Behavioral signs of recovery from unresponsive wakefulness syndrome to emergence of minimally conscious state after severe brain injury

BACKGROUND

A precise description of behavioral signs denoting transition from an unresponsive wakefulness syndrome/vegetative state (UWS/VS) to minimally conscious state (MCS) or emergence from MCS after severe brain injury is crucial for prognostic purposes. A few studies have attempted this goal but involved non-standardized instruments, limited temporal accuracy or samples or focused on patients with (sub)acute condition.

OBJECTIVES

We aimed to describe the behavioral signs that led to a change in diagnosis as well as the factors affecting this transition in a large sample of patients with chronic disorders of consciousness after severe brain injury.

METHODS

In this retrospective cohort study, patients in UWS/VS or MCS were assessed with the Coma Recovery Scale Revised (CRS-R) at 5 times within the 2 weeks after their admission to a neurorehabilitation center and then weekly until emergence from MCS, discharge or death.

RESULTS

Of the 185 patients included, 33 in UWS/VS and 45 in MCS transitioned to another state. Transition to MCS was mostly denoted by one behavioral sign (71%), predominantly visual fixation, followed by localization to noxious stimulation, and visual pursuit, and could be predicted by etiology, time post-injury and age. Emergence from MCS was characterized by one sign in 64% of patients and by 2 signs (functional communication and objects use) in the remaining patients and could be predicted by time post-injury and number of behavioral signs at admission.

CONCLUSIONS

Transition from UWS to MCS was predominantly signalled by visual fixation and could be predicted by etiology, time post-injury and age. Emergence from MCS was mostly signalled by one sign and could be predicted by time post-injury and number of behavioral signs at admission. Clinicians should pay particular attention to visual and motor subscales of the CRS-R to detect behavioral recovery after severe brain injury. Database registration. ClinicalTrials.gov: NCT04687397.

Do you see me? The role of visual fixation in chronic disorders of consciousness differential diagnosis

Visual fixation (VF) of a target is a possible, although atypical, feature of the Unresponsive Wakefulness Syndrome (UWS). Whether VF may indicate residual awareness in these patients is debatable, since it may simply subtend a series of reflex processes. Objective tools should therefore be used to identify aware VF, which depends on the integrity of visuomotor networks encompassing frontal-parietal-occipital areas. The aim of our study was to detect residual visuomotor network functionality potentially sustaining aware VF. To this end, we evaluated the visuomotor integration (VMI) and visual P300 patterns in a chronic Disorder of Consciousness (DOC) sample and a control group of healthy individuals (HC), using an associative stimulation protocol combining transcranial magnetic stimulation (TMS) with visual stimulation through transorbital alternating current stimulation. The Minimally Conscious State (MCS) patients showed preserved patterns of VMI and P300, whereas nearly all the UWS patients showed no significant VMI. Notably, the electrophysiological findings were correlated with the visual domain of the Coma Recovery Scale-Revised. Nonetheless, two fixating UWS individuals had a VMI similar to MCS patients. Our data suggest that some UWS patients showing VF could be aware, but unable to manifest it clearly, probably because of a severe motor output impairment, which is a condition compatible with the Functional Locked-In Syndrome.

Multiple Victims: The Result of Caring Patients in Vegetative State

Background:

Having a patient in a vegetative state in the family is a complicated and stressful experience. Caring for such patients with complete disability at home is very challenging.

Objectives:

The present study aimed to explore the outcomes of caring for patients in a vegetative state for families and caregivers at home.

Patients and Methods:

In this qualitative study, 16 vegetative patients’ caregivers were selected through purposive sampling. Unstructured interviews and observations were used for data gathering. Data collection was continued until saturation of data and emergence of the main themes. Data analysis was performed by the content analysis method.

Results:

The analysis of the gathered data led to three themes: “lost main caregiver”, “affected caring partner” and “affected family”. Each theme had some subthemes and subcategories.

Conclusions:

The three emerged themes in this study showed that all the family members of vegetative patients, depending on their responsibilities, were affected by physical, mental, social and economic issues.

Serial measurement of Wessex Head Injury Matrix in the diagnosis of patients in vegetative and minimally conscious states: a cohort analysis

OBJECTIVE

To evaluate serial application of the Wessex Head Injury Matrix (WHIM) in diagnosis of prolonged disorders of consciousness (PDOC). Specifically, to determine whether the trajectory of change predicts outcome status, and whether the current hierarchical order of WHIM items is correct for this context.

DESIGN

Analysis of prospectively gathered clinical cohort data.

SETTING

Consecutive admissions to a tertiary in-patient neurorehabilitation service for evaluation of PDOC in real-life clinical practice, over a 10-year period (2004-2014).

PARTICIPANTS

Patients (n=65) presenting in sudden-onset vegetative (VS) or minimally conscious states (MCS). Mean age 38.4 (sd14.1) years; male:female ratio 66%:33%. Aetiology of brain injury: 40(62%) traumatic; 12(19%) vascular; 11(17%) hypoxic; 3(3%) other.

PRIMARY OUTCOME MEASURE

WHIM alongside detailed clinical evaluation.

METHODS

The WHIM was administered serially by the multidisciplinary team throughout an in-patient evaluation programme (mean length 74 (sd42) days). Patients were divided into four groups, according to PDOC status on discharge (VS, MCS-Minus, MCS-Plus or Emerged).

RESULTS

WHIM hierarchical scores (Most Advanced Behaviour (MAB)) correlated with PDOC status at discharge (Pearson r=0.49, p<0.001). In the original order, the MAB distinguished the 'VS', 'MCS' and 'Emerged' categories (analysis of variance (ANOVA) post hoc p<0.001), but not the subgroups of MCS-Minus and MCS-Plus. In stepwise regression analysis, MAB-Ex (excluding two items) accounted for 68% of the variance in PDOC status at discharge. On multilevel statistical modelling, trajectory of change in MAB separated the four PDOC groups, both at individual and at group level (p<0.001). After reordering of items, the new-order MAB accounted for more (73%) of the variance in PDOC status, and also distinguished significantly between MCS-Minus and MCS-Plus groups at discharge (p<0.002).

CONCLUSIONS

The WHIM is a useful diagnostic tool in PDOC, and trajectory of change is an important predictor of outcome. The proposed new hierarchical order requires further evaluation in future multicentre analyses.

Disorders of consciousness and disordered care: families, caregivers, and narratives of necessity

By their nature, care decisions for patients with severe disorders of consciousness must involve surrogates. Patients, so impaired, have lost their decision-making capacity and the ability to direct their own care. Surrogates-family members, friends, or other intimates-must step in and make decisions about ongoing care or its withdrawal. This article shares the narrative experiences of these surrogate decision makers as they encounter the American health care system and accompany patients from injury through rehabilitation. Through their perspectives, the article considers challenges to ongoing care and rehabilitation that are a function of a prevailing medical infrastructure and reimbursement framework better suited to patients with acute care needs. Specific attention is paid to the ethical challenges posed by reimbursement strategies such as "medical necessity" as well as those proposed for the Affordable Care Act. The argument concludes that when it comes to care for a disorder related to consciousness, its provision is not discretionary, and its receipt is not an entitlement but a civil right.

DTI BASED STRUCTURAL DAMAGE CHARACTERIZATION FOR DISORDERS OF CONSCIOUSNESS

MRI Diffusion Tensor Imaging (DTI) has been recently proposed as a highly discriminative measurement to detect structural damages in Disorders of Consciousness patients (Vegetative State/Unresponsive Wakefulness Syndrome-(VS/UWS) and Minimally Consciousness State-MCS). In the DTI analysis, certain tensor features are often used as simplified scalar indices to represent these alterations. Those characteristics are mathematically and statistically more tractable than the full tensors. Nevertheless, most of these quantities are based on a tensor diffusivity estimation, the arithmetic average among the different strengths of the tensor orthogonal directions, which is supported on a symmetric linear relationship among the three directions, an unrealistic assumption for severely damaged brains. In this paper, we propose a new family of scalar quantities based on Generalized Ordered Weighted Aggregations (GOWA) to characterize morphological damages. The main idea is to compute a tensor diffusitivity estimation that captures the deviations in the water diffusivity associated to damaged tissue. This estimation is performed by weighting and combining differently each tensor orthogonal strength. Using these new scalar quantities we construct an affine invariant DTI tensor feature using regional tissue histograms. An evaluation of these new scalar quantities on 48 patients (23 VS/UWS and 25 MCS) was conducted. Our experiments demonstrate that this new representation outperforms state-of-the-art tensor based scalar representations for characterization and classification problems.