); (M.U.); (V.R.); (A.C.); (C.P.)
| | - Valentina Ruggiero
- S.Anna Institute—Research in Advanced Neurorehabilitation, 88900 Crotone, Italy; (M.V.); (S.C.); (M.R.); (L.F.L.); (M.U.); (V.R.); (A.C.); (C.P.)
| | - Antonio Cerasa
- S.Anna Institute—Research in Advanced Neurorehabilitation, 88900 Crotone, Italy; (M.V.); (S.C.); (M.R.); (L.F.L.); (M.U.); (V.R.); (A.C.); (C.P.)
- Institute for Biomedical Research and Innovation (IRIB)—National Research Council of Italy (CNR), 87050 Mangone, Italy
| | - Camillo Porcaro
- S.Anna Institute—Research in Advanced Neurorehabilitation, 88900 Crotone, Italy; (M.V.); (S.C.); (M.R.); (L.F.L.); (M.U.); (V.R.); (A.C.); (C.P.)
- Department of Information Engineering, Università Politecnica delle Marche, 60131 Ancona, Italy
- Centre for Human Brain Health, School of Psychology, University of Birmingham, Birmingham B15 2TT, UK
- Institute of Cognitive Sciences and Technologies (ISTC) - National Research Council (CNR), 00185 Rome, Italy
| |
Collapse
|
25
|
Xu C, Zou J, He F, Wen X, Li J, Gao J, Ding N, Luo B. Neural Tracking of Sound Rhythms Correlates With Diagnosis, Severity, and Prognosis of Disorders of Consciousness. Front Neurosci 2021; 15:646543. [PMID: 33994924 PMCID: PMC8113690 DOI: 10.3389/fnins.2021.646543] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2020] [Accepted: 03/19/2021] [Indexed: 12/03/2022] Open
Abstract
Effective diagnosis and prognosis of patients with disorders of consciousness (DOC) provides a basis for family counseling, decision-making, and the design of rehabilitation programs. However, effective and objective bedside evaluation is a challenging problem. In this study, we explored electroencephalography (EEG) response tracking sound rhythms as potential neural markers for DOC evaluation. We analyzed the responses to natural speech and tones modulated at 2 and 41 Hz. At the population level, patients with positive outcomes (DOC-P) showed higher cortical synchronization to modulated tones at 41 Hz compared with patients with negative outcomes (DOC-N). At the individual level, phase coherence to modulated tones at 41 Hz was significantly correlated with Coma Recovery Scale-Revised (CRS-R) and Glasgow Outcome Scale-Extended (GOS-E) scores. Furthermore, SVM classifiers, trained using phase coherences in higher frequency bands or combination of the low frequency aSSR and speech tracking responses, performed very well in diagnosis and prognosis of DOC. These findings show that EEG response to auditory rhythms is a potential tool for diagnosis, severity, and prognosis of DOC.
Collapse
Affiliation(s)
- Chuan Xu
- Department of Neurology, First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Jiajie Zou
- Key Laboratory for Biomedical Engineering of Ministry of Education, College of Biomedical Engineering and Instrument Sciences, Zhejiang University, Hangzhou, China.,Research Center for Advanced Artificial Intelligence Theory Zhejiang Lab, Hangzhou, China
| | - Fangping He
- Department of Neurology, First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Xinrui Wen
- Department of Neurology, First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Jingqi Li
- Department of Rehabilitation, Hangzhou Mingzhou Brain Rehabilitation Hospital, Hangzhou, China
| | - Jian Gao
- Department of Rehabilitation, Hangzhou Mingzhou Brain Rehabilitation Hospital, Hangzhou, China
| | - Nai Ding
- Key Laboratory for Biomedical Engineering of Ministry of Education, College of Biomedical Engineering and Instrument Sciences, Zhejiang University, Hangzhou, China.,Research Center for Advanced Artificial Intelligence Theory Zhejiang Lab, Hangzhou, China
| | - Benyan Luo
- Department of Neurology, First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| |
Collapse
|
26
|
Chaturvedi J, Mudgal SK, Venkataram T, Gupta P, Goyal N, Jain G, Sharma AK, Sharma SK, Bendok BR. Coma recovery scale: Key clinical tool ignored enough in disorders of consciousness. Surg Neurol Int 2021; 12:93. [PMID: 33767897 PMCID: PMC7982119 DOI: 10.25259/sni_935_2020] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Accepted: 02/06/2021] [Indexed: 01/10/2023] Open
Abstract
Background: Disorders of consciousness (DoC) includes coma, vegetative state (VS), minimally conscious state (MCS), and emergence from the MCS. Aneurysmal rupture with high-grade SAH, traumatic brain injury, and neoplastic brain lesions are some of the frequent pathologies leading to DoC. The diagnostic errors among these DoC are as high as ranging from 25% to 45%, with a probable error in the conclusion of patients’ state, treatment choice, end-of-life decision-making, and prognosis. Some studies also reported that 37–43% of patients were misdiagnosed in VS while demonstrating signs of awareness. Despite its wide acceptance, Coma Recovery Scale-Revised (CRS-r) remained underused or inappropriately utilized, which may lead to substandard or unprofessional patient care. Literature is rare on the knowledge of CRS-r among physicians published from India and across the globe. Therefore, we carried out the present study to ascertain physicians’ knowledge on CRS-r and raise awareness about its justifiable clinical utilization. We also explored the factors associated with this perceived level of experience among participants and recommend frequent physicians’ training for care of patients with DoC. Methods: An institution-based cross-sectional online survey was conducted from June 8 to July 7, 2020, among Ninety-six physicians recruited using a convenient sampling technique. Twenty-item, validated, reliable, and a pilot-tested questionnaire was used to assess the knowledge regarding CRS-r and collect socio-demographic variables. The analysis was performed using the Statistical Package for the Social Sciences version 23. Bivariate and multivariate logistic regression analyses were employed to assess the association of participants’ socio-demographic variables and their parent department of work with the knowledge. P < 0.05 was considered statistically significant in the multivariate analysis. Results: A total of Ninety-six participants were included in the analysis, and only 33.3% of them were found to have adequate knowledge of CRS-r. Multivariate analysis revealed that age (adjusted odds ratio [AOR] = 31.66; 95% CI: 6.25–160.36), gender (AOR = 44.16; 95% CI: 7.43–268.23), and parent department of working (AOR = 0.148; 95% CI: 0.06–0.39) were significantly associated with the knowledge. Conclusion: Knowledge of the physicians on CRS-r is found to be exceptionally low. It has a strong tendency to adversely affect patients’ optimal care with disorders of consciousness (DoC). Therefore, it is crucial to expand physicians’ knowledge and awareness regarding CRS-r to adequately screen patients with DoC.
Collapse
Affiliation(s)
- Jitender Chaturvedi
- Department of Neurosurgery, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India
| | - Shiv Kumar Mudgal
- Department of Nursing, Akal College of Nursing, Eternal University, Baru Sahib, Himachal Pradesh, India
| | - Tejas Venkataram
- Department of Neurosurgery, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India
| | - Priyanka Gupta
- Department of Neuroanaesthesia, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India
| | - Nishant Goyal
- Department of Neurosurgery, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India
| | - Gaurav Jain
- Department of Anesthesia, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India
| | - Anil Kumar Sharma
- Department of Neurosurgery, All India Institute of Medical Sciences, Raipur, Chhattisgarh, India
| | - Suresh Kumar Sharma
- Department of Nursing, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India
| | - Bernard R Bendok
- Department of Neurological Surgery, Mayo Clinic, Phoenix, Arizona, USA
| |
Collapse
|
27
|
Aubinet C, Chatelle C, Gillet S, Lejeune N, Thunus M, Hennen N, Cassol H, Laureys S, Majerus S. The Brief Evaluation of Receptive Aphasia test for the detection of language impairment in patients with severe brain injury. Brain Inj 2021; 35:705-717. [PMID: 33678094 DOI: 10.1080/02699052.2021.1894482] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
PRIMARY OBJECTIVE The assessment of language in patients post-comatose patients is limited by their reduced behavioral repertoire. We developed the Brief Evaluation of Receptive Aphasia (BERA) tool for assessing phonological, semantic and morphosyntactic abilities in patients with severe brain injury based on visual fixation responses. RESEARCH DESIGN Prospective cross-sectional study and case reports. METHODS AND PROCEDURE The BERA and Language Screening Test were first administered to 52 conscious patients with aphasia on two consecutive days in order to determine the validity and reliability of the BERA. Four post-comatose patients were further examined with the BERA, the Coma Recovery Scale-Revised (CRS-R), positron emission tomography and structural magnetic resonance imaging. MAIN OUTCOME AND RESULTS The BERA showed satisfactory intra- and inter-rater reliability, as well as internal and concurrent validity in patients with aphasia. The BERA scores indicated selective receptive difficulties for phonological, semantic and particularly morphosyntactic abilities in post-comatose patients. These results were in line with the cortical distribution of brain lesions. CONCLUSIONS The BERA may complement the widely used CRS-R for assessing and diagnosing patients with disorders of consciousness by providing a systematic and detailed characterization of residual language abilities.
Collapse
Affiliation(s)
- Charlène Aubinet
- GIGA-Consciousness, GIGA Research Center (B34, +1), University of Liège, Liège, Belgium.,Centre Du Cerveau², University Hospital of Liège (B34, +1), Liège, Belgium
| | - Camille Chatelle
- GIGA-Consciousness, GIGA Research Center (B34, +1), University of Liège, Liège, Belgium.,Centre Du Cerveau², University Hospital of Liège (B34, +1), Liège, Belgium
| | - Sophie Gillet
- Psychology and Neuroscience of Cognition Research Unit, University of Liège, Quartier Agora (B33), Liège, Belgium
| | - Nicolas Lejeune
- GIGA-Consciousness, GIGA Research Center (B34, +1), University of Liège, Liège, Belgium.,Centre Du Cerveau², University Hospital of Liège (B34, +1), Liège, Belgium.,Centre Neurologique William Lennox, Ottignies-Louvain-la-Neuve, Belgium.,Institute of NeuroScience, UCLouvain, Brussels, Belgium
| | - Margot Thunus
- Psychology and Neuroscience of Cognition Research Unit, University of Liège, Quartier Agora (B33), Liège, Belgium
| | - Noémie Hennen
- Psychology and Neuroscience of Cognition Research Unit, University of Liège, Quartier Agora (B33), Liège, Belgium
| | - Helena Cassol
- GIGA-Consciousness, GIGA Research Center (B34, +1), University of Liège, Liège, Belgium.,Centre Du Cerveau², University Hospital of Liège (B34, +1), Liège, Belgium
| | - Steven Laureys
- GIGA-Consciousness, GIGA Research Center (B34, +1), University of Liège, Liège, Belgium.,Centre Du Cerveau², University Hospital of Liège (B34, +1), Liège, Belgium
| | - Steve Majerus
- Psychology and Neuroscience of Cognition Research Unit, University of Liège, Quartier Agora (B33), Liège, Belgium
| |
Collapse
|
28
|
Sinitsyn DO, Poydasheva AG, Bakulin IS, Legostaeva LA, Iazeva EG, Sergeev DV, Sergeeva AN, Kremneva EI, Morozova SN, Lagoda DY, Casarotto S, Comanducci A, Ryabinkina YV, Suponeva NA, Piradov MA. Detecting the Potential for Consciousness in Unresponsive Patients Using the Perturbational Complexity Index. Brain Sci 2020; 10:E917. [PMID: 33260944 PMCID: PMC7760168 DOI: 10.3390/brainsci10120917] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2020] [Revised: 11/24/2020] [Accepted: 11/24/2020] [Indexed: 12/26/2022] Open
Abstract
The difficulties of behavioral evaluation of prolonged disorders of consciousness (DOC) motivate the development of brain-based diagnostic approaches. The perturbational complexity index (PCI), which measures the complexity of electroencephalographic (EEG) responses to transcranial magnetic stimulation (TMS), showed a remarkable sensitivity in detecting minimal signs of consciousness in previous studies. Here, we tested the reliability of PCI in an independently collected sample of 24 severely brain-injured patients, including 11 unresponsive wakefulness syndrome (UWS), 12 minimally conscious state (MCS) patients, and 1 emergence from MCS patient. We found that the individual maximum PCI value across stimulation sites fell within the consciousness range (i.e., was higher than PCI*, which is an empirical cutoff previously validated on a benchmark population) in 11 MCS patients, yielding a sensitivity of 92% that surpassed qualitative evaluation of resting EEG. Most UWS patients (n = 7, 64%) showed a slow and stereotypical TMS-EEG response, associated with low-complexity PCI values (i.e., ≤PCI*). Four UWS patients (36%) provided high-complexity PCI values, which might suggest a covert capacity for consciousness. In conclusion, this study successfully replicated the performance of PCI in discriminating between UWS and MCS patients, further motivating the application of TMS-EEG in the workflow of DOC evaluation.
Collapse
Affiliation(s)
- Dmitry O. Sinitsyn
- Research Center of Neurology, Volokolamskoe Shosse, 80, Moscow 125367, Russia; (A.G.P.); (I.S.B.); (L.A.L.); (E.G.I.); (D.V.S.); (A.N.S.); (E.I.K.); (S.N.M.); (D.Y.L.); (Y.V.R.); (N.A.S.); (M.A.P.)
| | - Alexandra G. Poydasheva
- Research Center of Neurology, Volokolamskoe Shosse, 80, Moscow 125367, Russia; (A.G.P.); (I.S.B.); (L.A.L.); (E.G.I.); (D.V.S.); (A.N.S.); (E.I.K.); (S.N.M.); (D.Y.L.); (Y.V.R.); (N.A.S.); (M.A.P.)
| | - Ilya S. Bakulin
- Research Center of Neurology, Volokolamskoe Shosse, 80, Moscow 125367, Russia; (A.G.P.); (I.S.B.); (L.A.L.); (E.G.I.); (D.V.S.); (A.N.S.); (E.I.K.); (S.N.M.); (D.Y.L.); (Y.V.R.); (N.A.S.); (M.A.P.)
| | - Liudmila A. Legostaeva
- Research Center of Neurology, Volokolamskoe Shosse, 80, Moscow 125367, Russia; (A.G.P.); (I.S.B.); (L.A.L.); (E.G.I.); (D.V.S.); (A.N.S.); (E.I.K.); (S.N.M.); (D.Y.L.); (Y.V.R.); (N.A.S.); (M.A.P.)
| | - Elizaveta G. Iazeva
- Research Center of Neurology, Volokolamskoe Shosse, 80, Moscow 125367, Russia; (A.G.P.); (I.S.B.); (L.A.L.); (E.G.I.); (D.V.S.); (A.N.S.); (E.I.K.); (S.N.M.); (D.Y.L.); (Y.V.R.); (N.A.S.); (M.A.P.)
| | - Dmitry V. Sergeev
- Research Center of Neurology, Volokolamskoe Shosse, 80, Moscow 125367, Russia; (A.G.P.); (I.S.B.); (L.A.L.); (E.G.I.); (D.V.S.); (A.N.S.); (E.I.K.); (S.N.M.); (D.Y.L.); (Y.V.R.); (N.A.S.); (M.A.P.)
| | - Anastasia N. Sergeeva
- Research Center of Neurology, Volokolamskoe Shosse, 80, Moscow 125367, Russia; (A.G.P.); (I.S.B.); (L.A.L.); (E.G.I.); (D.V.S.); (A.N.S.); (E.I.K.); (S.N.M.); (D.Y.L.); (Y.V.R.); (N.A.S.); (M.A.P.)
| | - Elena I. Kremneva
- Research Center of Neurology, Volokolamskoe Shosse, 80, Moscow 125367, Russia; (A.G.P.); (I.S.B.); (L.A.L.); (E.G.I.); (D.V.S.); (A.N.S.); (E.I.K.); (S.N.M.); (D.Y.L.); (Y.V.R.); (N.A.S.); (M.A.P.)
| | - Sofya N. Morozova
- Research Center of Neurology, Volokolamskoe Shosse, 80, Moscow 125367, Russia; (A.G.P.); (I.S.B.); (L.A.L.); (E.G.I.); (D.V.S.); (A.N.S.); (E.I.K.); (S.N.M.); (D.Y.L.); (Y.V.R.); (N.A.S.); (M.A.P.)
| | - Dmitry Yu. Lagoda
- Research Center of Neurology, Volokolamskoe Shosse, 80, Moscow 125367, Russia; (A.G.P.); (I.S.B.); (L.A.L.); (E.G.I.); (D.V.S.); (A.N.S.); (E.I.K.); (S.N.M.); (D.Y.L.); (Y.V.R.); (N.A.S.); (M.A.P.)
| | - Silvia Casarotto
- Department of Biomedical and Clinical Sciences “L. Sacco”, University of Milan, 20157 Milan, Italy;
| | | | - Yulia V. Ryabinkina
- Research Center of Neurology, Volokolamskoe Shosse, 80, Moscow 125367, Russia; (A.G.P.); (I.S.B.); (L.A.L.); (E.G.I.); (D.V.S.); (A.N.S.); (E.I.K.); (S.N.M.); (D.Y.L.); (Y.V.R.); (N.A.S.); (M.A.P.)
| | - Natalia A. Suponeva
- Research Center of Neurology, Volokolamskoe Shosse, 80, Moscow 125367, Russia; (A.G.P.); (I.S.B.); (L.A.L.); (E.G.I.); (D.V.S.); (A.N.S.); (E.I.K.); (S.N.M.); (D.Y.L.); (Y.V.R.); (N.A.S.); (M.A.P.)
| | - Michael A. Piradov
- Research Center of Neurology, Volokolamskoe Shosse, 80, Moscow 125367, Russia; (A.G.P.); (I.S.B.); (L.A.L.); (E.G.I.); (D.V.S.); (A.N.S.); (E.I.K.); (S.N.M.); (D.Y.L.); (Y.V.R.); (N.A.S.); (M.A.P.)
| |
Collapse
|
29
|
Wang J, Hu X, Hu Z, Sun Z, Laureys S, Di H. The misdiagnosis of prolonged disorders of consciousness by a clinical consensus compared with repeated coma-recovery scale-revised assessment. BMC Neurol 2020; 20:343. [PMID: 32919461 PMCID: PMC7488705 DOI: 10.1186/s12883-020-01924-9] [Citation(s) in RCA: 46] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2019] [Accepted: 09/08/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Previous studies have shown that a single Coma-Recovery Scale-Revision (CRS-R) assessment can identify high rates of misdiagnosis by clinical consensus. The aim of this study was to investigate the proportion of misdiagnosis by clinical consensus compared to repeated behavior-scale assessments in patients with prolonged disorders of consciousness (DOC). METHODS Patients with prolonged DOC during hospitalization were screened by clinicians, and the clinicians formed a clinical-consensus diagnosis. Trained professionals used the CRS-R to evaluate the consciousness levels of the enrolled patients repeatedly (≥5 times) within a week. Based on the repeated evaluation results, the enrolled patients with prolonged DOC were divided into unresponsive wakefulness syndrome (UWS), minimally conscious state (MCS), and emergence from MCS (EMCS). Finally, the relationship between the results of the CRS-R and the clinical consensus were analyzed. RESULTS In this study, 137 patients with a clinical-consensus diagnosis of prolonged DOC were enrolled. It was found that 24.7% of patients with clinical UWS were actually in MCS after a single CRS-R behavior evaluation, while the repeated CRS-R evaluation results showed that the proportion of misdiagnosis of MCS was 38.2%. A total of 16.7% of EMCS patients were misdiagnosed with clinical MCS, and 1.1% of EMCS patients were misdiagnosed with clinical UWS. CONCLUSIONS The rate of the misdiagnosis by clinical consensus is still relatively high. Therefore, clinicians should be aware of the importance of the bedside CRS-R behavior assessment and should apply the CRS-R tool in daily procedures. TRIAL REGISTRATION ClinicalTrials.gov ID: NCT04139239 ; Registered 24 October 2019 - Retrospectively registered.
Collapse
Affiliation(s)
- Jing Wang
- International Unresponsive Wakefulness Syndrome and Consciousness Science Institute, Hangzhou Normal University, Hangzhou, 310036 China
| | - Xiaohua Hu
- Rehabilitation Center for Brain Damage, Wujing Hospital of Hangzhou City, Hangzhou, China
| | - Zhouyao Hu
- International Unresponsive Wakefulness Syndrome and Consciousness Science Institute, Hangzhou Normal University, Hangzhou, 310036 China
| | - Ziwei Sun
- International Unresponsive Wakefulness Syndrome and Consciousness Science Institute, Hangzhou Normal University, Hangzhou, 310036 China
| | - Steven Laureys
- Coma Science Group, GIGA Consciousness, University and University Hospital of Liège, Liège, Belgium
| | - Haibo Di
- International Unresponsive Wakefulness Syndrome and Consciousness Science Institute, Hangzhou Normal University, Hangzhou, 310036 China
| |
Collapse
|
30
|
Gui P, Jiang Y, Zang D, Qi Z, Tan J, Tanigawa H, Jiang J, Wen Y, Xu L, Zhao J, Mao Y, Poo MM, Ding N, Dehaene S, Wu X, Wang L. Assessing the depth of language processing in patients with disorders of consciousness. Nat Neurosci 2020; 23:761-770. [DOI: 10.1038/s41593-020-0639-1] [Citation(s) in RCA: 42] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2019] [Accepted: 04/08/2020] [Indexed: 12/18/2022]
|
31
|
Lee HY, Park JH, Kim AR, Park M, Kim TW. Neurobehavioral recovery in patients who emerged from prolonged disorder of consciousness: a retrospective study. BMC Neurol 2020; 20:198. [PMID: 32434516 PMCID: PMC7238564 DOI: 10.1186/s12883-020-01758-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2019] [Accepted: 05/03/2020] [Indexed: 12/20/2022] Open
Abstract
Background We investigated the clinical course of patients with prolonged disorders of consciousness (PDoC), predictors of emergence from PDoC (EDoC), and the temporal dynamics of six neurobehavior domains based on the JFK Coma Recovery Scale-Revised (CRS-R) during the recovery. Methods A total of 50 traumatic and non-traumatic patients with PDoC were enrolled between October 2014 and February 2017. A retrospective analysis of the clinical findings and neurobehavioral signs was conducted using standardized methodology such as CRS-R. The findings were used to investigate the incidence and predictors of EDoC and determine the cumulative pattern of neurobehavioral recovery at 6 months, 1 year, and 2 years post-injury. Results The results showed that 46% of the subjects emerged from PDoC after 200 median days (64–1197 days) of injury onset. The significant predictors of EDoC included minimally conscious state (MCS) (vs. vegetative state), higher auditory, communication, arousal, total CRS-R scores, shorter lag time post-injury, and the absence of intra-axial lesions. In terms of cumulative recovery of motor and communication signs in patients who emerged from PDoC, 39 and 32% showed EDoC at 6 months post-injury, and 88 and 93% exhibited EDoC at 2 years post-injury, respectively. Conclusions Nearly half of the patients with PDoC recovered consciousness during inpatient rehabilitation. MCS, shorter lag time, the absence of intra-axial lesions, higher auditory, communication, arousal, and total CRS-R scores were important predictors for EDoC. Motor scores in the early stage of recovery and communication scores after prolonged intervals contributed to the higher levels of cumulative EDoC.
Collapse
Affiliation(s)
- Hoo Young Lee
- TBI rehabilitation center, National Traffic Injury Rehabilitation Hospital, 260, Jungang-ro, Dogok-ri, Yangpyeong-eup, Yangpyeong-gun, Gyeonggi-do, 12564, South Korea.,Department of Rehabilitation Medicine, Seoul National University Hospital, Seoul University College of Medicine, Seoul, South Korea.,Department of Medicine, the Graduate School of Yonsei University, Seoul, South Korea
| | - Jung Hyun Park
- Department of Medicine, the Graduate School of Yonsei University, Seoul, South Korea.,Department of Rehabilitation Medicine, Gangnam Severance Hospital, Rehabilitation Institute of Neuromuscular Disease, Yonsei University College of Medicine, Seoul, South Korea
| | - Ae Ryoung Kim
- Department of Rehabilitation Medicine, School of Medicine, Kyungpook National University, Kyungpook National University Hospital, Daegu, South Korea
| | - Misun Park
- Department of Biostatistics, Clinical Research Coordinating Center, Catholic Medical Center, The Catholic University of Korea, Seoul, Republic of Korea
| | - Tae-Woo Kim
- TBI rehabilitation center, National Traffic Injury Rehabilitation Hospital, 260, Jungang-ro, Dogok-ri, Yangpyeong-eup, Yangpyeong-gun, Gyeonggi-do, 12564, South Korea. .,Department of Rehabilitation Medicine, Seoul National University Hospital, Seoul University College of Medicine, Seoul, South Korea.
| |
Collapse
|
32
|
Abeyasinghe PM, Aiello M, Nichols ES, Cavaliere C, Fiorenza S, Masotta O, Borrelli P, Owen AM, Estraneo A, Soddu A. Consciousness and the Dimensionality of DOC Patients via the Generalized Ising Model. J Clin Med 2020; 9:E1342. [PMID: 32375368 PMCID: PMC7290966 DOI: 10.3390/jcm9051342] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2020] [Revised: 04/29/2020] [Accepted: 04/29/2020] [Indexed: 02/06/2023] Open
Abstract
The data from patients with severe brain injuries show complex brain functions. Due to the difficulties associated with these complex data, computational modeling is an especially useful tool to examine the structure-function relationship in these populations. By using computational modeling for patients with a disorder of consciousness (DoC), not only we can understand the changes of information transfer, but we also can test changes to different states of consciousness by hypothetically changing the anatomical structure. The generalized Ising model (GIM), which specializes in using structural connectivity to simulate functional connectivity, has been proven to effectively capture the relationship between anatomical structures and the spontaneous fluctuations of healthy controls (HCs). In the present study we implemented the GIM in 25 HCs as well as in 13 DoC patients diagnosed at three different states of consciousness. Simulated data were analyzed and the criticality and dimensionality were calculated for both groups; together, those values capture the level of information transfer in the brain. Ratifying previous studies, criticality was observed in simulations of HCs. We were also able to observe criticality for DoC patients, concluding that the GIM is generalizable for DoC patients. Furthermore, dimensionality increased for the DoC group as compared to healthy controls, and could distinguish different diagnostic groups of DoC patients.
Collapse
Affiliation(s)
- Pubuditha M. Abeyasinghe
- Department of Physics and Astronomy, Western University, London ON N6G2V4, Canada; (E.S.N.); (A.S.)
- Brain and Mind Institute, Western University, London ON N6A57, Canada;
- School of Psychological Sciences and Turner Institute for Brain and Mental Health, Monash University, Melbourne, VIC 3800, Australia
| | - Marco Aiello
- IRCCS SDN, Via E. Gianturco 113, 80143 Naples, Italy; (M.A.); (C.C.); (P.B.)
| | - Emily S. Nichols
- Department of Physics and Astronomy, Western University, London ON N6G2V4, Canada; (E.S.N.); (A.S.)
- Brain and Mind Institute, Western University, London ON N6A57, Canada;
| | - Carlo Cavaliere
- IRCCS SDN, Via E. Gianturco 113, 80143 Naples, Italy; (M.A.); (C.C.); (P.B.)
| | - Salvatore Fiorenza
- Clinical Scientific Institute Maugeri; Telese Terme Center; 82037 Telese Terme, Italy; (S.F.); (O.M.); (A.E.)
| | - Orsola Masotta
- Clinical Scientific Institute Maugeri; Telese Terme Center; 82037 Telese Terme, Italy; (S.F.); (O.M.); (A.E.)
| | - Pasquale Borrelli
- IRCCS SDN, Via E. Gianturco 113, 80143 Naples, Italy; (M.A.); (C.C.); (P.B.)
| | - Adrian M. Owen
- Brain and Mind Institute, Western University, London ON N6A57, Canada;
- Department of Psychology, Western University, London ON N6A5C2, Canada
- Department of Physiology and Pharmacology, Western University, London ON N6A5C1, Canada
| | - Anna Estraneo
- Clinical Scientific Institute Maugeri; Telese Terme Center; 82037 Telese Terme, Italy; (S.F.); (O.M.); (A.E.)
- Neurology Unit, SM della Pietà General Hospital, 80035 Nola, Italy
| | - Andrea Soddu
- Department of Physics and Astronomy, Western University, London ON N6G2V4, Canada; (E.S.N.); (A.S.)
- Brain and Mind Institute, Western University, London ON N6A57, Canada;
| |
Collapse
|
33
|
Cortese D, Riganello F, Arcuri F, Lucca L, Tonin P, Schnakers C, Laureys S. The Trace Conditional Learning of the Noxious Stimulus in UWS Patients and Its Prognostic Value in a GSR and HRV Entropy Study. Front Hum Neurosci 2020; 14:97. [PMID: 32327985 PMCID: PMC7161674 DOI: 10.3389/fnhum.2020.00097] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2019] [Accepted: 03/02/2020] [Indexed: 01/18/2023] Open
Abstract
The assessment of the consciousness level of Unresponsive Wakefulness Syndrome (UWS) patients often depends on a subjective interpretation of the observed spontaneous and volitional behavior. To date, the misdiagnosis level is around 30%. The aim of this study was to observe the behavior of UWS patients, during the administration of noxious stimulation by a Trace Conditioning protocol, assessed by the Galvanic Skin Response (GSR) and Heart Rate Variability (HRV) entropy. We recruited 13 Healthy Control (HC) and 30 UWS patients at 31 ± 9 days from the acute event evaluated by Coma Recovery Scale–Revised (CRS-R) and Nociception Coma Scale (NCS). Two different stimuli [musical stimulus (MUS) and nociceptive stimulus (NOC)], preceded, respectively by two different tones, were administered following the sequences (A) MUS1 – NOC1 – MUS2 – MUS3 – NOC2 – MUS4 – NOC3 – NOC*, and (B) MUS1*, NOC1*, NOC2*, MUS2*, NOC3*, MUS3*, NOC4*, MUS4*. All the (*) indicate the only tones administration. CRS-R and NCS assessments were repeated for three consecutive weeks. MUS4, NOC3, and NOC* were compared for GSR wave peak magnitude, time to reach the peak, and time of wave's decay by Wilcoxon's test to assess the Conditioned Response (CR). The Sample Entropy (SampEn) was recorded in baseline and both sequences. Machine Learning approach was used to identify a rule to discriminate the CR. The GSR magnitude of CR was higher comparing music stimulus (p < 0.0001) and CR extinction (p < 0.002) in nine patients and in HC. Patients with CR showed a higher SampEn in sequence A compared to patients without CR. Within the third and fourth weeks from protocol administration, eight of the nine patients (88.9%) evolved into MCS. The Machine-learning showed a high performance to differentiate presence/absence of CR (≥95%). The possibility to observe the CR to the noxious stimulus, by means of the GSR and SampEn, can represent a potential method to reduce the misdiagnosis in UWS patients.
Collapse
Affiliation(s)
- Daniela Cortese
- Research in Advanced NeuroRehabilitation, Istituto Sant'Anna, Crotone, Italy
| | - Francesco Riganello
- Research in Advanced NeuroRehabilitation, Istituto Sant'Anna, Crotone, Italy.,Coma Science Group, GIGA-Consciousness, University & Hospital of Liege, Liege, Belgium
| | - Francesco Arcuri
- Research in Advanced NeuroRehabilitation, Istituto Sant'Anna, Crotone, Italy
| | - Lucia Lucca
- Research in Advanced NeuroRehabilitation, Istituto Sant'Anna, Crotone, Italy
| | - Paolo Tonin
- Research in Advanced NeuroRehabilitation, Istituto Sant'Anna, Crotone, Italy
| | - Caroline Schnakers
- Neurosurgery Department, University of California, Los Angeles, Los Angeles, CA, United States.,Research Institute, Casa Colina Hospital and Centers of Healthcare, Pomona, CA, United States
| | - Steven Laureys
- Coma Science Group, GIGA-Consciousness, University & Hospital of Liege, Liege, Belgium
| |
Collapse
|
34
|
Kondziella D, Bender A, Diserens K, van Erp W, Estraneo A, Formisano R, Laureys S, Naccache L, Ozturk S, Rohaut B, Sitt JD, Stender J, Tiainen M, Rossetti AO, Gosseries O, Chatelle C. European Academy of Neurology guideline on the diagnosis of coma and other disorders of consciousness. Eur J Neurol 2020; 27:741-756. [PMID: 32090418 DOI: 10.1111/ene.14151] [Citation(s) in RCA: 313] [Impact Index Per Article: 78.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2019] [Accepted: 01/09/2020] [Indexed: 12/20/2022]
Abstract
BACKGROUND AND PURPOSE Patients with acquired brain injury and acute or prolonged disorders of consciousness (DoC) are challenging. Evidence to support diagnostic decisions on coma and other DoC is limited but accumulating. This guideline provides the state-of-the-art evidence regarding the diagnosis of DoC, summarizing data from bedside examination techniques, functional neuroimaging and electroencephalography (EEG). METHODS Sixteen members of the European Academy of Neurology (EAN) Scientific Panel on Coma and Chronic Disorders of Consciousness, representing 10 European countries, reviewed the scientific evidence for the evaluation of coma and other DoC using standard bibliographic measures. Recommendations followed the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system. The guideline was endorsed by the EAN. RESULTS Besides a comprehensive neurological examination, the following suggestions are made: probe for voluntary eye movements using a mirror; repeat clinical assessments in the subacute and chronic setting, using the Coma Recovery Scale - Revised; use the Full Outline of Unresponsiveness score instead of the Glasgow Coma Scale in the acute setting; obtain clinical standard EEG; search for sleep patterns on EEG, particularly rapid eye movement sleep and slow-wave sleep; and, whenever feasible, consider positron emission tomography, resting state functional magnetic resonance imaging (fMRI), active fMRI or EEG paradigms and quantitative analysis of high-density EEG to complement behavioral assessment in patients without command following at the bedside. CONCLUSIONS Standardized clinical evaluation, EEG-based techniques and functional neuroimaging should be integrated for multimodal evaluation of patients with DoC. The state of consciousness should be classified according to the highest level revealed by any of these three approaches.
Collapse
Affiliation(s)
- D Kondziella
- Department of Neurology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark.,Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark.,Department of Neurosciences, Norwegian University of Science and Technology, Trondheim, Norway
| | - A Bender
- Department of Neurology, Ludwig-Maximilians-Universität München, Munich, Germany.,Therapiezentrum Burgau, Burgau, Germany
| | - K Diserens
- Department of Clinical Neurosciences, Centre Hospitalier Universitaire Vaudois and University of Lausanne, Lausanne, Switzerland
| | - W van Erp
- Coma Science Group, GIGA Consciousness, University and University Hospital of Liège, Liège, Belgium.,Department of Primary Care, Radboud University Medical Center, Nijmegen, The Netherlands
| | - A Estraneo
- Neurology Unit, Santa Maria della Pietà General Hospital, Nola, Italy.,IRCCS Fondazione don Carlo Gnocchi ONLUS, Florence, Italy
| | - R Formisano
- Post-Coma Unit, Neurorehabilitation Hospital and Research Institution, Santa Lucia Foundation, Rome, Italy
| | - S Laureys
- Coma Science Group, GIGA Consciousness, University and University Hospital of Liège, Liège, Belgium
| | - L Naccache
- Department of Neurology, AP-HP, Groupe hospitalier Pitié-Salpêtrière, Paris, France.,Sorbonne Université, UPMC Univ Paris 06, Faculté de Médecine Pitié-Salpêtrière, Paris, France
| | - S Ozturk
- Department of Neurology, Faculty of Medicine, Selcuk University, Konya, Turkey
| | - B Rohaut
- Department of Neurology, AP-HP, Groupe hospitalier Pitié-Salpêtrière, Paris, France.,Sorbonne Université, UPMC Univ Paris 06, Faculté de Médecine Pitié-Salpêtrière, Paris, France.,Neuro-ICU, Department of Neurology, Columbia University, New York, NY, USA
| | - J D Sitt
- Sorbonne Université, UPMC Univ Paris 06, Faculté de Médecine Pitié-Salpêtrière, Paris, France
| | - J Stender
- Department of Neurosurgery, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - M Tiainen
- Department of Neurology, Helsinki University Hospital, Helsinki, Finland
| | - A O Rossetti
- Department of Clinical Neurosciences, Centre Hospitalier Universitaire Vaudois and University of Lausanne, Lausanne, Switzerland
| | - O Gosseries
- Coma Science Group, GIGA Consciousness, University and University Hospital of Liège, Liège, Belgium
| | - C Chatelle
- Coma Science Group, GIGA Consciousness, University and University Hospital of Liège, Liège, Belgium.,Laboratory for NeuroImaging of Coma and Consciousness - Department of Neurology, Harvard Medical School, Massachusetts General Hospital, Boston, MA, USA
| | | |
Collapse
|
35
|
Minimum Competency Recommendations for Programs That Provide Rehabilitation Services for Persons With Disorders of Consciousness: A Position Statement of the American Congress of Rehabilitation Medicine and the National Institute on Disability, Independent Living and Rehabilitation Research Traumatic Brain Injury Model Systems. Arch Phys Med Rehabil 2020; 101:1072-1089. [PMID: 32087109 DOI: 10.1016/j.apmr.2020.01.013] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2020] [Revised: 01/27/2020] [Accepted: 01/28/2020] [Indexed: 11/24/2022]
Abstract
Persons who have disorders of consciousness (DoC) require care from multidisciplinary teams with specialized training and expertise in management of the complex needs of this clinical population. The recent promulgation of practice guidelines for patients with prolonged DoC by the American Academy of Neurology, American Congress of Rehabilitation Medicine (ACRM), and National Institute on Disability, Independent Living, and Rehabilitation Research (NIDILRR) represents a major advance in the development of care standards in this area of brain injury rehabilitation. Implementation of these practice guidelines requires explication of the minimum competencies of clinical programs providing services to persons who have DoC. The Brain Injury Interdisciplinary Special Interest Group of the ACRM, in collaboration with the Disorders of Consciousness Special Interest Group of the NIDILRR-Traumatic Brain Injury Model Systems convened a multidisciplinary panel of experts to address this need through the present position statement. Content area-specific workgroups reviewed relevant peer-reviewed literature and drafted recommendations which were then evaluated by the expert panel using a modified Delphi voting process. The process yielded 21 recommendations on the structure and process of essential services required for effective DoC-focused rehabilitation, organized into 4 categories: diagnostic and prognostic assessment (4 recommendations), treatment (11 recommendations), transitioning care/long-term care needs (5 recommendations), and management of ethical issues (1 recommendation). With few exceptions, these recommendations focus on infrastructure requirements and operating procedures for the provision of DoC-focused neurorehabilitation services across subacute and postacute settings.
Collapse
|
36
|
Billeri L, Filoni S, Russo EF, Portaro S, Militi D, Calabrò RS, Naro A. Toward Improving Diagnostic Strategies in Chronic Disorders of Consciousness: An Overview on the (Re-)Emergent Role of Neurophysiology. Brain Sci 2020; 10:brainsci10010042. [PMID: 31936844 PMCID: PMC7016627 DOI: 10.3390/brainsci10010042] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2019] [Revised: 01/03/2020] [Accepted: 01/08/2020] [Indexed: 12/13/2022] Open
Abstract
The differential diagnosis of patients with Disorder of Consciousness (DoC), in particular in the chronic phase, is significantly difficult. Actually, about 40% of patients with unresponsive wakefulness syndrome (UWS) and the minimally conscious state (MCS) are misdiagnosed. Indeed, only advanced paraclinical approaches, including advanced EEG analyses, can allow achieving a more reliable diagnosis, that is, discovering residual traces of awareness in patients with UWS (namely, functional Locked-In Syndrome (fLIS)). These approaches aim at capturing the residual brain network models, at rest or that may be activated in response to relevant stimuli, which may be appropriate for awareness to emerge (despite their insufficiency to generate purposeful motor behaviors). For this, different brain network models have been studied in patients with DoC by using sensory stimuli (i.e., passive tasks), probing response to commands (i.e., active tasks), and during resting-state. Since it can be difficult for patients with DoC to perform even simple active tasks, this scoping review aims at summarizing the current, innovative neurophysiological examination methods in resting state/passive modality to differentiate and prognosticate patients with DoC. We conclude that the electrophysiologically-based diagnostic procedures represent an important resource for diagnosis, prognosis, and, therefore, management of patients with DoC, using advance passive and resting state paradigm analyses for the patients who lie in the “greyzones” between MCS, UWS, and fLIS.
Collapse
Affiliation(s)
- Luana Billeri
- IRCCS Centro Neurolesi Bonino Pulejo, 98124 Messina, Italy; (L.B.); (S.P.); (A.N.)
| | - Serena Filoni
- Padre Pio Foundation and Rehabilitation Centers, San Giovanni Rotondo, 71013 Foggia, Italy;
- Correspondence: (S.F.); (R.S.C.); Tel.: +39-090-6012-8166 (R.S.C.)
| | | | - Simona Portaro
- IRCCS Centro Neurolesi Bonino Pulejo, 98124 Messina, Italy; (L.B.); (S.P.); (A.N.)
| | | | - Rocco Salvatore Calabrò
- IRCCS Centro Neurolesi Bonino Pulejo, 98124 Messina, Italy; (L.B.); (S.P.); (A.N.)
- Correspondence: (S.F.); (R.S.C.); Tel.: +39-090-6012-8166 (R.S.C.)
| | - Antonino Naro
- IRCCS Centro Neurolesi Bonino Pulejo, 98124 Messina, Italy; (L.B.); (S.P.); (A.N.)
| |
Collapse
|
37
|
Bareham CA, Allanson J, Roberts N, Hutchinson PJA, Pickard JD, Menon DK, Chennu S. Longitudinal assessments highlight long-term behavioural recovery in disorders of consciousness. Brain Commun 2019; 1:fcz017. [PMID: 31886461 PMCID: PMC6924536 DOI: 10.1093/braincomms/fcz017] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2019] [Revised: 08/13/2019] [Accepted: 08/25/2019] [Indexed: 11/30/2022] Open
Abstract
Accurate diagnosis and prognosis of disorders of consciousness is complicated by the variability amongst patients' trajectories. However, the majority of research and scientific knowledge in this field is based on cross-sectional studies. The translational gap in applying this knowledge to inform clinical management can only be bridged by research that systematically examines follow-up. In this study, we present findings from a novel longitudinal study of the long-term recovery trajectory of 39 patients, repeatedly assessed using the Coma Recovery Scale-Revised once every 3 months for 2 years, generating 185 assessments. Despite the expected inter-patient variability, there was a statistically significant improvement in behaviour over time. Further, improvements began approximately 22 months after injury. Individual variation in the trajectory of recovery was influenced by initial diagnosis. Patients with an initial diagnosis of unresponsive wakefulness state, who progressed to the minimally conscious state, did so at a median of 485 days following onset-later than 12-month period after which current guidelines propose permanence. Although current guidelines are based on the expectation that patients with traumatic brain injury show potential for recovery over longer periods than those with non-traumatic injury, we did not observe any differences between trajectories in these two subgroups. However, age was a significant predictor, with younger patients showing more promising recovery. Also, progressive increases in arousal contributed exponentially to improvements in behavioural awareness, especially in minimally conscious patients. These findings highlight the importance of indexing arousal when measuring awareness, and the potential for interventions to regulate arousal to aid long-term behavioural recovery in disorders of consciousness.
Collapse
Affiliation(s)
- Corinne A Bareham
- Department of Clinical Neurosciences, University of Cambridge, Cambridge CB2 0QQ, UK
| | - Judith Allanson
- Cambridge University Hospitals NHS Foundation Trust, Cambridge CB2 0QQ, UK
| | - Neil Roberts
- Sawbridgeworth Medical Services, Jacobs & Gardens Neuro Centres, Sawbridgeworth CM21 0HH, UK
| | - Peter J A Hutchinson
- Department of Clinical Neurosciences, University of Cambridge, Cambridge CB2 0QQ, UK
| | - John D Pickard
- Department of Clinical Neurosciences, University of Cambridge, Cambridge CB2 0QQ, UK
| | - David K Menon
- Division of Anaesthesia, University of Cambridge, Cambridge CB2 0QQ, UK
| | - Srivas Chennu
- Department of Clinical Neurosciences, University of Cambridge, Cambridge CB2 0QQ, UK
- School of Computing, University of Kent, Chatham Maritime, ME4 4AG, UK
| |
Collapse
|
38
|
Zasler ND, Aloisi M, Contrada M, Formisano R. Disorders of consciousness terminology: history, evolution and future directions. Brain Inj 2019; 33:1684-1689. [DOI: 10.1080/02699052.2019.1656821] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Affiliation(s)
- Nathan D. Zasler
- Concussion Care Centre of Virginia, LTD; Tree of Life Services, Inc., Richmond, Virginia, USA
- Department of Physical Medicine and Rehabilitation, Virginia Commonwealth University, Richmond, Virginia, USA
- Department of Physical Medicine and Rehabilitation, University of Virginia, Charlottesville, Virginia, USA
| | | | | | | |
Collapse
|
39
|
Scarpino M, Lolli F, Hakiki B, Atzori T, Lanzo G, Sterpu R, Portaccio E, Romoli AM, Morrocchesi A, Amantini A, Macchi C, Grippo A. Prognostic value of post-acute EEG in severe disorders of consciousness, using American Clinical Neurophysiology Society terminology. Neurophysiol Clin 2019; 49:317-327. [DOI: 10.1016/j.neucli.2019.07.001] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2019] [Revised: 07/01/2019] [Accepted: 07/01/2019] [Indexed: 12/15/2022] Open
|
40
|
Xiao J, Xie Q, Lin Q, Yu T, Yu R, Li Y. Assessment of Visual Pursuit in Patients With Disorders of Consciousness Based on a Brain-Computer Interface. IEEE Trans Neural Syst Rehabil Eng 2019; 26:1141-1151. [PMID: 29877838 DOI: 10.1109/tnsre.2018.2835813] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
Visual pursuit assessment is extensively applied in the behavioral scale-based clinical examination of patients with disorders of consciousness (DOC). However, this assessment is challenging because it relies on behavioral markers, and these patients severely lack behavioral responses. Brain-computer interfaces (BCIs) may provide a potential solution to detect brain responses to external stimuli without requiring behavioral expressions. A BCI system was designed to simulate visual pursuit detection in the coma recovery scale-revised (CRS-R). The graphical user interface included four buttons, one that moved on the screen and three that did not. These buttons flashed in a random order. The patients were prompted to follow the moving button. Based on the collected electroencephalography data, the algorithm determined whether the patient focused on the moving target. Among the 14 DOC patients who participated in the assessments based on the BCI system and the CRS-R, four patients exhibited visual pursuit, and three were nonresponsive in both assessments. More importantly, seven patients who did not exhibit visual pursuit in CRS-R were detected to be responsive to the moving target stimuli in the BCI assessment. Furthermore, five out of seven recovered consciousness to some degree and showed visual pursuit in the second CRS-R assessment. The proposed BCI system is better able to detect visual pursuit than the behavioral scale-based assessment and thus can assist in clinically evaluating the challenging population of DOC patients.
Collapse
|
41
|
Gobert F, Luauté J, Raverot V, Cotton F, Dailler F, Claustrat B, Perrin F, Gronfier C. Is circadian rhythmicity a prerequisite to coma recovery? Circadian recovery concomitant to cognitive improvement in two comatose patients. J Pineal Res 2019; 66:e12555. [PMID: 30633817 DOI: 10.1111/jpi.12555] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2018] [Revised: 12/28/2018] [Accepted: 12/29/2018] [Indexed: 01/15/2023]
Abstract
Circadian rhythmicity (CR) is involved in the regulation of all integrated functions, from sleep-wake cycle regulation to metabolic function, mood and cognition. However, the interdependence of CR, cognition and consciousness has been poorly addressed. To clarify the state of CR in coma and to determine the chronological relationship between its recovery and consciousness after brain lesions, we conducted a longitudinal observational study investigating how the state of CR was chronologically related with the recovery of behavioural wakefulness, cognition and/or awareness. Among 16 acute comatose patients, we recruited two 37-year-old patients with a persistent disorder of consciousness, presenting diencephalic lesions caused by severe traumatic brain injuries. Two biological urinary markers of CR were explored every 2 hours during 24 hours (6-sulfatoxymelatonin, free cortisol) with a dedicated methodology to extract the endogenous component of rhythmicity (environmental light recording, near-constant-routine protocol, control of beta-blockers). They presented an initial absence of rhythmic secretions and a recovered CR 7-8 months later. This recovery was not associated with the restoration of behavioural wakefulness, but with an improvement of cognition and awareness (up to the minimally conscious state). MRI showed a lesion pattern compatible with the interruption of either the main hypothalamic-sympathetic pathway or the accessory habenular pathway. These results suggest that CR may be a prerequisite for coma recovery with a potential but still unproven favourable effect on brain function of the resorted circadian melatonin secretion and/or the functional recovery of the suprachiasmatic nucleus (SCN). Assessing circadian functions by urinary melatonin should be further explored as a biomarker of cognition reappearance and investigated to prognosticate functional recovery.
Collapse
Affiliation(s)
- Florent Gobert
- Neuro-Intensive Care Unit, Hospices Civils de Lyon, Neurological Hospital Pierre-Wertheimer, Bron, France
- ImpAct Team (Integrative, Multisensory, Perception, Action & Cognition), Lyon Neuroscience Research Centre (Université Claude Bernard Lyon 1, INSERM U1028, CNRS UMR5292), Bron, France
- CAP Team (Cognition Auditive et Psychoacoustique), Lyon Neuroscience Research Center (Université Claude Bernard Lyon 1, INSERM U1028, CNRS UMR5292), Lyon, France
| | - Jacques Luauté
- ImpAct Team (Integrative, Multisensory, Perception, Action & Cognition), Lyon Neuroscience Research Centre (Université Claude Bernard Lyon 1, INSERM U1028, CNRS UMR5292), Bron, France
- Neuro-Rehabilitation Unit, Hospices Civils de Lyon, Neurological Hospital Pierre-Wertheimer, Bron, France
| | - Véronique Raverot
- Hormone Laboratory, Hospices Civils de Lyon, Neurological Hospital Pierre-Wertheimer, Bron, France
| | - François Cotton
- Radiology Unit, Lyon-Sud Hospital, Hospices Civils de Lyon, Pierre-Benite, France
- CREATIS-LRMN (CNRS UMR 5220 - INSERM U630), Villeurbanne, France
| | - Frédéric Dailler
- Neuro-Intensive Care Unit, Hospices Civils de Lyon, Neurological Hospital Pierre-Wertheimer, Bron, France
| | - Bruno Claustrat
- Hormone Laboratory, Hospices Civils de Lyon, Neurological Hospital Pierre-Wertheimer, Bron, France
| | - Fabien Perrin
- CAP Team (Cognition Auditive et Psychoacoustique), Lyon Neuroscience Research Center (Université Claude Bernard Lyon 1, INSERM U1028, CNRS UMR5292), Lyon, France
| | - Claude Gronfier
- Lyon Neuroscience Research Center (CRNL), Integrative Physiology of the Brain Arousal Systems (Waking) team, INSERM UMRS 1028, CNRS UMR 5292, Université Claude Bernard Lyon 1, Université de Lyon, F-69000, Lyon, France
| |
Collapse
|
42
|
Blume C, Angerer M, Raml M, Del Giudice R, Santhi N, Pichler G, Kunz AB, Scarpatetti M, Trinka E, Schabus M. Healthier rhythm, healthier brain? Integrity of circadian melatonin and temperature rhythms relates to the clinical state of brain-injured patients. Eur J Neurol 2019; 26:1051-1059. [PMID: 30770613 PMCID: PMC6766891 DOI: 10.1111/ene.13935] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2018] [Accepted: 02/12/2019] [Indexed: 11/30/2022]
Abstract
Background Healthy circadian rhythmicity has been suggested to relate to a better state of brain‐injured patients and to support the emergence of consciousness in patient groups characterized by a relative instability thereof such as patients with disorders of consciousness (DOC). Methods Going beyond earlier studies, a systems‐level perspective was adopted and, using multilevel modelling, the joint predictive value of three indices of circadian rhythm integrity derived from skin temperature variations, melatoninsulfate secretion, and physical activity (wrist actigraphy) patterns was evaluated for the behaviourally assessed state [Coma Recovery Scale ‐ Revised (CRS‐R) score] of DOC patients [13 unresponsive wakefulness syndrome; seven minimally conscious (exit) state]. Additionally, it was assessed in a subset of 16 patients whether patients’ behavioural repertoire (CRS‐R score) varied (i) with time of day or (ii) offset from the body temperature maximum (BTmax), i.e. when cognitive performance is expected to peak. Results The results reveal that better integrity of circadian melatoninsulfate and temperature rhythms relate to a richer behavioural repertoire. Moreover, higher CRS‐R scores are, by trend, related to assessments taking place at a later daytime or deviating less from the pre‐specified time of occurrence of BTmax. Conclusions In conclusion, the results suggest that therapeutic approaches aimed at improving circadian rhythms in brain‐injured patients are promising and should be implemented in hospitals or nursing homes. Beyond this, it might be helpful to schedule diagnostic procedures and therapies around the (pre‐assessed) BTmax (≈4 pm in healthy individuals) as this is when patients should be most responsive.
Collapse
Affiliation(s)
- C Blume
- Department of Psychology, University of Salzburg, Laboratory for Sleep, Cognition, and Consciousness Research, Salzburg, Austria.,University of Salzburg, Centre for Cognitive Neuroscience, Salzburg, Austria
| | - M Angerer
- Department of Psychology, University of Salzburg, Laboratory for Sleep, Cognition, and Consciousness Research, Salzburg, Austria
| | - M Raml
- Department of Psychology, University of Salzburg, Laboratory for Sleep, Cognition, and Consciousness Research, Salzburg, Austria
| | - R Del Giudice
- Department of Psychology, University of Salzburg, Laboratory for Sleep, Cognition, and Consciousness Research, Salzburg, Austria
| | - N Santhi
- Surrey Sleep Research Centre, Faculty of Health and Medical Sciences, University of Surrey, Guildford, UK
| | - G Pichler
- Geriatric Health Centres of the City of Graz, Albert Schweitzer Clinic, Apallic Care Unit, Graz, Austria
| | - A B Kunz
- Department of Neurology, Paracelsus Medical University, Christian Doppler Medical Center, Salzburg, Austria.,Gunther Ladurner Nursing Home, Salzburg, Austria
| | - M Scarpatetti
- Geriatric Health Centres of the City of Graz, Albert Schweitzer Clinic, Apallic Care Unit, Graz, Austria
| | - E Trinka
- University of Salzburg, Centre for Cognitive Neuroscience, Salzburg, Austria.,Department of Neurology, Paracelsus Medical University, Christian Doppler Medical Center, Salzburg, Austria
| | - M Schabus
- Department of Psychology, University of Salzburg, Laboratory for Sleep, Cognition, and Consciousness Research, Salzburg, Austria.,University of Salzburg, Centre for Cognitive Neuroscience, Salzburg, Austria
| |
Collapse
|
43
|
O'Donnell JC, Browne KD, Kilbaugh TJ, Chen HI, Whyte J, Cullen DK. Challenges and demand for modeling disorders of consciousness following traumatic brain injury. Neurosci Biobehav Rev 2019; 98:336-346. [PMID: 30550859 PMCID: PMC7847278 DOI: 10.1016/j.neubiorev.2018.12.015] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2018] [Revised: 11/02/2018] [Accepted: 12/11/2018] [Indexed: 12/29/2022]
Abstract
Following severe traumatic brain injury (TBI), many patients experience coma - an unresponsive state lacking wakefulness or awareness. Coma rarely lasts more than two weeks, and emergence involves passing through a state of wakefulness without awareness of self or environment. Patients that linger in these Disorders of Consciousness (DoC) undergo clinical assessments of awareness for diagnosis into Unresponsive Wakefulness Syndrome (no awareness, also called vegetative state) or Minimally Conscious State (periodic increases in awareness). These diagnoses are notoriously inaccurate, offering little prognostic value. Recovery of awareness is unpredictable, returning within weeks, years, or never. This leaves patients' families with difficult decisions and little information on which to base them. Clinical studies have made significant advancements, but remain encumbered by high variability, limited data output, and a lack of necessary controls. Herein we discuss the clear and present need to establish a preclinical model of TBI-induced DoC, the significant challenges involved, and how such a model can be applied to support DoC research.
Collapse
Affiliation(s)
- John C O'Donnell
- Center for Brain Injury & Repair, Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States; Center for Neurotrauma, Neurodegeneration & Restoration, Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, PA, United States
| | - Kevin D Browne
- Center for Brain Injury & Repair, Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States; Center for Neurotrauma, Neurodegeneration & Restoration, Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, PA, United States
| | - Todd J Kilbaugh
- Center for Brain Injury & Repair, Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States; Department of Anesthesiology and Critical Care Medicine, Perelman School of Medicine, University of Pennsylvania, The Children's Hospital of Philadelphia, Philadelphia, PA, United States
| | - H Isaac Chen
- Center for Brain Injury & Repair, Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States; Center for Neurotrauma, Neurodegeneration & Restoration, Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, PA, United States
| | - John Whyte
- Moss Rehabilitation Research Institute, Elkins Park, PA, United States
| | - D Kacy Cullen
- Center for Brain Injury & Repair, Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States; Center for Neurotrauma, Neurodegeneration & Restoration, Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, PA, United States; Department of Bioengineering, School of Engineering and Applied Science, University of Pennsylvania, Philadelphia, PA, United States.
| |
Collapse
|
44
|
Spatially Overlapping Regions Show Abnormal Thalamo-frontal Circuit and Abnormal Precuneus in Disorders of Consciousness. Brain Topogr 2019; 32:445-460. [DOI: 10.1007/s10548-018-0693-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2018] [Accepted: 12/11/2018] [Indexed: 01/14/2023]
|
45
|
Lemaire J, Sontheimer A, Pereira B, Coste J, Rosenberg S, Sarret C, Coll G, Gabrillargues J, Jean B, Gillart T, Coste A, Roche B, Kelly A, Pontier B, Feschet F. Deep brain stimulation in five patients with severe disorders of consciousness. Ann Clin Transl Neurol 2018; 5:1372-1384. [PMID: 30480031 PMCID: PMC6243378 DOI: 10.1002/acn3.648] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2018] [Revised: 08/07/2018] [Accepted: 08/22/2018] [Indexed: 02/03/2023] Open
Abstract
OBJECTIVE The efficacy of deep brain stimulation in disorders of consciousness remains inconclusive. We investigated bilateral 30-Hz low-frequency stimulation designed to overdrive neuronal activity by dual pallido-thalamic targeting, using the Coma Recovery Scale Revised (CRS-R) to assess conscious behavior. METHODS We conducted a prospective, single center, observational 11-month pilot study comprising four phases: baseline (2 months); surgery and titration (1 month); blind, random, crossover, 1.5-month ON and OFF periods; and unblinded, 5-month stimulation ON. Five adult patients were included: one unresponsive-wakefulness-syndrome male (traumatic brain injury); and four patients in a minimally conscious state, one male (traumatic brain injury) and three females (two hemorrhagic strokes and one traumatic brain injury). Primary outcome measures focused on CRS-R scores. Secondary outcome measures focused notably on baseline brain metabolism and variation in activity (stimulation ON - baseline) using normalized fluorodeoxyglucose positron emission tomography maps. Statistical analysis used random-effect models. RESULTS The two male patients (one minimally conscious and one unresponsive wakefulness syndrome) showed improved mean CRS-R scores (stimulation ON vs. baseline), in auditory, visual and oromotor/verbal subscores, and visual subscores respectively. The metabolism of the medial cortices (low at baseline in all five patients) increased specifically in the two responders. INTERPRETATION Our findings show there were robust but limited individual clinical benefits, mainly in visual and auditory processes. Overall modifications seem linked to the modulation of thalamo-cortico-basal and tegmental loops activating default mode network cortices. Specifically, in the two responders there was an increase in medial cortex activity related to internal awareness.
Collapse
Affiliation(s)
- Jean‐Jacques Lemaire
- Service de NeurochirurgieCHU Clermont‐FerrandClermont‐FerrandF‐63000France
- Université Clermont AuvergneCNRS, SIGMA Clermont, Institut PascalClermont‐FerrandF‐63000France
| | - Anna Sontheimer
- Service de NeurochirurgieCHU Clermont‐FerrandClermont‐FerrandF‐63000France
- Université Clermont AuvergneCNRS, SIGMA Clermont, Institut PascalClermont‐FerrandF‐63000France
| | - Bruno Pereira
- Unité de Biostatistiques (Délégation Recherche Clinique & Innovation)CHU Clermont‐FerrandClermont‐FerrandF‐63000France
| | - Jérôme Coste
- Service de NeurochirurgieCHU Clermont‐FerrandClermont‐FerrandF‐63000France
- Université Clermont AuvergneCNRS, SIGMA Clermont, Institut PascalClermont‐FerrandF‐63000France
| | - Sarah Rosenberg
- Université Clermont AuvergneCNRS, SIGMA Clermont, Institut PascalClermont‐FerrandF‐63000France
| | - Catherine Sarret
- Université Clermont AuvergneCNRS, SIGMA Clermont, Institut PascalClermont‐FerrandF‐63000France
| | - Guillaume Coll
- Service de NeurochirurgieCHU Clermont‐FerrandClermont‐FerrandF‐63000France
- Université Clermont AuvergneCNRS, SIGMA Clermont, Institut PascalClermont‐FerrandF‐63000France
| | - Jean Gabrillargues
- Université Clermont AuvergneCNRS, SIGMA Clermont, Institut PascalClermont‐FerrandF‐63000France
- Service de RadiologieCHU Clermont‐FerrandClermont‐FerrandF‐63000France
| | - Betty Jean
- Service de RadiologieCHU Clermont‐FerrandClermont‐FerrandF‐63000France
| | - Thierry Gillart
- Département d'Anesthésie RéanimationCHU Clermont‐FerrandClermont‐FerrandF‐63000France
| | - Aurélien Coste
- Service de NeurochirurgieCHU Clermont‐FerrandClermont‐FerrandF‐63000France
| | - Basile Roche
- Université Clermont AuvergneCNRS, SIGMA Clermont, Institut PascalClermont‐FerrandF‐63000France
| | - Antony Kelly
- Service de Médecine NucléaireCentre Jean PerrinClermont‐FerrandF‐63000France
| | - Bénédicte Pontier
- Service de NeurochirurgieCHU Clermont‐FerrandClermont‐FerrandF‐63000France
- Université Clermont AuvergneCNRS, SIGMA Clermont, Institut PascalClermont‐FerrandF‐63000France
| | - Fabien Feschet
- Université Clermont AuvergneCNRS, SIGMA Clermont, Institut PascalClermont‐FerrandF‐63000France
| |
Collapse
|
46
|
Cavaliere C, Kandeepan S, Aiello M, Ribeiro de Paula D, Marchitelli R, Fiorenza S, Orsini M, Trojano L, Masotta O, St Lawrence K, Loreto V, Chronik BA, Nicolai E, Soddu A, Estraneo A. Multimodal Neuroimaging Approach to Variability of Functional Connectivity in Disorders of Consciousness: A PET/MRI Pilot Study. Front Neurol 2018; 9:861. [PMID: 30405513 PMCID: PMC6200912 DOI: 10.3389/fneur.2018.00861] [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: 03/01/2018] [Accepted: 09/24/2018] [Indexed: 12/18/2022] Open
Abstract
Behavioral assessments could not suffice to provide accurate diagnostic information in individuals with disorders of consciousness (DoC). Multimodal neuroimaging markers have been developed to support clinical assessments of these patients. Here we present findings obtained by hybrid fludeoxyglucose (FDG-)PET/MR imaging in three severely brain-injured patients, one in an unresponsive wakefulness syndrome (UWS), one in a minimally conscious state (MCS), and one patient emerged from MCS (EMCS). Repeated behavioral assessment by means of Coma Recovery Scale-Revised and neurophysiological evaluation were performed in the two weeks before and after neuroimaging acquisition, to ascertain that clinical diagnosis was stable. The three patients underwent one imaging session, during which two resting-state fMRI (rs-fMRI) blocks were run with a temporal gap of about 30 min. rs-fMRI data were analyzed with a graph theory approach applied to nine independent networks. We also analyzed the benefits of concatenating the two acquisitions for each patient or to select for each network the graph strength map with a higher ratio of fitness. Finally, as for clinical assessment, we considered the best functional connectivity pattern for each network and correlated graph strength maps to FDG uptake. Functional connectivity analysis showed several differences between the two rs-fMRI acquisitions, affecting in a different way each network and with a different variability for the three patients, as assessed by ratio of fitness. Moreover, combined PET/fMRI analysis demonstrated a higher functional/metabolic correlation for patients in EMCS and MCS compared to UWS. In conclusion, we observed for the first time, through a test-retest approach, a variability in the appearance and temporal/spatial patterns of resting-state networks in severely brain-injured patients, proposing a new method to select the most informative connectivity pattern.
Collapse
Affiliation(s)
- Carlo Cavaliere
- IRCCS SDN, Istituto di Ricerca Diagnostica e Nucleare, Naples, Italy.,Coma Science Group, GIGA-Research, University and University Hospital of Liege, Liege, Belgium
| | - Sivayini Kandeepan
- Department of Physics and Astronomy, Brain and Mind Institute, Western University, London, ON, Canada
| | - Marco Aiello
- IRCCS SDN, Istituto di Ricerca Diagnostica e Nucleare, Naples, Italy
| | | | - Rocco Marchitelli
- IRCCS SDN, Istituto di Ricerca Diagnostica e Nucleare, Naples, Italy
| | - Salvatore Fiorenza
- Neurorehabilitation Unit and Research Laboratory for Disorder of Consciousness, Maugeri ICS, IRCCS, Telese Terme, Italy
| | - Mario Orsini
- IRCCS SDN, Istituto di Ricerca Diagnostica e Nucleare, Naples, Italy
| | - Luigi Trojano
- Department of Psychology, University of Campania "Luigi Vanvitelli", Caserta, Italy
| | - Orsola Masotta
- Neurorehabilitation Unit and Research Laboratory for Disorder of Consciousness, Maugeri ICS, IRCCS, Telese Terme, Italy
| | - Keith St Lawrence
- Lawson Health Research Institute London, Medical Biophysics, University of Western Ontario, London, ON, Canada
| | - Vincenzo Loreto
- Neurorehabilitation Unit and Research Laboratory for Disorder of Consciousness, Maugeri ICS, IRCCS, Telese Terme, Italy
| | - Blaine Alexander Chronik
- Department of Physics and Astronomy, Brain and Mind Institute, Western University, London, ON, Canada
| | - Emanuele Nicolai
- IRCCS SDN, Istituto di Ricerca Diagnostica e Nucleare, Naples, Italy
| | - Andrea Soddu
- Department of Physics and Astronomy, Brain and Mind Institute, Western University, London, ON, Canada
| | - Anna Estraneo
- Neurorehabilitation Unit and Research Laboratory for Disorder of Consciousness, Maugeri ICS, IRCCS, Telese Terme, Italy
| |
Collapse
|
47
|
Giacino JT, Katz DI, Schiff ND, Whyte J, Ashman EJ, Ashwal S, Barbano R, Hammond FM, Laureys S, Ling GSF, Nakase-Richardson R, Seel RT, Yablon S, Getchius TSD, Gronseth GS, Armstrong MJ. Practice guideline update recommendations summary: Disorders of consciousness: Report of the Guideline Development, Dissemination, and Implementation Subcommittee of the American Academy of Neurology; the American Congress of Rehabilitation Medicine; and the National Institute on Disability, Independent Living, and Rehabilitation Research. Neurology 2018; 91:450-460. [PMID: 30089618 PMCID: PMC6139814 DOI: 10.1212/wnl.0000000000005926] [Citation(s) in RCA: 375] [Impact Index Per Article: 62.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2017] [Accepted: 05/22/2018] [Indexed: 01/05/2023] Open
Abstract
OBJECTIVE To update the 1995 American Academy of Neurology (AAN) practice parameter on persistent vegetative state and the 2002 case definition on minimally conscious state (MCS) and provide care recommendations for patients with prolonged disorders of consciousness (DoC). METHODS Recommendations were based on systematic review evidence, related evidence, care principles, and inferences using a modified Delphi consensus process according to the AAN 2011 process manual, as amended. RECOMMENDATIONS Clinicians should identify and treat confounding conditions, optimize arousal, and perform serial standardized assessments to improve diagnostic accuracy in adults and children with prolonged DoC (Level B). Clinicians should counsel families that for adults, MCS (vs vegetative state [VS]/unresponsive wakefulness syndrome [UWS]) and traumatic (vs nontraumatic) etiology are associated with more favorable outcomes (Level B). When prognosis is poor, long-term care must be discussed (Level A), acknowledging that prognosis is not universally poor (Level B). Structural MRI, SPECT, and the Coma Recovery Scale-Revised can assist prognostication in adults (Level B); no tests are shown to improve prognostic accuracy in children. Pain always should be assessed and treated (Level B) and evidence supporting treatment approaches discussed (Level B). Clinicians should prescribe amantadine (100-200 mg bid) for adults with traumatic VS/UWS or MCS (4-16 weeks post injury) to hasten functional recovery and reduce disability early in recovery (Level B). Family counseling concerning children should acknowledge that natural history of recovery, prognosis, and treatment are not established (Level B). Recent evidence indicates that the term chronic VS/UWS should replace permanent VS, with duration specified (Level B). Additional recommendations are included.
Collapse
Affiliation(s)
- Joseph T Giacino
- From the Department of Physical Medicine and Rehabilitation (J.T.G.), Spaulding Rehabilitation Hospital and Harvard Medical School; Department of Psychiatry (J.T.G.), Massachusetts General Hospital, Boston; Department of Neurology (D.I.K.), Boston University School of Medicine; Braintree Rehabilitation Hospital (D.I.K.), MA; Department of Neurology and Neuroscience (N.D.S.), Weill Cornell Medical College, New York, NY; Moss Rehabilitation Research Institute (J.W.), Elkins Park, PA; Bronson Neuroscience Center (E.J.A.), Bronson Methodist Hospital, Kalamazoo, MI; Department of Pediatrics, Division of Child Neurology (S.A.), Loma Linda University School of Medicine, CA; Department of Neurology (R.B.), University of Rochester Medical Center, NY; Indiana University Department of Physical Medicine & Rehabilitation (F.M.H.), University of Indiana School of Medicine, Indianapolis; Coma Science Group-GIGA Research and Department of Neurology (S.L.), Sart Tillman Liège University & University Hospital, Liège, Belgium; Department of Neurology (G.S.F.L.), Uniformed Services University of Health Sciences, Bethesda; Department of Neurology (G.S.F.L.), Johns Hopkins University, Baltimore, MD; James A. Haley Veterans' Hospital (R.N.-R.), US Department of Veterans Affairs, Tampa, FL; Crawford Research Institute (R.T.S.), Shepherd Center, Atlanta, GA; Center for Rehabilitation Science and Engineering, Department of Physical Medicine & Rehabilitation (R.T.S.), Virginia Commonwealth University School of Medicine, Richmond; Division of Physical Medicine & Rehabilitation (S.Y.), University of Mississippi School of Medicine; Brain Injury Program (S.Y.), Methodist Rehabilitation Center, Jackson, MS; Heart Rhythm Society (T.S.D.G.), Washington, DC; Department of Neurology (G.S.G.), University of Kansas Medical Center, Kansas City; and Department of Neurology (M.J.A.), University of Florida College of Medicine, Gainesville
| | - Douglas I Katz
- From the Department of Physical Medicine and Rehabilitation (J.T.G.), Spaulding Rehabilitation Hospital and Harvard Medical School; Department of Psychiatry (J.T.G.), Massachusetts General Hospital, Boston; Department of Neurology (D.I.K.), Boston University School of Medicine; Braintree Rehabilitation Hospital (D.I.K.), MA; Department of Neurology and Neuroscience (N.D.S.), Weill Cornell Medical College, New York, NY; Moss Rehabilitation Research Institute (J.W.), Elkins Park, PA; Bronson Neuroscience Center (E.J.A.), Bronson Methodist Hospital, Kalamazoo, MI; Department of Pediatrics, Division of Child Neurology (S.A.), Loma Linda University School of Medicine, CA; Department of Neurology (R.B.), University of Rochester Medical Center, NY; Indiana University Department of Physical Medicine & Rehabilitation (F.M.H.), University of Indiana School of Medicine, Indianapolis; Coma Science Group-GIGA Research and Department of Neurology (S.L.), Sart Tillman Liège University & University Hospital, Liège, Belgium; Department of Neurology (G.S.F.L.), Uniformed Services University of Health Sciences, Bethesda; Department of Neurology (G.S.F.L.), Johns Hopkins University, Baltimore, MD; James A. Haley Veterans' Hospital (R.N.-R.), US Department of Veterans Affairs, Tampa, FL; Crawford Research Institute (R.T.S.), Shepherd Center, Atlanta, GA; Center for Rehabilitation Science and Engineering, Department of Physical Medicine & Rehabilitation (R.T.S.), Virginia Commonwealth University School of Medicine, Richmond; Division of Physical Medicine & Rehabilitation (S.Y.), University of Mississippi School of Medicine; Brain Injury Program (S.Y.), Methodist Rehabilitation Center, Jackson, MS; Heart Rhythm Society (T.S.D.G.), Washington, DC; Department of Neurology (G.S.G.), University of Kansas Medical Center, Kansas City; and Department of Neurology (M.J.A.), University of Florida College of Medicine, Gainesville
| | - Nicholas D Schiff
- From the Department of Physical Medicine and Rehabilitation (J.T.G.), Spaulding Rehabilitation Hospital and Harvard Medical School; Department of Psychiatry (J.T.G.), Massachusetts General Hospital, Boston; Department of Neurology (D.I.K.), Boston University School of Medicine; Braintree Rehabilitation Hospital (D.I.K.), MA; Department of Neurology and Neuroscience (N.D.S.), Weill Cornell Medical College, New York, NY; Moss Rehabilitation Research Institute (J.W.), Elkins Park, PA; Bronson Neuroscience Center (E.J.A.), Bronson Methodist Hospital, Kalamazoo, MI; Department of Pediatrics, Division of Child Neurology (S.A.), Loma Linda University School of Medicine, CA; Department of Neurology (R.B.), University of Rochester Medical Center, NY; Indiana University Department of Physical Medicine & Rehabilitation (F.M.H.), University of Indiana School of Medicine, Indianapolis; Coma Science Group-GIGA Research and Department of Neurology (S.L.), Sart Tillman Liège University & University Hospital, Liège, Belgium; Department of Neurology (G.S.F.L.), Uniformed Services University of Health Sciences, Bethesda; Department of Neurology (G.S.F.L.), Johns Hopkins University, Baltimore, MD; James A. Haley Veterans' Hospital (R.N.-R.), US Department of Veterans Affairs, Tampa, FL; Crawford Research Institute (R.T.S.), Shepherd Center, Atlanta, GA; Center for Rehabilitation Science and Engineering, Department of Physical Medicine & Rehabilitation (R.T.S.), Virginia Commonwealth University School of Medicine, Richmond; Division of Physical Medicine & Rehabilitation (S.Y.), University of Mississippi School of Medicine; Brain Injury Program (S.Y.), Methodist Rehabilitation Center, Jackson, MS; Heart Rhythm Society (T.S.D.G.), Washington, DC; Department of Neurology (G.S.G.), University of Kansas Medical Center, Kansas City; and Department of Neurology (M.J.A.), University of Florida College of Medicine, Gainesville
| | - John Whyte
- From the Department of Physical Medicine and Rehabilitation (J.T.G.), Spaulding Rehabilitation Hospital and Harvard Medical School; Department of Psychiatry (J.T.G.), Massachusetts General Hospital, Boston; Department of Neurology (D.I.K.), Boston University School of Medicine; Braintree Rehabilitation Hospital (D.I.K.), MA; Department of Neurology and Neuroscience (N.D.S.), Weill Cornell Medical College, New York, NY; Moss Rehabilitation Research Institute (J.W.), Elkins Park, PA; Bronson Neuroscience Center (E.J.A.), Bronson Methodist Hospital, Kalamazoo, MI; Department of Pediatrics, Division of Child Neurology (S.A.), Loma Linda University School of Medicine, CA; Department of Neurology (R.B.), University of Rochester Medical Center, NY; Indiana University Department of Physical Medicine & Rehabilitation (F.M.H.), University of Indiana School of Medicine, Indianapolis; Coma Science Group-GIGA Research and Department of Neurology (S.L.), Sart Tillman Liège University & University Hospital, Liège, Belgium; Department of Neurology (G.S.F.L.), Uniformed Services University of Health Sciences, Bethesda; Department of Neurology (G.S.F.L.), Johns Hopkins University, Baltimore, MD; James A. Haley Veterans' Hospital (R.N.-R.), US Department of Veterans Affairs, Tampa, FL; Crawford Research Institute (R.T.S.), Shepherd Center, Atlanta, GA; Center for Rehabilitation Science and Engineering, Department of Physical Medicine & Rehabilitation (R.T.S.), Virginia Commonwealth University School of Medicine, Richmond; Division of Physical Medicine & Rehabilitation (S.Y.), University of Mississippi School of Medicine; Brain Injury Program (S.Y.), Methodist Rehabilitation Center, Jackson, MS; Heart Rhythm Society (T.S.D.G.), Washington, DC; Department of Neurology (G.S.G.), University of Kansas Medical Center, Kansas City; and Department of Neurology (M.J.A.), University of Florida College of Medicine, Gainesville
| | - Eric J Ashman
- From the Department of Physical Medicine and Rehabilitation (J.T.G.), Spaulding Rehabilitation Hospital and Harvard Medical School; Department of Psychiatry (J.T.G.), Massachusetts General Hospital, Boston; Department of Neurology (D.I.K.), Boston University School of Medicine; Braintree Rehabilitation Hospital (D.I.K.), MA; Department of Neurology and Neuroscience (N.D.S.), Weill Cornell Medical College, New York, NY; Moss Rehabilitation Research Institute (J.W.), Elkins Park, PA; Bronson Neuroscience Center (E.J.A.), Bronson Methodist Hospital, Kalamazoo, MI; Department of Pediatrics, Division of Child Neurology (S.A.), Loma Linda University School of Medicine, CA; Department of Neurology (R.B.), University of Rochester Medical Center, NY; Indiana University Department of Physical Medicine & Rehabilitation (F.M.H.), University of Indiana School of Medicine, Indianapolis; Coma Science Group-GIGA Research and Department of Neurology (S.L.), Sart Tillman Liège University & University Hospital, Liège, Belgium; Department of Neurology (G.S.F.L.), Uniformed Services University of Health Sciences, Bethesda; Department of Neurology (G.S.F.L.), Johns Hopkins University, Baltimore, MD; James A. Haley Veterans' Hospital (R.N.-R.), US Department of Veterans Affairs, Tampa, FL; Crawford Research Institute (R.T.S.), Shepherd Center, Atlanta, GA; Center for Rehabilitation Science and Engineering, Department of Physical Medicine & Rehabilitation (R.T.S.), Virginia Commonwealth University School of Medicine, Richmond; Division of Physical Medicine & Rehabilitation (S.Y.), University of Mississippi School of Medicine; Brain Injury Program (S.Y.), Methodist Rehabilitation Center, Jackson, MS; Heart Rhythm Society (T.S.D.G.), Washington, DC; Department of Neurology (G.S.G.), University of Kansas Medical Center, Kansas City; and Department of Neurology (M.J.A.), University of Florida College of Medicine, Gainesville
| | - Stephen Ashwal
- From the Department of Physical Medicine and Rehabilitation (J.T.G.), Spaulding Rehabilitation Hospital and Harvard Medical School; Department of Psychiatry (J.T.G.), Massachusetts General Hospital, Boston; Department of Neurology (D.I.K.), Boston University School of Medicine; Braintree Rehabilitation Hospital (D.I.K.), MA; Department of Neurology and Neuroscience (N.D.S.), Weill Cornell Medical College, New York, NY; Moss Rehabilitation Research Institute (J.W.), Elkins Park, PA; Bronson Neuroscience Center (E.J.A.), Bronson Methodist Hospital, Kalamazoo, MI; Department of Pediatrics, Division of Child Neurology (S.A.), Loma Linda University School of Medicine, CA; Department of Neurology (R.B.), University of Rochester Medical Center, NY; Indiana University Department of Physical Medicine & Rehabilitation (F.M.H.), University of Indiana School of Medicine, Indianapolis; Coma Science Group-GIGA Research and Department of Neurology (S.L.), Sart Tillman Liège University & University Hospital, Liège, Belgium; Department of Neurology (G.S.F.L.), Uniformed Services University of Health Sciences, Bethesda; Department of Neurology (G.S.F.L.), Johns Hopkins University, Baltimore, MD; James A. Haley Veterans' Hospital (R.N.-R.), US Department of Veterans Affairs, Tampa, FL; Crawford Research Institute (R.T.S.), Shepherd Center, Atlanta, GA; Center for Rehabilitation Science and Engineering, Department of Physical Medicine & Rehabilitation (R.T.S.), Virginia Commonwealth University School of Medicine, Richmond; Division of Physical Medicine & Rehabilitation (S.Y.), University of Mississippi School of Medicine; Brain Injury Program (S.Y.), Methodist Rehabilitation Center, Jackson, MS; Heart Rhythm Society (T.S.D.G.), Washington, DC; Department of Neurology (G.S.G.), University of Kansas Medical Center, Kansas City; and Department of Neurology (M.J.A.), University of Florida College of Medicine, Gainesville
| | - Richard Barbano
- From the Department of Physical Medicine and Rehabilitation (J.T.G.), Spaulding Rehabilitation Hospital and Harvard Medical School; Department of Psychiatry (J.T.G.), Massachusetts General Hospital, Boston; Department of Neurology (D.I.K.), Boston University School of Medicine; Braintree Rehabilitation Hospital (D.I.K.), MA; Department of Neurology and Neuroscience (N.D.S.), Weill Cornell Medical College, New York, NY; Moss Rehabilitation Research Institute (J.W.), Elkins Park, PA; Bronson Neuroscience Center (E.J.A.), Bronson Methodist Hospital, Kalamazoo, MI; Department of Pediatrics, Division of Child Neurology (S.A.), Loma Linda University School of Medicine, CA; Department of Neurology (R.B.), University of Rochester Medical Center, NY; Indiana University Department of Physical Medicine & Rehabilitation (F.M.H.), University of Indiana School of Medicine, Indianapolis; Coma Science Group-GIGA Research and Department of Neurology (S.L.), Sart Tillman Liège University & University Hospital, Liège, Belgium; Department of Neurology (G.S.F.L.), Uniformed Services University of Health Sciences, Bethesda; Department of Neurology (G.S.F.L.), Johns Hopkins University, Baltimore, MD; James A. Haley Veterans' Hospital (R.N.-R.), US Department of Veterans Affairs, Tampa, FL; Crawford Research Institute (R.T.S.), Shepherd Center, Atlanta, GA; Center for Rehabilitation Science and Engineering, Department of Physical Medicine & Rehabilitation (R.T.S.), Virginia Commonwealth University School of Medicine, Richmond; Division of Physical Medicine & Rehabilitation (S.Y.), University of Mississippi School of Medicine; Brain Injury Program (S.Y.), Methodist Rehabilitation Center, Jackson, MS; Heart Rhythm Society (T.S.D.G.), Washington, DC; Department of Neurology (G.S.G.), University of Kansas Medical Center, Kansas City; and Department of Neurology (M.J.A.), University of Florida College of Medicine, Gainesville
| | - Flora M Hammond
- From the Department of Physical Medicine and Rehabilitation (J.T.G.), Spaulding Rehabilitation Hospital and Harvard Medical School; Department of Psychiatry (J.T.G.), Massachusetts General Hospital, Boston; Department of Neurology (D.I.K.), Boston University School of Medicine; Braintree Rehabilitation Hospital (D.I.K.), MA; Department of Neurology and Neuroscience (N.D.S.), Weill Cornell Medical College, New York, NY; Moss Rehabilitation Research Institute (J.W.), Elkins Park, PA; Bronson Neuroscience Center (E.J.A.), Bronson Methodist Hospital, Kalamazoo, MI; Department of Pediatrics, Division of Child Neurology (S.A.), Loma Linda University School of Medicine, CA; Department of Neurology (R.B.), University of Rochester Medical Center, NY; Indiana University Department of Physical Medicine & Rehabilitation (F.M.H.), University of Indiana School of Medicine, Indianapolis; Coma Science Group-GIGA Research and Department of Neurology (S.L.), Sart Tillman Liège University & University Hospital, Liège, Belgium; Department of Neurology (G.S.F.L.), Uniformed Services University of Health Sciences, Bethesda; Department of Neurology (G.S.F.L.), Johns Hopkins University, Baltimore, MD; James A. Haley Veterans' Hospital (R.N.-R.), US Department of Veterans Affairs, Tampa, FL; Crawford Research Institute (R.T.S.), Shepherd Center, Atlanta, GA; Center for Rehabilitation Science and Engineering, Department of Physical Medicine & Rehabilitation (R.T.S.), Virginia Commonwealth University School of Medicine, Richmond; Division of Physical Medicine & Rehabilitation (S.Y.), University of Mississippi School of Medicine; Brain Injury Program (S.Y.), Methodist Rehabilitation Center, Jackson, MS; Heart Rhythm Society (T.S.D.G.), Washington, DC; Department of Neurology (G.S.G.), University of Kansas Medical Center, Kansas City; and Department of Neurology (M.J.A.), University of Florida College of Medicine, Gainesville
| | - Steven Laureys
- From the Department of Physical Medicine and Rehabilitation (J.T.G.), Spaulding Rehabilitation Hospital and Harvard Medical School; Department of Psychiatry (J.T.G.), Massachusetts General Hospital, Boston; Department of Neurology (D.I.K.), Boston University School of Medicine; Braintree Rehabilitation Hospital (D.I.K.), MA; Department of Neurology and Neuroscience (N.D.S.), Weill Cornell Medical College, New York, NY; Moss Rehabilitation Research Institute (J.W.), Elkins Park, PA; Bronson Neuroscience Center (E.J.A.), Bronson Methodist Hospital, Kalamazoo, MI; Department of Pediatrics, Division of Child Neurology (S.A.), Loma Linda University School of Medicine, CA; Department of Neurology (R.B.), University of Rochester Medical Center, NY; Indiana University Department of Physical Medicine & Rehabilitation (F.M.H.), University of Indiana School of Medicine, Indianapolis; Coma Science Group-GIGA Research and Department of Neurology (S.L.), Sart Tillman Liège University & University Hospital, Liège, Belgium; Department of Neurology (G.S.F.L.), Uniformed Services University of Health Sciences, Bethesda; Department of Neurology (G.S.F.L.), Johns Hopkins University, Baltimore, MD; James A. Haley Veterans' Hospital (R.N.-R.), US Department of Veterans Affairs, Tampa, FL; Crawford Research Institute (R.T.S.), Shepherd Center, Atlanta, GA; Center for Rehabilitation Science and Engineering, Department of Physical Medicine & Rehabilitation (R.T.S.), Virginia Commonwealth University School of Medicine, Richmond; Division of Physical Medicine & Rehabilitation (S.Y.), University of Mississippi School of Medicine; Brain Injury Program (S.Y.), Methodist Rehabilitation Center, Jackson, MS; Heart Rhythm Society (T.S.D.G.), Washington, DC; Department of Neurology (G.S.G.), University of Kansas Medical Center, Kansas City; and Department of Neurology (M.J.A.), University of Florida College of Medicine, Gainesville
| | - Geoffrey S F Ling
- From the Department of Physical Medicine and Rehabilitation (J.T.G.), Spaulding Rehabilitation Hospital and Harvard Medical School; Department of Psychiatry (J.T.G.), Massachusetts General Hospital, Boston; Department of Neurology (D.I.K.), Boston University School of Medicine; Braintree Rehabilitation Hospital (D.I.K.), MA; Department of Neurology and Neuroscience (N.D.S.), Weill Cornell Medical College, New York, NY; Moss Rehabilitation Research Institute (J.W.), Elkins Park, PA; Bronson Neuroscience Center (E.J.A.), Bronson Methodist Hospital, Kalamazoo, MI; Department of Pediatrics, Division of Child Neurology (S.A.), Loma Linda University School of Medicine, CA; Department of Neurology (R.B.), University of Rochester Medical Center, NY; Indiana University Department of Physical Medicine & Rehabilitation (F.M.H.), University of Indiana School of Medicine, Indianapolis; Coma Science Group-GIGA Research and Department of Neurology (S.L.), Sart Tillman Liège University & University Hospital, Liège, Belgium; Department of Neurology (G.S.F.L.), Uniformed Services University of Health Sciences, Bethesda; Department of Neurology (G.S.F.L.), Johns Hopkins University, Baltimore, MD; James A. Haley Veterans' Hospital (R.N.-R.), US Department of Veterans Affairs, Tampa, FL; Crawford Research Institute (R.T.S.), Shepherd Center, Atlanta, GA; Center for Rehabilitation Science and Engineering, Department of Physical Medicine & Rehabilitation (R.T.S.), Virginia Commonwealth University School of Medicine, Richmond; Division of Physical Medicine & Rehabilitation (S.Y.), University of Mississippi School of Medicine; Brain Injury Program (S.Y.), Methodist Rehabilitation Center, Jackson, MS; Heart Rhythm Society (T.S.D.G.), Washington, DC; Department of Neurology (G.S.G.), University of Kansas Medical Center, Kansas City; and Department of Neurology (M.J.A.), University of Florida College of Medicine, Gainesville
| | - Risa Nakase-Richardson
- From the Department of Physical Medicine and Rehabilitation (J.T.G.), Spaulding Rehabilitation Hospital and Harvard Medical School; Department of Psychiatry (J.T.G.), Massachusetts General Hospital, Boston; Department of Neurology (D.I.K.), Boston University School of Medicine; Braintree Rehabilitation Hospital (D.I.K.), MA; Department of Neurology and Neuroscience (N.D.S.), Weill Cornell Medical College, New York, NY; Moss Rehabilitation Research Institute (J.W.), Elkins Park, PA; Bronson Neuroscience Center (E.J.A.), Bronson Methodist Hospital, Kalamazoo, MI; Department of Pediatrics, Division of Child Neurology (S.A.), Loma Linda University School of Medicine, CA; Department of Neurology (R.B.), University of Rochester Medical Center, NY; Indiana University Department of Physical Medicine & Rehabilitation (F.M.H.), University of Indiana School of Medicine, Indianapolis; Coma Science Group-GIGA Research and Department of Neurology (S.L.), Sart Tillman Liège University & University Hospital, Liège, Belgium; Department of Neurology (G.S.F.L.), Uniformed Services University of Health Sciences, Bethesda; Department of Neurology (G.S.F.L.), Johns Hopkins University, Baltimore, MD; James A. Haley Veterans' Hospital (R.N.-R.), US Department of Veterans Affairs, Tampa, FL; Crawford Research Institute (R.T.S.), Shepherd Center, Atlanta, GA; Center for Rehabilitation Science and Engineering, Department of Physical Medicine & Rehabilitation (R.T.S.), Virginia Commonwealth University School of Medicine, Richmond; Division of Physical Medicine & Rehabilitation (S.Y.), University of Mississippi School of Medicine; Brain Injury Program (S.Y.), Methodist Rehabilitation Center, Jackson, MS; Heart Rhythm Society (T.S.D.G.), Washington, DC; Department of Neurology (G.S.G.), University of Kansas Medical Center, Kansas City; and Department of Neurology (M.J.A.), University of Florida College of Medicine, Gainesville
| | - Ronald T Seel
- From the Department of Physical Medicine and Rehabilitation (J.T.G.), Spaulding Rehabilitation Hospital and Harvard Medical School; Department of Psychiatry (J.T.G.), Massachusetts General Hospital, Boston; Department of Neurology (D.I.K.), Boston University School of Medicine; Braintree Rehabilitation Hospital (D.I.K.), MA; Department of Neurology and Neuroscience (N.D.S.), Weill Cornell Medical College, New York, NY; Moss Rehabilitation Research Institute (J.W.), Elkins Park, PA; Bronson Neuroscience Center (E.J.A.), Bronson Methodist Hospital, Kalamazoo, MI; Department of Pediatrics, Division of Child Neurology (S.A.), Loma Linda University School of Medicine, CA; Department of Neurology (R.B.), University of Rochester Medical Center, NY; Indiana University Department of Physical Medicine & Rehabilitation (F.M.H.), University of Indiana School of Medicine, Indianapolis; Coma Science Group-GIGA Research and Department of Neurology (S.L.), Sart Tillman Liège University & University Hospital, Liège, Belgium; Department of Neurology (G.S.F.L.), Uniformed Services University of Health Sciences, Bethesda; Department of Neurology (G.S.F.L.), Johns Hopkins University, Baltimore, MD; James A. Haley Veterans' Hospital (R.N.-R.), US Department of Veterans Affairs, Tampa, FL; Crawford Research Institute (R.T.S.), Shepherd Center, Atlanta, GA; Center for Rehabilitation Science and Engineering, Department of Physical Medicine & Rehabilitation (R.T.S.), Virginia Commonwealth University School of Medicine, Richmond; Division of Physical Medicine & Rehabilitation (S.Y.), University of Mississippi School of Medicine; Brain Injury Program (S.Y.), Methodist Rehabilitation Center, Jackson, MS; Heart Rhythm Society (T.S.D.G.), Washington, DC; Department of Neurology (G.S.G.), University of Kansas Medical Center, Kansas City; and Department of Neurology (M.J.A.), University of Florida College of Medicine, Gainesville
| | - Stuart Yablon
- From the Department of Physical Medicine and Rehabilitation (J.T.G.), Spaulding Rehabilitation Hospital and Harvard Medical School; Department of Psychiatry (J.T.G.), Massachusetts General Hospital, Boston; Department of Neurology (D.I.K.), Boston University School of Medicine; Braintree Rehabilitation Hospital (D.I.K.), MA; Department of Neurology and Neuroscience (N.D.S.), Weill Cornell Medical College, New York, NY; Moss Rehabilitation Research Institute (J.W.), Elkins Park, PA; Bronson Neuroscience Center (E.J.A.), Bronson Methodist Hospital, Kalamazoo, MI; Department of Pediatrics, Division of Child Neurology (S.A.), Loma Linda University School of Medicine, CA; Department of Neurology (R.B.), University of Rochester Medical Center, NY; Indiana University Department of Physical Medicine & Rehabilitation (F.M.H.), University of Indiana School of Medicine, Indianapolis; Coma Science Group-GIGA Research and Department of Neurology (S.L.), Sart Tillman Liège University & University Hospital, Liège, Belgium; Department of Neurology (G.S.F.L.), Uniformed Services University of Health Sciences, Bethesda; Department of Neurology (G.S.F.L.), Johns Hopkins University, Baltimore, MD; James A. Haley Veterans' Hospital (R.N.-R.), US Department of Veterans Affairs, Tampa, FL; Crawford Research Institute (R.T.S.), Shepherd Center, Atlanta, GA; Center for Rehabilitation Science and Engineering, Department of Physical Medicine & Rehabilitation (R.T.S.), Virginia Commonwealth University School of Medicine, Richmond; Division of Physical Medicine & Rehabilitation (S.Y.), University of Mississippi School of Medicine; Brain Injury Program (S.Y.), Methodist Rehabilitation Center, Jackson, MS; Heart Rhythm Society (T.S.D.G.), Washington, DC; Department of Neurology (G.S.G.), University of Kansas Medical Center, Kansas City; and Department of Neurology (M.J.A.), University of Florida College of Medicine, Gainesville
| | - Thomas S D Getchius
- From the Department of Physical Medicine and Rehabilitation (J.T.G.), Spaulding Rehabilitation Hospital and Harvard Medical School; Department of Psychiatry (J.T.G.), Massachusetts General Hospital, Boston; Department of Neurology (D.I.K.), Boston University School of Medicine; Braintree Rehabilitation Hospital (D.I.K.), MA; Department of Neurology and Neuroscience (N.D.S.), Weill Cornell Medical College, New York, NY; Moss Rehabilitation Research Institute (J.W.), Elkins Park, PA; Bronson Neuroscience Center (E.J.A.), Bronson Methodist Hospital, Kalamazoo, MI; Department of Pediatrics, Division of Child Neurology (S.A.), Loma Linda University School of Medicine, CA; Department of Neurology (R.B.), University of Rochester Medical Center, NY; Indiana University Department of Physical Medicine & Rehabilitation (F.M.H.), University of Indiana School of Medicine, Indianapolis; Coma Science Group-GIGA Research and Department of Neurology (S.L.), Sart Tillman Liège University & University Hospital, Liège, Belgium; Department of Neurology (G.S.F.L.), Uniformed Services University of Health Sciences, Bethesda; Department of Neurology (G.S.F.L.), Johns Hopkins University, Baltimore, MD; James A. Haley Veterans' Hospital (R.N.-R.), US Department of Veterans Affairs, Tampa, FL; Crawford Research Institute (R.T.S.), Shepherd Center, Atlanta, GA; Center for Rehabilitation Science and Engineering, Department of Physical Medicine & Rehabilitation (R.T.S.), Virginia Commonwealth University School of Medicine, Richmond; Division of Physical Medicine & Rehabilitation (S.Y.), University of Mississippi School of Medicine; Brain Injury Program (S.Y.), Methodist Rehabilitation Center, Jackson, MS; Heart Rhythm Society (T.S.D.G.), Washington, DC; Department of Neurology (G.S.G.), University of Kansas Medical Center, Kansas City; and Department of Neurology (M.J.A.), University of Florida College of Medicine, Gainesville
| | - Gary S Gronseth
- From the Department of Physical Medicine and Rehabilitation (J.T.G.), Spaulding Rehabilitation Hospital and Harvard Medical School; Department of Psychiatry (J.T.G.), Massachusetts General Hospital, Boston; Department of Neurology (D.I.K.), Boston University School of Medicine; Braintree Rehabilitation Hospital (D.I.K.), MA; Department of Neurology and Neuroscience (N.D.S.), Weill Cornell Medical College, New York, NY; Moss Rehabilitation Research Institute (J.W.), Elkins Park, PA; Bronson Neuroscience Center (E.J.A.), Bronson Methodist Hospital, Kalamazoo, MI; Department of Pediatrics, Division of Child Neurology (S.A.), Loma Linda University School of Medicine, CA; Department of Neurology (R.B.), University of Rochester Medical Center, NY; Indiana University Department of Physical Medicine & Rehabilitation (F.M.H.), University of Indiana School of Medicine, Indianapolis; Coma Science Group-GIGA Research and Department of Neurology (S.L.), Sart Tillman Liège University & University Hospital, Liège, Belgium; Department of Neurology (G.S.F.L.), Uniformed Services University of Health Sciences, Bethesda; Department of Neurology (G.S.F.L.), Johns Hopkins University, Baltimore, MD; James A. Haley Veterans' Hospital (R.N.-R.), US Department of Veterans Affairs, Tampa, FL; Crawford Research Institute (R.T.S.), Shepherd Center, Atlanta, GA; Center for Rehabilitation Science and Engineering, Department of Physical Medicine & Rehabilitation (R.T.S.), Virginia Commonwealth University School of Medicine, Richmond; Division of Physical Medicine & Rehabilitation (S.Y.), University of Mississippi School of Medicine; Brain Injury Program (S.Y.), Methodist Rehabilitation Center, Jackson, MS; Heart Rhythm Society (T.S.D.G.), Washington, DC; Department of Neurology (G.S.G.), University of Kansas Medical Center, Kansas City; and Department of Neurology (M.J.A.), University of Florida College of Medicine, Gainesville
| | - Melissa J Armstrong
- From the Department of Physical Medicine and Rehabilitation (J.T.G.), Spaulding Rehabilitation Hospital and Harvard Medical School; Department of Psychiatry (J.T.G.), Massachusetts General Hospital, Boston; Department of Neurology (D.I.K.), Boston University School of Medicine; Braintree Rehabilitation Hospital (D.I.K.), MA; Department of Neurology and Neuroscience (N.D.S.), Weill Cornell Medical College, New York, NY; Moss Rehabilitation Research Institute (J.W.), Elkins Park, PA; Bronson Neuroscience Center (E.J.A.), Bronson Methodist Hospital, Kalamazoo, MI; Department of Pediatrics, Division of Child Neurology (S.A.), Loma Linda University School of Medicine, CA; Department of Neurology (R.B.), University of Rochester Medical Center, NY; Indiana University Department of Physical Medicine & Rehabilitation (F.M.H.), University of Indiana School of Medicine, Indianapolis; Coma Science Group-GIGA Research and Department of Neurology (S.L.), Sart Tillman Liège University & University Hospital, Liège, Belgium; Department of Neurology (G.S.F.L.), Uniformed Services University of Health Sciences, Bethesda; Department of Neurology (G.S.F.L.), Johns Hopkins University, Baltimore, MD; James A. Haley Veterans' Hospital (R.N.-R.), US Department of Veterans Affairs, Tampa, FL; Crawford Research Institute (R.T.S.), Shepherd Center, Atlanta, GA; Center for Rehabilitation Science and Engineering, Department of Physical Medicine & Rehabilitation (R.T.S.), Virginia Commonwealth University School of Medicine, Richmond; Division of Physical Medicine & Rehabilitation (S.Y.), University of Mississippi School of Medicine; Brain Injury Program (S.Y.), Methodist Rehabilitation Center, Jackson, MS; Heart Rhythm Society (T.S.D.G.), Washington, DC; Department of Neurology (G.S.G.), University of Kansas Medical Center, Kansas City; and Department of Neurology (M.J.A.), University of Florida College of Medicine, Gainesville
| |
Collapse
|
48
|
Vanhaudenhuyse A, Charland-Verville V, Thibaut A, Chatelle C, Tshibanda JFL, Maudoux A, Faymonville ME, Laureys S, Gosseries O. Conscious While Being Considered in an Unresponsive Wakefulness Syndrome for 20 Years. Front Neurol 2018; 9:671. [PMID: 30233480 PMCID: PMC6127614 DOI: 10.3389/fneur.2018.00671] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2018] [Accepted: 07/26/2018] [Indexed: 11/13/2022] Open
Abstract
Despite recent advances in our understanding of consciousness disorders, accurate diagnosis of severely brain-damaged patients is still a major clinical challenge. We here present the case of a patient who was considered in an unresponsive wakefulness syndrome/vegetative state for 20 years. Repeated standardized behavioral examinations combined to neuroimaging assessments allowed us to show that this patient was in fact fully conscious and was able to functionally communicate. We thus revised the diagnosis into an incomplete locked-in syndrome, notably because the main brain lesion was located in the brainstem. Clinical examinations of severe brain injured patients suffering from serious motor impairment should systematically include repeated standardized behavioral assessments and, when possible, neuroimaging evaluations encompassing magnetic resonance imaging and 18F-fluorodeoxyglucose positron emission tomography.
Collapse
Affiliation(s)
- Audrey Vanhaudenhuyse
- Department of Algology and Palliative Care, University Hospital of Liege, Liege, Belgium.,GIGA-Consciousness, Sensation & Perception Research Group, University of Liege, Liege, Belgium
| | - Vanessa Charland-Verville
- GIGA-Consciousness, Coma Science Group & Neurology Department, University Hospital of Liege, Liege, Belgium
| | - Aurore Thibaut
- GIGA-Consciousness, Coma Science Group & Neurology Department, University Hospital of Liege, Liege, Belgium.,Neuromodulation Center, Spaulding Rehabilitation Hospital, Harvard Medical School, Boston, MA, United States
| | - Camille Chatelle
- GIGA-Consciousness, Coma Science Group & Neurology Department, University Hospital of Liege, Liege, Belgium.,Laboratory for NeuroImaging of Coma and Consciousness-Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
| | - Jean-Flory L Tshibanda
- GIGA-Consciousness, Coma Science Group & Neurology Department, University Hospital of Liege, Liege, Belgium.,Department of Radiology, University Hospital of Liege and University of Liege, Liege, Belgium
| | - Audrey Maudoux
- GIGA-Consciousness, Sensation & Perception Research Group, University of Liege, Liege, Belgium.,Otorhinolaryngology Head and Neck Surgery Department, University Hospital of Liege, Liege, Belgium
| | - Marie-Elisabeth Faymonville
- Department of Algology and Palliative Care, University Hospital of Liege, Liege, Belgium.,GIGA-Consciousness, Sensation & Perception Research Group, University of Liege, Liege, Belgium
| | - Steven Laureys
- GIGA-Consciousness, Coma Science Group & Neurology Department, University Hospital of Liege, Liege, Belgium
| | - Olivia Gosseries
- GIGA-Consciousness, Coma Science Group & Neurology Department, University Hospital of Liege, Liege, Belgium
| |
Collapse
|
49
|
Giacino JT, Katz DI, Schiff ND, Whyte J, Ashman EJ, Ashwal S, Barbano R, Hammond FM, Laureys S, Ling GSF, Nakase-Richardson R, Seel RT, Yablon S, Getchius TSD, Gronseth GS, Armstrong MJ. Practice Guideline Update Recommendations Summary: Disorders of Consciousness: Report of the Guideline Development, Dissemination, and Implementation Subcommittee of the American Academy of Neurology; the American Congress of Rehabilitation Medicine; and the National Institute on Disability, Independent Living, and Rehabilitation Research. Arch Phys Med Rehabil 2018; 99:1699-1709. [PMID: 30098791 DOI: 10.1016/j.apmr.2018.07.001] [Citation(s) in RCA: 135] [Impact Index Per Article: 22.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
OBJECTIVE To update the 1995 American Academy of Neurology (AAN) practice parameter on persistent vegetative state and the 2002 case definition on minimally conscious state (MCS) and provide care recommendations for patients with prolonged disorders of consciousness (DoC). METHODS Recommendations were based on systematic review evidence, related evidence, care principles, and inferences using a modified Delphi consensus process according to the AAN 2011 process manual, as amended. RECOMMENDATIONS Clinicians should identify and treat confounding conditions, optimize arousal, and perform serial standardized assessments to improve diagnostic accuracy in adults and children with prolonged DoC (Level B). Clinicians should counsel families that for adults, MCS (vs vegetative state [VS]/ unresponsive wakefulness syndrome [UWS]) and traumatic (vs nontraumatic) etiology are associated with more favorable outcomes (Level B). When prognosis is poor, long-term care must be discussed (Level A), acknowledging that prognosis is not universally poor (Level B). Structural MRI, SPECT, and the Coma Recovery Scale-Revised can assist prognostication in adults (Level B); no tests are shown to improve prognostic accuracy in children. Pain always should be assessed and treated (Level B) and evidence supporting treatment approaches discussed (Level B). Clinicians should prescribe amantadine (100-200 mg bid) for adults with traumatic VS/UWS or MCS (4-16 weeks post injury) to hasten functional recovery and reduce disability early in recovery (Level B). Family counseling concerning children should acknowledge that natural history of recovery, prognosis, and treatment are not established (Level B). Recent evidence indicates that the term chronic VS/UWS should replace permanent VS, with duration specified (Level B). Additional recommendations are included.
Collapse
Affiliation(s)
- Joseph T Giacino
- Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital and Harvard Medical School, Boston, MA; Department of Psychiatry, Massachusetts General Hospital, Boston, MA
| | - Douglas I Katz
- Department of Neurology, Boston University School of Medicine, Boston, MA; Braintree Rehabilitation Hospital, MA
| | - Nicholas D Schiff
- Department of Neurology and Neuroscience, Weill Cornell Medical College, New York, NY
| | - John Whyte
- Moss Rehabilitation Research Institute, Elkins Park, PA
| | - Eric J Ashman
- Bronson Neuroscience Center, Bronson Methodist Hospital, Kalamazoo, MI
| | - Stephen Ashwal
- Department of Pediatrics, Division of Child Neurology, Loma Linda University School of Medicine, CA
| | - Richard Barbano
- Department of Neurology, University of Rochester Medical Center, NY
| | - Flora M Hammond
- Indiana University Department of Physical Medicine & Rehabilitation, University of Indiana School of Medicine, Indianapolis
| | - Steven Laureys
- Coma Science Group-GIGA Research and Department of Neurology, Sart Tillman Liège University & University Hospital, Liège, Belgium
| | - Geoffrey S F Ling
- Department of Neurology, Uniformed Services University of Health Sciences, Bethesda; Department of Neurology, Johns Hopkins University, Baltimore, MD
| | | | - Ronald T Seel
- Crawford Research Institute, Shepherd Center, Atlanta, GA; Center for Rehabilitation Science and Engineering, Department of Physical Medicine & Rehabilitation, Virginia Commonwealth University School of Medicine, Richmond
| | - Stuart Yablon
- Division of Physical Medicine & Rehabilitation, University of Mississippi School of Medicine, Jackson, MS; Brain Injury Program, Methodist Rehabilitation Center, Jackson, MS
| | | | - Gary S Gronseth
- Department of Neurology, University of Kansas Medical Center, Kansas City
| | - Melissa J Armstrong
- Department of Neurology, University of Florida College of Medicine, Gainesville
| |
Collapse
|
50
|
Xiao J, Pan J, He Y, Xie Q, Yu T, Huang H, Lv W, Zhang J, Yu R, Li Y. Visual Fixation Assessment in Patients with Disorders of Consciousness Based on Brain-Computer Interface. Neurosci Bull 2018; 34:679-690. [PMID: 30014347 PMCID: PMC6060219 DOI: 10.1007/s12264-018-0257-z] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2018] [Accepted: 05/29/2018] [Indexed: 11/26/2022] Open
Abstract
Visual fixation is an item in the visual function subscale of the Coma Recovery Scale-Revised (CRS-R). Sometimes clinicians using the behavioral scales find it difficult to detect because of the motor impairment in patients with disorders of consciousness (DOCs). Brain-computer interface (BCI) can be used to improve clinical assessment because it directly detects the brain response to an external stimulus in the absence of behavioral expression. In this study, we designed a BCI system to assist the visual fixation assessment of DOC patients. The results from 15 patients indicated that three showed visual fixation in both CRS-R and BCI assessments and one did not show such behavior in the CRS-R assessment but achieved significant online accuracy in the BCI assessment. The results revealed that electroencephalography-based BCI can detect the brain response for visual fixation. Therefore, the proposed BCI may provide a promising method for assisting behavioral assessment using the CRS-R.
Collapse
Affiliation(s)
- Jun Xiao
- Center for Brain Computer Interfaces and Brain Information Processing, South China University of Technology, Guangzhou, 510640, China
| | - Jiahui Pan
- Center for Brain Computer Interfaces and Brain Information Processing, South China University of Technology, Guangzhou, 510640, China
| | - Yanbin He
- Coma Research Group, Centre for Hyperbaric Oxygen and Neurorehabilitation, General Hospital of Guangzhou Military Command, Guangzhou, 510010, China
| | - Qiuyou Xie
- Coma Research Group, Centre for Hyperbaric Oxygen and Neurorehabilitation, General Hospital of Guangzhou Military Command, Guangzhou, 510010, China
| | - Tianyou Yu
- Center for Brain Computer Interfaces and Brain Information Processing, South China University of Technology, Guangzhou, 510640, China
| | - Haiyun Huang
- Center for Brain Computer Interfaces and Brain Information Processing, South China University of Technology, Guangzhou, 510640, China
| | - Wei Lv
- Coma Research Group, Centre for Hyperbaric Oxygen and Neurorehabilitation, General Hospital of Guangzhou Military Command, Guangzhou, 510010, China
| | - Jiechun Zhang
- Coma Research Group, Centre for Hyperbaric Oxygen and Neurorehabilitation, General Hospital of Guangzhou Military Command, Guangzhou, 510010, China
| | - Ronghao Yu
- Coma Research Group, Centre for Hyperbaric Oxygen and Neurorehabilitation, General Hospital of Guangzhou Military Command, Guangzhou, 510010, China.
| | - Yuanqing Li
- Center for Brain Computer Interfaces and Brain Information Processing, South China University of Technology, Guangzhou, 510640, China.
| |
Collapse
|