Disconnecting Consciousness: Is There a Common Anesthetic End Point?

Developing an Electroencephalogram-based Model to Predict Awakening after Cardiac Arrest Using Partial Processing with the BIS Engine

BACKGROUND

Accurate prognostication in comatose survivors of cardiac arrest is a challenging and high-stakes endeavor. The authors sought to determine whether internal electroencephalogram (EEG) subparameters extracted by the BIS monitor (Medtronic, USA), a device commonly used to estimate depth of anesthesia intraoperatively, could be repurposed to predict recovery of consciousness after cardiac arrest.

METHODS

In this retrospective cohort study, a three-layer neural network was trained to predict recovery of consciousness to the point of command following versus not based on 48 h of continuous EEG recordings in 315 comatose patients admitted to a single U.S. academic medical center after cardiac arrest (derivation cohort, n = 181; validation cohort, n = 134). Continuous EEGs were partially processed into subparameters using virtualized emulation of the BIS Engine ( i.e. , the internal software of the BIS monitor) applied to signals from the frontotemporal leads of the standard 10-20 EEG montage. The model was trained on hourly averaged measurements of these internal subparameters. This model's performance was compared to the modified Westhall qualitative EEG scoring framework.

RESULTS

Maximum prognostic accuracy in the derivation cohort was achieved using a network trained on only four BIS subparameters (inverse burst suppression ratio, mean spectral power density, gamma power, and theta/delta power). In a held-out sample of 134 patients, the model outperformed current state-of-the-art qualitative EEG assessment techniques at predicting recovery of consciousness (area under the receiver operating characteristics curve, 0.86; accuracy, 0.87; sensitivity, 0.83; specificity, 0.88; positive predictive value, 0.71; negative predictive value, 0.94). Gamma band power has not been previously reported as a correlate of recovery potential after cardiac arrest.

CONCLUSIONS

In patients comatose after cardiac arrest, four EEG features calculated internally by the BIS Engine were repurposed by a compact neural network to achieve a prognostic accuracy superior to the current clinical qualitative accepted standard, with high sensitivity for recovery. These features hold promise for assessing patients after cardiac arrest.

The changes in neural complexity and connectivity in thalamocortical and cortico-cortical systems after propofol-induced unconsciousness in different temporal scales

Existing studies have indicated neural activity across diverse temporal and spatial scales. However, the alterations in complexity, functional connectivity, and directional connectivity within the thalamocortical and corticocortical systems across various scales during propofol-induced unconsciousness remain uncertain. We analyzed the stereo-electroencephalography (SEEG) from wakefulness to unconsciousness among the brain regions of the prefrontal cortex, temporal lobe, and anterior nucleus of the thalamus. The complexity (examined by permutation entropy (PE)), functional connectivity (permutation mutual information (PMI)), and directional connectivity (symbolic conditional mutual information (SCMI) and directionality index (DI)) were calculated across various scales. In the lower-band frequency (0.1-45 Hz) SEEG, after the loss of consciousness, PE significantly decreased (p < 0.001) in all regions and scales, except for the thalamus, which remained relatively unchanged at large scales (τ=32 ms). Following the loss of consciousness, inter-regional PMI either significantly increased or remained stable across different scales (τ=4 ms to 32 ms). During the unconscious state, SCMI between brain regions exhibited inconsistent changes across scales. In the late unconscious stage, the inter-regional DI across all scales indicated a shift from a balanced state of information flow between brain regions to a pattern where the prefrontal cortex and thalamus drive the temporal lobe. Our findings demonstrate that propofol-induced unconsciousness is associated with reduced cortical complexity, diverse functional connectivity, and a disrupted balance of information integration among thalamocortical and cortico-cortical systems. This study enhances the theoretical understanding of anesthetic-induced loss of consciousness by elucidating the scale- and region-specific effects of propofol on thalamocortical and cortico-cortical systems.

The ketamine chameleon: history, pharmacology, and the contested value of experience

INTRODUCTION

Since its synthesis in 1962, ketamine has been widely used in diverse medical contexts, from anesthesia to treatment-resistant depression. However, interpretations of ketamine's subjective effects remain polarized. Biomedical frameworks typically construe the drug's experiential effects as dissociative or psychotomimetic, while psychedelic paradigms emphasize the potential therapeutic merits of these non-ordinary states.

AREAS COVERED

Ketamine's psychoactive effects have inspired diverse interpretations. In this review, we trace the historical evolution of these perspectives - which we broadly categorize as 'dissociative,' 'dream-like,' and 'psychedelic' - and show how they emerged out of these clinical contexts. We highlight the influence of factors such as language, dose, and environmental context on ketamine's effects and therapeutic outcomes. We discuss potential mechanisms underlying these context-dependent effects and explore the broader clinical and research-related ramifications.

EXPERT OPINION

Ketamine's subjective effects are undeniably powerful, yet their therapeutic significance remains debated. A nuanced, interdisciplinary approach is essential for maximizing ketamine's potential. Future research should focus on how explanatory models, treatment environments, and patient preparation can optimize ketamine's benefits while minimizing distress. We suggest that, rather than being a tiger to be tamed as its creator once described, ketamine may best be understood as a chameleon whose color shifts depending on its context.

Imaging and Anesthesia Protocol Optimization in Sedated Clinical Resting-State fMRI

BACKGROUND AND PURPOSE

The quality of resting-state fMRI (rs-fMRI) under anesthesia is variable and there are no guidelines on optimal image acquisition or anesthesia protocol. We aim to identify the factors that may lead to compromised clinical rs-fMRI under anesthesia.

MATERIALS AND METHODS

In this cross-sectional study, we analyzed clinical rs-fMRI data acquired under anesthesia from 2009-2023 at Massachusetts General Hospital. Independent component analysis-driven resting-state networks (RSNs) of each patient were evaluated qualitatively and quantitatively and grouped as robust or weak. Overall networks were evaluated by using the qualitative method, and motor and language networks were evaluated by using the quantitative method. RSN robustness was analyzed in 4 outcome categories: overall, combined motor-language, individual motor, and language networks. Predictor variables included rs-fMRI acquisition parameters, anesthesia medications, underlying brain structural abnormalities, age, and sex. Logistic regression was used to examine the effect of the study variables on RSN robustness.

RESULTS

Sixty-nine patients were identified. With qualitative assessment, 40 had robust and 29 had weak overall RSN. Quantitatively, 45 patients had robust, while 24 had weak motor-language networks. Among all the predictor variables, only sevoflurane significantly contributed to the outcomes, with sevoflurane administration reducing the odds of having robust RSN in overall (OR = 0.2, 95% CI = 0.05-0.79, P = .02), motor-language (OR = 0.18, 95% CI = 0.04-0.80, P = .02), and individual motor (OR = 0.1, 95% CI = 0.02-0.64, P = .02) categories. Individual language network robustness was not associated with the tested predictor variables.

CONCLUSIONS

Sevoflurane anesthesia may compromise the visibility of fMRI RSN, particularly impacting motor networks. This finding suggests that the type of anesthesia is a critical factor in rs-fMRI quality. We did not observe the association of the MR acquisition technique or underlying structural abnormality with the RSN robustness.

CPR-Induced Consciousness during Ventricular Fibrillation: Case Report and Literature Review

Introduction

Over the years, numerous studies have suggested the occurrence of a peculiar phenomenon known as "CPRIC" during the revival process. The revelation of this phenomenon has ignited widespread discussion and investigation, yet many enigmas remain unsolved. This study describes the case of a 52-year-old man diagnosed with acute anterior myocardial infarction, who experienced ventricular fibrillation while awaiting further treatment. Despite ultimately not regaining spontaneous circulation, he remained conscious for a period during chest compressions and showed signs of resistance.

Methods

PubMed and Web of Science were searched until July 11, 2024. We included original studies and case reports relevant to CPRIC. For case reports, we extracted information on the author (year), country, patients, location, compression, signs of CPRIC, treatment of CPRIC, and patient outcomes. For other studies, we included the author (year), country, participants, and results. The extracted data were synthesized using a narrative approach.

Results

Of 3038 articles, 32 were included, i.e., 18 case reports (24 cases), 9 cross-sectional surveys, and 5 cohort studies. In CPRIC cases, patients exhibited various manifestations including opening their eyes, speaking, and moving. Other included studies explored healthcare workers' awareness and experiences of CPRIC, the incidence and manifestations of CPRIC, the impact of CPRIC on patient outcomes, memories and perceptions of cardiac arrest indicating consciousness, the effects of CPRIC on rescuers, and the management of CPRIC.

Conclusions

There is an urgent need to establish a globally recognized definition of CPRIC. It is crucial to develop clear algorithms that focus not only on identifying this phenomenon but also on determining the best approaches to manage it. Furthermore, CPRIC can cause multiple interruptions during CPR, making it essential to differentiate whether these interruptions are due to CPRIC or indicative of a return of spontaneous circulation.

Propofol disrupts the functional core-matrix architecture of the thalamus in humans

Research into the role of thalamocortical circuits in anesthesia-induced unconsciousness is difficult due to anatomical and functional complexity. Prior neuroimaging studies have examined either the thalamus as a whole or focused on specific subregions, overlooking the distinct neuronal subtypes like core and matrix cells. We conducted a study of heathy volunteers and functional magnetic resonance imaging during conscious baseline, deep sedation, and recovery. We advanced the functional gradient mapping technique to delineate the functional geometry of thalamocortical circuits, within a framework of the unimodal-transmodal functional axis of the cortex. Here we show a significant shift in this geometry during deep sedation, marked by a transmodal-deficient geometry. This alteration is closely linked to the spatial variations in the matrix cell composition within the thalamus. This research bridges cellular and systems-level understanding, highlighting the crucial role of thalamic core-matrix functional architecture in understanding the neural mechanisms of states of consciousness.

The Thalamus in Perioperative Neurocognitive Disorders

Thalamus function and structure are known predictors of individual differences in the risk of age-related neurocognitive disorders (NCD), such as dementia. However, to date, little is known about their role in the perioperative setting. Here, we provide a narrative review of brain-imaging studies of preoperative and postoperative thalamus scanning parameters associated with risks of developing perioperative NCD, such as postoperative delirium (POD) and postoperative cognitive dysfunction (POCD) during the postoperative phase. These findings are discussed in light of the concept of reserve capacity.

In vivo imaging reveals a synchronized correlation among neurotransmitter dynamics during propofol and sevoflurane anesthesia

General anesthesia is widely applied in clinical practice. However, the precise mechanism of loss of consciousness induced by general anesthetics remains unknown. Here, we measured the dynamics of five neurotransmitters, including γ-aminobutyric acid, glutamate, norepinephrine, acetylcholine, and dopamine, in the medial prefrontal cortex and primary visual cortex of C57BL/6 mice through in vivo fiber photometry and genetically encoded neurotransmitter sensors under anesthesia to reveal the mechanism of general anesthesia from a neurotransmitter perspective. Results revealed that the concentrations of γ-aminobutyric acid, glutamate, norepinephrine, and acetylcholine increased in the cortex during propofol-induced loss of consciousness. Dopamine levels did not change following the hypnotic dose of propofol but increased significantly following surgical doses of propofol anesthesia. Notably, the concentrations of the five neurotransmitters generally decreased during sevoflurane-induced loss of consciousness. Furthermore, the neurotransmitter dynamic networks were not synchronized in the non-anesthesia groups but were highly synchronized in the anesthetic groups. These findings suggest that neurotransmitter dynamic network synchronization may cause anesthetic-induced loss of consciousness.

Overview and Clinical Applications of Artificial Intelligence and Machine Learning in Cardiac Anesthesiology

Artificial intelligence- (AI) and machine learning (ML)-based applications are becoming increasingly pervasive in the healthcare setting. This has in turn challenged clinicians, hospital administrators, and health policymakers to understand such technologies and develop frameworks for safe and sustained clinical implementation. Within cardiac anesthesiology, challenges and opportunities for AI/ML to support patient care are presented by the vast amounts of electronic health data, which are collected rapidly, interpreted, and acted upon within the periprocedural area. To address such challenges and opportunities, in this article, the authors review 3 recent applications relevant to cardiac anesthesiology, including depth of anesthesia monitoring, operating room resource optimization, and transthoracic/transesophageal echocardiography, as conceptual examples to explore strengths and limitations of AI/ML within healthcare, and characterize this evolving landscape. Through reviewing such applications, the authors introduce basic AI/ML concepts and methodologies, as well as practical considerations and ethical concerns for initiating and maintaining safe clinical implementation of AI/ML-based algorithms for cardiac anesthesia patient care.

Prelimbic cortical pyramidal neurons to ventral tegmental area projections promotes arousal from sevoflurane anesthesia

AIMS

General anesthesia has been used in surgical procedures for approximately 180 years, yet the precise mechanism of anesthetic drugs remains elusive. There is significant anatomical connectivity between the ventral tegmental area (VTA) and the prelimbic cortex (PrL). Projections from VTA dopaminergic neurons (VTADA ) to the PrL play a role in the transition from sevoflurane anesthesia to arousal. It is still uncertain whether the prelimbic cortex pyramidal neuron (PrLPyr ) and its projections to VTA (PrLPyr -VTA) are involved in anesthesia-arousal regulation.

METHODS

We employed chemogenetics and optogenetics to selectively manipulate neuronal activity in the PrLPyr -VTA pathway. Electroencephalography spectra and burst-suppression ratios (BSR) were used to assess the depth of anesthesia. Furthermore, the loss or recovery of the righting reflex was monitored to indicate the induction or emergence time of general anesthesia. To elucidate the receptor mechanisms in the PrLPyr -VTA projection's impact on anesthesia and arousal, we microinjected NMDA receptor antagonists (MK-801) or AMPA receptor antagonists (NBQX) into the VTA.

RESULTS

Our findings show that chemogenetic or optogenetic activation of PrLPyr neurons prolonged anesthesia induction and promoted emergence. Additionally, chemogenetic activation of the PrLPyr -VTA neural pathway delayed anesthesia induction and promoted anesthesia emergence. Likewise, optogenetic activation of the PrLPyr -VTA projections extended the induction time and facilitated emergence from sevoflurane anesthesia. Moreover, antagonizing NMDA receptors in the VTA attenuates the delayed anesthesia induction and promotes emergence caused by activating the PrLPyr -VTA projections.

CONCLUSION

This study demonstrates that PrLPyr neurons and their projections to the VTA are involved in facilitating emergence from sevoflurane anesthesia, with the PrLPyr -VTA pathway exerting its effects through the activation of NMDA receptors within the VTA.

Propofol Disrupts the Functional Core-Matrix Architecture of the Thalamus in Humans

Research into the role of thalamocortical circuits in anesthesia-induced unconsciousness is difficult due to anatomical and functional complexity. Prior neuroimaging studies have examined either the thalamus as a whole or focused on specific subregions, overlooking the distinct neuronal subtypes like core and matrix cells. We conducted a study of heathy volunteers and functional magnetic resonance imaging during conscious baseline, deep sedation, and recovery. We advanced the functional gradient mapping technique to delineate the functional geometry of thalamocortical circuits, within a framework of the unimodal-transmodal functional axis of the cortex. We observed a significant shift in this geometry during unconsciousness, marked by the dominance of unimodal over transmodal geometry. This alteration was closely linked to the spatial variations in the density of matrix cells within the thalamus. This research bridges cellular and systems-level understanding, highlighting the crucial role of thalamic core-matrix functional architecture in understanding the neural mechanisms of states of consciousness.

Rapid thalamocortical network switching mediated by cortical synchronization underlies propofol-induced EEG signatures: a biophysical model

Propofol-mediated unconsciousness elicits strong alpha/low-beta and slow oscillations in the electroencephalogram (EEG) of patients. As anesthetic dose increases, the EEG signal changes in ways that give clues to the level of unconsciousness; the network mechanisms of these changes are only partially understood. Here, we construct a biophysical thalamocortical network involving brain stem influences that reproduces transitions in dynamics seen in the EEG involving the evolution of the power and frequency of alpha/low-beta and slow rhythm, as well as their interactions. Our model suggests that propofol engages thalamic spindle and cortical sleep mechanisms to elicit persistent alpha/low-beta and slow rhythms, respectively. The thalamocortical network fluctuates between two mutually exclusive states on the timescale of seconds. One state is characterized by continuous alpha/low-beta-frequency spiking in thalamus (C-state), whereas in the other, thalamic alpha spiking is interrupted by periods of co-occurring thalamic and cortical silence (I-state). In the I-state, alpha colocalizes to the peak of the slow oscillation; in the C-state, there is a variable relationship between an alpha/beta rhythm and the slow oscillation. The C-state predominates near loss of consciousness; with increasing dose, the proportion of time spent in the I-state increases, recapitulating EEG phenomenology. Cortical synchrony drives the switch to the I-state by changing the nature of the thalamocortical feedback. Brain stem influence on the strength of thalamocortical feedback mediates the amount of cortical synchrony. Our model implicates loss of low-beta, cortical synchrony, and coordinated thalamocortical silent periods as contributing to the unconscious state.NEW & NOTEWORTHY GABAergic anesthetics induce alpha/low-beta and slow oscillations in the EEG, which interact in dose-dependent ways. We constructed a thalamocortical model to investigate how these interdependent oscillations change with propofol dose. We find two dynamic states of thalamocortical coordination, which change on the timescale of seconds and dose-dependently mirror known changes in EEG. Thalamocortical feedback determines the oscillatory coupling and power seen in each state, and this is primarily driven by cortical synchrony and brain stem neuromodulation.

The Conscious Nematode: Exploring Hallmarks of Minimal Phenomenal Consciousness in Caenorhabditis Elegans

While subcellular components of cognition and affectivity that involve the interaction between experience, environment, and physiology -such as learning, trauma, or emotion- are being identified, the physical mechanisms of phenomenal consciousness remain more elusive. We are interested in exploring whether ancient, simpler organisms such as nematodes have minimal consciousness. Is there something that feels like to be a worm? Or are worms blind machines? 'Simpler' models allow us to simultaneously extract data from multiple levels such as slow and fast neural dynamics, structural connectivity, molecular dynamics, behavior, decision making, etc., and thus, to test predictions of the current frameworks in dispute. In the present critical review, we summarize the current models of consciousness in order to reassess in light of the new evidence whether Caenorhabditis elegans, a nematode with a nervous system composed of 302 neurons, has minimal consciousness. We also suggest empirical paths to further advance consciousness research using C. elegans.

A scoping review for building a criticality-based conceptual framework of altered states of consciousness

The healthy conscious brain is thought to operate near a critical state, reflecting optimal information processing and high susceptibility to external stimuli. Conversely, deviations from the critical state are hypothesized to give rise to altered states of consciousness (ASC). Measures of criticality could therefore be an effective way of establishing the conscious state of an individual. Furthermore, characterizing the direction of a deviation from criticality may enable the development of treatment strategies for pathological ASC. The aim of this scoping review is to assess the current evidence supporting the criticality hypothesis, and the use of criticality as a conceptual framework for ASC. Using the PRISMA guidelines, Web of Science and PubMed were searched from inception to February 7th 2022 to find articles relating to measures of criticality across ASC. N = 427 independent papers were initially found on the subject. N = 378 were excluded because they were either: not related to criticality; not related to consciousness; not presenting results from a primary study; presenting model data. N = 49 independent papers were included in the present research, separated in 7 sub-categories of ASC: disorders of consciousness (DOC) (n = 5); sleep (n = 13); anesthesia (n = 18); epilepsy (n = 12); psychedelics and shamanic state of consciousness (n = 4); delirium (n = 1); meditative state (n = 2). Each category included articles suggesting a deviation of the critical state. While most studies were only able to identify a deviation from criticality without being certain of its direction, the preliminary consensus arising from the literature is that non-rapid eye movement (NREM) sleep reflects a subcritical state, epileptic seizures reflect a supercritical state, and psychedelics are closer to the critical state than normal consciousness. This scoping review suggests that, though the literature is limited and methodologically inhomogeneous, ASC are characterized by a deviation from criticality, though its direction is not clearly reported in a majority of studies. Criticality could become, with more extensive research, an effective and objective way to characterize ASC, and help identify therapeutic avenues to improve criticality in pathological brain states. Furthermore, we suggest how anesthesia and psychedelics could potentially be used as neuromodulation techniques to restore criticality in DOC.

s-ketamine enhances thalamocortical and corticocortical synaptic transmission in acute murine brain slices via increased AMPA-receptor-mediated pathways

Despite ongoing research efforts and routine clinical use, the neuronal mechanisms underlying the anesthesia-induced loss of consciousness are still under debate. Unlike most anesthetics, ketamine increases thalamic and cortical activity. Ketamine is considered to act via a NMDA-receptor antagonism-mediated reduction of inhibition, i.e., disinhibition. Intact interactions between the thalamus and cortex constitute a prerequisite for the maintenance of consciousness and are thus a promising target for anesthetics to induce loss of consciousness. In this study, we aim to characterize the influence of s-ketamine on the thalamocortical network using acute brain-slice preparation. We performed whole-cell patch-clamp recordings from pyramidal neurons in cortical lamina IV and thalamocortical relay neurons in acute brain slices from CB57BL/6N mice. Excitatory postsynaptic potentials (EPSPs) were obtained via electrical stimulation of the cortex with a bipolar electrode that was positioned to lamina II/III (electrically induced EPSPs, eEPSPs) or via optogenetic activation of thalamocortical relay neurons (optogenetically induced EPSPs, oEPSPs). Intrinsic neuronal properties (like resting membrane potential, membrane threshold for action potential generation, input resistance, and tonic action potential frequency), as well as NMDA-receptor-dependent and independent spontaneous GABA_A-receptor-mediated inhibitory postsynaptic currents (sIPSCs) were evaluated. Wilcoxon signed-rank test (level of significance < 0.05) served as a statistical test and Cohen's U3_1 was used to determine the actual effect size. Within 20 min, s-ketamine (5 μM) significantly increased both intracortical eEPSPs as well as thalamocortical oEPSPs. NMDA-receptor-mediated intracortical eEPSPs were significantly reduced. Intrinsic neuronal properties of cortical pyramidal neurons from lamina IV and thalamocortical relay neurons in the ventrobasal thalamic complex were not substantially affected. Neither a significant effect on NMDA-receptor-dependent GABA_A sIPSCs (thought to underly a disinhibitory effect) nor a reduction of NMDA-receptor independent GABA_A sIPSCs was observed. Both thalamocortical and intracortical AMPA-receptor-mediated EPSPs were significantly increased.In conclusion, our findings show no evidence for a NMDA-receptor antagonism-based disinhibition, but rather suggest an enhanced thalamocortical and intracortical synaptic transmission, which appears to be driven via increased AMPA-receptor-mediated transmission.

Spatiotemporal patterns of population response in the visual cortex under isoflurane: from wakefulness to loss of consciousness

Anesthetic drugs are widely used in medicine and research to mediate loss of consciousness (LOC). Isoflurane is a commonly used anesthetic drug; however, its effects on cortical sensory processing, in particular around LOC, are not well understood. Using voltage-sensitive dye imaging, we measured visually evoked neuronal population response from the visual cortex in awake and anesthetized mice at 3 increasing concentrations of isoflurane, thus controlling the level of anesthesia from wakefulness to deep anesthesia. At low concentration of isoflurane, the effects on neuronal measures were minor relative to the awake condition. These effects augmented with increasing isoflurane concentration, while around LOC point, they showed abrupt and nonlinear changes. At the network level, we found that isoflurane decreased the stimulus-evoked intra-areal spatial spread of local neural activation, previously reported to be mediated by horizontal connections, and also reduced intra-areal synchronization of neuronal population. The synchronization between different visual areas decreased with higher isoflurane levels. Isoflurane reduced the population response amplitude and prolonged their latencies while higher visual areas showed increased vulnerability to isoflurane concentration. Our results uncover the changes in neural activity and synchronization at isoflurane concentrations leading to LOC and suggest reverse hierarchical shutdown of cortical areas.

Selective corticocortical connectivity suppression during propofol-induced anesthesia in healthy volunteers

We comprehensively studied directional feedback and feedforward connectivity to explore potential connectivity changes that underlie propofol-induced deep sedation. We further investigated the corticocortical connectivity patterns within and between hemispheres. Sixty-channel electroencephalographic data were collected from 19 healthy volunteers in a resting wakefulness state and propofol-induced deep unconsciousness state defined by a bispectral index value of 40. A source analysis was employed to locate cortical activity. The Desikan-Killiany atlas was used to partition cortices, and directional functional connectivity was assessed by normalized symbolic transfer entropy between higher-order (prefrontal and frontal) and lower-order (auditory, sensorimotor and visual) cortices and between hot-spot frontal and parietal cortices. We found that propofol significantly suppressed feedforward connectivity from the left parietal to right frontal cortex and bidirectional connectivity between the left frontal and left parietal cortex, between the frontal and auditory cortex, and between the frontal and sensorimotor cortex. However, there were no significant changes in either feedforward or feedback connectivity between the prefrontal and all the lower-order cortices and between the frontal and visual cortices or in feedback connectivity from the frontal to parietal cortex. Propofol anesthetic selectively decreased the unidirectional interaction between higher-order frontoparietal cortices and bidirectional interactions between the higher-order frontal cortex and lower-order auditory and sensorimotor cortices, which indicated that both feedback and feedforward connectivity were suppressed under propofol-induced deep sedation. Our findings provide critical insights into the connectivity changes underlying the top-down mechanism of propofol anesthesia at deep sedation.

Supplementary Information

The online version contains supplementary material available at 10.1007/s11571-021-09775-x.

Does Machine Understanding Require Consciousness?

This article addresses the question of whether machine understanding requires consciousness. Some researchers in the field of machine understanding have argued that it is not necessary for computers to be conscious as long as they can match or exceed human performance in certain tasks. But despite the remarkable recent success of machine learning systems in areas such as natural language processing and image classification, important questions remain about their limited performance and about whether their cognitive abilities entail genuine understanding or are the product of spurious correlations. Here I draw a distinction between natural, artificial, and machine understanding. I analyse some concrete examples of natural understanding and show that although it shares properties with the artificial understanding implemented in current machine learning systems it also has some essential differences, the main one being that natural understanding in humans entails consciousness. Moreover, evidence from psychology and neurobiology suggests that it is this capacity for consciousness that, in part at least, explains for the superior performance of humans in some cognitive tasks and may also account for the authenticity of semantic processing that seems to be the hallmark of natural understanding. I propose a hypothesis that might help to explain why consciousness is important to understanding. In closing, I suggest that progress toward implementing human-like understanding in machines—machine understanding—may benefit from a naturalistic approach in which natural processes are modelled as closely as possible in mechanical substrates.

Whole-brain modelling identifies distinct but convergent paths to unconsciousness in anaesthesia and disorders of consciousness

The human brain entertains rich spatiotemporal dynamics, which are drastically reconfigured when consciousness is lost due to anaesthesia or disorders of consciousness (DOC). Here, we sought to identify the neurobiological mechanisms that explain how transient pharmacological intervention and chronic neuroanatomical injury can lead to common reconfigurations of neural activity. We developed and systematically perturbed a neurobiologically realistic model of whole-brain haemodynamic signals. By incorporating PET data about the cortical distribution of GABA receptors, our computational model reveals a key role of spatially-specific local inhibition for reproducing the functional MRI activity observed during anaesthesia with the GABA-ergic agent propofol. Additionally, incorporating diffusion MRI data obtained from DOC patients reveals that the dynamics that characterise loss of consciousness can also emerge from randomised neuroanatomical connectivity. Our results generalise between anaesthesia and DOC datasets, demonstrating how increased inhibition and connectome perturbation represent distinct neurobiological paths towards the characteristic activity of the unconscious brain.

General anesthesia globally synchronizes activity selectively in layer 5 cortical pyramidal neurons

General anesthetics induce loss of consciousness, a global change in behavior. However, a corresponding global change in activity in the context of defined cortical cell types has not been identified. Here, we show that spontaneous activity of mouse layer 5 pyramidal neurons, but of no other cortical cell type, becomes consistently synchronized in vivo by different general anesthetics. This heightened neuronal synchrony is aperiodic, present across large distances, and absent in cortical neurons presynaptic to layer 5 pyramidal neurons. During the transition to and from anesthesia, changes in synchrony in layer 5 coincide with the loss and recovery of consciousness. Activity within both apical and basal dendrites is synchronous, but only basal dendrites’ activity is temporally locked to somatic activity. Given that layer 5 is a major cortical output, our results suggest that brain-wide synchrony in layer 5 pyramidal neurons may contribute to the loss of consciousness during general anesthesia.

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Activity of layer 5 PNs synchronizes globally in different anesthetics

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Other mouse cortical cell types show no consistent increase in synchrony

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Changes in layer 5 synchrony coincide with the loss and recovery of consciousness

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Basal, but not apical, layer 5 dendrites are in synchrony with somas

Constrained Functional Connectivity Dynamics in Pediatric Surgical Patients Undergoing General Anesthesia

BACKGROUND

Functional connectivity in cortical networks is thought to be important for consciousness and can be disrupted during the anesthetized state. Recent work in adults has revealed dynamic connectivity patterns during stable general anesthesia but whether similar connectivity state transitions occur in the developing brain remains undetermined. We tested the hypothesis that anesthetic-induced unconsciousness is associated with disruption of functional connectivity in the developing brain and that, like adults, there are dynamic shifts in connectivity patterns during the stable maintenance phase of general anesthesia.

METHODS

This was a preplanned analysis of a previously reported single-center, prospective, cross-sectional study of healthy (ASA I or II) children aged 8-16 years undergoing surgery with general anesthesia (n=50) at Michigan Medicine. Whole scalp (16-channel), wireless electroencephalographic data were collected from the preoperative period through the recovery of consciousness. Functional connectivity was measured using weighted phase lag index and discrete connectivity states were classified using cluster analysis.

RESULTS

Changes in functional connectivity were associated with anesthetic state transitions across multiple regions and frequency bands. An increase in prefrontal-frontal alpha (median[25th, 75th]; baseline 0.070[0.049, 0.101] vs. maintenance 0.474[0.286, 0.606], p<0.001) and theta connectivity (0.038[0.029, 0.048] vs 0.399[0.254, 0.488], p<0.001), and decrease in parietal-occipital alpha connectivity (0.171[0.145, 0.243] vs. 0.089[0.055, 0.132], p<0.001) were among those with the greatest effect size. Contrary to our hypothesis, connectivity patterns during the maintenance phase of general anesthesia were dominated by stable theta and alpha prefrontal-frontal and alpha frontal-parietal connectivity, and exhibited high between-cluster similarity (r = 0.75 to 0.87).

CONCLUSIONS

Changes in functional connectivity are associated with anesthetic state transitions but, unlike adults, connectivity patterns are constrained during general anesthesia in late childhood and early adolescence.

A reduced level of consciousness affects non-conscious processes

Being conscious is a profound aspect of human existence, and understanding its function and its inception is considered one of the truly grand scientific challenges. However, the nature of consciousness remains enigmatic, to a large part because "being conscious" can refer to both the content (phenomenology) and the level (arousal) of consciousness, and how these different aspects are related remains unclear. To empirically assess the relation between level and content of consciousness, we manipulated these two aspects by presenting stimuli consciously or non-consciously and by using Propofol sedation, while brain activity was measured using fMRI. We observed that sedation affected both conscious and non-conscious processes but at different hierarchical levels; while conscious processing was altered in higher-order regions (the intraparietal sulcus) and spared sensory areas, the opposite effect was observed for non-conscious processing. The observation that Propofol affected non-conscious processing calls for a reconsideration of what kind of information one can gain on "consciousness" from recording neural responses to sedation without considering both (content) conscious and (content) non-conscious processing.

Monitoring nociception and awareness during palliative sedation: A systematic review

BACKGROUND

Providing unawareness and pain relief are core elements of palliative sedation. In addition to clinical scales, nociception and electroencephalogram-based depth of sedation monitoring are used to assess the level of consciousness and analgesia during sedation in intensive care units and during procedures.

AIM

To determine whether reported devices impact the outcomes of palliative sedation.

DESIGN

Systematic review and narrative synthesis of research published between January 2000 and December 2020.

DATA SOURCES

Embase, Google Scholar, PubMed, CENTRAL, and the Cochrane Library. All reports describing the use of any monitoring device to assess the level of consciousness or analgesia during palliative sedation were screened for inclusion. Data concerning safety and efficacy were extracted. Patient comfort was the primary outcome of interest. Articles reporting sedation but that did not meet guidelines of the European Association for Palliative Care were excluded.

RESULTS

Six reports of five studies were identified. Four of these were case series and two were case reports. Together, these six reports involved a total of 67 sedated adults. Methodological quality was assessed fair to good. Medication regimens were adjusted to bispectral index monitoring values in two studies, which found poor correlation between monitoring values and observational scores. In another study, high nociception index values, representing absence of pain, were used to detect opioid overdosing. Relatives and caregivers found the procedures feasible and acceptable.

The neural basis of consciousness

Consciousness has evolved and is a feature of all animals with sufficiently complex nervous systems. It is, therefore, primarily a problem for biology, rather than physics. In this review, I will consider three aspects of consciousness: level of consciousness, whether we are awake or in a coma; the contents of consciousness, what determines how a small amount of sensory information is associated with subjective experience, while the rest is not; and meta-consciousness, the ability to reflect upon our subjective experiences and, importantly, to share them with others. I will discuss and compare current theories of the neural and cognitive mechanisms involved in producing these three aspects of consciousness and conclude that the research in this area is flourishing and has already succeeded to delineate these mechanisms in surprising detail.

Integrated information structure collapses with anesthetic loss of conscious arousal in Drosophila melanogaster

The physical basis of consciousness remains one of the most elusive concepts in current science. One influential conjecture is that consciousness is to do with some form of causality, measurable through information. The integrated information theory of consciousness (IIT) proposes that conscious experience, filled with rich and specific content, corresponds directly to a hierarchically organised, irreducible pattern of causal interactions; i.e. an integrated informational structure among elements of a system. Here, we tested this conjecture in a simple biological system (fruit flies), estimating the information structure of the system during wakefulness and general anesthesia. Consistent with this conjecture, we found that integrated interactions among populations of neurons during wakefulness collapsed to isolated clusters of interactions during anesthesia. We used classification analysis to quantify the accuracy of discrimination between wakeful and anesthetised states, and found that informational structures inferred conscious states with greater accuracy than a scalar summary of the structure, a measure which is generally championed as the main measure of IIT. In stark contrast to a view which assumes feedforward architecture for insect brains, especially fly visual systems, we found rich information structures, which cannot arise from purely feedforward systems, occurred across the fly brain. Further, these information structures collapsed uniformly across the brain during anesthesia. Our results speak to the potential utility of the novel concept of an “informational structure” as a measure for level of consciousness, above and beyond simple scalar values.

The physical basis of consciousness remains elusive. Efforts to measure consciousness have generally been restricted to simple, scalar quantities which summarise the complexity of a system, inspired by integrated information theory, which links a multi-dimensional, informational structure to the contents of experience in a system. Due to the complexity of the definition of the structure, assessment of its utility as a measure of conscious arousal in a system has largely been ignored. In this manuscript we evaluate the utility of such an information structure in measuring the level of arousal in the fruit fly. Our results indicate that this structure can be more informative about the level of arousal in a system than even the single-value summary proposed by the theory itself. These results may push consciousness research towards the notion of multi-dimensional informational structures, instead of traditional scalar summaries.

Muting, not fragmentation, of functional brain networks under general anesthesia

Changes in resting-state functional connectivity (rs-FC) under general anesthesia have been widely studied with the goal of identifying neural signatures of consciousness. This work has commonly revealed an apparent fragmentation of whole-brain network structure during unconsciousness, which has been interpreted as reflecting a break-down in connectivity and a disruption of the brain's ability to integrate information. Here we show, by studying rs-FC under varying depths of isoflurane-induced anesthesia in nonhuman primates, that this apparent fragmentation, rather than reflecting an actual change in network structure, can be simply explained as the result of a global reduction in FC. Specifically, by comparing the actual FC data to surrogate data sets that we derived to test competing hypotheses of how FC changes as a function of dose, we found that increases in whole-brain modularity and the number of network communities - considered hallmarks of fragmentation - are artifacts of constructing FC networks by thresholding based on correlation magnitude. Taken together, our findings suggest that deepening levels of unconsciousness are instead associated with the increasingly muted expression of functional networks, an observation that constrains current interpretations as to how anesthesia-induced FC changes map onto existing neurobiological theories of consciousness.

Hierarchical disruption in the cortex of anesthetized monkeys as a new signature of consciousness loss

Anesthesia induces a reconfiguration of the repertoire of functional brain states leading to a high function-structure similarity. However, it is unclear how these functional changes lead to loss of consciousness. Here we suggest that the mechanism of conscious access is related to a general dynamical rearrangement of the intrinsic hierarchical organization of the cortex. To measure cortical hierarchy, we applied the Intrinsic Ignition analysis to resting-state fMRI data acquired in awake and anesthetized macaques. Our results reveal the existence of spatial and temporal hierarchical differences of neural activity within the macaque cortex, with a strong modulation by the depth of anesthesia and the employed anesthetic agent. Higher values of Intrinsic Ignition correspond to rich and flexible brain dynamics whereas lower values correspond to poor and rigid, structurally driven brain dynamics. Moreover, spatial and temporal hierarchical dimensions are disrupted in a different manner, involving different hierarchical brain networks. All together suggest that disruption of brain hierarchy is a new signature of consciousness loss.

Differential effects of propofol and ketamine on critical brain dynamics

Whether the brain operates at a critical "tipping" point is a long standing scientific question, with evidence from both cellular and systems-scale studies suggesting that the brain does sit in, or near, a critical regime. Neuroimaging studies of humans in altered states of consciousness have prompted the suggestion that maintenance of critical dynamics is necessary for the emergence of consciousness and complex cognition, and that reduced or disorganized consciousness may be associated with deviations from criticality. Unfortunately, many of the cellular-level studies reporting signs of criticality were performed in non-conscious systems (in vitro neuronal cultures) or unconscious animals (e.g. anaesthetized rats). Here we attempted to address this knowledge gap by exploring critical brain dynamics in invasive ECoG recordings from multiple sessions with a single macaque as the animal transitioned from consciousness to unconsciousness under different anaesthetics (ketamine and propofol). We use a previously-validated test of criticality: avalanche dynamics to assess the differences in brain dynamics between normal consciousness and both drug-states. Propofol and ketamine were selected due to their differential effects on consciousness (ketamine, but not propofol, is known to induce an unusual state known as "dissociative anaesthesia"). Our analyses indicate that propofol dramatically restricted the size and duration of avalanches, while ketamine allowed for more awake-like dynamics to persist. In addition, propofol, but not ketamine, triggered a large reduction in the complexity of brain dynamics. All states, however, showed some signs of persistent criticality when testing for exponent relations and universal shape-collapse. Further, maintenance of critical brain dynamics may be important for regulation and control of conscious awareness.

Changes in measures of consciousness during anaesthesia of one hemisphere (Wada test)

BACKGROUND

In the Wada test, one hemisphere is selectively anaesthetised by unilateral intracarotid injection of a fast-acting anaesthetic agent. This gives a unique opportunity to observe the functions and physiological activity of one hemisphere while anaesthetising the other, allowing direct comparisons between brain states and hemispheres that are not possible in any other setting.

AIM

To test whether potential measures of consciousness would be affected by selective anaesthesia of one hemisphere, and reliably distinguish the states of the anesthetised and non-anesthetised hemispheres.

METHODS

We analysed EEG data from 7 patients undergoing Wada-tests in preparation for neurosurgery and computed several measures reported to correlate with the state of consciousness: power spectral density, functional connectivity, and measures of signal diversity. These measures were compared between conditions (normal rest vs. unilateral anaesthesia) and hemispheres (injected vs. non-injected), and used with a support vector machine to classify the state and site of injection objectively from individual patient's recordings.

RESULTS

Although brain function, assessed behaviourally, appeared to be substantially altered only on the injected side, we found large bilateral changes in power spectral density for all frequency bands tested, and functional connectivity changed significantly both between and within both hemispheres. Surprisingly, we found no statistically significant differences in the measures of signal diversity between hemispheres or states, for the group of 7 patients, although 4 of the individual patients showed a significant decrease in signal diversity on the injected side. Nevertheless, including signal diversity measures improved the classification results, indicating that these measures carry at least some non-redundant information about the condition and injection site. We propose that several of these results may be explained by conduction of activity, via the corpus callosum, from the injected to the contralateral hemisphere and vice versa, without substantially affecting the function of the receiving hemisphere, thus reflecting what we call "cross-state unreceptiveness".

Granger Causality of the Electroencephalogram Reveals Abrupt Global Loss of Cortical Information Flow during Propofol-induced Loss of Responsiveness

It is a commonly held view that information flow between widely separated regions of the cerebral cortex is a necessary component in the generation of wakefulness (also termed “connected” consciousness). This study therefore hypothesized that loss of wakefulness caused by propofol anesthesia should be associated with loss of information flow, as estimated by the effective connectivity in the scalp electroencephalogram (EEG) signal.

In healthy adult volunteers, propofol anesthesia–induced loss of consciousness was associated with an abrupt, substantial, and global decrease in connectivity. These changes are comparably reversed at regain of consciousness. These observations suggest that information flow is an important indicator of wakefulness.

Supplemental Digital Content is available in the text.

Detection of Electrophysiological Activity of Amygdala during Anesthesia Using Stereo-EEG: A Preliminary Research in Anesthetized Epileptic Patients

Recent studies of anesthesia mechanisms have focused on neuronal network and functional connectivity. The stereo-electroencephalography (SEEG) recordings provide appropriate temporal and spatial resolution to study whole-brain dynamics; however, the feasibility to detect subcortical signals during anesthesia still needs to be studied with clinical evidence. Here, we focus on the amygdala to investigate if SEEG can be used to detect cortical and subcortical electrophysiological activity in anesthetized epileptic patients. Therefore, we present direct evidence in humans that SEEG indeed can be used to record cortical and subcortical electrophysiological activity during anesthesia. The study was carried out in propofol-anesthetized five epileptic patients. The electrophysiology activity of the amygdala and other cortical areas from anesthesia to the recovery of consciousness was investigated using stereo-EEG (SEEG). Results indicated that with the decrease of propofol concentration, power spectral density (PSD) in the delta band of the amygdala significantly decreased. When it was close to recovery, the correlation between the amygdala and ipsilateral temporal lobe significantly decreased followed by a considerable increase when awake. The findings of the current study suggest SEEG as an effective tool for providing direct evidence of the anesthesia mechanism.

Use of Processed Electroencephalography in the Clinical Setting

Purpose of Review

Processed electroencephalography (pEEG) is widely used in clinical practice. Few clinicians utilize the full potential of these devices. This brief review will address the improvements in patient management available from the utilization of all pEEG data.

Recent Findings

Anesthesiologists easily learn to recognize raw pEEG patterns that are consistent with an appropriate level of hypnotic effect. Power distribution within the waveform can be displayed in a visual format that identifies signatures of the principal anesthetic hypnotics. Opinion on the benefit of pEEG data in the mitigation of postoperative neurological impairment remains divided.

Summary

Looking beyond the index number can aid clinical decision making and improve confidence in the benefits of this monitoring modality.

Validation of a new approach for distinguishing anesthetized from awake state in patients using directed transfer function applied to raw EEG

We test whether a measure based on the directed transfer function (DTF) calculated from short segments of electroencephalography (EEG) time-series can be used to monitor the state of the patients also during sevoflurane anesthesia as it can for patients undergoing propofol anesthesia. We collected and analyzed 25-channel EEG from 7 patients (3 females, ages 41–56 years) undergoing surgical anesthesia with sevoflurane, and quantified the sensor space directed connectivity for every 1-s epoch using DTF. The resulting connectivity parameters were compared to corresponding parameters from our previous study (n = 8, patients anesthetized with propofol and remifentanil, but otherwise using a similar protocol). Statistical comparisons between and within studies were done using permutation statistics, a data driven algorithm based on the DTF-parameters was employed to classify the epochs as coming from awake or anesthetized state. According to results of the permutation tests, DTF-parameter topographies were significantly different between the awake and anesthesia state at the group level. However, the topographies were not significantly different when comparing results computed from sevoflurane and propofol data, neither in the awake nor in anesthetized state. Optimizing the algorithm for simultaneously having high sensitivity and specificity in classification yielded an accuracy of 95.1% (SE = 0.96%), with sensitivity of 98.4% (SE = 0.80%) and specificity of 94.8% (SE = 0.10%). These findings indicate that the DTF changes in a similar manner when humans undergo general anesthesia caused by two distinct anesthetic agents with different molecular mechanisms of action.

The predictive global neuronal workspace: A formal active inference model of visual consciousness

The global neuronal workspace (GNW) model has inspired over two decades of hypothesis-driven research on the neural basis of consciousness. However, recent studies have reported findings that are at odds with empirical predictions of the model. Further, the macro-anatomical focus of current GNW research has limited the specificity of predictions afforded by the model. In this paper we present a neurocomputational model - based on Active Inference - that captures central architectural elements of the GNW and is able to address these limitations. The resulting 'predictive global workspace' casts neuronal dynamics as approximating Bayesian inference, allowing precise, testable predictions at both the behavioural and neural levels of description. We report simulations demonstrating the model's ability to reproduce: 1) the electrophysiological and behavioural results observed in previous studies of inattentional blindness; and 2) the previously introduced four-way taxonomy predicted by the GNW, which describes the relationship between consciousness, attention, and sensory signal strength. We then illustrate how our model can reconcile/explain (apparently) conflicting findings, extend the GNW taxonomy to include the influence of prior expectations, and inspire novel paradigms to test associated behavioural and neural predictions.

The Biology of General Anesthesia from Paramecium to Primate

General anesthesia serves a critically important function in the clinical care of human patients. However, the anesthetized state has foundational implications for biology because anesthetic drugs are effective in organisms ranging from paramecia, to plants, to primates. Although unconsciousness is typically considered the cardinal feature of general anesthesia, this endpoint is only strictly applicable to a select subset of organisms that are susceptible to being anesthetized. We review the behavioral endpoints of general anesthetics across species and propose the isolation of an organism from its environment - both in terms of the afferent arm of sensation and the efferent arm of action - as a generalizable definition. We also consider the various targets and putative mechanisms of general anesthetics across biology and identify key substrates that are conserved, including cytoskeletal elements, ion channels, mitochondria, and functionally coupled electrical or neural activity. We conclude with a unifying framework related to network function and suggest that general anesthetics - from single cells to complex brains - create inefficiency and enhance modularity, leading to the dissociation of functions both within an organism and between the organism and its surroundings. Collectively, we demonstrate that general anesthesia is not restricted to the domain of modern medicine but has broad biological relevance with wide-ranging implications for a diverse array of species.

State-Dependent and Bandwidth-Specific Effects of Ketamine and Propofol on Electroencephalographic Complexity in Rats

There is an ongoing debate as to whether ketamine anesthesia suppresses neurophysiologic complexity at doses sufficient for surgical anesthesia, with previous human studies reporting surrogates of both suppressed and preserved levels of cortical complexity. However, these studies have not assessed cortical dynamics in higher gamma frequencies, which have previously been demonstrated to correlate with the level of consciousness during anesthesia. In this study, we used Lempel-Ziv complexity (LZc) to characterize frontal and parietal electroencephalographic complexity (0.5–175 Hz, 0.5–55 Hz, 65–175 Hz) before, during, and after ketamine or propofol anesthesia in the rat. To control for the potential influence of spectral changes in complexity estimation, LZc was normalized with phase-shuffled surrogate data. We demonstrate that ketamine and propofol anesthesia were characterized by a significant reduction in broadband (0.5–175 Hz) LZc. Further analysis showed that while the reduction of LZc during ketamine anesthesia was significant in 65–175 Hz range, during propofol anesthesia, a significant decrease was observed in 0.5–55 Hz bandwidth. LZc in broadband and 0.5–55 Hz range showed a significant increase during emergence from ketamine anesthesia. Phase-shuffled normalized LZc revealed that (1) decrease in complexity during ketamine and propofol anesthesia—not increase in complexity during emergence—were dissociable from the influence of spectral changes, and (2) reduced LZc during ketamine anesthesia was present across all three bandwidths. Ketamine anesthesia was characterized by reduced complexity in high gamma bandwidth, as reflected in both raw and phase-shuffled normalized LZc, which suggests that reduced high gamma complexity is a neurophysiological feature of ketamine anesthesia.

Desflurane Anesthesia Alters Cortical Layer-specific Hierarchical Interactions in Rat Cerebral Cortex

BACKGROUND

Neurocognitive investigations suggest that conscious sensory perception depends on recurrent neuronal interactions among sensory, parietal, and frontal cortical regions, which are suppressed by general anesthetics. The purpose of this work was to investigate if local interactions in sensory cortex are also altered by anesthetics. The authors hypothesized that desflurane would reduce recurrent neuronal interactions in cortical layer-specific manner consistent with the anatomical disposition of feedforward and feedback pathways.

METHODS

Single-unit neuronal activity was measured in freely moving adult male rats (268 units; 10 animals) using microelectrode arrays chronically implanted in primary and secondary visual cortex. Layer-specific directional interactions were estimated by mutual information and transfer entropy of multineuron spike patterns within and between cortical layers three and five. The effect of incrementally increasing and decreasing steady-state concentrations of desflurane (0 to 8% to 0%) was tested for statistically significant quadratic trend across the successive anesthetic states.

RESULTS

Desflurane produced robust, state-dependent reduction (P = 0.001) of neuronal interactions between primary and secondary visual areas and between layers three and five, as indicated by mutual information (37 and 41% decrease at 8% desflurane from wakeful baseline at [mean ± SD] 0.52 ± 0.51 and 0.53 ± 0.51 a.u., respectively) and transfer entropy (77 and 78% decrease at 8% desflurane from wakeful baseline at 1.86 ± 1.56 a.u. and 1.87 ± 1.67 a.u., respectively). In addition, a preferential suppression of feedback between secondary and primary visual cortex was suggested by the reduction of directional index of transfer entropy overall (P = 0.001; 89% decrease at 8% desflurane from 0.11 ± 0.18 a.u. at baseline) and specifically, in layer five (P = 0.001; 108% decrease at 8% desflurane from 0.12 ± 0.19 a.u. at baseline).

CONCLUSIONS

Desflurane anesthesia reduces neuronal interactions in visual cortex with a preferential effect on feedback. The findings suggest that neuronal disconnection occurs locally, among hierarchical sensory regions, which may contribute to global functional disconnection underlying anesthetic-induced unconsciousness.

Dissociation as a disorder of integration - On the footsteps of Pierre Janet

At the end of the 19th century Pierre Janet described dissociation as an altered state of consciousness manifested in disrupted integration of psychological functions. Clinically, such disruption comprises compartmentalization symptoms like amnesia, detachment symptoms like depersonalization/derealization, and structural dissociation of personality with changes in the sense of self. The exact neuronal mechanisms leading to these different symptoms remain unclear. We here suggest to put Janet's original account of dissociation as disrupted integration of psychological functions into a novel context, that is, a neuronal context as related to current brain imaging. This requires a combined theoretical and empirical approach on data supporting such neuronal reframing of Janet. For that, we here review (i) past and (ii) recent psychological and neuronal views on dissociation together with neuroscientific theories of integration, which (iii) are supported and complemented by preliminary fMRI data. We propose three neuronal mechanisms of dynamic integration operating at different levels of the brain's spontaneous activity - temporo-spatial binding on the regional level, temporo-spatial synchronization on the network level, and temporo-spatial globalization on the global level. These neuronal mechanisms, in turn, may be related to different symptomatic manifestation of dissociation operating at different levels, e.g., compartmentalization, detachment, and structural, which, as we suggest, can all be traced to disrupted integration of neuronal and psychological functions as originally envisioned by Janet.

The (Un)Conscious Mouse as a Model for Human Brain Functions: Key Principles of Anesthesia and Their Impact on Translational Neuroimaging

In recent years, technical and procedural advances have brought functional magnetic resonance imaging (fMRI) to the field of murine neuroscience. Due to its unique capacity to measure functional activity non-invasively, across the entire brain, fMRI allows for the direct comparison of large-scale murine and human brain functions. This opens an avenue for bidirectional translational strategies to address fundamental questions ranging from neurological disorders to the nature of consciousness. The key challenges of murine fMRI are: (1) to generate and maintain functional brain states that approximate those of calm and relaxed human volunteers, while (2) preserving neurovascular coupling and physiological baseline conditions. Low-dose anesthetic protocols are commonly applied in murine functional brain studies to prevent stress and facilitate a calm and relaxed condition among animals. Yet, current mono-anesthesia has been shown to impair neural transmission and hemodynamic integrity. By linking the current state of murine electrophysiology, Ca2+ imaging and fMRI of anesthetic effects to findings from human studies, this systematic review proposes general principles to design, apply and monitor anesthetic protocols in a more sophisticated way. The further development of balanced multimodal anesthesia, combining two or more drugs with complementary modes of action helps to shape and maintain specific brain states and relevant aspects of murine physiology. Functional connectivity and its dynamic repertoire as assessed by fMRI can be used to make inferences about cortical states and provide additional information about whole-brain functional dynamics. Based on this, a simple and comprehensive functional neurosignature pattern can be determined for use in defining brain states and anesthetic depth in rest and in response to stimuli. Such a signature can be evaluated and shared between labs to indicate the brain state of a mouse during experiments, an important step toward translating findings across species.

Functional Magnetic Resonance Imaging in the Final Stage of Creutzfeldt-Jakob Disease

Sporadic Creutzfeldt-Jakob disease (sCJD) is a rare fatal degenerative disease of the central nervous system. The clinical course is characterized by rapid progression of neurological and neuromuscular symptoms. The late stage with loss of consciousness is not well characterized. We report a 62-year-old male patient with sCJD with the clinical picture of a vegetative state/apallic syndrome, in whom we studied cortical responses using a vibration paradigm. The functional magnetic resonance imaging (fMRI) investigation demonstrated a clear response within the sensorimotor cortex, the cerebellum, the parietal cortex, the insular, and frontal inferior region. The finding of persistent cortical activity on fMRI in a patient with CJD in a state of unconsciousness has implications for the clinical management and for ethical considerations.

Conscious Processing and the Global Neuronal Workspace Hypothesis

We review the central tenets and neuroanatomical basis of the global neuronal workspace (GNW) hypothesis, which attempts to account for the main scientific observations regarding the elementary mechanisms of conscious processing in the human brain. The GNW hypothesis proposes that, in the conscious state, a non-linear network ignition associated with recurrent processing amplifies and sustains a neural representation, allowing the corresponding information to be globally accessed by local processors. We examine this hypothesis in light of recent data that contrast brain activity evoked by either conscious or non-conscious contents, as well as during conscious or non-conscious states, particularly general anesthesia. We also discuss the relationship between the intertwined concepts of conscious processing, attention, and working memory.

Having a Conscious Patient During Cardiopulmonary Resuscitation: Is It Not Time to Consider Sedation Protocol?: A Case Report

A middle-aged man with acute inferior wall myocardial infarction was admitted in cardiac arrest and in an unresponsive state to the hospital. Cardiopulmonary resuscitation (CPR) was initiated. Patient showed signs of consciousness throughout the CPR. The impact of awareness during CPR on the neuropsychological status of a patient with a favorable neurological outcome is yet to be studied on a large scale. Sedation protocol without compromising hemodynamic status may prove a fair choice in such cases.

Near-Death Experience as a Probe to Explore (Disconnected) Consciousness

Forty-five years ago, the first evidence of near-death experience (NDE) during comatose state was provided, setting the stage for a new paradigm for studying the neural basis of consciousness in unresponsive states. At present, the state of consciousness associated with NDEs remains an open question. In the common view, consciousness is said to disappear in a coma with the brain shutting down, but this is an oversimplification. We argue that a novel framework distinguishing awareness, wakefulness, and connectedness is needed to comprehend the phenomenon. Classical NDEs correspond to internal awareness experienced in unresponsive conditions, thereby corresponding to an episode of disconnected consciousness. Our proposal suggests new directions for NDE research, and more broadly, consciousness science.

Reorganization of rich-clubs in functional brain networks during propofol-induced unconsciousness and natural sleep

BACKGROUND

General anesthesia (GA) provides an invaluable experimental tool to understand the essential neural mechanisms underlying consciousness. Previous neuroimaging studies have shown the functional integration and segregation of brain functional networks during anesthetic-induced alteration of consciousness. However, the organization pattern of hubs in functional brain networks remains unclear. Moreover, comparisons with the well-characterized physiological unconsciousness can help us understand the neural mechanisms of anesthetic-induced unconsciousness.

METHODS

Resting-state functional magnetic resonance imaging was performed during wakefulness, mild propofol-induced sedation (m-PIS), and deep PIS (d-PIS) with clinical unconsciousness on 8 healthy volunteers and wakefulness and natural sleep on 9 age- and sex-matched healthy volunteers. Large-scale functional brain networks of each volunteer were constructed based on 160 regions of interest. Then, rich-club organizations in brain functional networks and nodal properties (nodal strength and efficiency) were assessed and analyzed among the different states and groups.

RESULTS

Rich-clubs in the functional brain networks were reorganized during alteration of consciousness induced by propofol. Firstly, rich-club nodes were switched from the posterior cingulate cortex (PCC), angular gyrus, and anterior and middle insula to the inferior parietal lobule (IPL), inferior parietal sulcus (IPS), and cerebellum. When sedation was deepened to unconsciousness, the rich-club nodes were switched to the occipital and angular gyrus. These results suggest that the rich-club nodes were switched among the high-order cognitive function networks (default mode network [DMN] and fronto-parietal network [FPN]), sensory networks (occipital network [ON]), and cerebellum network (CN) from consciousness (wakefulness) to propofol-induced unconsciousness. At the same time, compared with wakefulness, local connections were switched to rich-club connections during propofol-induced unconsciousness, suggesting a strengthening of the overall information commutation of networks. Nodal efficiency of the anterior and middle insula and ventral frontal cortex was significantly decreased. Additionally, from wakefulness to natural sleep, a similar pattern of rich-club reorganization with propofol-induced unconsciousness was observed: rich-club nodes were switched from the DMN (including precuneus and PCC) to the sensorimotor network (SMN, including part of the frontal and temporal gyrus). Compared with natural sleep, nodal efficiency of the insula, frontal gyrus, PCC, and cerebellum significantly decreased during propofol-induced unconsciousness.

CONCLUSIONS

Our study demonstrated that the rich-club reorganization in functional brain networks is characterized by switching of rich-club nodes between the high-order cognitive and sensory and motor networks during propofol-induced alteration of consciousness and natural sleep. These findings will help understand the common neurological mechanism of pharmacological and physiological unconsciousness.

Level of Consciousness Is Dissociable from Electroencephalographic Measures of Cortical Connectivity, Slow Oscillations, and Complexity

Leading neuroscientific theories posit a central role for the functional integration of cortical areas in conscious states. Considerable evidence supporting this hypothesis is based on network changes during anesthesia, but it is unclear whether these changes represent state-related (conscious vs unconscious) or drug-related (anesthetic vs no anesthetic) effects. We recently demonstrated that carbachol delivery to prefrontal cortex (PFC) restored wakefulness despite continuous administration of the general anesthetic sevoflurane. By contrast, carbachol delivery to parietal cortex, or noradrenaline delivery to either prefrontal or parietal cortices, failed to restore wakefulness. Thus, carbachol-induced reversal of sevoflurane anesthesia represents a unique state that combines wakefulness with clinically relevant anesthetic concentrations in the brain. To differentiate the state-related and drug-related associations of cortical connectivity and dynamics, we analyzed the electroencephalographic data gathered from adult male Sprague Dawley rats during the aforementioned experiments for changes in functional cortical gamma connectivity (25–155 Hz), slow oscillations (0.5–1 Hz), and complexity (<175 Hz). We show that higher gamma (85–155 Hz) connectivity is decreased (p ≤ 0.02) during sevoflurane anesthesia, an expected finding, but was not restored during wakefulness induced by carbachol delivery to PFC. Conversely, for rats in which wakefulness was not restored, the functional gamma connectivity remained reduced, but there was a significant decrease (p < 0.001) in the power of slow oscillations and increase (p < 0.001) in cortical complexity, which was similar to that observed during wakefulness induced after carbachol delivery to PFC. We conclude that the level of consciousness can be dissociated from cortical connectivity, oscillations, and dynamics.

SIGNIFICANCE STATEMENT Numerous theories of consciousness suggest that functional connectivity across the cortex is characteristic of the conscious state and is reduced during anesthesia. However, it is unknown whether the observed changes are state-related (conscious vs unconscious) or drug-related (drug vs no drug). We used a novel rat model in which cholinergic stimulation of PFC produced wakefulness despite continuous exposure to a general anesthetic. We demonstrate that, as expected, general anesthesia reduces connectivity. Surprisingly, the connectivity remains suppressed despite pharmacologically induced wakefulness in the presence of anesthetic, with restoration occurring only after the anesthetic is discontinued. Thus, whether an animal exhibits wakefulness or not can be dissociated from cortical connectivity, prompting a reevaluation of the role of connectivity in level of consciousness.

A general spectral decomposition of causal influences applied to integrated information

BACKGROUND

Quantifying interactions among many neurons is fundamental to understanding system-level phenomena such as attention, learning and even conscious experience. Causal influences in the brain, quantified as integrated information, are thought to support subjective conscious experience. Recent empirical work has shown that the spectral decomposition of causal influences, for example using Granger causality, can reveal frequency-specific influences that are not observed in the time domain. However, a spectral decomposition of integrated information has not been put forward, limiting its adoption for analyzing neural data.

NEW METHOD

We present a general and flexible framework for deriving the spectral decomposition of causal influences in autoregressive processes.

RESULTS

We use the framework to derive a spectral decomposition of integrated information. We show that other well-known measures, including Granger causality, can be derived using the same framework. Using simulations, we demonstrate a complex interplay between the spectral decomposition of integrated information and other measures that is not observed in the time domain.

COMPARISON WITH EXISTING METHODS

This paper provides a spectral decomposition of integrated information for the first time. Although a spectral decomposition of Granger causality has been derived, that approach is only applicable to uni-directional causal influences, not multi-directional causal influences as required for integrated information.

CONCLUSIONS

Our novel framework can be used to derive the spectral decomposition of uni- and multi-directional measures of causal influences. We use this framework to derive a spectral decomposition of integrated information, paving the way for better understanding how frequency-specific causal influences in the brain relate to cognition.

Resting-state Dynamics as a Cortical Signature of Anesthesia in Monkeys

WHAT WE ALREADY KNOW ABOUT THIS TOPIC

WHAT THIS ARTICLE TELLS US THAT IS NEW: BACKGROUND:: The mechanism by which anesthetics induce a loss of consciousness remains a puzzling problem. We hypothesized that a cortical signature of anesthesia could be found in an increase in similarity between the matrix of resting-state functional correlations and the anatomical connectivity matrix of the brain, resulting in an increased function-structure similarity.

METHODS

We acquired resting-state functional magnetic resonance images in macaque monkeys during wakefulness (n = 3) or anesthesia with propofol (n = 3), ketamine (n = 3), or sevoflurane (n = 3). We used the k-means algorithm to cluster dynamic resting-state data into independent functional brain states. For each condition, we performed a regression analysis to quantify function-structure similarity and the repertoire of functional brain states.

RESULTS

Seven functional brain states were clustered and ranked according to their similarity to structural connectivity, with higher ranks corresponding to higher function-structure similarity and lower ranks corresponding to lower correlation between brain function and brain anatomy. Anesthesia shifted the brain state composition from a low rank (rounded rank [mean ± SD]) in the awake condition (awake rank = 4 [3.58 ± 1.03]) to high ranks in the different anesthetic conditions (ketamine rank = 6 [6.10 ± 0.32]; moderate propofol rank = 6 [6.15 ± 0.76]; deep propofol rank = 6 [6.16 ± 0.46]; moderate sevoflurane rank = 5 [5.10 ± 0.81]; deep sevoflurane rank = 6 [5.81 ± 1.11]; P < 0.0001).

CONCLUSIONS

Whatever the molecular mechanism, anesthesia led to a massive reconfiguration of the repertoire of functional brain states that became predominantly shaped by brain anatomy (high function-structure similarity), giving rise to a well-defined cortical signature of anesthesia-induced loss of consciousness.

Anesthetics Have Different Effects on the Electrocorticographic Spectra of Wild-type and Mitochondrial Mutant Mice

WHAT WE ALREADY KNOW ABOUT THIS TOPIC

WHAT THIS ARTICLE TELLS US THAT IS NEW: BACKGROUND:: Knockout of the mitochondrial protein Ndufs4 (Ndufs4[KO]) in mice causes hypersensitivity to volatile anesthetics but resistance to ketamine. The authors hypothesized that electrocorticographic changes underlying the responses of Ndufs4(KO) to volatile anesthetics and to ketamine would be similar in mutant and control mice.

METHODS

Electrocorticographic recordings at equipotent volatile anesthetic concentrations were compared between genotypes. In separate studies, control and cell type-specific Ndufs4(KO) mice were anesthetized with intraperitoneal ketamine to determine their ED50s.

RESULTS

Ndufs4 (KO) did not differ from controls in baseline electrocorticography (N = 5). Compared to baseline, controls exposed to isoflurane (EC50) lost power (expressed as mean baseline [µV/Hz]; mean isoflurane [µV/Hz]) in delta (2.45; 0.50), theta (1.41; 0.16), alpha (0.23; 0.05), beta (0.066; 0.016), and gamma (0.020; 0.005) frequency bands (N = 5). Compared to baseline, at their isoflurane EC50, Ndufs4(KO) maintained power in delta (1.08; 1.38), theta (0.36; 0.26), and alpha (0.09; 0.069) frequency bands but decreased in beta (0.041; 0.023) and gamma (0.020; 0.0068) frequency bands (N = 5). Similar results were seen for both genotypes in halothane. Vesicular glutamate transporter 2 (VGLUT2)-specific Ndufs4(KO) mice were markedly resistant to ketamine (ED50; 125 mg/kg) compared to control mice (ED50; 75 mg/kg; N = 6). At their respective ED95s for ketamine, mutant (N = 5) electrocorticography spectra showed a decrease in power in the beta (0.040; 0.020) and gamma (0.035; 0.015) frequency bands not seen in controls (N = 7).

CONCLUSIONS

Significant differences exist between the electrocorticographies of mutant and control mice at equipotent doses for volatile anesthetics and ketamine. The energetic state specifically of excitatory neurons determines the behavioral response to ketamine.