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Magnani FG, Barbadoro F, Cacciatore M, Leonardi M. The importance of instrumental assessment in disorders of consciousness: a comparison between American, European, and UK International recommendations. Crit Care 2022; 26:245. [PMID: 35948933 PMCID: PMC9367125 DOI: 10.1186/s13054-022-04119-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2022] [Accepted: 08/03/2022] [Indexed: 11/23/2022] Open
Abstract
The use of instrumental tools for improving both the diagnostic accuracy and the prognostic soundness in patients with disorders of consciousness (DOC) plays an important role. However, the most recent international guidelines on DOC published by the American and the European Academies of Neurology and by the UK Royal College of Physicians contain heterogeneous recommendations on the implementation of these techniques in the clinical routine for both diagnosis and prognosis. With the present work, starting from the comparison of the DOC guidelines’ recommendations, we look for possible explanations behind such discrepancies considering the adopted methodologies and the reference health systems that could have affected the guidelines’ perspectives. We made a provocative argument about the need to find the most appropriate common methodology to retrieve and grade the evidence, increase the meta-analytic studies, and reduce the health policies that influence on the guidelines development that, in turn, should inform the health policies with the strongest scientific evidence.
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2
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Yelden K, James LM, Duport S, Kempny A, Farmer SF, Leff AP, Playford ED. A simple intervention for disorders of consciousness- is there a light at the end of the tunnel? Front Neurol 2022; 13:824880. [PMID: 35937075 PMCID: PMC9355643 DOI: 10.3389/fneur.2022.824880] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Accepted: 06/27/2022] [Indexed: 12/02/2022] Open
Abstract
Sleep is a physiological state necessary for memory processing, learning and brain plasticity. Patients with disorders of consciousness (DOC) show none or minimal sign of awareness of themselves or their environment but appear to have sleep-wake cycles. The aim of our study was to assess baseline circadian rhythms and sleep in patients with DOC; to optimize circadian rhythm using an intervention combining blue light, melatonin and caffeine, and to identify the impact of this intervention on brain function using event related potentials. We evaluated baseline circadian rhythms and sleep in 17 patients with DOC with 24-h polysomnography (PSG) and 4-hourly saliva melatonin measurements for 48 h. Ten of the 17 patients (5 female, age 30–71) were then treated for 5 weeks with melatonin each night and blue light and caffeine treatment in the mornings. Behavioral assessment of arousal and awareness [Coma recovery scale-revised (CRS-R)], 24-h polysomnography and 4-hourly saliva melatonin measurements, oddball mismatch negativity (MMN) and subject's own name (SON) experiments were performed twice at baseline and following intervention. Baseline sleep was abnormal in all patients. Cosinor analysis of saliva melatonin results revealed that averaged baseline % rhythmicity was low (M: 31%, Range: 13–66.4%, SD: 18.4). However, increase in % Melatonin Rhythm following intervention was statistically significant (p = 0.012). 7 patients showed improvement of CRS-R scores with intervention and this was statistically significant (p = 0.034). All the patients who had improvement of clinical scores also had statistically significant improvement of neurophysiological responses on MMN and SON experiments at group level (p = 0.001). Our study shows that sleep and circadian rhythms are severely deranged in DOC but optimization is possible with melatonin, caffeine and blue light treatment. Clinical and physiological parameters improved with this simple and inexpensive intervention. Optimization of sleep and circadian rhythms should be integrated into rehabilitation programs for people with DOC.
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Affiliation(s)
- Kudret Yelden
- Neurological Rehabilitation, Royal Hospital for Neuro-Disability, London, United Kingdom
- Department of Neuroscience, King's College Hospital, London, United Kingdom
- UCL Queen Square Institute of Neurology, University College London, London, United Kingdom
- *Correspondence: Kudret Yelden
| | - Leon M. James
- Neurophysiology Department, Bupa Cromwell Hospital, London, United Kingdom
| | - Sophie Duport
- Research Department, Royal Hospital for Neuro-Disability, London, United Kingdom
| | - Agnieszka Kempny
- Research Department, Royal Hospital for Neuro-Disability, London, United Kingdom
| | - Simon F. Farmer
- UCL Queen Square Institute of Neurology, University College London, London, United Kingdom
- National Hospital for Neurology and Neurosurgery, University College London Hospital, London, United Kingdom
| | - Alex P. Leff
- UCL Queen Square Institute of Neurology, University College London, London, United Kingdom
- National Hospital for Neurology and Neurosurgery, University College London Hospital, London, United Kingdom
| | - E. Diane Playford
- UCL Queen Square Institute of Neurology, University College London, London, United Kingdom
- Warwick Medical School, University of Warwick, Coventry, United Kingdom
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3
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Vitello MM, Szymkowicz E, Laureys S, Alnagger N, Gosseries O, Thibaut A. Neuroimaging and neurophysiological diagnosis and prognosis in paediatric disorders of consciousness. Dev Med Child Neurol 2022; 64:681-690. [PMID: 35089596 DOI: 10.1111/dmcn.15150] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2021] [Revised: 12/10/2021] [Accepted: 12/14/2021] [Indexed: 12/01/2022]
Abstract
The diagnosis and prognosis of disorders of consciousness (DOC) such as coma, unresponsive wakefulness syndrome, or minimally conscious state are especially challenging in children. In some paediatric patients with severe acquired brain injury, medical comorbidities or developmental factors may obscure the detection of signs of consciousness via clinical assessments, thus leading to misdiagnosis. To circumvent these biases, patients benefit from multimodal assessments that combine behavioural, neuroimaging, and neurophysiological measures. In this review, we provide original data for such diagnostic procedures in children. Neuroimaging is largely underdocumented in children and most neurophysiological research consists of a cohort study design aimed at providing prognostic markers for clinical outcomes. The scarcity of available data on complementary diagnostic approaches in children makes it difficult to establish clear paediatric guidelines. Although there is preliminary evidence for the applicability of paradigms involving event-related potentials as support for diagnosis in children, more well-designed studies need to be conducted to promote evidence-based practices in paediatric DOC.
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Affiliation(s)
- Marie M Vitello
- Coma Science Group, GIGA-Consciousness, University of Liège, Liège, Belgium.,Centre du Cerveau, University Hospital of Liège, Liège, Belgium
| | - Emilie Szymkowicz
- Coma Science Group, GIGA-Consciousness, University of Liège, Liège, Belgium.,Centre du Cerveau, University Hospital of Liège, Liège, Belgium
| | - Steven Laureys
- Coma Science Group, GIGA-Consciousness, University of Liège, Liège, Belgium.,Centre du Cerveau, University Hospital of Liège, Liège, Belgium
| | - Naji Alnagger
- 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
| | - Aurore Thibaut
- Coma Science Group, GIGA-Consciousness, University of Liège, Liège, Belgium.,Centre du Cerveau, University Hospital of Liège, Liège, Belgium
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4
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Aubinet C, Schnakers C, Majerus S. Language Assessment in Patients with Disorders of Consciousness. Semin Neurol 2022; 42:273-282. [PMID: 36100226 DOI: 10.1055/s-0042-1755561] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
Abstract
The assessment of residual language abilities in patients with disorders of consciousness (DoC) after severe brain injury is particularly challenging due to their limited behavioral repertoire. Moreover, associated language impairment such as receptive aphasia may lead to an underestimation of actual consciousness levels. In this review, we examine past research on the assessment of residual language processing in DoC patients, and we discuss currently available tools for identifying language-specific abilities and their prognostic value. We first highlight the need for validated and sensitive bedside behavioral assessment tools for residual language abilities in DoC patients. As regards neuroimaging and electrophysiological methods, the tasks involving higher level linguistic commands appear to be the most informative about level of consciousness and have the best prognostic value. Neuroimaging methods should be combined with the most appropriate behavioral tools in multimodal assessment protocols to assess receptive language abilities in DoC patients in the most complete and sensitive manner.
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Affiliation(s)
- Charlène Aubinet
- Coma Science Group, GIGA Consciousness, University of Liège, Liège, Belgium.,Centre du Cerveau, University Hospital of Liège, Liège, Belgium.,Psychology and Neuroscience of Cognition Research Unit, University of Liège, Liège, Belgium
| | - Caroline Schnakers
- Research Institute, Casa Colina Hospital and Centers for Healthcare, Pomona, California
| | - Steve Majerus
- Psychology and Neuroscience of Cognition Research Unit, University of Liège, Liège, Belgium
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5
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Thibaut A, Panda R, Annen J, Sanz LRD, Naccache L, Martial C, Chatelle C, Aubinet C, Bonin EAC, Barra A, Briand MM, Cecconi B, Wannez S, Stender J, Laureys S, Gosseries O. Preservation of Brain Activity in Unresponsive Patients Identifies MCS Star. Ann Neurol 2021; 90:89-100. [PMID: 33938027 PMCID: PMC8252577 DOI: 10.1002/ana.26095] [Citation(s) in RCA: 59] [Impact Index Per Article: 19.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2020] [Revised: 04/28/2021] [Accepted: 04/29/2021] [Indexed: 01/18/2023]
Abstract
Objective Brain‐injured patients who are unresponsive at the bedside (ie, vegetative state/unresponsive wakefulness syndrome – VS/UWS) may present brain activity similar to patients in minimally conscious state (MCS). This peculiar condition has been termed “non‐behavioural MCS” or “MCS*”. In the present study we aimed to investigate the proportion and underlying brain characteristics of patients in MCS*. Methods Brain 18F‐fluorodeoxyglucose Positron Emission Tomography (FDG‐PET) was acquired on 135 brain‐injured patients diagnosed in prolonged VS/UWS (n = 48) or MCS (n = 87). From an existing database, relative metabolic preservation in the fronto‐parietal network (measured with standardized uptake value) was visually inspected by three experts. Patients with hypometabolism of the fronto‐parietal network were labelled “VS/UWS”, while its (partial) preservation either confirmed the behavioural diagnosis of “MCS” or, in absence of behavioural signs of consciousness, suggested a diagnosis of “MCS*”. Clinical outcome at 1‐year follow‐up, functional connectivity, grey matter atrophy, and regional brain metabolic patterns were investigated in the three groups (VS/UWS, MCS* and MCS). Results 67% of behavioural VS/UWS presented a partial preservation of brain metabolism (ie, MCS*). Compared to VS/UWS patients, MCS* patients demonstrated a better outcome, global functional connectivity and grey matter preservation more compatible with the diagnosis of MCS. MCS* patients presented lower brain metabolism mostly in the posterior brain regions compared to MCS patients. Interpretation MCS* is a frequent phenomenon that is associated with better outcome and better brain preservation than the diagnosis of VS/UWS. Complementary exams should be provided to all unresponsive patients before taking medical decisions. ANN NEUROL 2021;90:89–100
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Affiliation(s)
- Aurore Thibaut
- Coma Science Group, GIGA-Consciousness, University of Liège, Liège, Belgium.,Centre du Cerveau2, University Hospital of Liège, Liège, Belgium
| | - Rajanikant Panda
- Coma Science Group, GIGA-Consciousness, University of Liège, Liège, Belgium.,Centre du Cerveau2, University Hospital of Liège, Liège, Belgium
| | - Jitka Annen
- Coma Science Group, GIGA-Consciousness, University of Liège, Liège, Belgium.,Centre du Cerveau2, University Hospital of Liège, Liège, Belgium
| | - Leandro R D Sanz
- Coma Science Group, GIGA-Consciousness, University of Liège, Liège, Belgium.,Centre du Cerveau2, University Hospital of Liège, Liège, Belgium
| | - Lionel Naccache
- PICNIC Lab, Institut du cerveau, INSERM U1127, Sorbonne Université, Paris, France
| | - Charlotte Martial
- Coma Science Group, GIGA-Consciousness, University of Liège, Liège, Belgium.,Centre du Cerveau2, University Hospital of Liège, Liège, Belgium
| | - Camille Chatelle
- Coma Science Group, GIGA-Consciousness, University of Liège, Liège, Belgium.,Centre du Cerveau2, University Hospital of Liège, Liège, Belgium
| | - Charlène Aubinet
- Coma Science Group, GIGA-Consciousness, University of Liège, Liège, Belgium.,Centre du Cerveau2, University Hospital of Liège, Liège, Belgium
| | - Estelle A C Bonin
- Coma Science Group, GIGA-Consciousness, University of Liège, Liège, Belgium.,Centre du Cerveau2, University Hospital of Liège, Liège, Belgium
| | - Alice Barra
- Coma Science Group, GIGA-Consciousness, University of Liège, Liège, Belgium.,Centre du Cerveau2, University Hospital of Liège, Liège, Belgium
| | - Marie-Michèle Briand
- Coma Science Group, GIGA-Consciousness, University of Liège, Liège, Belgium.,Centre du Cerveau2, University Hospital of Liège, Liège, Belgium
| | - Benedetta Cecconi
- Coma Science Group, GIGA-Consciousness, University of Liège, Liège, Belgium.,Centre du Cerveau2, University Hospital of Liège, Liège, Belgium
| | - Sarah Wannez
- Coma Science Group, GIGA-Consciousness, University of Liège, Liège, Belgium.,Centre du Cerveau2, University Hospital of Liège, Liège, Belgium
| | - Johan Stender
- Department of Neurology, Bispebjerg Hospital, Copenhagen, Denmark
| | - Steven Laureys
- Coma Science Group, GIGA-Consciousness, University of Liège, Liège, Belgium.,Centre du Cerveau2, University Hospital of Liège, Liège, Belgium
| | - Olivia Gosseries
- Coma Science Group, GIGA-Consciousness, University of Liège, Liège, Belgium.,Centre du Cerveau2, University Hospital of Liège, Liège, Belgium
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6
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Calabrò RS, Pignolo L, Müller-Eising C, Naro A. Pain Perception in Disorder of Consciousness: A Scoping Review on Current Knowledge, Clinical Applications, and Future Perspective. Brain Sci 2021; 11:665. [PMID: 34065349 DOI: 10.3390/brainsci11050665] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2021] [Revised: 05/05/2021] [Accepted: 05/19/2021] [Indexed: 01/18/2023] Open
Abstract
Pain perception in individuals with prolonged disorders of consciousness (PDOC) is still a matter of debate. Advanced neuroimaging studies suggest some cortical activations even in patients with unresponsive wakefulness syndrome (UWS) compared to those with a minimally conscious state (MCS). Therefore, pain perception has to be considered even in individuals with UWS. However, advanced neuroimaging assessment can be challenging to conduct, and its findings are sometimes difficult to be interpreted. Conversely, multichannel electroencephalography (EEG) and laser-evoked potentials (LEPs) can be carried out quickly and are more adaptable to the clinical needs. In this scoping review, we dealt with the neurophysiological basis underpinning pain in PDOC, pointing out how pain perception assessment in these individuals might help in reducing the misdiagnosis rate. The available literature data suggest that patients with UWS show a more severe functional connectivity breakdown among the pain-related brain areas compared to individuals in MCS, pointing out that pain perception increases with the level of consciousness. However, there are noteworthy exceptions, because some UWS patients show pain-related cortical activations that partially overlap those observed in MCS individuals. This suggests that some patients with UWS may have residual brain functional connectivity supporting the somatosensory, affective, and cognitive aspects of pain processing (i.e., a conscious experience of the unpleasantness of pain), rather than only being able to show autonomic responses to potentially harmful stimuli. Therefore, the significance of the neurophysiological approach to pain perception in PDOC seems to be clear, and despite some methodological caveats (including intensity of stimulation, multimodal paradigms, and active vs. passive stimulation protocols), remain to be solved. To summarize, an accurate clinical and neurophysiological assessment should always be performed for a better understanding of pain perception neurophysiological underpinnings, a more precise differential diagnosis at the level of individual cases as well as group comparisons, and patient-tailored management.
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7
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Schnakers C, Hirsch M, Noé E, Llorens R, Lejeune N, Veeramuthu V, De Marco S, Demertzi A, Duclos C, Morrissey AM, Chatelle C, Estraneo A. Covert Cognition in Disorders of Consciousness: A Meta-Analysis. Brain Sci 2020; 10:E930. [PMID: 33276451 DOI: 10.3390/brainsci10120930] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2020] [Revised: 11/16/2020] [Accepted: 11/24/2020] [Indexed: 12/20/2022] Open
Abstract
Covert cognition in patients with disorders of consciousness represents a real diagnostic conundrum for clinicians. In this meta-analysis, our main objective was to identify clinical and demographic variables that are more likely to be associated with responding to an active paradigm. Among 2018 citations found on PubMed, 60 observational studies were found relevant. Based on the QUADAS-2, 49 studies were considered. Data from 25 publications were extracted and included in the meta-analysis. Most of these studies used electrophysiology as well as counting tasks or mental imagery. According to our statistical analysis, patients clinically diagnosed as being in a vegetative state and in a minimally conscious state minus (MCS-) show similar likelihood in responding to active paradigm and responders are most likely suffering from a traumatic brain injury. In the future, multi-centric studies should be performed in order to increase sample size, with similar methodologies and include structural and functional neuroimaging in order to identify cerebral markers related to such a challenging diagnosis.
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8
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Møller MLH, Højlund A, Jensen M, Gansonre C, Shtyrov Y. Applied potential of task-free event-related paradigms for assessing neurocognitive functions in disorders of consciousness. Brain Commun 2020; 2:fcaa087. [PMID: 33134912 PMCID: PMC7585695 DOI: 10.1093/braincomms/fcaa087] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2019] [Revised: 04/21/2020] [Accepted: 04/29/2020] [Indexed: 12/17/2022] Open
Abstract
Diagnosing patients with disorders of consciousness is immensely difficult and often results in misdiagnoses, which can have fatal consequences. Despite the severity of this well-known issue, a reliable assessment tool has not yet been developed and implemented in the clinic. The main aim of this focused review is to evaluate the various event-related potential paradigms, recorded using EEG, which may be used to improve the assessment of patients with disorders of consciousness; we also provide a brief comparison of these paradigms with other measures. Notably, most event-related potential studies on the topic have focused on testing a small set of components, or even just a single component. However, to be of practical use, we argue that an assessment should probe a range of cognitive and linguistic functions at once. We suggest a novel approach that combines a set of well-tested auditory event-related potential components: N100, mismatch negativity, P3a, N400, early left anterior negativity and lexical response enhancement. Combining these components in a single, task-free design will provide a multidimensional assessment of cognitive and linguistic processes, which may help physicians make a more precise diagnosis.
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Affiliation(s)
- Marie Louise Holm Møller
- Center of Functionally Integrative Neuroscience (CFIN), Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Andreas Højlund
- Center of Functionally Integrative Neuroscience (CFIN), Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Mads Jensen
- Center of Functionally Integrative Neuroscience (CFIN), Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Christelle Gansonre
- Center of Functionally Integrative Neuroscience (CFIN), Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Yury Shtyrov
- Center of Functionally Integrative Neuroscience (CFIN), Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
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9
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Song M, Yang Y, Yang Z, Cui Y, Yu S, He J, Jiang T. Prognostic models for prolonged disorders of consciousness: an integrative review. Cell Mol Life Sci 2020; 77:3945-61. [PMID: 32306061 DOI: 10.1007/s00018-020-03512-z] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2019] [Revised: 03/23/2020] [Accepted: 03/30/2020] [Indexed: 12/21/2022]
Abstract
Disorders of consciousness (DoC) are acquired conditions of severe altered consciousness. During the past decades, some prognostic models for DoC have been explored on the basis of a variety of predictors, including demographics, neurological examinations, clinical diagnosis, neurophysiology and brain images. In this article, a systematic review of pertinent literature was conducted. We identified and evaluated 21 prognostic models involving a total of 1201 DoC patients. In terms of the reported accuracies of predicting the prognosis of DoC, these 21 models vary widely, ranging from 60 to 90%. Using improvement of consciousness level as favorable outcome criteria, we performed a quantitative meta-analysis, and found that the pooled sensitivity and specificity of the hybrid model that combined more than one technique were both superior to those of any single technique, including EEG and fMRI at the tasks and resting state. These results support the view that any single technique has its own advantages and limitations; and the integrations of multiple techniques, including diverse brain images and different paradigms, have the potential to improve predictive accuracy for DoC. Then, we provide methodological points of view and some prospects about future research. Totally, in comparison to a great many diagnostic methods for the DoC, the research of prognostic models is sparse and preliminary, still largely in its infancy with many challenges and opportunities.
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10
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Formisano R, Giustini M, Aloisi M, Contrada M, Schnakers C, Zasler N, Estraneo A. An International survey on diagnostic and prognostic protocols in patients with disorder of consciousness. Brain Inj 2019; 33:974-984. [DOI: 10.1080/02699052.2019.1622785] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Affiliation(s)
| | | | | | - Marianna Contrada
- IRCCS Santa Lucia Foundation, Rome, Italy
- Behavioral Neuroscience, Sapienza University of Rome, Rome Italy
| | - Caroline Schnakers
- Research Institute, Casa Colina Hospital and Centers of Healthcare, Pomona, CA, USA; Psychiatry Department, University of California, Los Angeles, CA, USA
| | - Nathan Zasler
- Department of Physical Medicine and Rehabilitation, Concussion Care Centre of Virginia, Ltd, Tree of Life Services, Inc, Richmond, Virginia, USA
| | - Anna Estraneo
- Emergency Neurology Department, Santa Maria della Pietà General Hospital, Nola NA, Italy
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11
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O'Donnell JC, Browne KD, Kilbaugh TJ, Chen HI, Whyte J, Cullen DK. Challenges and demand for modeling disorders of consciousness following traumatic brain injury. Neurosci Biobehav Rev 2019; 98:336-346. [PMID: 30550859 PMCID: PMC7847278 DOI: 10.1016/j.neubiorev.2018.12.015] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2018] [Revised: 11/02/2018] [Accepted: 12/11/2018] [Indexed: 12/29/2022]
Abstract
Following severe traumatic brain injury (TBI), many patients experience coma - an unresponsive state lacking wakefulness or awareness. Coma rarely lasts more than two weeks, and emergence involves passing through a state of wakefulness without awareness of self or environment. Patients that linger in these Disorders of Consciousness (DoC) undergo clinical assessments of awareness for diagnosis into Unresponsive Wakefulness Syndrome (no awareness, also called vegetative state) or Minimally Conscious State (periodic increases in awareness). These diagnoses are notoriously inaccurate, offering little prognostic value. Recovery of awareness is unpredictable, returning within weeks, years, or never. This leaves patients' families with difficult decisions and little information on which to base them. Clinical studies have made significant advancements, but remain encumbered by high variability, limited data output, and a lack of necessary controls. Herein we discuss the clear and present need to establish a preclinical model of TBI-induced DoC, the significant challenges involved, and how such a model can be applied to support DoC research.
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Affiliation(s)
- John C O'Donnell
- Center for Brain Injury & Repair, Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States; Center for Neurotrauma, Neurodegeneration & Restoration, Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, PA, United States
| | - Kevin D Browne
- Center for Brain Injury & Repair, Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States; Center for Neurotrauma, Neurodegeneration & Restoration, Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, PA, United States
| | - Todd J Kilbaugh
- Center for Brain Injury & Repair, Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States; Department of Anesthesiology and Critical Care Medicine, Perelman School of Medicine, University of Pennsylvania, The Children's Hospital of Philadelphia, Philadelphia, PA, United States
| | - H Isaac Chen
- Center for Brain Injury & Repair, Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States; Center for Neurotrauma, Neurodegeneration & Restoration, Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, PA, United States
| | - John Whyte
- Moss Rehabilitation Research Institute, Elkins Park, PA, United States
| | - D Kacy Cullen
- Center for Brain Injury & Repair, Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States; Center for Neurotrauma, Neurodegeneration & Restoration, Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, PA, United States; Department of Bioengineering, School of Engineering and Applied Science, University of Pennsylvania, Philadelphia, PA, United States.
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12
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Pascarella A, Fiorenza S, Masotta O, Tibollo V, Vella D, Nardone A, Rossi M, Volanti P, Madonia F, Castronovo G, De Cicco D, Guarnaschelli C, Achilli MP, Chiapparino C, Angelillo MT, Tommasi MA, Pisano F, Grioni G, Vezzadini G, Ferriero G, Salvaderi S, Bellazzi R, Estraneo A. Multicentre registry of brain-injured patients with disorder of consciousness: rationale and preliminary data. Funct Neurol 2019; 33:19-30. [PMID: 29633693 PMCID: PMC5901937 DOI: 10.11138/fneur/2018.33.1.019] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Diagnostic accuracy and reliable estimation of clinical evolution are challenging issues in the management of patients with disorders of consciousness (DoC). Longitudinal systematic investigations conducted in large cohorts of patients with DoC could make it possible to identify reliable diagnostic and prognostic markers. On the basis of this consideration, we devised a multicentre prospective registry for patients with DoC admitted to ten intensive rehabilitation units. The registry collects homogeneous and detailed data on patients' demographic and clinical features, neurophysiological and neuroimaging findings, and medical and surgical complications. Here we present the rationale and the design of the registry and the preliminary results obtained in 53 patients with DoC (vegetative state or minimally conscious state) enrolled during the first seven months of the study. Data at 6-month post-injury follow-up were available for 46 of them. This registry could be an important tool for collecting high-quality data through the application of rigorous methods, and it could be used in the routine management of patients with DoC admitted to rehabilitation settings.
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Affiliation(s)
- Angelo Pascarella
- Neurorehabilitation Unit and Research Laboratory for Disorder of Consciousness, Scientific Institute of Telese Terme, ICS Maugeri, Telese Terme (BN), Italy
| | - Salvatore Fiorenza
- Neurorehabilitation Unit and Research Laboratory for Disorder of Consciousness, Scientific Institute of Telese Terme, ICS Maugeri, Telese Terme (BN), Italy
| | - Orsola Masotta
- Neurorehabilitation Unit and Research Laboratory for Disorder of Consciousness, Scientific Institute of Telese Terme, ICS Maugeri, Telese Terme (BN), Italy
| | - Valentina Tibollo
- Laboratory of System Engineer for Clinical Research, ICS Maugeri, Pavia, Italy
| | - Danila Vella
- Laboratory of System Engineer for Clinical Research, ICS Maugeri, Pavia, Italy
| | - Antonio Nardone
- Neurorehabilitation Unit, Institute of Pavia, ICS Maugeri, Pavia, Italy
- Department of Clinical-Surgical, Diagnostic and Pediatric Sciences, University of Pavia, Pavia, Italy
| | - Maria Rossi
- Neurorehabilitation Unit, Institute of Pavia, ICS Maugeri, Pavia, Italy
| | - Paolo Volanti
- Neurorehabilitation Unit, Institute of Mistretta, ICS Maugeri, Mistretta (ME), Italy
| | - Francesca Madonia
- Neurorehabilitation Unit, Institute of Mistretta, ICS Maugeri, Mistretta (ME), Italy
| | | | - Domenico De Cicco
- Neurorehabilitation Unit, Institute of Sciacca, ICS Maugeri, Sciacca (AG), Italy
| | | | - Maria Pia Achilli
- Neurorehabilitation Unit, Institute of Montescano, ICS Maugeri, Montescano (PV), Italy
| | - Concetta Chiapparino
- Neurorehabilitation Unit, Institute of Cassano delle Murge, ICS Maugeri, Cassano delle Murge (BA), Italy
| | - Maria Teresa Angelillo
- Neurorehabilitation Unit, Institute of Cassano delle Murge, ICS Maugeri, Cassano delle Murge (BA), Italy
| | | | - Fabrizio Pisano
- Neurorehabilitation Unit, Institute of Veruno, ICS Maugeri, Veruno (NO), Italy
| | - Giuseppe Grioni
- Neurorehabilitation Unit, Institute of Castel Goffredo, ICS Maugeri, Castel Goffredo (MN), Italy
| | - Giuliana Vezzadini
- Neurorehabilitation Unit, Institute of Castel Goffredo, ICS Maugeri, Castel Goffredo (MN), Italy
| | - Giorgio Ferriero
- Neurorehabilitation Unit, Institute of Lissone, ICS Maugeri, Lissone (MB), Italy
| | - Stefano Salvaderi
- Neurorehabilitation Unit, Institute of Lissone, ICS Maugeri, Lissone (MB), Italy
| | - Riccardo Bellazzi
- Laboratory of System Engineer for Clinical Research, ICS Maugeri, Pavia, Italy
| | - Anna Estraneo
- Neurorehabilitation Unit and Research Laboratory for Disorder of Consciousness, Scientific Institute of Telese Terme, ICS Maugeri, Telese Terme (BN), Italy
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Schneider C, Perdikis S, Silva M, Johr J, Pincherle A, Millan JDR, Diserens K. Motor Attempt EEG Paradigm as a Diagnostic Tool for Disorders of Consciousness. Annu Int Conf IEEE Eng Med Biol Soc 2018; 2018:4681-4684. [PMID: 30441394 DOI: 10.1109/embc.2018.8513217] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
To investigate whether a motor attempt EEG paradigm coupled with functional electrical stimulation can detect command following and, therefore, signs of conscious awareness in patients with disorders of consciousness, we recorded nine patients admitted to acute rehabilitation after a brain lesion. We extracted peak classification accuracy and peak session discriminant power (PSDP) and we assessed their correlation to the established coma recovery scale revised (CRS-R) and the agreement with diagnosis based on the novel motor behavior tool (MBT). Only PSDP correlated significantly with CRS-R and it also outperformed peak accuracy regarding the MBT. We conclude that PSDP might be more suitable than accuracy to complement CRS-R and MBT in evaluating ambiguous cases and in detecting cognitive motor dissociation.
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Hauger SL, Olafsen K, Schnakers C, Andelic N, Nilsen KB, Helseth E, Funderud I, Andersson S, Schanke AK, Løvstad M. Cognitive Event-Related Potentials during the Sub-Acute Phase of Severe Traumatic Brain Injury and Their Relationship to Outcome. J Neurotrauma 2017; 34:3124-3133. [PMID: 28594285 DOI: 10.1089/neu.2017.5062] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
Predicting outcome in the early phase after severe traumatic brain injury (sTBI) is a major clinical challenge, particularly identifying patients with potential for good cognitive outcome. The current single-center prospective study aimed to explore presence and normalization of electroencephalography (EEG)-based event-related potentials (ERPs) in the early phase followings TBI, and their relationship to functional and cognitive outcome 6 months post-injury. Fourteen adult patients (eight males) with sTBI were recruited from the neurointensive care unit (mean age = 38.2 years [standard deviation (SD) = 14.7]; mean lowest Glasgow Coma Scale (GCS) score within first 24 h = 5.4, SD = 1.87). EEG recordings were conducted biweekly at three time-points applying an ERP paradigm encompassing a passive condition involving hearing their own name randomly interspersed between an unfamiliar name (UN), and an active condition with instruction to count their own name. Functional and cognitive outcome 6 months post-injury was measured with Glasgow Outcome Scale-Extended (GOSE) and neuropsychological tests of attention and memory. Ten patients demonstrated a significantly enhanced cognitive P3 in the active counting task compared with passive listening across recordings, and six presented with normalization of P3 in the counting task. Moreover, P3 amplitude to the counting task at the third time-point was positively correlated with both functional outcome (GOSE) and cognition (verbal learning, attentional set-shifting, and switching) 6 months post-injury. ERP can index cognitive capacities in the early phase following sTBI, and the cognitive P3 component in an active design is associated with functional and cognitive outcome, demonstrating that the cognitive P3 may yield valuable information of residual cognition and provide supplementary prognostic information.
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Affiliation(s)
- Solveig L Hauger
- 1 Department of Research, Sunnaas Rehabilitation Hospital , Nesoddtangen, Norway .,2 Department of Psychology, University of Oslo , Norway
| | - Kjell Olafsen
- 3 Department of Neurointensive Treatment, Oslo University Hospital , Norway
| | - Caroline Schnakers
- 4 Neurosurgery Department, University of California , Los Angeles.,5 Research Institute , Casa Colina Hospital and Centers of Healthcare, Pomona, California
| | - Nada Andelic
- 6 Department of Physical Medicine and Rehabilitation, Oslo University Hospital , Norway .,7 Institute of Health and Society, CHARM (Center for Habilitation and Rehabilitation Models and Services), Faculty of Medicine, University of Oslo , Norway
| | - Kristian Bernhard Nilsen
- 8 Department of Neurology, Oslo University Hospital , Norway .,9 Department of Neuroscience, Norwegian University of Science and Technology , Norway
| | - Eirik Helseth
- 10 Department of Neurosurgery, Oslo University Hospital , Norway .,11 Faculty of Medicine, University of Oslo , Norway
| | | | | | - Anne-Kristine Schanke
- 1 Department of Research, Sunnaas Rehabilitation Hospital , Nesoddtangen, Norway .,2 Department of Psychology, University of Oslo , Norway
| | - Marianne Løvstad
- 1 Department of Research, Sunnaas Rehabilitation Hospital , Nesoddtangen, Norway .,2 Department of Psychology, University of Oslo , Norway
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15
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Edlow BL, Chatelle C, Spencer CA, Chu CJ, Bodien YG, O'Connor KL, Hirschberg RE, Hochberg LR, Giacino JT, Rosenthal ES, Wu O. Early detection of consciousness in patients with acute severe traumatic brain injury. Brain 2017; 140:2399-2414. [PMID: 29050383 DOI: 10.1093/brain/awx176] [Citation(s) in RCA: 198] [Impact Index Per Article: 28.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2017] [Accepted: 05/29/2017] [Indexed: 01/03/2023] Open
Abstract
See Schiff (doi:10.1093/awx209) for a scientific commentary on this article. Patients with acute severe traumatic brain injury may recover consciousness before self-expression. Without behavioural evidence of consciousness at the bedside, clinicians may render an inaccurate prognosis, increasing the likelihood of withholding life-sustaining therapies or denying rehabilitative services. Task-based functional magnetic resonance imaging and electroencephalography techniques have revealed covert consciousness in the chronic setting, but these techniques have not been tested in the intensive care unit. We prospectively enrolled 16 patients admitted to the intensive care unit for acute severe traumatic brain injury to test two hypotheses: (i) in patients who lack behavioural evidence of language expression and comprehension, functional magnetic resonance imaging and electroencephalography detect command-following during a motor imagery task (i.e. cognitive motor dissociation) and association cortex responses during language and music stimuli (i.e. higher-order cortex motor dissociation); and (ii) early responses to these paradigms are associated with better 6-month outcomes on the Glasgow Outcome Scale-Extended. Patients underwent functional magnetic resonance imaging on post-injury Day 9.2 ± 5.0 and electroencephalography on Day 9.8 ± 4.6. At the time of imaging, behavioural evaluation with the Coma Recovery Scale-Revised indicated coma (n = 2), vegetative state (n = 3), minimally conscious state without language (n = 3), minimally conscious state with language (n = 4) or post-traumatic confusional state (n = 4). Cognitive motor dissociation was identified in four patients, including three whose behavioural diagnosis suggested a vegetative state. Higher-order cortex motor dissociation was identified in two additional patients. Complete absence of responses to language, music and motor imagery was only observed in coma patients. In patients with behavioural evidence of language function, responses to language and music were more frequently observed than responses to motor imagery (62.5-80% versus 33.3-42.9%). Similarly, in 16 matched healthy subjects, responses to language and music were more frequently observed than responses to motor imagery (87.5-100% versus 68.8-75.0%). Except for one patient who died in the intensive care unit, all patients with cognitive motor dissociation and higher-order cortex motor dissociation recovered beyond a confusional state by 6 months. However, 6-month outcomes were not associated with early functional magnetic resonance imaging and electroencephalography responses for the entire cohort. These observations suggest that functional magnetic resonance imaging and electroencephalography can detect command-following and higher-order cortical function in patients with acute severe traumatic brain injury. Early detection of covert consciousness and cortical responses in the intensive care unit could alter time-sensitive decisions about withholding life-sustaining therapies.
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Affiliation(s)
- Brian L Edlow
- Center for Neurotechnology and Neurorecovery, Massachusetts General Hospital, 175 Cambridge Street, Boston, MA, 02114, USA.,Department of Neurology, Massachusetts General Hospital, Harvard Medical School, 175 Cambridge Street, Boston, MA, 02114, USA.,Athinoula A. Martinos Center for Biomedical Imaging, Department of Radiology, Massachusetts General Hospital, Harvard Medical School, 149 13th Street, Charlestown, MA 02129, USA
| | - Camille Chatelle
- Center for Neurotechnology and Neurorecovery, Massachusetts General Hospital, 175 Cambridge Street, Boston, MA, 02114, USA.,Department of Neurology, Massachusetts General Hospital, Harvard Medical School, 175 Cambridge Street, Boston, MA, 02114, USA.,Coma Science Group, GIGA Consciousness, University and University Hospital of Liège, Liège, Belgium
| | - Camille A Spencer
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, 175 Cambridge Street, Boston, MA, 02114, USA
| | - Catherine J Chu
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, 175 Cambridge Street, Boston, MA, 02114, USA
| | - Yelena G Bodien
- Center for Neurotechnology and Neurorecovery, Massachusetts General Hospital, 175 Cambridge Street, Boston, MA, 02114, USA.,Department of Neurology, Massachusetts General Hospital, Harvard Medical School, 175 Cambridge Street, Boston, MA, 02114, USA.,Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Harvard Medical School, 300 First Avenue, Charlestown, MA, 02129, USA
| | - Kathryn L O'Connor
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, 175 Cambridge Street, Boston, MA, 02114, USA
| | - Ronald E Hirschberg
- Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Harvard Medical School, 300 First Avenue, Charlestown, MA, 02129, USA.,Department of Physical Medicine and Rehabilitation, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Boston, MA, 02114, USA
| | - Leigh R Hochberg
- Center for Neurotechnology and Neurorecovery, Massachusetts General Hospital, 175 Cambridge Street, Boston, MA, 02114, USA.,Department of Neurology, Massachusetts General Hospital, Harvard Medical School, 175 Cambridge Street, Boston, MA, 02114, USA.,Department of Engineering, Brown University, 184 Hope St, Providence, RI, 02912, USA
| | - Joseph T Giacino
- Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Harvard Medical School, 300 First Avenue, Charlestown, MA, 02129, USA.,Department of Physical Medicine and Rehabilitation, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Boston, MA, 02114, USA
| | - Eric S Rosenthal
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, 175 Cambridge Street, Boston, MA, 02114, USA
| | - Ona Wu
- Athinoula A. Martinos Center for Biomedical Imaging, Department of Radiology, Massachusetts General Hospital, Harvard Medical School, 149 13th Street, Charlestown, MA 02129, USA
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