1
|
Moretta P, Femiano C, Cavallo ND, Lanzillo A, Luciano F, Ferrante C, Maiorino A, Santangelo G, Marcuccio L. Family caregivers improve the diagnostic accuracy of disorders of consciousness: from remote to near-bed auditory stimulation. Eur J Phys Rehabil Med 2024; 60:198-206. [PMID: 38381451 PMCID: PMC11114155 DOI: 10.23736/s1973-9087.24.08179-6] [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: 08/07/2023] [Revised: 10/20/2023] [Accepted: 01/17/2024] [Indexed: 02/22/2024]
Abstract
BACKGROUND Family caregivers (FC) contribute to reducing the misdiagnosis rate in patients with disorders of consciousness (DOC). Unfortunately, the recent pandemic of COVID-19 imposed drastic restrictions that limited the access of FC to the sensory/cognitive stimulation protocols. Telemedicine approaches have been implemented to avoid discontinuity in care pathways and to ensure caregivers involvement in rehabilitation programs. AIM The aim was to investigate whether the presence of FC remotely connected might help clinicians in eliciting higher cortically mediated behavioral responses in patients with DOC. DESIGN Cross-sectional study. SETTING Post-acute Unit of Neurorehabilitation. POPULATION DOC due to severe brain injury. METHODS Consecutive patients with DOC were assessed by means of the Coma Recovery Scale-Revised (CRS-R) by two expert examiners. Each patient underwent to five assessments in two weeks in three different conditions: 1) by the examiner only (standard); 2) with the verbal stimulation given by the FC remotely connected by PC tablet (caregiver in remote); and 3) with the verbal stimulation given by the FC physically present (caregiver in presence). RESULTS Thirty patients with DOC (VS/UWS=10; MCS=20; mean age: 51, range: 21-79; vascular: 16; anoxic: 6; TBI=8) and their FC were enrolled. Higher total scores of CRS-R were recorded both in "caregiver in remote" and in "caregiver in presence" than in standard condition (standard vs. remote, Z=2.942, P=0.003; standard vs. presence, Z=3.736, P<0.001). Furthermore, the administration of the CRS-R with a FC, elicited higher levels of behavioral responses in MCS patients, than CRS-R performed in standard condition. In particular, 2 patients out of 30 (6.66%) showed higher scores and better diagnosis when the CRS-R was administered with FC in remote. Similarly, 5 out of 30 patients (16.66%) showed better diagnoses when the CRS-R was administered with FC in presence. Five patients changed diagnosis between standard and presence conditions (3 MCS- were diagnosed as MCS+; 2 MCS+ were diagnosed as conscious). CONCLUSIONS Our findings add new evidence regarding the beneficial role of family members in the diagnosis of DOC, even mediated by telemedicine approach. CLINICAL REHABILITATION IMPACT In future guidelines, FC should have an active and supporting role in the diagnostic and rehabilitative process of DOC.
Collapse
Affiliation(s)
- Pasquale Moretta
- Istituti Clinici Scientifici Maugeri IRCCS, Neurological Rehabilitation Unit of Telese Terme, Telese Terme, Benevento, Italy -
| | - Cinzia Femiano
- Istituti Clinici Scientifici Maugeri IRCCS, Neurological Rehabilitation Unit of Telese Terme, Telese Terme, Benevento, Italy
| | - Nicola D Cavallo
- Department of Psychology, Luigi Vanvitelli University of Campania, Caserta, Italy
| | - Anna Lanzillo
- Istituti Clinici Scientifici Maugeri IRCCS, Neurological Rehabilitation Unit of Telese Terme, Telese Terme, Benevento, Italy
| | - Fabrizio Luciano
- Istituti Clinici Scientifici Maugeri IRCCS, Neurological Rehabilitation Unit of Telese Terme, Telese Terme, Benevento, Italy
| | - Cesario Ferrante
- Istituti Clinici Scientifici Maugeri IRCCS, Neurological Rehabilitation Unit of Telese Terme, Telese Terme, Benevento, Italy
| | - Antonio Maiorino
- Istituti Clinici Scientifici Maugeri IRCCS, Neurological Rehabilitation Unit of Telese Terme, Telese Terme, Benevento, Italy
| | - Gabriella Santangelo
- Department of Psychology, Luigi Vanvitelli University of Campania, Caserta, Italy
| | - Laura Marcuccio
- Istituti Clinici Scientifici Maugeri IRCCS, Neurological Rehabilitation Unit of Telese Terme, Telese Terme, Benevento, Italy
| |
Collapse
|
2
|
Fischer D, Edlow BL. Coma Prognostication After Acute Brain Injury: A Review. JAMA Neurol 2024:2815829. [PMID: 38436946 DOI: 10.1001/jamaneurol.2023.5634] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/05/2024]
Abstract
Importance Among the most impactful neurologic assessments is that of neuroprognostication, defined here as the prediction of neurologic recovery from disorders of consciousness caused by severe, acute brain injury. Across a range of brain injury etiologies, these determinations often dictate whether life-sustaining treatment is continued or withdrawn; thus, they have major implications for morbidity, mortality, and health care costs. Neuroprognostication relies on a diverse array of tests, including behavioral, radiologic, physiological, and serologic markers, that evaluate the brain's functional and structural integrity. Observations Prognostic markers, such as the neurologic examination, electroencephalography, and conventional computed tomography and magnetic resonance imaging (MRI), have been foundational in assessing a patient's current level of consciousness and capacity for recovery. Emerging techniques, such as functional MRI, diffusion MRI, and advanced forms of electroencephalography, provide new ways of evaluating the brain, leading to evolving schemes for characterizing neurologic function and novel methods for predicting recovery. Conclusions and Relevance Neuroprognostic markers are rapidly evolving as new ways of assessing the brain's structural and functional integrity after brain injury are discovered. Many of these techniques remain in development, and further research is needed to optimize their prognostic utility. However, even as such efforts are underway, a series of promising findings coupled with the imperfect predictive value of conventional prognostic markers and the high stakes of these assessments have prompted clinical guidelines to endorse emerging techniques for neuroprognostication. Thus, clinicians have been thrust into an uncertain predicament in which emerging techniques are not yet perfected but too promising to ignore. This review illustrates the current, and likely future, landscapes of prognostic markers. No matter how much prognostic markers evolve and improve, these assessments must be approached with humility and individualized to reflect each patient's values.
Collapse
Affiliation(s)
- David Fischer
- Division of Neurocritical Care, Department of Neurology, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Brian L Edlow
- Center for Neurotechnology and Neurorecovery, Department of Neurology, Massachusetts General Hospital and Harvard Medical School, Boston
- Athinoula A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital and Harvard Medical School, Charlestown
| |
Collapse
|
3
|
Boerwinkle VL, Manjón I, Sussman BL, McGary A, Mirea L, Gillette K, Broman-Fulks J, Cediel EG, Arhin M, Hunter SE, Wyckoff SN, Allred K, Tom D. Resting-State Functional Magnetic Resonance Imaging Network Association With Mortality, Epilepsy, Cognition, and Motor Two-Year Outcomes in Suspected Severe Neonatal Acute Brain Injury. Pediatr Neurol 2024; 152:41-55. [PMID: 38198979 DOI: 10.1016/j.pediatrneurol.2023.12.003] [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: 06/12/2023] [Revised: 11/14/2023] [Accepted: 12/06/2023] [Indexed: 01/12/2024]
Abstract
BACKGROUND AND OBJECTIVES In acute brain injury of neonates, resting-state functional magnetic resonance imaging (MRI) (RS) showed incremental association with consciousness, mortality, cognitive and motor development, and epilepsy, with correction for multiple comparisons, at six months postgestation in neonates with suspected acute brain injury (ABI). However, there are relatively few developmental milestones at six months to benchmark against, thus, we extended this cohort study to evaluate two-year outcomes. METHODS In 40 consecutive neonates with ABI and RS, ordinal scores of resting-state networks; MRI, magnetic resonance spectroscopy, and electroencephalography; and up to 42-month outcomes of mortality, general and motor development, Pediatric Cerebral Performance Category Scale (PCPC), and epilepsy informed associations between tests and outcomes. RESULTS Mean gestational age was 37.8 weeks, 68% were male, and 60% had hypoxic-ischemic encephalopathy. Three died in-hospital, four at six to 42 months, and five were lost to follow-up. Associations included basal ganglia network with PCPC (P = 0.0003), all-mortality (P = 0.005), and motor (P = 0.0004); language/frontoparietal network with developmental delay (P = 0.009), PCPC (P = 0.006), and all-mortality (P = 0.01); default mode network with developmental delay (P = 0.003), PCPC (P = 0.004), neonatal intensive care unit mortality (P = 0.01), and motor (P = 0.009); RS seizure onset zone with epilepsy (P = 0.01); and anatomic MRI with epilepsy (P = 0.01). CONCLUSION For the first time, at any age, resting state functional MRI in ABI is associated with long-term epilepsy and RSNs predicted mortality in neonates. Severity of RSN abnormality was associated with incrementally worsened neurodevelopment including cognition, language, and motor function over two years.
Collapse
Affiliation(s)
- Varina L Boerwinkle
- Division of Child Neurology, University of North Carolina Medical School, Chapel Hill, North Carolina.
| | - Iliana Manjón
- University of Arizona College of Medicine - Tucson, Tucson, Arizona
| | - Bethany L Sussman
- Division of Neuroscience Research, Barrow Neurological Institute at Phoenix Children's Hospital, Phoenix, Arizona
| | - Alyssa McGary
- Department of Clinical Research, Phoenix Children's Hospital, Phoenix, Arizona
| | - Lucia Mirea
- Department of Clinical Research, Phoenix Children's Hospital, Phoenix, Arizona
| | - Kirsten Gillette
- Division of Child Neurology, University of North Carolina Medical School, Chapel Hill, North Carolina
| | - Jordan Broman-Fulks
- Division of Child Neurology, University of North Carolina Medical School, Chapel Hill, North Carolina
| | - Emilio G Cediel
- Division of Child Neurology, University of North Carolina Medical School, Chapel Hill, North Carolina
| | - Martin Arhin
- Division of Child Neurology, University of North Carolina Medical School, Chapel Hill, North Carolina
| | - Senyene E Hunter
- Division of Child Neurology, University of North Carolina Medical School, Chapel Hill, North Carolina
| | - Sarah N Wyckoff
- Division of Neuroscience Research, Barrow Neurological Institute at Phoenix Children's Hospital, Phoenix, Arizona
| | - Kimberlee Allred
- Division of Neonatology, Phoenix Children's Hospital, Phoenix, Arizona
| | - Deborah Tom
- Division of Neonatology, Phoenix Children's Hospital, Phoenix, Arizona
| |
Collapse
|
4
|
Claassen J, Kondziella D, Alkhachroum A, Diringer M, Edlow BL, Fins JJ, Gosseries O, Hannawi Y, Rohaut B, Schnakers C, Stevens RD, Thibaut A, Monti M. Cognitive Motor Dissociation: Gap Analysis and Future Directions. Neurocrit Care 2024; 40:81-98. [PMID: 37349602 DOI: 10.1007/s12028-023-01769-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Accepted: 05/26/2023] [Indexed: 06/24/2023]
Abstract
BACKGROUND Patients with disorders of consciousness who are behaviorally unresponsive may demonstrate volitional brain responses to motor imagery or motor commands detectable on functional magnetic resonance imaging or electroencephalography. This state of cognitive motor dissociation (CMD) may have prognostic significance. METHODS The Neurocritical Care Society's Curing Coma Campaign identified an international group of experts who convened in a series of monthly online meetings between September 2021 and April 2023 to examine the science of CMD and identify key knowledge gaps and unmet needs. RESULTS The group identified major knowledge gaps in CMD research: (1) lack of information about patient experiences and caregiver accounts of CMD, (2) limited epidemiological data on CMD, (3) uncertainty about underlying mechanisms of CMD, (4) methodological variability that limits testing of CMD as a biomarker for prognostication and treatment trials, (5) educational gaps for health care personnel about the incidence and potential prognostic relevance of CMD, and (6) challenges related to identification of patients with CMD who may be able to communicate using brain-computer interfaces. CONCLUSIONS To improve the management of patients with disorders of consciousness, research efforts should address these mechanistic, epidemiological, bioengineering, and educational gaps to enable large-scale implementation of CMD assessment in clinical practice.
Collapse
Affiliation(s)
- Jan Claassen
- Department of Neurology, Neurological Institute, Columbia University Irving Medical Center, NewYork Presbyterian Hospital, 177 Fort Washington Avenue, MHB 8 Center, Room 300, New York, NY, 10032, USA.
| | - Daniel Kondziella
- Department of Neurology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | | | - Michael Diringer
- Department of Neurology, Washington University, St. Louis, MO, USA
| | - Brian L Edlow
- Department of Neurology, Center for Neurotechnology and Neurorecovery, Massachusetts General Hospital, Boston, MA, 02114, USA
| | - Joseph J Fins
- Division of Medical Ethics, Department of Medicine, Weill Cornell Medical College, NewYork Presbyterian Hospital, New York, NY, 10032, USA
| | - Olivia Gosseries
- Coma Science Group, GIGA Consciousness, University of Liege, Liege, Belgium
- Centre du Cerveau, University Hospital of Liege, Liege, Belgium
| | - Yousef Hannawi
- Division of Cerebrovascular Diseases and Neurocritical Care, Department of Neurology, The Ohio State University, Columbus, OH, USA
| | - Benjamin Rohaut
- Sorbonne Université, Assistance Publique-Hôpitaux de Paris (AP-HP) - Pitié Salpêtrière, Paris, France
| | | | - Robert D Stevens
- Department of Anesthesiology and Critical Care Medicine, Neurology, and Radiology, School of Medicine, Secondary Appointment in Biomedical Engineering, Whiting School of Engineering, Johns Hopkins University, Baltimore, MD, USA
| | - Aurore Thibaut
- Coma Science Group, GIGA Consciousness, University of Liege, Liege, Belgium
- Centre du Cerveau, University Hospital of Liege, Liege, Belgium
| | - Martin Monti
- Department of Psychology, University of California Los Angeles, Los Angeles, CA, USA
| |
Collapse
|
5
|
Golden K, Bodien YG, Giacino JT. Disorders of Consciousness: Classification and Taxonomy. Phys Med Rehabil Clin N Am 2024; 35:15-33. [PMID: 37993185 DOI: 10.1016/j.pmr.2023.06.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2023]
Abstract
In this article, we discuss the taxonomy associated with the four major disorders of consciousness (DoC): coma, vegetative state or unresponsive wakefulness syndrome, minimally conscious state, and post-traumatic confusional state. We briefly review the history of each disorder and then provide operational definitions and diagnostic criteria for each one. We rely heavily on recently released practice guidelines and, where appropriate, identify knowledge gaps and discuss future directions to advance DoC research and practice.
Collapse
Affiliation(s)
- Katherine Golden
- School of Health & Rehabilitation Sciences, MGH Institute of Health Professions, 36 1st Avenue, Boston, MA 02129, USA
| | - Yelena G Bodien
- Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, 300 1st Avenue, Charlestown, MA, 02129, USA; Center for Neurotechnology and Neurorecovery, Department of Neurology, Massachusetts General Hospital and Harvard Medical School, 55 Fruit Street, Boston, MA 02114, USA; Department of Physical Medicine and Rehabilitation, Harvard Medical School, 25 Shattuck Street, Boston, MA, USA
| | - Joseph T Giacino
- Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, 300 1st Avenue, Charlestown, MA, 02129, USA; Center for Neurotechnology and Neurorecovery, Department of Neurology, Massachusetts General Hospital and Harvard Medical School, 55 Fruit Street, Boston, MA 02114, USA.
| |
Collapse
|
6
|
Coppola L, Smaldone G, Grimaldi AM, Estraneo A, Magliacano A, Soddu A, Ciccarelli G, Salvatore M, Cavaliere C. Peripheral blood BDNF and soluble CAM proteins as possible markers of prolonged disorders of consciousness: a pilot study. Sci Rep 2024; 14:341. [PMID: 38172270 PMCID: PMC10764320 DOI: 10.1038/s41598-023-50581-8] [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: 10/09/2023] [Accepted: 12/21/2023] [Indexed: 01/05/2024] Open
Abstract
Although clinical examination still represents the gold standard for the differential diagnosis of prolonged disorders of consciousness (pDoC), the introduction of innovative markers is essential for diagnosis and prognosis, due to the problem of covert cognition. We evaluated the brain-derived neurotrophic factor protein (BDNF) and the soluble cell adhesion molecules proteins (CAMs) in a cohort of prolonged disorders of consciousness patients to identify a possible application in the clinical context. Furthermore, peripheral blood determinations were correlated with imaging parameters such as white matter hyperintensities (WMH), cranial standardized uptake value (cSUV), electroencephalography (EEG) data and clinical setting. Our results, although preliminary, identify BDNF as a possible blood marker for the diagnosis of pDoC (p value 0.001), the soluble CAMs proteins CD44, Vcam-1, E-selectin (p value < 0.01) and Icam-3 (p value < 0.05) showed a higher peripheral blood value in pDoC compared with control. Finally, soluble Ncam protein could find useful applications in the clinical evolution of the pDoC, showing high levels in the MCS and EMCS subgroups (p value < 0. 001) compared to VS/UWS.
Collapse
Affiliation(s)
| | | | | | - A Estraneo
- Istituto Di Ricovero e Cura a Carattere Scientifico (IRCCS) Fondazione Don Carlo Gnocchi, Florence, Italy
| | - A Magliacano
- Istituto Di Ricovero e Cura a Carattere Scientifico (IRCCS) Fondazione Don Carlo Gnocchi, Florence, Italy
| | - A Soddu
- Department of Physics and Astronomy, Western Institute of Neuroscience, University of Western Ontario, London, ON, Canada
| | | | | | | |
Collapse
|
7
|
Abstract
Covert consciousness is a state of residual awareness following severe brain injury or neurological disorder that evades routine bedside behavioral detection. Patients with covert consciousness have preserved awareness but are incapable of self-expression through ordinary means of behavior or communication. Growing recognition of the limitations of bedside neurobehavioral examination in reliably detecting consciousness, along with advances in neurotechnologies capable of detecting brain states or subtle signs indicative of consciousness not discernible by routine examination, carry promise to transform approaches to classifying, diagnosing, prognosticating and treating disorders of consciousness. Here we describe and critically evaluate the evolving clinical category of covert consciousness, including approaches to its diagnosis through neuroimaging, electrophysiology, and novel behavioral tools, its prognostic relevance, and open questions pertaining to optimal clinical management of patients with covert consciousness recovering from severe brain injury.
Collapse
Affiliation(s)
- Michael J. Young
- Department of Neurology, Center for Neurotechnology and Neurorecovery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Brian L. Edlow
- Department of Neurology, Center for Neurotechnology and Neurorecovery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
- Athinoula A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital, Charlestown, MA, USA
| | - Yelena G. Bodien
- Department of Neurology, Center for Neurotechnology and Neurorecovery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
- Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Harvard Medical School, Boston, MA, USA
| |
Collapse
|
8
|
Schnakers C. Assessing consciousness and cognition in disorders of consciousness. NeuroRehabilitation 2024; 54:11-21. [PMID: 38251070 DOI: 10.3233/nre-230140] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2024]
Abstract
Detecting willful cognition in these patients is known to be challenging due to the patients' motor disabilities and high vigilance fluctuations but also due to the lack of expertise and use of adequate tools to assess these patients in specific settings. This review will discuss the main disorders of consciousness after severe brain injury, how to assess consciousness and cognition in these patients, as well as the challenges and tools available to overcome these challenges and reach an accurate diagnosis.
Collapse
Affiliation(s)
- Caroline Schnakers
- Research Institute, Casa Colina Hospital and Centers for Healthcare, 255 E. Bonita Avenue, Pomona, CA 91769, USA. Tel.: +1 909 596 7733 (ext. 3038); E-mail:
| |
Collapse
|
9
|
Edlow BL, Boerwinkle VL, Annen J, Boly M, Gosseries O, Laureys S, Mukherjee P, Puybasset L, Stevens RD, Threlkeld ZD, Newcombe VFJ, Fernandez-Espejo D. Common Data Elements for Disorders of Consciousness: Recommendations from the Working Group on Neuroimaging. Neurocrit Care 2023; 39:611-617. [PMID: 37552410 DOI: 10.1007/s12028-023-01794-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2023] [Accepted: 06/22/2023] [Indexed: 08/09/2023]
Abstract
BACKGROUND Over the past 5 decades, advances in neuroimaging have yielded insights into the pathophysiologic mechanisms that cause disorders of consciousness (DoC) in patients with severe brain injuries. Structural, functional, metabolic, and perfusion imaging studies have revealed specific neuroanatomic regions, such as the brainstem tegmentum, thalamus, posterior cingulate cortex, medial prefrontal cortex, and occipital cortex, where lesions correlate with the current or future state of consciousness. Advanced imaging modalities, such as diffusion tensor imaging, resting-state functional magnetic resonance imaging (fMRI), and task-based fMRI, have been used to improve the accuracy of diagnosis and long-term prognosis, culminating in the endorsement of fMRI for the clinical evaluation of patients with DoC in the 2018 US (task-based fMRI) and 2020 European (task-based and resting-state fMRI) guidelines. As diverse neuroimaging techniques are increasingly used for patients with DoC in research and clinical settings, the need for a standardized approach to reporting results is clear. The success of future multicenter collaborations and international trials fundamentally depends on the implementation of a shared nomenclature and infrastructure. METHODS To address this need, the Neurocritical Care Society's Curing Coma Campaign convened an international panel of DoC neuroimaging experts to propose common data elements (CDEs) for data collection and reporting in this field. RESULTS We report the recommendations of this CDE development panel and disseminate CDEs to be used in neuroimaging studies of patients with DoC. CONCLUSIONS These CDEs will support progress in the field of DoC neuroimaging and facilitate international collaboration.
Collapse
Affiliation(s)
- Brian L Edlow
- Center for Neurotechnology and Neurorecovery, Department of Neurology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA.
- Athinoula A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital, Charlestown, MA, USA.
| | - Varina L Boerwinkle
- Clinical Resting-State Functional Magnetic Resonance Imaging Laboratory and Service, Department of Neurology, University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | - Jitka Annen
- Coma Science Group, GIGA Consciousness, University of Liège, Liège, Belgium
- Centre de Cerveau2, University Hospital of Liège, Liège, Belgium
| | - Melanie Boly
- Department of Neurology, University of Wisconsin, Madison, WI, USA
- Department of Psychiatry, Wisconsin Institute for Sleep and Consciousness, University of Wisconsin, Madison, WI, USA
| | - Olivia Gosseries
- Coma Science Group, GIGA Consciousness, University of Liège, Liège, Belgium
- Centre de Cerveau2, University Hospital of Liège, Liège, Belgium
| | - Steven Laureys
- Coma Science Group, GIGA Consciousness, University of Liège, Liège, Belgium
- Centre de Cerveau2, University Hospital of Liège, Liège, Belgium
- CERVO Research Institute, Laval University, Quebec, Canada
| | - Pratik Mukherjee
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, San Francisco, CA, USA
| | - Louis Puybasset
- Department of Anesthesiology and Intensive Care, Groupe Hospitalier Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Robert D Stevens
- Departments of Anesthesiology and Critical Care Medicine, Neurology, Radiology, and Biomedical Engineering, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Zachary D Threlkeld
- Department of Neurology, Stanford University School of Medicine, Stanford, CA, USA
| | | | - Davinia Fernandez-Espejo
- School of Psychology and Centre for Human Brain Health, University of Birmingham, Birmingham, UK
| |
Collapse
|
10
|
Owen M, Huang Z, Duclos C, Lavazza A, Grasso M, Hudetz AG. Theoretical Neurobiology of Consciousness Applied to Human Cerebral Organoids. Camb Q Healthc Ethics 2023:1-21. [PMID: 37850471 DOI: 10.1017/s0963180123000543] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2023]
Abstract
Organoids and specifically human cerebral organoids (HCOs) are one of the most relevant novelties in the field of biomedical research. Grown either from embryonic or induced pluripotent stem cells, HCOs can be used as in vitro three-dimensional models, mimicking the developmental process and organization of the developing human brain. Based on that, and despite their current limitations, it cannot be assumed that they will never at any stage of development manifest some rudimentary form of consciousness. In the absence of behavioral indicators of consciousness, the theoretical neurobiology of consciousness being applied to unresponsive brain-injured patients can be considered with respect to HCOs. In clinical neurology, it is difficult to discern a capacity for consciousness in unresponsive brain-injured patients who provide no behavioral indicators of consciousness. In such scenarios, a validated neurobiological theory of consciousness, which tells us what the neural mechanisms of consciousness are, could be used to identify a capacity for consciousness. Like the unresponsive patients that provide a diagnostic difficulty for neurologists, HCOs provide no behavioral indicators of consciousness. Therefore, this article discusses how three prominent neurobiological theories of consciousness apply to human cerebral organoids. From the perspective of the Temporal Circuit Hypothesis, the Global Neuronal Workspace Theory, and the Integrated Information Theory, we discuss what neuronal structures and functions might indicate that cerebral organoids have a neurobiological capacity to be conscious.
Collapse
Affiliation(s)
- Matthew Owen
- Philosophy Department, Yakima Valley College, Yakima, WA, USA
- Center for Consciousness Science, University of Michigan, Ann Arbor, MI, USA
| | - Zirui Huang
- Center for Consciousness Science, University of Michigan, Ann Arbor, MI, USA
- Department of Anesthesiology, University of Michigan, Ann Arbor, MI, USA
| | - Catherine Duclos
- Department of Anesthesiology and Pain Medicine, Université de Montréal, Montréal, QC, Canada
- Department of Neuroscience, Université de Montréal, Montréal, QC, Canada
- Centre for Advanced Research in Sleep Medicine, Centre intégré universitaire de santé et de services sociaux (CIUSSS) du Nord-de-l'île-de-Montréal, Montréal, QC, Canada
- CIFAR Azrieli Global Scholars Program, Toronto, ON, Canada
| | - Andrea Lavazza
- Centro Universitario Internazionale, Arezzo, Italy
- University of Pavia, Pavia, Italy
| | - Matteo Grasso
- Center for Sleep and Consciousness, University of Wisconsin-Madison, Madison, WI, USA
| | - Anthony G Hudetz
- Center for Consciousness Science, University of Michigan, Ann Arbor, MI, USA
- Department of Anesthesiology, University of Michigan, Ann Arbor, MI, USA
| |
Collapse
|
11
|
Thibaut A, Fregni F, Estraneo A, Fiorenza S, Noe E, Llorens R, Ferri J, Formisano R, Morone G, Bender A, Rosenfelder M, Lamberti G, Kodratyeva E, Kondratyev S, Legostaeva L, Suponeva N, Krewer C, Müller F, Dardenne N, Jedidi H, Laureys S, Gosseries O, Lejeune N, Martens G. Sham-controlled randomized multicentre trial of transcranial direct current stimulation for prolonged disorders of consciousness. Eur J Neurol 2023; 30:3016-3031. [PMID: 37515394 DOI: 10.1111/ene.15974] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2022] [Revised: 06/01/2023] [Accepted: 07/04/2023] [Indexed: 07/30/2023]
Abstract
BACKGROUND AND PURPOSE Transcranial direct current stimulation (tDCS) has been shown to improve signs of consciousness in a subset of patients with disorders of consciousness (DoC). However, no multicentre study confirmed its efficacy when applied during rehabilitation. In this randomized controlled double-blind study, the effects of tDCS whilst patients were in rehabilitation were tested at the group level and according to their diagnosis and aetiology to better target DoC patients who might repond to tDCS. METHODS Patients received 2 mA tDCS or sham applied over the left prefrontal cortex for 4 weeks. Behavioural assessments were performed weekly and up to 3 months' follow-up. Analyses were conducted at the group and subgroup levels based on the diagnosis (minimally conscious state [MCS] and unresponsive wakefulness syndrome) and the aetiology (traumatic or non-traumatic). Interim analyses were planned to continue or stop the trial. RESULTS The trial was stopped for futility when 62 patients from 10 centres were enrolled (44 ± 14 years, 37 ± 24.5 weeks post-injury, 18 women, 32 MCS, 39 non-traumatic). Whilst, at the group level, no treatment effect was found, the subgroup analyses at 3 months' follow-up revealed a significant improvement for patients in MCS and with traumatic aetiology. CONCLUSIONS Transcranial direct current stimulation during rehabilitation does not seem to enhance patients' recovery. However, diagnosis and aetiology appear to be important factors leading to a response to the treatment. These findings bring novel insights into possible cortical plasticity changes in DoC patients given these differential results according to the subgroups of patients.
Collapse
Affiliation(s)
- Aurore Thibaut
- Coma Science Group, GIGA-Consciousness, Centre du Cerveau2, University and University Hospital of Liège, Liège, Belgium
| | - Felipe Fregni
- Neuromodulation Lab, Spaulding Rehabilitation Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Anna Estraneo
- Neurorehabilitation Department, Scientific Institute for Research and Health Care, Don Carlo Gnocchi Foundation, Sant'Angelo dei Lombardi, Florence, Italy
| | - Salvatore Fiorenza
- Neurorehabilitation Department, Scientific Institute for Research and Health Care, Don Carlo Gnocchi Foundation, Sant'Angelo dei Lombardi, Florence, Italy
| | - Enrique Noe
- IRENEA Instituto de Rehabilitación Neurológica, Fundación Hospitales Vithas, Valéncia, Spain
| | - Roberto Llorens
- IRENEA Instituto de Rehabilitación Neurológica, Fundación Hospitales Vithas, Valéncia, Spain
- Neurorehabilitation and Brain Research Group, Instituto Universitario de Investigación en Tecnología Centrada en el Ser Humano, Universitat Politècnica de València, Valencia, Spain
| | - Joan Ferri
- IRENEA Instituto de Rehabilitación Neurológica, Fundación Hospitales Vithas, Valéncia, Spain
| | - Rita Formisano
- Santa Lucia Foundation, Neurorehabilitation and Scientific Institute for Research, Rome, Italy
| | - Giovanni Morone
- Santa Lucia Foundation, Neurorehabilitation and Scientific Institute for Research, Rome, Italy
| | - Andreas Bender
- Therapiezentrum Burgau, Burgau, Germany
- Department of Neurology, Ludwig-Maximilians University of Munich, Munich, Germany
| | - Martin Rosenfelder
- Therapiezentrum Burgau, Burgau, Germany
- Clinical and Biological Psychology, Institute of Psychology and Education, Ulm University, Ulm, Germany
| | - Gianfranco Lamberti
- Neurorehabilitation Department AUSL Piacenza - University of Parma, Piacenza, Italy
| | | | | | | | | | - Carmen Krewer
- Department for Neurology, Research Group, Schoen Clinic Bad Aibling, Bad Aibling, Germany
- Chair of Human Movement Science, Department of Sports and Health Sciences, Technical University of Munich, Munich, Germany
| | - Friedemann Müller
- Department for Neurology, Research Group, Schoen Clinic Bad Aibling, Bad Aibling, Germany
| | - Nadia Dardenne
- University and Hospital Biostatistics Center (B-STAT), Faculty of Medicine, University of Liège, Liège, Belgium
| | | | - Steven Laureys
- Coma Science Group, GIGA-Consciousness, Centre du Cerveau2, University and University Hospital of Liège, Liège, Belgium
- Joint International Research Unit on Consciousness, CERVO Brain Research Centre, CIUSS, University Laval, Quebec, Canada
| | - Olivia Gosseries
- Coma Science Group, GIGA-Consciousness, Centre du Cerveau2, University and University Hospital of Liège, Liège, Belgium
| | - Nicolas Lejeune
- Coma Science Group, GIGA-Consciousness, Centre du Cerveau2, University and University Hospital of Liège, Liège, Belgium
- Centre Hospitalier Neurologique William Lennox, Ottignies-Louvain-la-Neuve, Belgium
| | - Géraldine Martens
- Coma Science Group, GIGA-Consciousness, Centre du Cerveau2, University and University Hospital of Liège, Liège, Belgium
| |
Collapse
|
12
|
Boerwinkle VL, Gillette K, Rubinos CA, Broman-Fulks J, Aseem F, DeHoff GK, Arhin M, Cediel E, Strohm T. Functional MRI for Acute Covert Consciousness: Emerging Data and Implementation Case Series. Semin Neurol 2023; 43:712-734. [PMID: 37788679 DOI: 10.1055/s-0043-1775845] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/05/2023]
Abstract
Although research studies have begun to demonstrate relationships between disorders of consciousness and brain network biomarkers, there are limited data on the practical aspects of obtaining such network biomarkers to potentially guide care. As the state of knowledge continues to evolve, guidelines from professional societies such as the American and European Academies of Neurology and many experts have advocated that the risk-benefit ratio for the assessment of network biomarkers has begun to favor their application toward potentially detecting covert consciousness. Given the lack of detailed operationalization guidance and the context of the ethical implications, herein we offer a roadmap based on local institutional experience with the implementation of functional MRI in the neonatal, pediatric, and adult intensive care units of our local government-supported health system. We provide a case-based demonstrative approach intended to review the current literature and to assist with the initiation of such services at other facilities.
Collapse
Affiliation(s)
- Varina L Boerwinkle
- Division of Child Neurology, University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - Kirsten Gillette
- Division of Child Neurology, University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - Clio A Rubinos
- Division of Neurocritical Care, University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - Jordan Broman-Fulks
- Division of Child Neurology, University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - Fazila Aseem
- Division of Neurocritical Care, University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - Grace K DeHoff
- Division of Neurocritical Care, University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - Martin Arhin
- Division of Child Neurology, University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - Emilio Cediel
- Division of Child Neurology, University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - Tamara Strohm
- Division of Neurocritical Care, University of North Carolina School of Medicine, Chapel Hill, North Carolina
| |
Collapse
|
13
|
Eilander HJ, van Erp WS, Driessen DMF, Overbeek BUH, Lavrijsen JCM. Post-Acute Level Of Consciousness scale revised (PALOC-sr): adaptation of a scale for classifying the level of consciousness in patients with a prolonged disorder of consciousness. BRAIN IMPAIR 2023; 24:341-346. [PMID: 38167183 DOI: 10.1017/brimp.2022.7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
OBJECTIVE To present an updated version of the 'Post-acute Level Of Consciousness scale' (PALOC-s), in accordance with the latest scientific insights. METHODS Within the context of a research project, 20 years ago, the PALOC-s was developed for the purpose of following the development of the level of consciousness of young unconscious patients participating in a rehabilitation program. Meanwhile, the understanding of the behavior related to different levels of consciousness has developed and terminology has changed, resulting in the need to revise the PALOC-s. With the preservation of the original description of the eight hierarchical levels of PALOC-s, adaptations are made in the terminology and grouping of these levels. RESULTS AND CONCLUSION This manuscript presents the revised version of PALOC-sr, which is suitable for use in clinical practice. The validation of this scale is recommended for its optimal use in future (international) research projects.
Collapse
Affiliation(s)
- Henk J Eilander
- Department of Elderly Care Medicine, Radboud Institute of Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Willemijn S van Erp
- Department of Elderly Care Medicine, Radboud Institute of Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
- Accolade Zorg, Bosch en Duin, The Netherlands
- Libra Revalidatie & Audiologie, locatie Leijpark, Tilburg, The Netherlands
| | - Daniëlle M F Driessen
- Department of Elderly Care Medicine, Radboud Institute of Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
- Libra Revalidatie & Audiologie, locatie Leijpark, Tilburg, The Netherlands
| | - Berno U H Overbeek
- Department of Elderly Care Medicine, Radboud Institute of Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
- Azora, Terborg, The Netherlands
- Kalorama, Veste Brakkestein, Nijmegen, The Netherlands
| | - Jan C M Lavrijsen
- Department of Elderly Care Medicine, Radboud Institute of Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| |
Collapse
|
14
|
Boerwinkle VL, Sussman BL, Broman-Fulks J, Garzon-Cediel E, Gillette K, Reuther WR, Scher MS. Treatable brain network biomarkers in children in coma using task and resting-state functional MRI: a case series. Front Neurol 2023; 14:1227195. [PMID: 37638177 PMCID: PMC10448513 DOI: 10.3389/fneur.2023.1227195] [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: 05/22/2023] [Accepted: 07/20/2023] [Indexed: 08/29/2023] Open
Abstract
The withdrawal of life-sustaining therapies is frequently considered for pediatric patients with severe acute brain injuries who are admitted to the intensive care unit. However, it is worth noting that some children with a resultant poor neurological status may ultimately survive and achieve a positive neurological outcome. Evidence suggests that adults with hidden consciousness may have a more favorable prognosis compared to those without it. Currently, no treatable network disorders have been identified in cases of severe acute brain injury, aside from seizures detectable through an electroencephalogram (EEG) and neurostimulation via amantadine. In this report, we present three cases in which multimodal brain network evaluation played a helpful role in patient care. This evaluation encompassed various assessments such as continuous video EEG, visual-evoked potentials, somatosensory-evoked potentials, auditory brainstem-evoked responses, resting-state functional MRI (rs-fMRI), and passive-based and command-based task-based fMRI. It is worth noting that the latter three evaluations are unique as they have not yet been established as part of the standard care protocol for assessing acute brain injuries in children with suppressed consciousness. The first patient underwent serial fMRIs after experiencing a coma induced by trauma. Subsequently, the patient displayed improvement following the administration of antiseizure medication to address abnormal signals. In the second case, a multimodal brain network evaluation uncovered covert consciousness, a previously undetected condition in a pediatric patient with acute brain injury. In both patients, this discovery potentially influenced decisions concerning the withdrawal of life support. Finally, the third patient serves as a comparative control case, demonstrating the absence of detectable networks. Notably, this patient underwent the first fMRI prior to experiencing brain death as a pediatric patient. Consequently, this case series illustrates the clinical feasibility of employing multimodal brain network evaluation in pediatric patients. This approach holds potential for clinical interventions and may significantly enhance prognostic capabilities beyond what can be achieved through standard testing methods alone.
Collapse
Affiliation(s)
- Varina L. Boerwinkle
- Division of Pediatric Neurology, Department of Neurology, University of North Carolina, Chapel Hill, NC, United States
| | - Bethany L. Sussman
- Neuroscience Research, Barrow Neurological Institute at Phoenix Children's Hospital, Phoenix, AZ, United States
| | - Jordan Broman-Fulks
- Division of Pediatric Neurology, Department of Neurology, University of North Carolina, Chapel Hill, NC, United States
| | - Emilio Garzon-Cediel
- Division of Pediatric Neurology, Department of Neurology, University of North Carolina, Chapel Hill, NC, United States
| | - Kirsten Gillette
- Division of Pediatric Neurology, Department of Neurology, University of North Carolina, Chapel Hill, NC, United States
| | - William R. Reuther
- Division of Pediatric Neurology, Department of Neurology, University of North Carolina, Chapel Hill, NC, United States
| | - Mark S. Scher
- Division of Pediatric Neurology, Emeritus Scholar Tenured Full Professor Case Western Reserve University School of Medicine Department of Pediatrics, Rainbow Babies and Children's Hospital/University Hospitals Cleveland Medical Center, Cleveland, OH, United States
| |
Collapse
|
15
|
Ferré F, Heine L, Naboulsi E, Gobert F, Beaudoin-Gobert M, Dailler F, Buffières W, Corneyllie A, Sarton B, Riu B, Luauté J, Silva S, Perrin F. Self-processing in coma, unresponsive wakefulness syndrome and minimally conscious state. Front Hum Neurosci 2023; 17:1145253. [PMID: 37125347 PMCID: PMC10132704 DOI: 10.3389/fnhum.2023.1145253] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2023] [Accepted: 03/23/2023] [Indexed: 05/02/2023] Open
Abstract
Introduction Behavioral and cerebral dissociation has been now clearly established in some patients with acquired disorders of consciousness (DoC). Altogether, these studies mainly focused on the preservation of high-level cognitive markers in prolonged DoC, but did not specifically investigate lower but key-cognitive functions to consciousness emergence, such as the ability to take a first-person perspective, notably at the acute stage of coma. We made the hypothesis that the preservation of self-recognition (i) is independent of the behavioral impairment of consciousness, and (ii) can reflect the ability to recover consciousness. Methods Hence, using bedside Electroencephalography (EEG) recordings, we acquired, in a large cohort of 129 severely brain damaged patients, the brain response to the passive listening of the subject's own name (SON) and unfamiliar other first names (OFN). One hundred and twelve of them (mean age ± SD = 46 ± 18.3 years, sex ratio M/F: 71/41) could be analyzed for the detection of an individual and significant discriminative P3 event-related brain response to the SON as compared to OFN ('SON effect', primary endpoint assessed by temporal clustering permutation tests). Results Patients were either coma (n = 38), unresponsive wakefulness syndrome (UWS, n = 30) or minimally conscious state (MCS, n = 44), according to the revised version of the Coma Recovery Scale (CRS-R). Overall, 33 DoC patients (29%) evoked a 'SON effect'. This electrophysiological index was similar between coma (29%), MCS (23%) and UWS (34%) patients (p = 0.61). MCS patients at the time of enrolment were more likely to emerged from MCS (EMCS) at 6 months than coma and UWS patients (p = 0.013 for comparison between groups). Among the 72 survivors' patients with event-related responses recorded within 3 months after brain injury, 75% of the 16 patients with a SON effect were EMCS at 6 months, while 59% of the 56 patients without a SON effect evolved to this favorable behavioral outcome. Discussion About 30% of severely brain-damaged patients suffering from DoC are capable to process salient self-referential auditory stimuli, even in case of absence of behavioral detection of self-conscious processing. We suggest that self-recognition covert brain ability could be an index of consciousness recovery, and thus could help to predict good outcome.
Collapse
Affiliation(s)
- Fabrice Ferré
- CAP Team (Cognition Auditive et Psychoacoustique), Lyon Neuroscience Research Centre (Université Claude Bernard Lyon 1, INSERM U1028, CNRS UMR5292), Bron Cedex, France
- Intensive Care Unit, Purpan University Teaching Hospital, Place du Dr Joseph Baylac, Toulouse CEDEX 9, France
- Toulouse NeuroImaging Centre (ToNIC), UPS—INSERM UMR, Place du Dr Joseph Baylac, Purpan University Teaching Hospital, Toulouse CEDEX 3, France
- *Correspondence: Fabrice Ferré,
| | - Lizette Heine
- CAP Team (Cognition Auditive et Psychoacoustique), Lyon Neuroscience Research Centre (Université Claude Bernard Lyon 1, INSERM U1028, CNRS UMR5292), Bron Cedex, France
| | - Edouard Naboulsi
- Intensive Care Unit, Purpan University Teaching Hospital, Place du Dr Joseph Baylac, Toulouse CEDEX 9, France
| | - Florent Gobert
- CAP Team (Cognition Auditive et Psychoacoustique), Lyon Neuroscience Research Centre (Université Claude Bernard Lyon 1, INSERM U1028, CNRS UMR5292), Bron Cedex, France
- Neuro-Intensive Care Unit, Hospices Civils de Lyon, Neurological Hospital Pierre-Wertheimer, Bron, France
- Trajectoires Team, Lyon Neuroscience Research Centre (Université Claude Bernard Lyon 1, INSERM U1028, CNRS UMR5292), Bron, France
| | - Maude Beaudoin-Gobert
- Physical Medicine and Rehabilitation Department, Henry-Gabrielle Hospital, Hospices Civils de Lyon, Saint Genis Laval, France
| | - Frédéric Dailler
- Neuro-Intensive Care Unit, Hospices Civils de Lyon, Neurological Hospital Pierre-Wertheimer, Bron, France
| | - William Buffières
- Intensive Care Unit, Purpan University Teaching Hospital, Place du Dr Joseph Baylac, Toulouse CEDEX 9, France
- Toulouse NeuroImaging Centre (ToNIC), UPS—INSERM UMR, Place du Dr Joseph Baylac, Purpan University Teaching Hospital, Toulouse CEDEX 3, France
| | - Alexandra Corneyllie
- CAP Team (Cognition Auditive et Psychoacoustique), Lyon Neuroscience Research Centre (Université Claude Bernard Lyon 1, INSERM U1028, CNRS UMR5292), Bron Cedex, France
| | - Benjamine Sarton
- Intensive Care Unit, Purpan University Teaching Hospital, Place du Dr Joseph Baylac, Toulouse CEDEX 9, France
- Toulouse NeuroImaging Centre (ToNIC), UPS—INSERM UMR, Place du Dr Joseph Baylac, Purpan University Teaching Hospital, Toulouse CEDEX 3, France
| | - Béatrice Riu
- Intensive Care Unit, Purpan University Teaching Hospital, Place du Dr Joseph Baylac, Toulouse CEDEX 9, France
| | - Jacques Luauté
- Physical Medicine and Rehabilitation Department, Henry-Gabrielle Hospital, Hospices Civils de Lyon, Saint Genis Laval, France
| | - Stein Silva
- Intensive Care Unit, Purpan University Teaching Hospital, Place du Dr Joseph Baylac, Toulouse CEDEX 9, France
- Toulouse NeuroImaging Centre (ToNIC), UPS—INSERM UMR, Place du Dr Joseph Baylac, Purpan University Teaching Hospital, Toulouse CEDEX 3, France
| | - Fabien Perrin
- CAP Team (Cognition Auditive et Psychoacoustique), Lyon Neuroscience Research Centre (Université Claude Bernard Lyon 1, INSERM U1028, CNRS UMR5292), Bron Cedex, France
| |
Collapse
|
16
|
Magliacano A, Liuzzi P, Formisano R, Grippo A, Angelakis E, Thibaut A, Gosseries O, Lamberti G, Noé E, Bagnato S, Edlow BL, Lejeune N, Veeramuthu V, Trojano L, Zasler N, Schnakers C, Bartolo M, Mannini A, Estraneo A. Predicting Long-Term Recovery of Consciousness in Prolonged Disorders of Consciousness Based on Coma Recovery Scale-Revised Subscores: Validation of a Machine Learning-Based Prognostic Index. Brain Sci 2022; 13:51. [PMID: 36672033 PMCID: PMC9856168 DOI: 10.3390/brainsci13010051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2022] [Revised: 12/21/2022] [Accepted: 12/23/2022] [Indexed: 12/30/2022] Open
Abstract
Prognosis of prolonged Disorders of Consciousness (pDoC) is influenced by patients' clinical diagnosis and Coma Recovery Scale-Revised (CRS-R) total score. We compared the prognostic accuracy of a novel Consciousness Domain Index (CDI) with that of clinical diagnosis and CRS-R total score, for recovery of full consciousness at 6-, 12-, and 24-months post-injury. The CDI was obtained by a combination of the six CRS-R subscales via an unsupervised machine learning technique. We retrospectively analyzed data on 143 patients with pDoC (75 in Minimally Conscious State; 102 males; median age = 53 years; IQR = 35; time post-injury = 1-3 months) due to different etiologies enrolled in an International Brain Injury Association Disorders of Consciousness Special Interest Group (IBIA DoC-SIG) multicenter longitudinal study. Univariate and multivariate analyses were utilized to assess the association between outcomes and the CDI, compared to clinical diagnosis and CRS-R. The CDI, the clinical diagnosis, and the CRS-R total score were significantly associated with a good outcome at 6, 12 and 24 months. The CDI showed the highest univariate prediction accuracy and sensitivity, and regression models including the CDI provided the highest values of explained variance. A combined scoring system of the CRS-R subscales by unsupervised machine learning may improve clinical ability to predict recovery of consciousness in patients with pDoC.
Collapse
Affiliation(s)
- Alfonso Magliacano
- IRCCS Fondazione Don Carlo Gnocchi ONLUS, 50143 Firenze, Italy
- Polo Specialistico Riabilitativo, Fondazione Don Carlo Gnocchi, 83054 Sant’Angelo dei Lombardi, Italy
| | - Piergiuseppe Liuzzi
- IRCCS Fondazione Don Carlo Gnocchi ONLUS, 50143 Firenze, Italy
- Scuola Superiore Sant’Anna, Istituto di BioRobotica, 56025 Pontedera, Italy
| | | | | | - Efthymios Angelakis
- Neurosurgery Department, University of Athens Medical School, 11527 Athens, Greece
| | - Aurore Thibaut
- Coma Science Group, GIGA Consciousness-University and University Hospital of Liège-Liège-Belgium, 4000 Liège, Belgium
| | - Olivia Gosseries
- Coma Science Group, GIGA Consciousness-University and University Hospital of Liège-Liège-Belgium, 4000 Liège, Belgium
| | - Gianfranco Lamberti
- Neurorehabilitation and Vegetative State Unit E. Viglietta, 12100 Cuneo, Italy
| | - Enrique Noé
- IRENEA-Instituto de Rehabilitación Neurológica, Fundación Hospitales Vithas, 46011 Valencia, Spain
| | - Sergio Bagnato
- Unit of Neurophysiology and Unit for Severe Acquired Brain Injuries, Rehabilitation Department, Giuseppe Giglio Foundation, 90015 Cefalù, Italy
| | - Brian L. Edlow
- Center for Neurotechnology and Neurorecovery, Department of Neurology, Massachusetts General Hospital, Boston, MA 02114, USA
| | | | - Vigneswaran Veeramuthu
- Division of Clinical Neuropsychology, Thomson Hospital Kota Damansara, Petaling Jaya 47810, Malaysia
| | - Luigi Trojano
- Department of Psychology, University of Campania L. Vanvitelli, 81100 Caserta, Italy
| | - Nathan Zasler
- Concussion Care Centre of Virginia, Ltd., Richmond, VA 23233, USA
| | - Caroline Schnakers
- Research Institute, Casa Colina Hospital and Centers for Healthcare, Pomona, CA 91767, USA
| | | | - Andrea Mannini
- IRCCS Fondazione Don Carlo Gnocchi ONLUS, 50143 Firenze, Italy
| | - Anna Estraneo
- IRCCS Fondazione Don Carlo Gnocchi ONLUS, 50143 Firenze, Italy
- Polo Specialistico Riabilitativo, Fondazione Don Carlo Gnocchi, 83054 Sant’Angelo dei Lombardi, Italy
| |
Collapse
|
17
|
Willacker L, Raiser TM, Bassi M, Bender A, Comanducci A, Rosanova M, Sobel N, Arzi A, Belloli L, Casarotto S, Colombo M, Derchi CC, Fló Rama E, Grill E, Hohl M, Kuehlmeyer K, Manasova D, Rosenfelder MJ, Valota C, Sitt JD. PerBrain: a multimodal approach to personalized tracking of evolving state-of-consciousness in brain-injured patients: protocol of an international, multicentric, observational study. BMC Neurol 2022; 22:468. [PMID: 36494776 PMCID: PMC9733076 DOI: 10.1186/s12883-022-02958-x] [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: 09/07/2022] [Accepted: 11/01/2022] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Disorders of consciousness (DoC) are severe neurological conditions in which consciousness is impaired to various degrees. They are caused by injury or malfunction of neural systems regulating arousal and awareness. Over the last decades, major efforts in improving and individualizing diagnostic and prognostic accuracy for patients affected by DoC have been made, mainly focusing on introducing multimodal assessments to complement behavioral examination. The present EU-funded multicentric research project "PerBrain" is aimed at developing an individualized diagnostic hierarchical pathway guided by both behavior and multimodal neurodiagnostics for DoC patients. METHODS In this project, each enrolled patient undergoes repetitive behavioral, clinical, and neurodiagnostic assessments according to a patient-tailored multi-layer workflow. Multimodal diagnostic acquisitions using state-of-the-art techniques at different stages of the patients' clinical evolution are performed. The techniques applied comprise well-established behavioral scales, innovative neurophysiological techniques (such as quantitative electroencephalography and transcranial magnetic stimulation combined with electroencephalography), structural and resting-state functional magnetic resonance imaging, and measurements of physiological activity (i.e. nasal airflow respiration). In addition, the well-being and treatment decision attitudes of patients' informal caregivers (primarily family members) are investigated. Patient and caregiver assessments are performed at multiple time points within one year after acquired brain injury, starting at the acute disease phase. DISCUSSION Accurate classification and outcome prediction of DoC are of crucial importance for affected patients as well as their caregivers, as individual rehabilitation strategies and treatment decisions are critically dependent on the latter. The PerBrain project aims at optimizing individual DoC diagnosis and accuracy of outcome prediction by integrating data from the suggested multimodal examination methods into a personalized hierarchical diagnosis and prognosis procedure. Using the parallel tracking of both patients' neurological status and their caregivers' mental situation, well-being, and treatment decision attitudes from the acute to the chronic phase of the disease and across different countries, this project aims at significantly contributing to the current clinical routine of DoC patients and their family members. TRIAL REGISTRATION ClinicalTrials.gov, NCT04798456 . Registered 15 March 2021 - Retrospectively registered.
Collapse
Affiliation(s)
- L. Willacker
- grid.5252.00000 0004 1936 973XDepartment of Neurology, University Hospital of the Ludwig-Maximilians-Universität München, Marchioninistr. 15, Munich, Germany
| | - T. M. Raiser
- grid.5252.00000 0004 1936 973XDepartment of Neurology, University Hospital of the Ludwig-Maximilians-Universität München, Marchioninistr. 15, Munich, Germany
| | - M. Bassi
- grid.4708.b0000 0004 1757 2822Department of Biomedical and Clinical Sciences, University of Milano, Milan, Italy
| | - A. Bender
- grid.5252.00000 0004 1936 973XDepartment of Neurology, University Hospital of the Ludwig-Maximilians-Universität München, Marchioninistr. 15, Munich, Germany ,grid.478057.90000 0004 0381 347XTherapiezentrum Burgau, Hospital for Neurological Rehabilitation, Burgau, Germany
| | - A. Comanducci
- grid.418563.d0000 0001 1090 9021IRCCS Fondazione Don Carlo Gnocchi ONLUS, Milan, Italy
| | - M. Rosanova
- grid.4708.b0000 0004 1757 2822Department of Biomedical and Clinical Sciences, University of Milano, Milan, Italy
| | - N. Sobel
- grid.13992.300000 0004 0604 7563Department of Brain Sciences, Weizmann Institute of Science, Rehovot, Israel
| | - A. Arzi
- Sorbonne Université, Institut du Cerveau - Paris Brain Institute - ICM, Inserm, CNRS, 75013 Paris, France ,grid.9619.70000 0004 1937 0538Department of Medical Neurobiology and Department of Cognitive and Brain Sciences, The Hebrew University of Jerusalem, Jerusalem, Israel
| | - L. Belloli
- Sorbonne Université, Institut du Cerveau - Paris Brain Institute - ICM, Inserm, CNRS, 75013 Paris, France ,grid.7345.50000 0001 0056 1981Laboratorio de Inteligencia Artificial Aplicada, Instituto de Ciencias de la Computación, Universidad de Buenos Aires, Buenos Aires, Argentina ,grid.423606.50000 0001 1945 2152Consejo Nacional de Investigaciones Científicas y Técnicas (CONICET), Ministry of Science, Technology and Innovation, Buenos Aires, Argentina
| | - S. Casarotto
- grid.4708.b0000 0004 1757 2822Department of Biomedical and Clinical Sciences, University of Milano, Milan, Italy ,grid.418563.d0000 0001 1090 9021IRCCS Fondazione Don Carlo Gnocchi ONLUS, Milan, Italy
| | - M. Colombo
- grid.4708.b0000 0004 1757 2822Department of Biomedical and Clinical Sciences, University of Milano, Milan, Italy
| | - C. C. Derchi
- grid.418563.d0000 0001 1090 9021IRCCS Fondazione Don Carlo Gnocchi ONLUS, Milan, Italy
| | - E. Fló Rama
- Sorbonne Université, Institut du Cerveau - Paris Brain Institute - ICM, Inserm, CNRS, 75013 Paris, France
| | - E. Grill
- grid.5252.00000 0004 1936 973XInstitute for Medical Information Processing, Biometry and Epidemiology, Ludwig-Maximilians-Universität München, Munich, Germany ,grid.411095.80000 0004 0477 2585German Center for Vertigo and Balance Disorders, Klinikum der Universität München, Munich, Germany
| | - M. Hohl
- grid.5252.00000 0004 1936 973XDepartment of Neurology, University Hospital of the Ludwig-Maximilians-Universität München, Marchioninistr. 15, Munich, Germany
| | - K. Kuehlmeyer
- grid.5252.00000 0004 1936 973XInstitute of Ethics, History and Theory of Medicine, Ludwig-Maximilians-Universität München, Munich, Germany
| | - D. Manasova
- Sorbonne Université, Institut du Cerveau - Paris Brain Institute - ICM, Inserm, CNRS, 75013 Paris, France ,grid.508487.60000 0004 7885 7602Université Paris Cité, Paris, France
| | - M. J. Rosenfelder
- grid.478057.90000 0004 0381 347XTherapiezentrum Burgau, Hospital for Neurological Rehabilitation, Burgau, Germany ,grid.6582.90000 0004 1936 9748Clinical and Biological Psychology, Institute of Psychology and Education, Ulm University, Ulm, Germany
| | - C. Valota
- grid.4708.b0000 0004 1757 2822Department of Biomedical and Clinical Sciences, University of Milano, Milan, Italy ,grid.418563.d0000 0001 1090 9021IRCCS Fondazione Don Carlo Gnocchi ONLUS, Milan, Italy
| | - J. D. Sitt
- Sorbonne Université, Institut du Cerveau - Paris Brain Institute - ICM, Inserm, CNRS, 75013 Paris, France
| |
Collapse
|
18
|
Coppola L, Mirabelli P, Baldi D, Smaldone G, Estraneo A, Soddu A, Grimaldi AM, Mele G, Salvatore M, Cavaliere C. An innovative approach for the evaluation of prolonged disorders of consciousness using NF-L and GFAP biomarkers: a pivotal study. Sci Rep 2022; 12:18446. [PMID: 36323711 PMCID: PMC9630372 DOI: 10.1038/s41598-022-21930-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2022] [Accepted: 10/06/2022] [Indexed: 11/05/2022] Open
Abstract
Behavioral assessments during the clinical evaluation in prolonged disorders of consciousness patients could be not sufficient for a correct diagnosis and prognostication. To this aim, we used an innovative approach, involving the ultra-sensitive determination of biological markers, correlating them with imaging parameters to investigate the prolonged disorders of consciousness (pDoC).We assessed the serum concentration of neurofilament light chain(NF-L) and glial fibrillary acidic protein (GFAP) in pDoC (n = 16), and healthy controls (HC, n = 6) as well as several clinical imaging parameters such as Fractional Anisotropy (FA), Whole Brain SUV, and White Matter Hyperintensities volumes (WMH) using PET-MRI acquisition. As for differential diagnosis task, only the imaging WMH volume was able to discriminate between vegetative state/unresponsive wakefulness syndrome (VS/UWS), and minimally conscious state (MCS) patients (p-value < 0.01), while all selected markers (both imaging and in vitro) were able to differentiate between pDoC patients and HC. At subject level, serum NF-L concentrations significantly differ according to clinical progression and consciousness recovery (p-value < 0.01), highlighting a potential play for the longitudinal management of these patients.
Collapse
Affiliation(s)
| | | | | | | | - A. Estraneo
- grid.418563.d0000 0001 1090 9021Istituto Di Ricovero E Cura a Carattere Scientifico (IRCCS) Fondazione Don Carlo Gnocchi, Florence, Italy
| | - A. Soddu
- grid.39381.300000 0004 1936 8884Department of Physics and Astronomy, Western Institute of Neuroscience, University of Western Ontario, London, ON Canada
| | | | - G. Mele
- IRCCS Synlab SDN, Napoli, Italy
| | | | | |
Collapse
|
19
|
Schnakers C, Bauer C, Formisano R, Noé E, Llorens R, Lejeune N, Farisco M, Teixeira L, Morrissey AM, De Marco S, Veeramuthu V, Ilina K, Edlow BL, Gosseries O, Zandalasini M, De Bellis F, Thibaut A, Estraneo A. What names for covert awareness? A systematic review. Front Hum Neurosci 2022; 16:971315. [PMID: 35992948 PMCID: PMC9389234 DOI: 10.3389/fnhum.2022.971315] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2022] [Accepted: 07/15/2022] [Indexed: 12/14/2022] Open
Abstract
Background With the emergence of Brain Computer Interfaces (BCI), clinicians have been facing a new group of patients with severe acquired brain injury who are unable to show any behavioral sign of consciousness but respond to active neuroimaging or electrophysiological paradigms. However, even though well documented, there is still no consensus regarding the nomenclature for this clinical entity. Objectives This systematic review aims to 1) identify the terms used to indicate the presence of this entity through the years, and 2) promote an informed discussion regarding the rationale for these names and the best candidates to name this fascinating disorder. Methods The Disorders of Consciousness Special Interest Group (DoC SIG) of the International Brain Injury Association (IBIA) launched a search on Pubmed and Google scholar following PRISMA guidelines to collect peer-reviewed articles and reviews on human adults (>18 years) published in English between 2006 and 2021. Results The search launched in January 2021 identified 4,089 potentially relevant titles. After screening, 1,126 abstracts were found relevant. Finally, 161 manuscripts were included in our analyses. Only 58% of the manuscripts used a specific name to discuss this clinical entity, among which 32% used several names interchangeably throughout the text. We found 25 different names given to this entity. The five following names were the ones the most frequently used: covert awareness, cognitive motor dissociation, functional locked-in, non-behavioral MCS (MCS*) and higher-order cortex motor dissociation. Conclusion Since 2006, there has been no agreement regarding the taxonomy to use for unresponsive patients who are able to respond to active neuroimaging or electrophysiological paradigms. Developing a standard taxonomy is an important goal for future research studies and clinical translation. We recommend a Delphi study in order to build such a consensus.
Collapse
Affiliation(s)
- Caroline Schnakers
- Research Institute, Casa Colina Hospital and Centers for Healthcare, Pomona, CA, United States
- *Correspondence: Caroline Schnakers
| | - Chase Bauer
- College of Osteopathic Medicine, Western University of Health Sciences, Pomona, CA, United States
| | | | - Enrique Noé
- Vithas Neuro Rehab Human Brain, Fundación Hospitales Vithas, Valencia, Spain
| | - Roberto Llorens
- Vithas Neuro Rehab Human Brain, Fundación Hospitales Vithas, Valencia, Spain
- Neurorehabilitation and Brain Research Group, Instituto de Investigación e Innovación en Bioingeniería, Universitat Politècnica de València, Valencia, Spain
| | - Nicolas Lejeune
- Centre Hospitalier Neurologique William Lennox, Ottignies-Louvain-la-Neuve, Belgium
- GIGA-Consciousness, Coma Science Group, University of Liège, Liege, Belgium
| | - Michele Farisco
- Centre for Research Ethics and Bioethics, Uppsala University, Uppsala, Sweden
- Science and Society Unit, Biogem, Biology and Molecular Genetics Research Institute, Ariano Irpino, Italy
| | - Liliana Teixeira
- Center for Innovative Care and Health Technology, School of Health Sciences, Polytechnic of Leiria, Leiria, Portugal
| | - Ann-Marie Morrissey
- Ageing Research Centre, School of Allied Health, Health Research Institute, University of Limerick, Limerick, Ireland
| | - Sabrina De Marco
- Clínica Universitaria Reina Fabiola, Universidad Católica de Córdoba, Córdoba, Argentina
| | | | - Kseniya Ilina
- Research Center of Neurology, Moscow, Russia
- Faculty of Fundamental Medicine, Lomonosov Moscow State University, Moscow, Russia
| | - Brian L. Edlow
- Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
| | - Olivia Gosseries
- GIGA-Consciousness, Coma Science Group, University of Liège, Liege, Belgium
- Centre du Cerveau, University Hospital of Liege, Liege, Belgium
| | - Matteo Zandalasini
- Unità Spinale, Neuroriabilitazione e Medicina Riabilitativa Intensiva, Dipartimento di Medicina Riabilitativa, Azienda USL di Piacenza, Piacenza, Italy
| | | | - Aurore Thibaut
- GIGA-Consciousness, Coma Science Group, University of Liège, Liege, Belgium
- Centre du Cerveau, University Hospital of Liege, Liege, Belgium
| | - Anna Estraneo
- IRCCS Fondazione Don Carlo Gnocchi, Florence, Italy
- Neurology Unit, SM della Pietà General Hospital, Nola, Italy
| |
Collapse
|
20
|
van der Lande GJM, Blume C, Annen J. Sleep and circadian disturbance in disorders of consciousness: current methods and the way towards clinical implementation. Semin Neurol 2022; 42:283-298. [PMID: 35793707 DOI: 10.1055/a-1893-2785] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Affiliation(s)
| | - Christine Blume
- Centre for Chronobiology, Psychiatric Hospital of the University of Basel, Basel, Switzerland.,Transfaculty Research Platform Molecular and Cognitive Neurosciences, University of Basel, Basel, Switzerland
| | - Jitka Annen
- Coma Science Group, GIGA-Consciousness, University of Liège, Liège, Belgium.,Centre du Cerveau2, University Hospital of Liège, Liège, Belgium
| |
Collapse
|
21
|
Young M, Peterson AH. Neuroethics across the Disorders of Consciousness Care Continuum. Semin Neurol 2022; 42:375-392. [PMID: 35738293 DOI: 10.1055/a-1883-0701] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
|
22
|
|
23
|
Peterson A, Mintz K, Owen AM. Unlocking the Voices of Patients with Severe Brain Injury. NEUROETHICS-NETH 2022. [DOI: 10.1007/s12152-022-09492-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
|
24
|
Istace T. Empowering the voiceless. Disorders of consciousness, neuroimaging and supported decision-making. Front Psychiatry 2022; 13:923488. [PMID: 36147989 PMCID: PMC9488582 DOI: 10.3389/fpsyt.2022.923488] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2022] [Accepted: 08/11/2022] [Indexed: 11/21/2022] Open
Abstract
Patients suffering from (Prolonged) Disorder of Consciousness are deemed incompetent to give valid informed consent due to the presumed impairment of their cognitive functions and the impossibility to communicate with them. Neuroscientists have, however, discovered ways in which communication with some of these patients might be possible by using neuroimaging. This would for the first time make it possible to include them in the decision-making on their own medical treatment. In this article, I elaborate on the prospect of communicating with patients with impaired consciousness in order to obtain their informed consent. I first map the current state-of-the-art in neuroimaging research that exhibits the possibility of communicating with some of these patients. Secondly, I examine how obtaining informed consent from these patients might be possible, given that the specificities and limitations of communication via neuroimaging render the task of assessing their competence rather difficult. Thirdly, I identify some of the important ethical and legal considerations that have to be taken into account before introducing neuroimaging in clinical practice as a means to obtain informed consent. Lastly, I look into the concept of supported decision-making and how this concept relates to the use of neurotechnology to support minimally conscious patients in their abilities to decide over their own medical treatment.
Collapse
Affiliation(s)
- Timo Istace
- Department of Law, Research Group Personal Rights and Property Rights, University of Antwerp, Antwerp, Belgium.,Antwerp Health Law and Ethics Chair (AHLEC), Antwerp, Belgium
| |
Collapse
|
25
|
Estraneo A, Magliacano A, Fiorenza S, Formisano R, Grippo A, Angelakis E, Cassol H, Thibaut A, Gosseries O, Lamberti G, Noé E, Bagnato S, Edlow BL, Chatelle C, Lejeune N, Veeramuthu V, Bartolo M, Mattia D, Toppi J, Zasler N, Schnakers C, Trojano L. Risk factors for 2-year mortality in patients with prolonged disorders of consciousness: An international multicentre study. Eur J Neurol 2021; 29:390-399. [PMID: 34657359 DOI: 10.1111/ene.15143] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2021] [Revised: 10/07/2021] [Accepted: 10/11/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND AND PURPOSE Patients with prolonged disorders of consciousness (pDoC) have a high mortality rate due to medical complications. Because an accurate prognosis is essential for decision-making on patients' management, we analysed data from an international multicentre prospective cohort study to evaluate 2-year mortality rate and bedside predictors of mortality. METHODS We enrolled adult patients in prolonged vegetative state/unresponsive wakefulness syndrome (VS/UWS) or minimally conscious state (MCS) after traumatic and nontraumatic brain injury within 3 months postinjury. At enrolment, we collected demographic (age, sex), anamnestic (aetiology, time postinjury), clinical (Coma Recovery Scale-Revised [CRS-R], Disability Rating Scale, Nociception Coma Scale-Revised), and neurophysiologic (electroencephalogram [EEG], somatosensory evoked and event-related potentials) data. Patients were followed up to gather data on mortality up to 24 months postinjury. RESULTS Among 143 traumatic (n = 55) and nontraumatic (n = 88) patients (VS/UWS, n = 68, 19 females; MCS, n = 75, 22 females), 41 (28.7%) died within 24 months postinjury. Mortality rate was higher in VS/UWS (42.6%) than in MCS (16%; p < 0.001). Multivariate regression in VS/UWS showed that significant predictors of mortality were older age and lower CRS-R total score, whereas in MCS female sex and absence of alpha rhythm on EEG at study entry were significant predictors. CONCLUSIONS This study demonstrated that a feasible multimodal assessment in the postacute phase can help clinicians to identify patients with pDoC at higher risk of mortality within 24 months after brain injury. This evidence can help clinicians and patients' families to navigate the complex clinical decision-making process and promote an international standardization of prognostic procedures for patients with pDoC.
Collapse
Affiliation(s)
- Anna Estraneo
- Don Carlo Gnocchi Foundation, Scientific Institute for Research and Health Care, Florence, Italy.,Neurology Unit, Santa Maria della Pietà General Hospital, Nola, Italy
| | - Alfonso Magliacano
- Don Carlo Gnocchi Foundation, Scientific Institute for Research and Health Care, Florence, Italy.,Department of Psychology, University of Campania Luigi Vanvitelli, Caserta, Italy
| | - Salvatore Fiorenza
- Maugeri Clinical Scientific Institutes, Scientific Institute for Research and Health Care, Laboratory for the Multimodal Evaluation of Disorders of Consciousness, Telese Terme, Italy
| | - Rita Formisano
- Santa Lucia Foundation, Scientific Institute for Research and Health Care, Rome, Italy
| | - Antonello Grippo
- Don Carlo Gnocchi Foundation, Scientific Institute for Research and Health Care, Florence, Italy
| | - Efthymios Angelakis
- Neurosurgery Department, University of Athens Medical School, Athens, Greece
| | - Helena Cassol
- Coma Science Group, GIGA Consciousness, University and University Hospital of Liège, Liège, Belgium
| | - Aurore Thibaut
- Coma Science Group, GIGA Consciousness, University and University Hospital of Liège, Liège, Belgium
| | - Olivia Gosseries
- Coma Science Group, GIGA Consciousness, University and University Hospital of Liège, Liège, Belgium
| | | | - Enrique Noé
- NEURORHB-Neurorehabilitation Service of Vithas Hospitals, Valencia, Spain
| | - Sergio Bagnato
- Unit of Neurophysiology and Unit for Severe Acquired Brain Injuries, Rehabilitation Department, Giuseppe Giglio Foundation, Cefalù, Italy
| | - Brian L Edlow
- Center for Neurotechnology and Neurorecovery, Department of Neurology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Camille Chatelle
- Center for Neurotechnology and Neurorecovery, Department of Neurology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Nicolas Lejeune
- Centre Hospitalier Neurologique William Lennox, Ottignies-Louvain-la-Neuve, Belgium
| | | | | | - Donatella Mattia
- Santa Lucia Foundation, Scientific Institute for Research and Health Care, Rome, Italy
| | - Jlenia Toppi
- Department of Computer, Control, and Management Engineering, Sapienza University of Rome, Rome, Italy
| | - Nathan Zasler
- Concussion Care Centre of Virginia, Richmond, Virginia, USA
| | - Caroline Schnakers
- Research Institute, Casa Colina Hospital and Centers for Healthcare, Pomona, California, USA
| | - Luigi Trojano
- Department of Psychology, University of Campania Luigi Vanvitelli, Caserta, Italy
| |
Collapse
|
26
|
Sanz LRD, Thibaut A, Edlow BL, Laureys S, Gosseries O. Update on neuroimaging in disorders of consciousness. Curr Opin Neurol 2021; 34:488-496. [PMID: 34054109 PMCID: PMC8938964 DOI: 10.1097/wco.0000000000000951] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
PURPOSE OF REVIEW Neuroimaging has acquired a prominent place in the assessment of disorders of consciousness (DoC). Rapidly evolving technologies combined with state-of-the-art data analyses open new horizons to probe brain activity, but selecting appropriate imaging modalities from the plethora of available techniques can be challenging for clinicians. This update reviews selected advances in neuroimaging that demonstrate clinical relevance and translational potential in the assessment of severely brain-injured patients with DoC. RECENT FINDINGS Magnetic resonance imaging and high-density electroencephalography provide measurements of brain connectivity between functional networks, assessments of language function, detection of covert consciousness, and prognostic markers of recovery. Positron emission tomography can identify patients with preserved brain metabolism despite clinical unresponsiveness and can measure glucose consumption rates in targeted brain regions. Transcranial magnetic stimulation and near-infrared spectroscopy are noninvasive and practical tools with promising clinical applications. SUMMARY Each neuroimaging technique conveys advantages and pitfalls to assess consciousness. We recommend a multimodal approach in which complementary techniques provide diagnostic and prognostic information about brain function. Patients demonstrating neuroimaging evidence of covert consciousness may benefit from early adapted rehabilitation. Translating methodological advances to clinical care will require the implementation of recently published international guidelines and the integration of neuroimaging techniques into patient-centered decision-making algorithms.
Collapse
Affiliation(s)
- Leandro R. D. Sanz
- Coma Science Group, GIGA Consciousness, University of Liège, Liège, Belgium
- Centre du Cerveau, University Hospital of Liège, Liège, Belgium
| | - Aurore Thibaut
- Coma Science Group, GIGA Consciousness, University of Liège, Liège, Belgium
- Centre du Cerveau, University Hospital of Liège, Liège, Belgium
| | - Brian L. Edlow
- Center for Neurotechnology and Neurorecovery, Department of Neurology, Massachusetts General Hospital and Harvard Medical School, Boston, MA USA
- Athinoula A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital and Harvard Medical School, Charlestown, MA, USA
| | - Steven Laureys
- Coma Science Group, GIGA Consciousness, University of Liège, Liège, Belgium
- Centre du Cerveau, University Hospital of Liège, Liège, Belgium
| | - Olivia Gosseries
- Coma Science Group, GIGA Consciousness, University of Liège, Liège, Belgium
- Centre du Cerveau, University Hospital of Liège, Liège, Belgium
| |
Collapse
|
27
|
Translation and Transcultural Adaptation of the Wessex Head Injury Matrix, Italian Version: A Preliminary Report. Brain Sci 2021; 11:brainsci11060810. [PMID: 34207277 PMCID: PMC8234881 DOI: 10.3390/brainsci11060810] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Revised: 06/08/2021] [Accepted: 06/11/2021] [Indexed: 11/22/2022] Open
Abstract
Background: Patients who are in a coma, a vegetative state or a minimally conscious state present a clinical challenge for neurological assessment, which is a prerequisite for establishing a prognosis and planning management. Several scales have been developed to evaluate these patients. The Wessex Head Injury Matrix is a comprehensive tool but is currently available only in the French and English languages. The aim of this study was to translate and evaluate the reliability of the Italian version of the scale. Methods: The original scale was translated according to a standard protocol: three separate translations were made, and a selected version was back-translated to check for any errors in order to obtain the most accurate Italian translation. A final back translation of the agreed version was made as a further check. The final version was then administered blind to a consecutive series of patients with severe acquired brain injury by two examiners. Inter-rater and test-retest reliability were assessed using a weighted Cohen’s kappa (Kw). Concurrent validity of the WHIM was evaluated by ρ Spearman’s correlation coefficient using the Glasgow Coma Scale (GCS) and the Coma Recovery Scale Revised (CRS-R) as the available gold standard. Results: Twenty-four patients (12 males and 12 females; mean age 59.9 ± 20.1; mean duration from index event 17.7 ± 20.0 days) with stroke (n = 15), traumatic brain injury (n = 7) and anoxic encephalopathy (n = 2) were included. Inter-rater [Kw 0.80 (95% CI 0.75–0.84)] and test-retest reliability [Kw 0.77 (95% CI 0.72–0.81)] showed good values. WHIM total scores correlated significantly with total scores on the GCS (ρ = 0.776; p < 0.001) and the CRS-R (ρ = 0.881; p < 0.001) demonstrating concurrent validity; Conclusion: The Italian version of the scale is now available for clinical practice and research.
Collapse
|