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Guideline of clinical neurorestorative treatment for brain trauma (2022 China version). JOURNAL OF NEURORESTORATOLOGY 2022. [DOI: 10.1016/j.jnrt.2022.100005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
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102
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Curley WH, Comanducci A, Fecchio M. Conventional and Investigational Approaches Leveraging Clinical EEG for Prognosis in Acute Disorders of Consciousness. Semin Neurol 2022; 42:309-324. [PMID: 36100227 DOI: 10.1055/s-0042-1755220] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
Abstract
Prediction of recovery of consciousness after severe brain injury is difficult and limited by a lack of reliable, standardized biomarkers. Multiple approaches for analysis of clinical electroencephalography (EEG) that shed light on prognosis in acute severe brain injury have emerged in recent years. These approaches fall into two major categories: conventional characterization of EEG background and quantitative measurement of resting state or stimulus-induced EEG activity. Additionally, a small number of studies have associated the presence of electrophysiologic sleep features with prognosis in the acute phase of severe brain injury. In this review, we focus on approaches for the analysis of clinical EEG that have prognostic significance and that could be readily implemented with minimal additional equipment in clinical settings, such as intensive care and intensive rehabilitation units, for patients with acute disorders of consciousness.
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Affiliation(s)
- William H Curley
- Harvard Medical School, Boston, Massachusetts.,Department of Neurology, Center for Neurotechnology and Neurorecovery, Massachusetts General Hospital, Boston, Massachusetts
| | - Angela Comanducci
- IRCSS Fondazione Don Carlo Gnocchi ONLUS, Milan, Italy.,Università Campus Bio-Medico di Roma, Rome, Italy
| | - Matteo Fecchio
- Department of Neurology, Center for Neurotechnology and Neurorecovery, Massachusetts General Hospital, Boston, Massachusetts
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103
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Baek H, Lockwood D, Mason EJ, Obusez E, Poturalski M, Rammo R, Nagel SJ, Jones SE. Clinical Intervention Using Focused Ultrasound (FUS) Stimulation of the Brain in Diverse Neurological Disorders. Front Neurol 2022; 13:880814. [PMID: 35614924 PMCID: PMC9124976 DOI: 10.3389/fneur.2022.880814] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Accepted: 04/07/2022] [Indexed: 12/02/2022] Open
Abstract
Various surgical techniques and pharmaceutical treatments have been developed to improve the current technologies of treating brain diseases. Focused ultrasound (FUS) is a new brain stimulation modality that can exert a therapeutic effect on diseased brain cells, with this effect ranging from permanent ablation of the pathological neural circuit to transient excitatory/inhibitory modulation of the neural activity depending on the acoustic energy of choice. With the development of intraoperative imaging technology, FUS has become a clinically available noninvasive neurosurgical option with visual feedback. Over the past 10 years, FUS has shown enormous potential. It can deliver acoustic energy through the physical barrier of the brain and eliminate abnormal brain cells to treat patients with Parkinson's disease and essential tremor. In addition, FUS can help introduce potentially beneficial therapeutics at the exact brain region where they need to be, bypassing the brain's function barrier, which can be applied for a wide range of central nervous system disorders. In this review, we introduce the current FDA-approved clinical applications of FUS, ranging from thermal ablation to blood barrier opening, as well as the emerging applications of FUS in the context of pain control, epilepsy, and neuromodulation. We also discuss the expansion of future applications and challenges. Broadening FUS technologies requires a deep understanding of the effect of ultrasound when targeting various brain structures in diverse disease conditions in the context of skull interface, anatomical structure inside the brain, and pathology.
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Affiliation(s)
- Hongchae Baek
- Cleveland Clinic, Imaging Institute, Cleveland, OH, United States
- Center for Neurological Restoration, Cleveland Clinic, Neurological Institute, Cleveland, OH, United States
| | - Daniel Lockwood
- Cleveland Clinic, Imaging Institute, Cleveland, OH, United States
| | | | - Emmanuel Obusez
- Cleveland Clinic, Imaging Institute, Cleveland, OH, United States
| | | | - Richard Rammo
- Center for Neurological Restoration, Cleveland Clinic, Neurological Institute, Cleveland, OH, United States
| | - Sean J. Nagel
- Center for Neurological Restoration, Cleveland Clinic, Neurological Institute, Cleveland, OH, United States
| | - Stephen E. Jones
- Cleveland Clinic, Imaging Institute, Cleveland, OH, United States
- *Correspondence: Stephen E. Jones
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104
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Papadimitriou C, Weaver JA, Guernon A, Walsh E, Mallinson T, Pape TLB. "Fluctuation is the norm": Rehabilitation practitioner perspectives on ambiguity and uncertainty in their work with persons in disordered states of consciousness after traumatic brain injury. PLoS One 2022; 17:e0267194. [PMID: 35446897 PMCID: PMC9022828 DOI: 10.1371/journal.pone.0267194] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Accepted: 04/04/2022] [Indexed: 11/19/2022] Open
Abstract
The purpose of this study is to describe the clinical lifeworld of rehabilitation practitioners who work with patients in disordered states of consciousness (DoC) after severe traumatic brain injury (TBI). We interviewed 21 practitioners using narrative interviewing methods from two specialty health systems that admit patients in DoC to inpatient rehabilitation. The overarching theme arising from the interview data is "Experiencing ambiguity and uncertainty in clinical reasoning about consciousness" when treating persons in DoC. We describe practitioners' practices of looking for consistency, making sense of ambiguous and hard to explain patient responses, and using trial and error or "tinkering" to care for patients. Due to scientific uncertainty about diagnosis and prognosis in DoC and ambiguity about interpretation of patient responses, working in the field of DoC disrupts the canonical meaning-making processes that practitioners have been trained in. Studying the lifeworld of rehabilitation practitioners through their story-making and story-telling uncovers taken-for-granted assumptions and normative structures that may exist in rehabilitation medical and scientific culture, including practitioner training. We are interested in understanding these canonical breaches in order to make visible how practitioners make meaning while treating patients.
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Affiliation(s)
- Christina Papadimitriou
- Departments of Interdisciplinary Health Sciences, and Sociology, Oakland University, Rochester, MI, United States of America
| | - Jennifer A. Weaver
- Department of Occupational Therapy, Colorado State University, Fort Collins, CO, United States of America
| | - Ann Guernon
- Speech-Language Pathology Department, Lewis University, Romeoville, IL, United States of America
| | - Elyse Walsh
- Research Service and Center for Innovation in Complex Chronic Healthcare, Edward Hines Jr. VA, Hines, IL, United States of America
| | - Trudy Mallinson
- Department of Clinical Research & Leadership, George Washington University, Washington, DC, United States of America
| | - Theresa L. Bender Pape
- Research Service and Center for Innovation in Complex Chronic Healthcare, Edward Hines Jr. VA, Hines, IL, United States of America
- Department of Physical Medicine and Rehabilitation, Northwestern University, Chicago, IL, United States of America
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105
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Aronson JP, Katnani HA, Huguenard A, Mulvaney G, Bader ER, Yang JC, Eskandar EN. Phasic stimulation in the nucleus accumbens enhances learning after traumatic brain injury. Cereb Cortex Commun 2022; 3:tgac016. [PMID: 35529519 PMCID: PMC9070350 DOI: 10.1093/texcom/tgac016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2021] [Revised: 03/31/2022] [Accepted: 04/04/2022] [Indexed: 11/13/2022] Open
Abstract
Traumatic brain injury (TBI) is a significant cause of morbidity and mortality worldwide. Despite improvements in survival, treatments that improve functional outcome remain lacking. There is, therefore, a pressing need to develop novel treatments to improve functional recovery. Here, we investigated task-matched deep-brain stimulation of the nucleus accumbens (NAc) to augment reinforcement learning in a rodent model of TBI. We demonstrate that task-matched deep brain stimulation (DBS) of the NAc can enhance learning following TBI. We further demonstrate that animals receiving DBS exhibited greater behavioral improvement and enhanced neural proliferation. Treated animals recovered to an uninjured behavioral baseline and showed retention of improved performance even after stimulation was stopped. These results provide encouraging early evidence for the potential of NAc DBS to improve functional outcomes following TBI and that its effects may be broad, with alterations in neurogenesis and synaptogenesis.
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Affiliation(s)
- Joshua P Aronson
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
- Section of Neurosurgery, Department of Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
| | - Husam A Katnani
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Anna Huguenard
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Graham Mulvaney
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Edward R Bader
- Department of Neurological Surgery, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Jimmy C Yang
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Emad N Eskandar
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
- Department of Neurological Surgery, Albert Einstein College of Medicine, Bronx, NY, USA
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106
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Servider J, Saadon JR, Adachi J, Shen E, Mikell CB, Mofakham S. Cortical recordings reveal hidden early signs of recovery following traumatic brain injury: A case report. Brain Res 2022; 1786:147903. [PMID: 35381214 DOI: 10.1016/j.brainres.2022.147903] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Revised: 03/29/2022] [Accepted: 03/31/2022] [Indexed: 11/02/2022]
Abstract
Prognosticating recovery of consciousness after severe traumatic brain injury (TBI) is a difficult task. Understanding the mechanism of recovery of consciousness in these patients will undoubtedly help clarify this issue. Recent research has underscored the importance of electrophysiological data in characterizing the state of the brain during this period of unconsciousness. Here, we investigated cortical electrophysiological recordings from a single TBI patient and discovered that high-frequency activity associated with the return of consciousness reappeared in a spatiotemporal fashion. We observed a shift toward higher frequencies first in the anterior cingulate cortex, and then later in the dorsolateral prefrontal cortex. This finding suggests that recovery may originate in more internal cortices and progress to superficial ones. Although this observation occurred in a single patient, it points to a potential mechanism for recovery of normal cortical activity in the return of consciousness following TBI.
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Affiliation(s)
- John Servider
- Department of Neurosurgery, Renaissance School of Medicine at Stony Brook University, Stony Brook, NY, USA
| | - Jordan R Saadon
- Department of Neurosurgery, Renaissance School of Medicine at Stony Brook University, Stony Brook, NY, USA
| | - Joseph Adachi
- Department of Neurosurgery, Renaissance School of Medicine at Stony Brook University, Stony Brook, NY, USA
| | - Erica Shen
- Department of Neurosurgery, University of Connecticut School of Medicine, Farmington, CT, USA
| | - Charles B Mikell
- Department of Neurosurgery, Renaissance School of Medicine at Stony Brook University, Stony Brook, NY, USA
| | - Sima Mofakham
- Department of Neurosurgery, Renaissance School of Medicine at Stony Brook University, Stony Brook, NY, USA; Department of Electrical and Computer Engineering, Stony Brook University, Stony Brook, NY, USA.
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107
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Cain JA, Spivak NM, Coetzee JP, Crone JS, Johnson MA, Lutkenhoff ES, Real C, Buitrago-Blanco M, Vespa PM, Schnakers C, Monti MM. Ultrasonic Deep Brain Neuromodulation in Acute Disorders of Consciousness: A Proof-of-Concept. Brain Sci 2022; 12:428. [PMID: 35447960 PMCID: PMC9032970 DOI: 10.3390/brainsci12040428] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Revised: 03/17/2022] [Accepted: 03/19/2022] [Indexed: 02/04/2023] Open
Abstract
The promotion of recovery in patients who have entered a disorder of consciousness (DOC; e.g., coma or vegetative states) following severe brain injury remains an enduring medical challenge despite an ever-growing scientific understanding of these conditions. Indeed, recent work has consistently implicated altered cortical modulation by deep brain structures (e.g., the thalamus and the basal ganglia) following brain damage in the arising of, and recovery from, DOCs. The (re)emergence of low-intensity focused ultrasound (LIFU) neuromodulation may provide a means to selectively modulate the activity of deep brain structures noninvasively for the study and treatment of DOCs. This technique is unique in its combination of relatively high spatial precision and noninvasive implementation. Given the consistent implication of the thalamus in DOCs and prior results inducing behavioral recovery through invasive thalamic stimulation, here we applied ultrasound to the central thalamus in 11 acute DOC patients, measured behavioral responsiveness before and after sonication, and applied functional MRI during sonication. With respect to behavioral responsiveness, we observed significant recovery in the week following thalamic LIFU compared with baseline. With respect to functional imaging, we found decreased BOLD signals in the frontal cortex and basal ganglia during LIFU compared with baseline. In addition, we also found a relationship between altered connectivity of the sonicated thalamus and the degree of recovery observed post-LIFU.
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Affiliation(s)
- Josh A. Cain
- Department of Psychology, University of California Los Angeles, Los Angeles, CA 90095, USA; (J.P.C.); (J.S.C.); (M.A.J.); (E.S.L.)
| | - Norman M. Spivak
- Brain Injury Research Center (BIRC), Department of Neurosurgery, University of California Los Angeles, Los Angeles, CA 90095, USA; (N.M.S.); (C.R.); (M.B.-B.); (P.M.V.)
- UCLA-Caltech Medical Scientist Training Program, University of California Los Angeles, Los Angeles, CA 90095, USA
| | - John P. Coetzee
- Department of Psychology, University of California Los Angeles, Los Angeles, CA 90095, USA; (J.P.C.); (J.S.C.); (M.A.J.); (E.S.L.)
- Department of Psychiatry, Stanford School of Medicine, Palo Alto, CA 94304, USA
- Palo Alto VA Medical Center, VA Palo Alto Health Care System, Palo Alto, CA 94304, USA
| | - Julia S. Crone
- Department of Psychology, University of California Los Angeles, Los Angeles, CA 90095, USA; (J.P.C.); (J.S.C.); (M.A.J.); (E.S.L.)
| | - Micah A. Johnson
- Department of Psychology, University of California Los Angeles, Los Angeles, CA 90095, USA; (J.P.C.); (J.S.C.); (M.A.J.); (E.S.L.)
| | - Evan S. Lutkenhoff
- Department of Psychology, University of California Los Angeles, Los Angeles, CA 90095, USA; (J.P.C.); (J.S.C.); (M.A.J.); (E.S.L.)
| | - Courtney Real
- Brain Injury Research Center (BIRC), Department of Neurosurgery, University of California Los Angeles, Los Angeles, CA 90095, USA; (N.M.S.); (C.R.); (M.B.-B.); (P.M.V.)
| | - Manuel Buitrago-Blanco
- Brain Injury Research Center (BIRC), Department of Neurosurgery, University of California Los Angeles, Los Angeles, CA 90095, USA; (N.M.S.); (C.R.); (M.B.-B.); (P.M.V.)
- Department of Neurosurgery, University of California Los Angeles, Los Angeles, CA 90095, USA
| | - Paul M. Vespa
- Brain Injury Research Center (BIRC), Department of Neurosurgery, University of California Los Angeles, Los Angeles, CA 90095, USA; (N.M.S.); (C.R.); (M.B.-B.); (P.M.V.)
- Department of Neurosurgery, University of California Los Angeles, Los Angeles, CA 90095, USA
| | - Caroline Schnakers
- Research Institute, Casa Colina Hospital and Centers for Healthcare, Pomona, CA 91767, USA;
| | - Martin M. Monti
- Department of Psychology, University of California Los Angeles, Los Angeles, CA 90095, USA; (J.P.C.); (J.S.C.); (M.A.J.); (E.S.L.)
- Brain Injury Research Center (BIRC), Department of Neurosurgery, University of California Los Angeles, Los Angeles, CA 90095, USA; (N.M.S.); (C.R.); (M.B.-B.); (P.M.V.)
- Department of Neurosurgery, University of California Los Angeles, Los Angeles, CA 90095, USA
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108
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Tasserie J, Uhrig L, Sitt JD, Manasova D, Dupont M, Dehaene S, Jarraya B. Deep brain stimulation of the thalamus restores signatures of consciousness in a nonhuman primate model. SCIENCE ADVANCES 2022; 8:eabl5547. [PMID: 35302854 PMCID: PMC8932660 DOI: 10.1126/sciadv.abl5547] [Citation(s) in RCA: 46] [Impact Index Per Article: 23.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/21/2021] [Accepted: 01/26/2022] [Indexed: 05/27/2023]
Abstract
Loss of consciousness is associated with the disruption of long-range thalamocortical and corticocortical brain communication. We tested the hypothesis that deep brain stimulation (DBS) of central thalamus might restore both arousal and awareness following consciousness loss. We applied anesthesia to suppress consciousness in nonhuman primates. During anesthesia, central thalamic stimulation induced arousal in an on-off manner and increased functional magnetic resonance imaging activity in prefrontal, parietal, and cingulate cortices. Moreover, DBS restored a broad dynamic repertoire of spontaneous resting-state activity, previously described as a signature of consciousness. None of these effects were obtained during the stimulation of a control site in the ventrolateral thalamus. Last, DBS restored a broad hierarchical response to auditory violations that was disrupted under anesthesia. Thus, DBS restored the two dimensions of consciousness, arousal and conscious access, following consciousness loss, paving the way to its therapeutical translation in patients with disorders of consciousness.
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Affiliation(s)
- Jordy Tasserie
- Cognitive Neuroimaging Unit, CEA, INSERM, Université Paris-Saclay, NeuroSpin Center, 91191 Gif/Yvette, France
| | - Lynn Uhrig
- Cognitive Neuroimaging Unit, CEA, INSERM, Université Paris-Saclay, NeuroSpin Center, 91191 Gif/Yvette, France
- Department of Anesthesiology and Critical Care, Necker Hospital, AP-HP, Université de Paris, Paris, France
| | - Jacobo D. Sitt
- Sorbonne Université, Institut du Cerveau–Paris Brain Institute–ICM, Inserm, CNRS, APHP, Hôpital de la Pitié Salpêtrière, Paris, France
| | - Dragana Manasova
- Sorbonne Université, Institut du Cerveau–Paris Brain Institute–ICM, Inserm, CNRS, APHP, Hôpital de la Pitié Salpêtrière, Paris, France
- Université de Paris, Paris, France
| | - Morgan Dupont
- Cognitive Neuroimaging Unit, CEA, INSERM, Université Paris-Saclay, NeuroSpin Center, 91191 Gif/Yvette, France
| | - Stanislas Dehaene
- Cognitive Neuroimaging Unit, CEA, INSERM, Université Paris-Saclay, NeuroSpin Center, 91191 Gif/Yvette, France
- Collège de France, Université Paris-Sciences-Lettres (PSL), Paris, France
| | - Béchir Jarraya
- Cognitive Neuroimaging Unit, CEA, INSERM, Université Paris-Saclay, NeuroSpin Center, 91191 Gif/Yvette, France
- University of Versailles Saint-Quentin-en-Yvelines, Université Paris-Saclay, Versailles, France
- Foch Hospital, Suresnes, France
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109
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Wang Z, Feng Z, Yuan Y, Yang G, Hu Y, Zheng L. Bifurcations in the firing of neuronal population caused by a small difference in pulse parameters during sustained stimulations in rat hippocampus in vivo. IEEE Trans Biomed Eng 2022; 69:2893-2904. [PMID: 35254971 DOI: 10.1109/tbme.2022.3157342] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
OBJECTIVE The bifurcation of neuronal firing is one of important nonlinear phenomena in the nervous system and is characterized by a significant change in the rate or temporal pattern of neuronal firing on responding to a small disturbance from external inputs. Previous studies have reported firing bifurcations for individual neurons, not for a population of neurons. We hypothesized that the integrated firing of a neuronal population could also show a bifurcation behavior that should be important in certain situations such as deep brain stimulations. The hypothesis was verified by experiments of rat hippocampus in vivo. METHODS Stimulation sequences of paired-pulses with two different inter-pulse-intervals (IPIs) or with two different pulse intensities were applied on the alveus of hippocampal CA1 region in anaesthetized rats. The amplitude and area of antidromic population spike (APS) were used as indices to evaluate the differences in the responses of neuronal population to the different pulses in stimulations. RESULTS During sustained paired-pulse stimulations with a high mean pulse frequency such as ~130 Hz, a small difference of only a few percent in the two IPIs or in the two intensities was able to generate a sequence of evoked APSs with a substantial bifurcation in their amplitudes and areas. CONCLUSION Small differences in the excitatory inputs can cause nonlinearly enlarged differences in the induced firing of neuronal populations. SIGNIFICANCE The novel dynamics and bifurcation of neuronal responses to electrical stimulations provide important clues for developing new paradigms to extend neural stimulations to treat more diseases.
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110
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Almeida VN. The neural hierarchy of consciousness. Neuropsychologia 2022; 169:108202. [PMID: 35271856 DOI: 10.1016/j.neuropsychologia.2022.108202] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2021] [Revised: 02/25/2022] [Accepted: 03/01/2022] [Indexed: 01/08/2023]
Abstract
The chief undertaking in the studies of consciousness is that of unravelling "the minimal set of neural processes that are together sufficient for the conscious experience of a particular content - the neural correlates of consciousness". To this day, this crusade remains at an impasse, with a clash of two main theories: consciousness may arise either in a graded and cortically-localised fashion, or in an all-or-none and widespread one. In spite of the long-lasting theoretical debates, neurophysiological theories of consciousness have been mostly dissociated from them. Herein, a theoretical review will be put forth with the aim to change that. In its first half, we will cover the hard available evidence on the neurophysiology of consciousness, whereas in its second half we will weave a series of considerations on both theories and substantiate a novel take on conscious awareness: the levels of processing approach, partitioning the conscious architecture into lower- and higher-order, graded and nonlinear.
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Affiliation(s)
- Victor N Almeida
- Faculdade de Letras, Universidade Federal de Minas Gerais (UFMG), Av. Pres. Antônio Carlos, 6627, Pampulha, Belo Horizonte, MG, 31270-901, Brazil.
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111
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Wong JK, Deuschl G, Wolke R, Bergman H, Muthuraman M, Groppa S, Sheth SA, Bronte-Stewart HM, Wilkins KB, Petrucci MN, Lambert E, Kehnemouyi Y, Starr PA, Little S, Anso J, Gilron R, Poree L, Kalamangalam GP, Worrell GA, Miller KJ, Schiff ND, Butson CR, Henderson JM, Judy JW, Ramirez-Zamora A, Foote KD, Silburn PA, Li L, Oyama G, Kamo H, Sekimoto S, Hattori N, Giordano JJ, DiEuliis D, Shook JR, Doughtery DD, Widge AS, Mayberg HS, Cha J, Choi K, Heisig S, Obatusin M, Opri E, Kaufman SB, Shirvalkar P, Rozell CJ, Alagapan S, Raike RS, Bokil H, Green D, Okun MS. Proceedings of the Ninth Annual Deep Brain Stimulation Think Tank: Advances in Cutting Edge Technologies, Artificial Intelligence, Neuromodulation, Neuroethics, Pain, Interventional Psychiatry, Epilepsy, and Traumatic Brain Injury. Front Hum Neurosci 2022; 16:813387. [PMID: 35308605 PMCID: PMC8931265 DOI: 10.3389/fnhum.2022.813387] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2021] [Accepted: 01/11/2022] [Indexed: 01/09/2023] Open
Abstract
DBS Think Tank IX was held on August 25-27, 2021 in Orlando FL with US based participants largely in person and overseas participants joining by video conferencing technology. The DBS Think Tank was founded in 2012 and provides an open platform where clinicians, engineers and researchers (from industry and academia) can freely discuss current and emerging deep brain stimulation (DBS) technologies as well as the logistical and ethical issues facing the field. The consensus among the DBS Think Tank IX speakers was that DBS expanded in its scope and has been applied to multiple brain disorders in an effort to modulate neural circuitry. After collectively sharing our experiences, it was estimated that globally more than 230,000 DBS devices have been implanted for neurological and neuropsychiatric disorders. As such, this year's meeting was focused on advances in the following areas: neuromodulation in Europe, Asia and Australia; cutting-edge technologies, neuroethics, interventional psychiatry, adaptive DBS, neuromodulation for pain, network neuromodulation for epilepsy and neuromodulation for traumatic brain injury.
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Affiliation(s)
- Joshua K. Wong
- Department of Neurology, Fixel Institute for Neurological Diseases, University of Florida, Gainesville, FL, United States
| | - Günther Deuschl
- Department of Neurology, Christian-Albrechts-University, Kiel, Germany
| | - Robin Wolke
- Department of Neurology, Christian-Albrechts-University, Kiel, Germany
| | - Hagai Bergman
- Department of Medical Neurobiology (Physiology), Institute of Medical Research Israel-Canada, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Muthuraman Muthuraman
- Biomedical Statistics and Multimodal Signal Processing Unit, Section of Movement Disorders and Neurostimulation, Focus Program Translational Neuroscience, Department of Neurology, University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany
| | - Sergiu Groppa
- Biomedical Statistics and Multimodal Signal Processing Unit, Section of Movement Disorders and Neurostimulation, Focus Program Translational Neuroscience, Department of Neurology, University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany
| | - Sameer A. Sheth
- Department of Neurological Surgery, Baylor College of Medicine, Houston, TX, United States
| | - Helen M. Bronte-Stewart
- The Human Motor Control and Neuromodulation Laboratory, Department of Neurology and Neurological Sciences, Stanford University School of Medicine, Stanford University, Stanford, CA, United States
| | - Kevin B. Wilkins
- The Human Motor Control and Neuromodulation Laboratory, Department of Neurology and Neurological Sciences, Stanford University School of Medicine, Stanford University, Stanford, CA, United States
| | - Matthew N. Petrucci
- The Human Motor Control and Neuromodulation Laboratory, Department of Neurology and Neurological Sciences, Stanford University School of Medicine, Stanford University, Stanford, CA, United States
| | - Emilia Lambert
- The Human Motor Control and Neuromodulation Laboratory, Department of Neurology and Neurological Sciences, Stanford University School of Medicine, Stanford University, Stanford, CA, United States
| | - Yasmine Kehnemouyi
- The Human Motor Control and Neuromodulation Laboratory, Department of Neurology and Neurological Sciences, Stanford University School of Medicine, Stanford University, Stanford, CA, United States
| | - Philip A. Starr
- Department of Neurological Surgery, Kavli Institute for Fundamental Neuroscience, University of California, San Francisco, San Francisco, CA, United States
| | - Simon Little
- Department of Neurological Surgery, Kavli Institute for Fundamental Neuroscience, University of California, San Francisco, San Francisco, CA, United States
| | - Juan Anso
- Department of Neurological Surgery, Kavli Institute for Fundamental Neuroscience, University of California, San Francisco, San Francisco, CA, United States
| | - Ro’ee Gilron
- Department of Neurological Surgery, Kavli Institute for Fundamental Neuroscience, University of California, San Francisco, San Francisco, CA, United States
| | - Lawrence Poree
- Department of Anesthesia, University of California, San Francisco, San Francisco, CA, United States
| | - Giridhar P. Kalamangalam
- Department of Neurology, Wilder Center for Epilepsy Research, University of Florida, Gainesville, FL, United States
| | | | - Kai J. Miller
- Department of Neurosurgery, Mayo Clinic, Rochester, NY, United States
| | - Nicholas D. Schiff
- Department of Neurology, Weill Cornell Brain and Spine Institute, Weill Cornell Medicine, New York, NY, United States
| | - Christopher R. Butson
- Department of Neurology, Fixel Institute for Neurological Diseases, University of Florida, Gainesville, FL, United States
| | - Jaimie M. Henderson
- Department of Neurosurgery, Stanford University, Stanford, CA, United States
| | - Jack W. Judy
- Department of Electrical and Computer Engineering, University of Florida, Gainesville, FL, United States
| | - Adolfo Ramirez-Zamora
- Department of Neurology, Fixel Institute for Neurological Diseases, University of Florida, Gainesville, FL, United States
| | - Kelly D. Foote
- Department of Neurosurgery, Fixel Institute for Neurological Diseases, University of Florida, Gainesville, FL, United States
| | - Peter A. Silburn
- Queensland Brain Institute, University of Queensland and Saint Andrews War Memorial Hospital, Brisbane, QLD, Australia
| | - Luming Li
- National Engineering Laboratory for Neuromodulation, School of Aerospace Engineering, Tsinghua University, Beijing, China
| | - Genko Oyama
- Department of Neurology, Faculty of Medicine, Juntendo University, Tokyo, Japan
| | - Hikaru Kamo
- Department of Neurology, Faculty of Medicine, Juntendo University, Tokyo, Japan
| | - Satoko Sekimoto
- Department of Neurology, Faculty of Medicine, Juntendo University, Tokyo, Japan
| | - Nobutaka Hattori
- Department of Neurology, Faculty of Medicine, Juntendo University, Tokyo, Japan
| | - James J. Giordano
- Neuroethics Studies Program, Department of Neurology, Georgetown University Medical Center, Washington, DC, United States
| | - Diane DiEuliis
- US Department of Defense Fort Lesley J. McNair, National Defense University, Washington, DC, United States
| | - John R. Shook
- Department of Philosophy and Science Education, University of Buffalo, Buffalo, NY, United States
| | - Darin D. Doughtery
- Department of Psychiatry, Massachusetts General Hospital and Harvard Medical School, Boston, MA, United States
| | - Alik S. Widge
- Department of Psychiatry, University of Minnesota, Minneapolis, MN, United States
| | - Helen S. Mayberg
- Department of Neurology and Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Jungho Cha
- Department of Neurology and Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Kisueng Choi
- Department of Neurology and Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Stephen Heisig
- Department of Neurology and Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Mosadolu Obatusin
- Department of Neurology and Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Enrico Opri
- Department of Neurology, Emory University, Atlanta, GA, United States
| | - Scott B. Kaufman
- Department of Psychology, Columbia University, New York, NY, United States
| | - Prasad Shirvalkar
- The Human Motor Control and Neuromodulation Laboratory, Department of Neurology and Neurological Sciences, Stanford University School of Medicine, Stanford University, Stanford, CA, United States
- Department of Anesthesiology (Pain Management) and Neurology, University of California, San Francisco, San Francisco, CA, United States
| | - Christopher J. Rozell
- School of Electrical and Computer Engineering, Georgia Institute of Technology, Atlanta, GA, United States
| | - Sankaraleengam Alagapan
- School of Electrical and Computer Engineering, Georgia Institute of Technology, Atlanta, GA, United States
| | - Robert S. Raike
- Restorative Therapies Group Implantables, Research and Core Technology, Medtronic Inc., Minneapolis, MN, United States
| | - Hemant Bokil
- Boston Scientific Neuromodulation Corporation, Valencia, CA, United States
| | - David Green
- NeuroPace, Inc., Mountain View, CA, United States
| | - Michael S. Okun
- Department of Neurology, Fixel Institute for Neurological Diseases, University of Florida, Gainesville, FL, United States
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112
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Treatment of Psychiatric Problems After Traumatic Brain Injury. Biol Psychiatry 2022; 91:508-521. [PMID: 34511181 DOI: 10.1016/j.biopsych.2021.07.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2021] [Revised: 06/14/2021] [Accepted: 07/06/2021] [Indexed: 02/07/2023]
Abstract
Psychiatric sequelae of traumatic brain injury (TBI) can cause significant and often chronic impairment in functioning and quality of life; however, their phenomenological and mechanistic complexities continue to present significant treatment challenges. The clinical presentation is often an amalgam of syndromes and co-occurring symptoms that require a highly nuanced and systematic approach to treatment. Although few randomized controlled trials have tested treatments for psychiatric problems after TBI and the synthesis of results continues to be compromised by the heterogeneity of study populations, small samples, and differing inclusion criteria and outcome measures, an increasing body of literature supports evidence-based treatment strategies. We provide a narrative review of pharmacological, psychoeducational/behavioral, and neuromodulation treatments for psychiatric conditions in adults with TBI and discuss known or postulated mechanisms of action for these treatment approaches. Where data are available, we focus on randomized controlled trials and large case series in which a psychiatric condition provides both a selection criterion and a primary or secondary outcome. We conclude by proposing directions for future research, particularly the need for novel neuropharmacological, behavioral, and neurophysiological studies and pragmatic trials of multicomponent and adaptive models that will increase understanding of the mechanisms underlying post-TBI psychiatric disorders and accelerate dissemination and implementation of effective person-centered care.
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113
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Thalamic T-Type Calcium Channels as Targets for Hypnotics and General Anesthetics. Int J Mol Sci 2022; 23:ijms23042349. [PMID: 35216466 PMCID: PMC8876360 DOI: 10.3390/ijms23042349] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Revised: 02/17/2022] [Accepted: 02/18/2022] [Indexed: 12/19/2022] Open
Abstract
General anesthetics mainly act by modulating synaptic inhibition on the one hand (the potentiation of GABA transmission) or synaptic excitation on the other (the inhibition of NMDA receptors), but they can also have effects on numerous other proteins, receptors, and channels. The effects of general anesthetics on ion channels have been the subject of research since the publication of reports of direct actions of these drugs on ion channel proteins. In particular, there is considerable interest in T-type voltage-gated calcium channels that are abundantly expressed in the thalamus, where they control patterns of cellular excitability and thalamocortical oscillations during awake and sleep states. Here, we summarized and discussed our recent studies focused on the CaV3.1 isoform of T-channels in the nonspecific thalamus (intralaminar and midline nuclei), which acts as a key hub through which natural sleep and general anesthesia are initiated. We used mouse genetics and in vivo and ex vivo electrophysiology to study the role of thalamic T-channels in hypnosis induced by a standard general anesthetic, isoflurane, as well as novel neuroactive steroids. From the results of this study, we conclude that CaV3.1 channels contribute to thalamocortical oscillations during anesthetic-induced hypnosis, particularly the slow-frequency range of δ oscillations (0.5–4 Hz), by generating “window current” that contributes to the resting membrane potential. We posit that the role of the thalamic CaV3.1 isoform of T-channels in the effects of various classes of general anesthetics warrants consideration.
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114
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Cosgrove ME, Saadon JR, Mikell CB, Stefancin PL, Alkadaa L, Wang Z, Saluja S, Servider J, Razzaq B, Huang C, Mofakham S. Thalamo-Prefrontal Connectivity Correlates With Early Command-Following After Severe Traumatic Brain Injury. Front Neurol 2022; 13:826266. [PMID: 35250829 PMCID: PMC8895046 DOI: 10.3389/fneur.2022.826266] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Accepted: 01/25/2022] [Indexed: 12/19/2022] Open
Abstract
Recovery of consciousness after traumatic brain injury (TBI) is heterogeneous and difficult to predict. Structures such as the thalamus and prefrontal cortex are thought to be important in facilitating consciousness. We sought to investigate whether the integrity of thalamo-prefrontal circuits, assessed via diffusion tensor imaging (DTI), was associated with the return of goal-directed behavior after severe TBI. We classified a cohort of severe TBI patients (N = 25, 20 males) into Early and Late/Never outcome groups based on their ability to follow commands within 30 days post-injury. We assessed connectivity between whole thalamus, and mediodorsal thalamus (MD), to prefrontal cortex (PFC) subregions including dorsolateral PFC (dlPFC), medial PFC (mPFC), anterior cingulate (ACC), and orbitofrontal (OFC) cortices. We found that the integrity of thalamic projections to PFC subregions (L OFC, L and R ACC, and R mPFC) was significantly associated with Early command-following. This association persisted when the analysis was restricted to prefrontal-mediodorsal (MD) thalamus connectivity. In contrast, dlPFC connectivity to thalamus was not significantly associated with command-following. Using the integrity of thalamo-prefrontal connections, we created a linear regression model that demonstrated 72% accuracy in predicting command-following after a leave-one-out analysis. Together, these data support a role for thalamo-prefrontal connectivity in the return of goal-directed behavior following TBI.
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Affiliation(s)
- Megan E. Cosgrove
- Department of Neurosurgery, Renaissance School of Medicine at Stony Brook University, Stony Brook, NY, United States
| | - Jordan R. Saadon
- Department of Neurosurgery, Renaissance School of Medicine at Stony Brook University, Stony Brook, NY, United States
| | - Charles B. Mikell
- Department of Neurosurgery, Renaissance School of Medicine at Stony Brook University, Stony Brook, NY, United States
| | | | - Leor Alkadaa
- Department of Neurosurgery, Renaissance School of Medicine at Stony Brook University, Stony Brook, NY, United States
| | - Zhe Wang
- Department of Neurosurgery, Renaissance School of Medicine at Stony Brook University, Stony Brook, NY, United States
| | - Sabir Saluja
- Department of Neurosurgery, Renaissance School of Medicine at Stony Brook University, Stony Brook, NY, United States
| | - John Servider
- Department of Neurosurgery, Renaissance School of Medicine at Stony Brook University, Stony Brook, NY, United States
| | - Bayan Razzaq
- Department of Neurosurgery, Renaissance School of Medicine at Stony Brook University, Stony Brook, NY, United States
| | - Chuan Huang
- Department of Radiology, Renaissance School of Medicine at Stony Brook University, Stony Brook, NY, United States
- Department of Psychiatry, Renaissance School of Medicine at Stony Brook University, Stony Brook, NY, United States
| | - Sima Mofakham
- Department of Neurosurgery, Renaissance School of Medicine at Stony Brook University, Stony Brook, NY, United States
- Department of Electrical and Computer Engineering, Stony Brook University, Stony Brook, NY, United States
- *Correspondence: Sima Mofakham
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115
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Spivak NM, Sanguinetti JL, Monti MM. Focusing in on the Future of Focused Ultrasound as a Translational Tool. Brain Sci 2022; 12:158. [PMID: 35203922 PMCID: PMC8870102 DOI: 10.3390/brainsci12020158] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Revised: 01/14/2022] [Accepted: 01/22/2022] [Indexed: 12/22/2022] Open
Abstract
This article summarizes the field of focused ultrasound for use in neuromodulation and discusses different ways of targeting, delivering, and validating focused ultrasound. A discussion is focused on parameter space and different ongoing theories of ultrasonic neuromodulation. Current and future applications of the technique are discussed.
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Affiliation(s)
- Norman M. Spivak
- UCLA—Caltech Medical Scientist Training Program, David Geffen School of Medicine, Los Angeles, CA 90095, USA
- Department of Neurosurgery, University of California, Los Angeles, CA 90095, USA;
- Department of Psychiatry and Biobehavioral Sciences, University of California, Los Angeles, CA 90095, USA
| | - Joseph L. Sanguinetti
- Department of Psychology, University of Arizona, Tucson, AZ 85721, USA;
- Department of Psychology, University of New Mexico, Albuquerque, NM 87131, USA
| | - Martin M. Monti
- Department of Neurosurgery, University of California, Los Angeles, CA 90095, USA;
- Department of Psychiatry and Biobehavioral Sciences, University of California, Los Angeles, CA 90095, USA
- Department of Psychology, University of California, Los Angeles, CA 90095, USA
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116
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Overbeek BUH, Lavrijsen JCM, van Gaal S, Kondziella D, Eilander HJ, Koopmans RTCM. Towards consensus on visual pursuit and visual fixation in patients with disorders of consciousness. A Delphi study. J Neurol 2022; 269:3204-3215. [PMID: 35001197 DOI: 10.1007/s00415-021-10905-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2021] [Revised: 11/10/2021] [Accepted: 11/11/2021] [Indexed: 10/19/2022]
Abstract
BACKGROUND The aim of this Delphi study was to reach consensus about definition, operationalization and assessment of visual pursuit (VP) and visual fixation (VF). METHODS In a three-round international Delphi study, clinical and research experts on disorders of consciousness indicated their level of agreement on 87 statements using a 5-point Likert scale. Consensus for agreement was defined by a median of 5, an interquartile range (IQR) ≤ 1, and ≥ 80% indicating moderate or strong agreement. RESULTS Forty-three experts from three continents participated, 32 completed all three rounds. For VP, the consensus statements with the highest levels of agreement were on the term 'pursuit of a visual stimulus', the description 'ability to follow visually in horizontal and/or vertical plane', a duration > 2 s, tracking in horizontal and vertical planes, and a frequency of more than 2 times per assessment. For VF, consensus statements with the highest levels of agreement were on the term 'sustained VF', the description 'sustained fixation in response to a salient stimulus', a duration of > 2 s and a frequency of 2 or more times per assessment. The assessment factors with the highest levels of agreement were personalized stimuli, the use of eye tracking technology, a patient dependent time of assessment, sufficient environmental light, upright posture, and the necessity to exclude ocular/oculomotor problems. CONCLUSION This first international Delphi study on VP and VF in patients with disorders of consciousness provides provisional operational definitions and an overview of the most relevant assessment factors.
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Affiliation(s)
- Berno U H Overbeek
- Department of Primary and Community Care, Radboud Institute of Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands. .,Kalorama, Beek Ubbergen, The Netherlands. .,Azora, Terborg, The Netherlands.
| | - Jan C M Lavrijsen
- Department of Primary and Community Care, Radboud Institute of Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Simon van Gaal
- Faculty of Social and Behavioural Sciences, Department of Psychology, University of Amsterdam, Amsterdam, The Netherlands
| | - Daniel Kondziella
- Department of Neurology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark.,Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Henk J Eilander
- Department of Primary and Community Care, Radboud Institute of Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Raymond T C M Koopmans
- Department of Primary and Community Care, Radboud Institute of Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands.,Center for Specialized Geriatric Care, Joachim en Anna, Nijmegen, The Netherlands
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117
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Mofakham S, Liu Y, Hensley A, Saadon JR, Gammel T, Cosgrove ME, Adachi J, Mohammad S, Huang C, Djurić PM, Mikell CB. Injury to thalamocortical projections following traumatic brain injury results in attractor dynamics for cortical networks. Prog Neurobiol 2022; 210:102215. [PMID: 34995694 DOI: 10.1016/j.pneurobio.2022.102215] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2021] [Revised: 12/29/2021] [Accepted: 01/03/2022] [Indexed: 12/11/2022]
Abstract
Major theories of consciousness predict that complex electroencephalographic (EEG) activity is required for consciousness, yet it is not clear how such activity arises in the corticothalamic system. The thalamus is well-known to control cortical excitability via interlaminar projections, but whether thalamic input is needed for complexity is not known. We hypothesized that the thalamus facilitates complex activity by adjusting synaptic connectivity, thereby increasing the availability of different configurations of cortical neurons (cortical "states"), as well as the probability of state transitions. To test this hypothesis, we characterized EEG activity from prefrontal cortex (PFC) in traumatic brain injury (TBI) patients with and without injuries to thalamocortical projections, measured with diffusion tensor imaging (DTI). We found that injury to thalamic projections (especially from the mediodorsal thalamus) was strongly associated with unconsciousness and delta-band EEG activity. Using advanced signal processing techniques, we found that lack of thalamic input led to 1.) attractor dynamics for cortical networks with a tendency to visit the same states, 2.) a reduced repertoire of possible states, and 3.) high predictability of transitions between states. These results imply that complex PFC activity associated with consciousness depends on thalamic input. Our model implies that restoration of cortical connectivity is a critical function of the thalamus after brain injury. We draw a critical connection between thalamic input and complex cortical activity associated with consciousness.
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Affiliation(s)
- Sima Mofakham
- Department of Neurosurgery, Stony Brook University Hospital, Stony Brook, NY, USA; Department of Electrical and Computer Engineering, Stony Brook University, Stony Brook, NY, USA.
| | - Yuhao Liu
- Department of Electrical and Computer Engineering, Stony Brook University, Stony Brook, NY, USA
| | - Asher Hensley
- Department of Electrical and Computer Engineering, Stony Brook University, Stony Brook, NY, USA
| | - Jordan R Saadon
- Department of Neurosurgery, Stony Brook University Hospital, Stony Brook, NY, USA
| | - Theresa Gammel
- Department of Neurosurgery, Stony Brook University Hospital, Stony Brook, NY, USA
| | - Megan E Cosgrove
- Department of Neurosurgery, Stony Brook University Hospital, Stony Brook, NY, USA
| | - Joseph Adachi
- Department of Neurosurgery, Stony Brook University Hospital, Stony Brook, NY, USA
| | - Selma Mohammad
- Department of Neurosurgery, Stony Brook University Hospital, Stony Brook, NY, USA
| | - Chuan Huang
- Department of Radiology, Stony Brook University Hospital, Stony Brook, NY, USA; Department of Psychiatry, Stony Brook University Hospital, Stony Brook, NY, USA
| | - Petar M Djurić
- Department of Electrical and Computer Engineering, Stony Brook University, Stony Brook, NY, USA
| | - Charles B Mikell
- Department of Neurosurgery, Stony Brook University Hospital, Stony Brook, NY, USA
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118
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Fridman EA, Schiff ND. Organizing a Rational Approach to Treatments of Disorders of Consciousness Using the Anterior Forebrain Mesocircuit Model. J Clin Neurophysiol 2022; 39:40-48. [PMID: 34474427 PMCID: PMC8900660 DOI: 10.1097/wnp.0000000000000729] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
SUMMARY Organizing a rational treatment strategy for patients with multifocal structural brain injuries and disorders of consciousness (DOC) is an important and challenging clinical goal. Among potential clinical end points, restoring elements of communication to DOC patients can support improved patient care, caregiver satisfaction, and patients' quality of life. Over the past decade, several studies have considered the use of the anterior forebrain mesocircuit model to approach this problem because this model proposes a supervening circuit-level impairment arising across DOC of varying etiologies. We review both the conceptual foundation of the mesocircuit model and studies of mechanisms underlying DOC that test predictions of this model. We consider how this model can guide therapeutic interventions and discuss a proposed treatment algorithm based on these ideas. Although the approach reviewed originates in the evaluation of patients with chronic DOC, we consider some emerging implications for patients in acute and subacute settings.
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Affiliation(s)
- Esteban A Fridman
- Brain and Mind Research Institute, Weill Cornell Medicine, New York, New York, U.S.A
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119
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Fins JJ. Consciousness, Conflations, and Disability Rights: Denials of Care for Children in the "Minimally Conscious State". THE JOURNAL OF LAW, MEDICINE & ETHICS : A JOURNAL OF THE AMERICAN SOCIETY OF LAW, MEDICINE & ETHICS 2022; 50:181-183. [PMID: 35243988 DOI: 10.1017/jme.2022.22] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
This essay critiques the fiercely utilitarian allocation scheme of Cameron et al. Children have no hope of recovery if their lives are cut short based on administrative protocols that misrepresent the nature of their conditions. Unilateral futility judgements - especially those based on a false predicate - are discriminatory. When considering the best interests of children, we should see possibility in disability and not advance ill-informed utilitarianism.
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120
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Naccache L, Luauté J, Silva S, Sitt JD, Rohaut B. Toward a coherent structuration of disorders of consciousness expertise at a country scale: A proposal for France. Rev Neurol (Paris) 2021; 178:9-20. [PMID: 34980510 DOI: 10.1016/j.neurol.2021.12.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Accepted: 12/15/2021] [Indexed: 12/23/2022]
Abstract
Probing consciousness and cognitive abilities in non-communicating patients is one of the most challenging diagnostic issues. A fast growing medical and scientific literature explores the various facets of this challenge, often coined under the generic expression of 'Disorders of Consciousness' (DoC). Crucially, a set of independent converging results demonstrated both (1) the diagnostic and prognostic importance of this expertise, and (2) the need to combine behavioural measures with brain structure and activity data to improve diagnostic and prognostication accuracy as well as potential therapeutic intervention. Thus, probing consciousness in DoC patients appears as a crucial activity rich of human, medical, economic and ethical consequences, but this activity needs to be organized in order to offer this expertise to each concerned patient. More precisely, diagnosis of consciousness differs in difficulty across patients: while a minimal set of data can be sufficient to reach a confident result, some patients need a higher level of expertise that relies on additional behavioural and brain activity and brain structure measures. In order to enable this service on a systematic mode, we present two complementary proposals in the present article. First, we sketch a structuration of DoC expertise at a country-scale, namely France. More precisely, we suggest that a 2-tiers network composed of local (Tier-1) and regional (Tier-2) centers backed by distant electronic databases and algorithmic centers could optimally enable the systematic implementation of DoC expertise in France. Second, we propose to create a national common register of DoC patients in order to better monitor this activity, to improve its performance on the basis of nation-wide collected evidence, and to promote rational decision-making.
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Affiliation(s)
- L Naccache
- Sorbonne université, institut du cerveau - Paris Brain Institute - ICM, Inserm, CNRS, Paris, France; Sorbonne université, UPMC Univ Paris 06, faculté de médecine Pitié-Salpêtrière, Paris, France; AP-HP, hôpital groupe hospitalier Pitié-Salpêtrière, DMU neurosciences, department of clinical neurophysiology, Paris, France; AP-HP, hôpital groupe hospitalier Pitié-Salpêtrière, DMU neurosciences, department of neurology, Neuro ICU, Paris, France.
| | - J Luauté
- Service de médecine physique et réadaptation, hôpital Henry-Gabrielle, Hospices Civils de Lyon, Saint-Genis Laval, France; Équipe « Trajectoires », centre de recherche en neurosciences de Lyon, Inserm UMR-S 1028, CNRS UMR 5292, université de Lyon, université Lyon 1, Bron, France
| | - S Silva
- Intensive Care Unit, Purpan University Hospital, 31000 Toulouse, France; Toulouse NeuroImaging Center (ToNIC lab) URM UPS/INSERM 1214, 31000 Toulouse, France
| | - J D Sitt
- Sorbonne université, institut du cerveau - Paris Brain Institute - ICM, Inserm, CNRS, Paris, France; Sorbonne université, UPMC Univ Paris 06, faculté de médecine Pitié-Salpêtrière, Paris, France
| | - B Rohaut
- Sorbonne université, institut du cerveau - Paris Brain Institute - ICM, Inserm, CNRS, Paris, France; Sorbonne université, UPMC Univ Paris 06, faculté de médecine Pitié-Salpêtrière, Paris, France; AP-HP, hôpital groupe hospitalier Pitié-Salpêtrière, DMU neurosciences, department of neurology, Neuro ICU, Paris, France
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121
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Abstract
Impaired consciousness during seizures severely affects quality of life for people with
epilepsy but the mechanisms are just beginning to be understood. Consciousness is thought
to involve large-scale brain networks, so it is puzzling that focal seizures often impair
consciousness. Recent work investigating focal temporal lobe or limbic seizures in human
patients and experimental animal models suggests that impaired consciousness is caused by
active inhibition of subcortical arousal mechanisms. Focal limbic seizures exhibit
decreased neuronal firing in brainstem, basal forebrain, and thalamic arousal networks,
and cortical arousal can be restored when subcortical arousal circuits are stimulated
during seizures. These findings open the possibility of restoring arousal and
consciousness therapeutically during and following seizures by thalamic neurostimulation.
When seizures cannot be stopped by existing treatments, targeted subcortical stimulation
may improve arousal and consciousness, leading to improved safety and better psychosocial
function for people with epilepsy.
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Affiliation(s)
- Hal Blumenfeld
- Departments of Neurology, Neuroscience, Neurosurgery, Yale University School of Medicine, New Haven, CT, USA
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122
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Li J, Curley WH, Guerin B, Dougherty DD, Dalca AV, Fischl B, Horn A, Edlow BL. Mapping the subcortical connectivity of the human default mode network. Neuroimage 2021; 245:118758. [PMID: 34838949 PMCID: PMC8945548 DOI: 10.1016/j.neuroimage.2021.118758] [Citation(s) in RCA: 34] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2021] [Revised: 10/29/2021] [Accepted: 11/23/2021] [Indexed: 01/17/2023] Open
Abstract
The default mode network (DMN) mediates self-awareness and introspection, core components of human consciousness. Therapies to restore consciousness in patients with severe brain injuries have historically targeted subcortical sites in the brainstem, thalamus, hypothalamus, basal forebrain, and basal ganglia, with the goal of reactivating cortical DMN nodes. However, the subcortical connectivity of the DMN has not been fully mapped, and optimal subcortical targets for therapeutic neuromodulation of consciousness have not been identified. In this work, we created a comprehensive map of DMN subcortical connectivity by combining high-resolution functional and structural datasets with advanced signal processing methods. We analyzed 7 Tesla resting-state functional MRI (rs-fMRI) data from 168 healthy volunteers acquired in the Human Connectome Project. The rs-fMRI blood-oxygen-level-dependent (BOLD) data were temporally synchronized across subjects using the BrainSync algorithm. Cortical and subcortical DMN nodes were jointly analyzed and identified at the group level by applying a novel Nadam-Accelerated SCAlable and Robust (NASCAR) tensor decomposition method to the synchronized dataset. The subcortical connectivity map was then overlaid on a 7 Tesla 100 µm ex vivo MRI dataset for neuroanatomic analysis using automated segmentation of nuclei within the brainstem, thalamus, hypothalamus, basal forebrain, and basal ganglia. We further compared the NASCAR subcortical connectivity map with its counterpart generated from canonical seed-based correlation analyses. The NASCAR method revealed that BOLD signal in the central lateral nucleus of the thalamus and ventral tegmental area of the midbrain is strongly correlated with that of the DMN. In an exploratory analysis, additional subcortical sites in the median and dorsal raphe, lateral hypothalamus, and caudate nuclei were correlated with the cortical DMN. We also found that the putamen and globus pallidus are negatively correlated (i.e., anti-correlated) with the DMN, providing rs-fMRI evidence for the mesocircuit hypothesis of human consciousness, whereby a striatopallidal feedback system modulates anterior forebrain function via disinhibition of the central thalamus. Seed-based analyses yielded similar subcortical DMN connectivity, but the NASCAR result showed stronger contrast and better spatial alignment with dopamine immunostaining data. The DMN subcortical connectivity map identified here advances understanding of the subcortical regions that contribute to human consciousness and can be used to inform the selection of therapeutic targets in clinical trials for patients with disorders of consciousness.
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Affiliation(s)
- Jian Li
- 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
| | - William H Curley
- Center for Neurotechnology and Neurorecovery, Department of Neurology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
| | - Bastien Guerin
- Athinoula A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital and Harvard Medical School, Charlestown, MA, USA; Harvard Medical School, Boston, MA, USA
| | - Darin D Dougherty
- Athinoula A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital and Harvard Medical School, Charlestown, MA, USA; Department of Psychiatry, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Adrian V Dalca
- Athinoula A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital and Harvard Medical School, Charlestown, MA, USA; Computer Science and Artificial Intelligence Laboratory, Massachusetts Institute of Technology, Cambridge, MA, USA
| | - Bruce Fischl
- Athinoula A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital and Harvard Medical School, Charlestown, MA, USA; Computer Science and Artificial Intelligence Laboratory, Massachusetts Institute of Technology, Cambridge, MA, USA
| | - Andreas Horn
- Center for Neurotechnology and Neurorecovery, Department of Neurology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA; Center for Brain Circuit Therapeutics, Department of Neurology, Brigham & Women's Hospital and Harvard Medical School, Boston, MA, USA; Department of Neurosurgery, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA; Movement Disorders & Neuromodulation Section, Department of Neurology, Charité - Universitätsmedizin, Berlin, Germany
| | - 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.
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Janson AP, Baker JL, Sani I, Purpura KP, Schiff ND, Butson CR. Selective activation of central thalamic fiber pathway facilitates behavioral performance in healthy non-human primates. Sci Rep 2021; 11:23054. [PMID: 34845232 PMCID: PMC8630225 DOI: 10.1038/s41598-021-02270-7] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2021] [Accepted: 11/09/2021] [Indexed: 01/28/2023] Open
Abstract
Central thalamic deep brain stimulation (CT-DBS) is an investigational therapy to treat enduring cognitive dysfunctions in structurally brain injured (SBI) patients. However, the mechanisms of CT-DBS that promote restoration of cognitive functions are unknown, and the heterogeneous etiology and recovery profiles of SBI patients contribute to variable outcomes when using conventional DBS strategies,which may result in off-target effects due to activation of multiple pathways. To disambiguate the effects of stimulation of two adjacent thalamic pathways, we modeled and experimentally compared conventional and novel 'field-shaping' methods of CT-DBS within the central thalamus of healthy non-human primates (NHP) as they performed visuomotor tasks. We show that selective activation of the medial dorsal thalamic tegmental tract (DTTm), but not of the adjacent centromedian-parafascicularis (CM-Pf) pathway, results in robust behavioral facilitation. Our predictive modeling approach in healthy NHPs directly informs ongoing and future clinical investigations of conventional and novel methods of CT-DBS for treating cognitive dysfunctions in SBI patients, for whom no therapy currently exists.
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Affiliation(s)
- A. P. Janson
- Department of Biomedical Engineering, University of Utah, Salt Lake City, UT USA
- Scientific Computing and Imaging Institute, Salt Lake City, UT USA
- Departments of Neurology and Neurosurgery, Vanderbilt University Medical Center, Nashville, TN USA
| | - J. L. Baker
- Feil Family Brain and Mind Research Institute, Weill Cornell Medicine, New York, NY USA
| | - I. Sani
- The Rockefeller University, New York, NY USA
- Department of Basic Neurosciences, University of Geneva, Geneva, Switzerland
| | - K. P. Purpura
- Feil Family Brain and Mind Research Institute, Weill Cornell Medicine, New York, NY USA
| | - N. D. Schiff
- Feil Family Brain and Mind Research Institute, Weill Cornell Medicine, New York, NY USA
| | - C. R. Butson
- Department of Biomedical Engineering, University of Utah, Salt Lake City, UT USA
- Scientific Computing and Imaging Institute, Salt Lake City, UT USA
- Departments of Neurology, Neurosurgery, and Psychiatry, Salt Lake City, UT USA
- Norman Fixel Institute for Neurological Diseases, University of Florida, Gainesville, FL USA
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Electrocorticography reveals thalamic control of cortical dynamics following traumatic brain injury. Commun Biol 2021; 4:1210. [PMID: 34675341 PMCID: PMC8531397 DOI: 10.1038/s42003-021-02738-2] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2021] [Accepted: 09/15/2021] [Indexed: 12/26/2022] Open
Abstract
The return of consciousness after traumatic brain injury (TBI) is associated with restoring complex cortical dynamics; however, it is unclear what interactions govern these complex dynamics. Here, we set out to uncover the mechanism underlying the return of consciousness by measuring local field potentials (LFP) using invasive electrophysiological recordings in patients recovering from TBI. We found that injury to the thalamus, and its efferent projections, on MRI were associated with repetitive and low complexity LFP signals from a highly structured phase space, resembling a low-dimensional ring attractor. But why do thalamic injuries in TBI patients result in a cortical attractor? We built a simplified thalamocortical model, which connotes that thalamic input facilitates the formation of cortical ensembles required for the return of cognitive function and the content of consciousness. These observations collectively support the view that thalamic input to the cortex enables rich cortical dynamics associated with consciousness.
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125
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Zhu B, Shin U, Shoaran M. Closed-Loop Neural Prostheses With On-Chip Intelligence: A Review and a Low-Latency Machine Learning Model for Brain State Detection. IEEE TRANSACTIONS ON BIOMEDICAL CIRCUITS AND SYSTEMS 2021; 15:877-897. [PMID: 34529573 PMCID: PMC8733782 DOI: 10.1109/tbcas.2021.3112756] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/22/2023]
Abstract
The application of closed-loop approaches in systems neuroscience and therapeutic stimulation holds great promise for revolutionizing our understanding of the brain and for developing novel neuromodulation therapies to restore lost functions. Neural prostheses capable of multi-channel neural recording, on-site signal processing, rapid symptom detection, and closed-loop stimulation are critical to enabling such novel treatments. However, the existing closed-loop neuromodulation devices are too simplistic and lack sufficient on-chip processing and intelligence. In this paper, we first discuss both commercial and investigational closed-loop neuromodulation devices for brain disorders. Next, we review state-of-the-art neural prostheses with on-chip machine learning, focusing on application-specific integrated circuits (ASIC). System requirements, performance and hardware comparisons, design trade-offs, and hardware optimization techniques are discussed. To facilitate a fair comparison and guide design choices among various on-chip classifiers, we propose a new energy-area (E-A) efficiency figure of merit that evaluates hardware efficiency and multi-channel scalability. Finally, we present several techniques to improve the key design metrics of tree-based on-chip classifiers, both in the context of ensemble methods and oblique structures. A novel Depth-Variant Tree Ensemble (DVTE) is proposed to reduce processing latency (e.g., by 2.5× on seizure detection task). We further develop a cost-aware learning approach to jointly optimize the power and latency metrics. We show that algorithm-hardware co-design enables the energy- and memory-optimized design of tree-based models, while preserving a high accuracy and low latency. Furthermore, we show that our proposed tree-based models feature a highly interpretable decision process that is essential for safety-critical applications such as closed-loop stimulation.
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126
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Diotaiuti P, Valente G, Mancone S. Development and Preliminary Italian Validation of the Emergency Response and Psychological Adjustment Scale. Front Psychol 2021; 12:687514. [PMID: 34421737 PMCID: PMC8376143 DOI: 10.3389/fpsyg.2021.687514] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Accepted: 07/05/2021] [Indexed: 01/29/2023] Open
Abstract
Evaluating the personal adaptation response to the emergency situations is very important for the prevention of mental distress, for the activation of network and community synergies and for the planning and implementation of appropriate psycho-social interventions. So far there are no short tools for the overall assessment of cognitive, emotional and behavioral responses of psychological adaptation to the emergency in the psychometric panorama. The Emergency Response and Psychological Adjustment Scale (ERPAS) was administered to a sample of 1,088 participants, while the concurrent validity was tested through a second administration to 600 participants along with the GSE (Generalized Self-Efficacy Scale) and the BDI-II (Beck Depression Inventory-II). Confirmatory factor analysis bore out a five-factor solution (including 18 items) with good fit indices of adaptation to data, χ2/df = 1.440, RMSEA = 0.028, RMSEA 90% CI = 0.018–0.038, GFI = 0.996, AGFI = 0.959, CFI = 0.982, and NFI = 0.944. Evidence of convergent validity was provided by the significant correlations with variables such as cognitive and somatic depression, and perceived general self-efficacy. The analyses also showed a strong invariance across gender. The ERPAS tool prefigures application during the assessment in multiple emergency contexts (e.g. earthquakes, floods, pandemics, terrorist attacks, war events, major accidents, major fires). This validation study of the ERPAS has shown that this version is a reliable and valid measurement for assessing people's modes of personal response (cognitive, emotional, behavioral) in emergency contexts.
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Affiliation(s)
- Pierluigi Diotaiuti
- Department of Human Sciences, Society and Health, University of Cassino and Southern Lazio, Cassino, Italy
| | - Giuseppe Valente
- Department of Human Sciences, Society and Health, University of Cassino and Southern Lazio, Cassino, Italy
| | - Stefania Mancone
- Department of Human Sciences, Society and Health, University of Cassino and Southern Lazio, Cassino, Italy
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127
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Martin RA, Cukiert A, Blumenfeld H. Short-term changes in cortical physiological arousal measured by electroencephalography during thalamic centromedian deep brain stimulation. Epilepsia 2021; 62:2604-2614. [PMID: 34405892 DOI: 10.1111/epi.17042] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2021] [Revised: 08/03/2021] [Accepted: 08/03/2021] [Indexed: 11/29/2022]
Abstract
OBJECTIVE The intralaminar thalamus is well implicated in the processes of arousal and attention. Stimulation of the intralaminar thalamus has been used therapeutically to improve level of alertness in minimally conscious individuals and to reduce seizures in refractory epilepsy, both presumably through modulation of thalamocortical function. Little work exists that directly measures the effects of intralaminar thalamic stimulation on cortical physiological arousal in humans. Therefore, our goal was to quantify cortical physiological arousal in individuals with epilepsy receiving thalamic intralaminar deep brain stimulation. METHODS We recorded scalp electroencephalogram (EEG) during thalamic intralaminar centromedian (CM) nucleus stimulation in 11 patients with medically refractory epilepsy. Participants underwent stimulation at 130 Hz and 300 µs for periods of 5 min alternating with 5 min of rest while stimulus voltage was titrated upward from 1 to 5 V. EEG signal power was analyzed in different frequency ranges in relation to stimulus strength and time. RESULTS We found a progressive increase in broadband gamma (25-100 Hz) cortical EEG power (F = 7.64, p < .05) and decrease in alpha (8-13 Hz) power (F = 4.37, p < .05) with thalamic CM stimulation. Topographic maps showed these changes to be widely distributed across the cortical surface rather than localized to one region. SIGNIFICANCE Previous work has shown that broadband increases in gamma frequency power and decreases in alpha frequency power are generally associated with states of cortical activation and increased arousal/attention. Our observed changes therefore support the possible role of cortical activation and increased physiological arousal in therapeutic effects of intralaminar thalamic stimulation for improving both epilepsy and attention. Further investigations with this approach may lead to methods for determining optimal deep brain stimulation parameters to improve clinical outcome in these disorders.
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Affiliation(s)
- Reese A Martin
- Yale Department of Neurology, Yale University School of Medicine, New Haven, Connecticut, USA
| | | | - Hal Blumenfeld
- Yale Department of Neurology, Yale University School of Medicine, New Haven, Connecticut, USA.,Yale Department of Neuroscience, Yale University School of Medicine, New Haven, Connecticut, USA.,Yale Department of Neurosurgery, Yale University School of Medicine, New Haven, Connecticut, USA
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128
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Huang Z, Tarnal V, Vlisides PE, Janke EL, McKinney AM, Picton P, Mashour GA, Hudetz AG. Asymmetric neural dynamics characterize loss and recovery of consciousness. Neuroimage 2021; 236:118042. [PMID: 33848623 PMCID: PMC8310457 DOI: 10.1016/j.neuroimage.2021.118042] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2020] [Revised: 03/01/2021] [Accepted: 04/04/2021] [Indexed: 02/07/2023] Open
Abstract
Anesthetics are known to disrupt neural interactions in cortical and subcortical brain circuits. While the effect of anesthetic drugs on consciousness is reversible, the neural mechanism mediating induction and recovery may be different. Insight into these distinct mechanisms can be gained from a systematic comparison of neural dynamics during slow induction of and emergence from anesthesia. To this end, we used functional magnetic resonance imaging (fMRI) data obtained in healthy volunteers before, during, and after the administration of propofol at incrementally adjusted target concentrations. We analyzed functional connectivity of corticocortical and subcorticocortical networks and the temporal autocorrelation of fMRI signal as an index of neural processing timescales. We found that en route to unconsciousness, temporal autocorrelation across the entire brain gradually increased, whereas functional connectivity gradually decreased. In contrast, regaining consciousness was associated with an abrupt restoration of cortical but not subcortical temporal autocorrelation and an abrupt boost of subcorticocortical functional connectivity. Pharmacokinetic effects could not account for the difference in neural dynamics between induction and emergence. We conclude that the induction and recovery phases of anesthesia follow asymmetric neural dynamics. A rapid increase in the speed of cortical neural processing and subcorticocortical neural interactions may be a mechanism that reboots consciousness.
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Affiliation(s)
- Zirui Huang
- Department of Anesthesiology, University of Michigan Medical School, Ann Arbor, MI 48109, USA; Center for Consciousness Science, University of Michigan Medical School, Ann Arbor, MI 48109, USA.
| | - Vijay Tarnal
- Department of Anesthesiology, University of Michigan Medical School, Ann Arbor, MI 48109, USA; Center for Consciousness Science, University of Michigan Medical School, Ann Arbor, MI 48109, USA
| | - Phillip E Vlisides
- Department of Anesthesiology, University of Michigan Medical School, Ann Arbor, MI 48109, USA; Center for Consciousness Science, University of Michigan Medical School, Ann Arbor, MI 48109, USA
| | - Ellen L Janke
- Department of Anesthesiology, University of Michigan Medical School, Ann Arbor, MI 48109, USA; Center for Consciousness Science, University of Michigan Medical School, Ann Arbor, MI 48109, USA
| | - Amy M McKinney
- Department of Anesthesiology, University of Michigan Medical School, Ann Arbor, MI 48109, USA
| | - Paul Picton
- Department of Anesthesiology, University of Michigan Medical School, Ann Arbor, MI 48109, USA
| | - George A Mashour
- Department of Anesthesiology, University of Michigan Medical School, Ann Arbor, MI 48109, USA; Center for Consciousness Science, University of Michigan Medical School, Ann Arbor, MI 48109, USA; Neuroscience Graduate Program, University of Michigan, Ann Arbor, MI 48109, USA
| | - Anthony G Hudetz
- Department of Anesthesiology, University of Michigan Medical School, Ann Arbor, MI 48109, USA; Center for Consciousness Science, University of Michigan Medical School, Ann Arbor, MI 48109, USA; Neuroscience Graduate Program, University of Michigan, Ann Arbor, MI 48109, USA.
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Gummadavelli A, Martin R, Goshay D, Sieu LA, Xu J, Gruenbaum BF, McCafferty C, Gerrard JL, Blumenfeld H. Cortical low-frequency power correlates with behavioral impairment in animal model of focal limbic seizures. Epilepsia 2021; 62:1960-1970. [PMID: 34240747 PMCID: PMC8349876 DOI: 10.1111/epi.16964] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Revised: 05/29/2021] [Accepted: 06/01/2021] [Indexed: 11/29/2022]
Abstract
OBJECTIVE Impairment in consciousness is a debilitating symptom during and after seizures; however, its mechanism remains unclear. Limbic seizures have been shown to spread to arousal circuitry to result in a "network inhibition" phenomenon. However, prior animal model studies did not relate physiological network changes to behavioral responses during or following seizures. METHODS Focal onset limbic seizures were induced while rats were performing an operant conditioned behavioral task requiring response to an auditory stimulus to quantify how and when impairment of behavioral response occurs. Correct responses were rewarded with sucrose. Cortical and hippocampal electrophysiology measured by local field potential recordings was analyzed for changes in low- and high-frequency power in relation to behavioral responsiveness during seizures. RESULTS As seen in patients with seizures, ictal (p < .0001) and postictal (p = .0015) responsiveness was variably impaired. Analysis of cortical and hippocampal electrophysiology revealed that ictal (p = .002) and postictal (p = .009) frontal cortical low-frequency 3-6-Hz power was associated with poor behavioral performance. In contrast, the hippocampus showed increased power over a wide frequency range during seizures, and suppression postictally, neither of which were related to behavioral impairment. SIGNIFICANCE These findings support prior human studies of temporal lobe epilepsy as well as anesthetized animal models suggesting that focal limbic seizures depress consciousness through remote network effects on the cortex, rather than through local hippocampal involvement. By identifying the cortical physiological changes associated with impaired arousal and responsiveness in focal seizures, these results may help guide future therapies to restore ictal and postictal consciousness, improving quality of life for people with epilepsy.
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Affiliation(s)
- Abhijeet Gummadavelli
- Department of Neurology, Yale University School of Medicine, 333 Cedar Street, New Haven, Connecticut 06520, USA
- Department of Neurosurgery, Yale University School of Medicine, 333 Cedar Street, New Haven, Connecticut 06520, USA
| | - Reese Martin
- Department of Neurology, Yale University School of Medicine, 333 Cedar Street, New Haven, Connecticut 06520, USA
| | - Derek Goshay
- Department of Neurology, Yale University School of Medicine, 333 Cedar Street, New Haven, Connecticut 06520, USA
| | - Lim-Anna Sieu
- Department of Neurology, Yale University School of Medicine, 333 Cedar Street, New Haven, Connecticut 06520, USA
| | - Jingwen Xu
- Department of Neurology, Yale University School of Medicine, 333 Cedar Street, New Haven, Connecticut 06520, USA
| | - Benjamin F. Gruenbaum
- Department of Neurology, Yale University School of Medicine, 333 Cedar Street, New Haven, Connecticut 06520, USA
| | - Cian McCafferty
- Department of Neurology, Yale University School of Medicine, 333 Cedar Street, New Haven, Connecticut 06520, USA
| | - Jason L. Gerrard
- Department of Neurosurgery, Yale University School of Medicine, 333 Cedar Street, New Haven, Connecticut 06520, USA
| | - Hal Blumenfeld
- Department of Neurology, Yale University School of Medicine, 333 Cedar Street, New Haven, Connecticut 06520, USA
- Department of Neurosurgery, Yale University School of Medicine, 333 Cedar Street, New Haven, Connecticut 06520, USA
- Department of Neuroscience, Yale University School of Medicine, 333 Cedar Street, New Haven, Connecticut 06520, USA
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Sanz Perl Y, Pallavicini C, Pérez Ipiña I, Demertzi A, Bonhomme V, Martial C, Panda R, Annen J, Ibañez A, Kringelbach M, Deco G, Laufs H, Sitt J, Laureys S, Tagliazucchi E. Perturbations in dynamical models of whole-brain activity dissociate between the level and stability of consciousness. PLoS Comput Biol 2021; 17:e1009139. [PMID: 34314430 PMCID: PMC8315553 DOI: 10.1371/journal.pcbi.1009139] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2020] [Accepted: 06/01/2021] [Indexed: 01/07/2023] Open
Abstract
Consciousness transiently fades away during deep sleep, more stably under anesthesia, and sometimes permanently due to brain injury. The development of an index to quantify the level of consciousness across these different states is regarded as a key problem both in basic and clinical neuroscience. We argue that this problem is ill-defined since such an index would not exhaust all the relevant information about a given state of consciousness. While the level of consciousness can be taken to describe the actual brain state, a complete characterization should also include its potential behavior against external perturbations. We developed and analyzed whole-brain computational models to show that the stability of conscious states provides information complementary to their similarity to conscious wakefulness. Our work leads to a novel methodological framework to sort out different brain states by their stability and reversibility, and illustrates its usefulness to dissociate between physiological (sleep), pathological (brain-injured patients), and pharmacologically-induced (anesthesia) loss of consciousness.
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Affiliation(s)
- Yonatan Sanz Perl
- Department of Physics, University of Buenos Aires, Intendente Güiraldes 2160—Ciudad Universitaria—Buenos Aires, Argentina
- National Scientific and Technical Research Council (CONICET), CABA, Buenos Aires, Argentina
- Cognitive Neuroscience Center (CNC), Universidad de San Andrés, Buenos Aires, Argentina
- Center for Brain and Cognition, Computational Neuroscience Group, Universitat Pompeu Fabra, Barcelona, Spain
- * E-mail: (YSP); (ET)
| | - Carla Pallavicini
- Department of Physics, University of Buenos Aires, Intendente Güiraldes 2160—Ciudad Universitaria—Buenos Aires, Argentina
- National Scientific and Technical Research Council (CONICET), CABA, Buenos Aires, Argentina
- Fundación para la Lucha contra las Enfermedades Neurológicas de la Infancia (FLENI), Buenos Aires, Argentina
| | - Ignacio Pérez Ipiña
- Department of Physics, University of Buenos Aires, Intendente Güiraldes 2160—Ciudad Universitaria—Buenos Aires, Argentina
- Fundación para la Lucha contra las Enfermedades Neurológicas de la Infancia (FLENI), Buenos Aires, Argentina
| | - Athena Demertzi
- Physiology of Cognition Research Lab, GIGA-Consciousness, GIGA Institute, University of Liège, Liège, Belgium
| | - Vincent Bonhomme
- Anesthesia and Intensive Care Laboratory, GIGA-Consciousness, GIGA Institute, University of Liège, Liège, Belgium
- University Department of Anesthesia and Intensive Care Medicine, Centre Hospitalier Régional de la Citadelle (CHR Citadelle), Liège, Belgium
- Department of Anesthesia and Intensive Care Medicine, Centre Hospitalier Universitaire de Liège (CHU Liège), Liège, Belgium
| | - Charlotte Martial
- Coma Science Group, GIGA Consciousness, University of Liège, Liège, Belgium
- Centre du Cerveau², Centre Hospitalier Universitaire de Liège (CHU Liège), Liège, Belgium
| | - Rajanikant Panda
- Coma Science Group, GIGA Consciousness, University of Liège, Liège, Belgium
- Centre du Cerveau², Centre Hospitalier Universitaire de Liège (CHU Liège), Liège, Belgium
| | - Jitka Annen
- Coma Science Group, GIGA Consciousness, University of Liège, Liège, Belgium
- Centre du Cerveau², Centre Hospitalier Universitaire de Liège (CHU Liège), Liège, Belgium
| | - Agustin Ibañez
- National Scientific and Technical Research Council (CONICET), CABA, Buenos Aires, Argentina
- Cognitive Neuroscience Center (CNC), Universidad de San Andrés, Buenos Aires, Argentina
- Latin American Brain Health Institute (BrainLat), Universidad Adolfo Ibáñez, Santiago, Chile
- Global Brain Health Institute (GBHI), University of California-San Francisco (UCSF), San Francisco, California, United States and Trinity College Dublin, Ireland
| | - Morten Kringelbach
- Department of Psychiatry, University of Oxford, Oxford, United Kingdom
- Center for Music in the Brain, Department of Clinical Medicine, Aarhus University, Århus, Denmark
- Life and Health Sciences Research Institute (ICVS), School of Medicine, University of Minho, Braga, Portugal
- Centre for Eudaimonia and Human Flourishing, University of Oxford, Oxford, United Kingdom
| | - Gustavo Deco
- Center for Brain and Cognition, Computational Neuroscience Group, Universitat Pompeu Fabra, Barcelona, Spain
- Department of Information and Communication Technologies, Universitat Pompeu Fabra, Barcelona, Spain
- Institució Catalana de la Recerca i Estudis Avançats (ICREA), Barcelona, Spain
- Department of Neuropsychology, Max Planck Institute for Human Cognitive and Brain Sciences, Leipzig, Germany
- School of Psychological Sciences, Monash University, Melbourne, Australia
| | - Helmut Laufs
- Department of Neurology and Brain Imaging Center, Goethe University, Frankfurt am Main, Germany
- Department of Neurology, Christian Albrechts University, Kiel, Germany
| | - Jacobo Sitt
- Institut du Cerveau et de la Moelle épinière, ICM, Paris, France
- Inserm U 1127, Paris, France
- CNRS UMR 7225, Paris, France
| | - Steven Laureys
- Coma Science Group, GIGA Consciousness, University of Liège, Liège, Belgium
- Centre du Cerveau², Centre Hospitalier Universitaire de Liège (CHU Liège), Liège, Belgium
| | - Enzo Tagliazucchi
- Department of Physics, University of Buenos Aires, Intendente Güiraldes 2160—Ciudad Universitaria—Buenos Aires, Argentina
- National Scientific and Technical Research Council (CONICET), CABA, Buenos Aires, Argentina
- Latin American Brain Health Institute (BrainLat), Universidad Adolfo Ibáñez, Santiago, Chile
- Department of Neurology, Christian Albrechts University, Kiel, Germany
- * E-mail: (YSP); (ET)
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131
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Garzón Diaz FA. Bioethical Aspects of Patients in a Minimally Conscious State. REVISTA LATINOAMERICANA DE BIOÉTICA 2021. [DOI: 10.18359/rlbi.5594] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
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132
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Klink PC, Aubry JF, Ferrera VP, Fox AS, Froudist-Walsh S, Jarraya B, Konofagou EE, Krauzlis RJ, Messinger A, Mitchell AS, Ortiz-Rios M, Oya H, Roberts AC, Roe AW, Rushworth MFS, Sallet J, Schmid MC, Schroeder CE, Tasserie J, Tsao DY, Uhrig L, Vanduffel W, Wilke M, Kagan I, Petkov CI. Combining brain perturbation and neuroimaging in non-human primates. Neuroimage 2021; 235:118017. [PMID: 33794355 PMCID: PMC11178240 DOI: 10.1016/j.neuroimage.2021.118017] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2020] [Revised: 03/07/2021] [Accepted: 03/22/2021] [Indexed: 12/11/2022] Open
Abstract
Brain perturbation studies allow detailed causal inferences of behavioral and neural processes. Because the combination of brain perturbation methods and neural measurement techniques is inherently challenging, research in humans has predominantly focused on non-invasive, indirect brain perturbations, or neurological lesion studies. Non-human primates have been indispensable as a neurobiological system that is highly similar to humans while simultaneously being more experimentally tractable, allowing visualization of the functional and structural impact of systematic brain perturbation. This review considers the state of the art in non-human primate brain perturbation with a focus on approaches that can be combined with neuroimaging. We consider both non-reversible (lesions) and reversible or temporary perturbations such as electrical, pharmacological, optical, optogenetic, chemogenetic, pathway-selective, and ultrasound based interference methods. Method-specific considerations from the research and development community are offered to facilitate research in this field and support further innovations. We conclude by identifying novel avenues for further research and innovation and by highlighting the clinical translational potential of the methods.
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Affiliation(s)
- P Christiaan Klink
- Department of Vision & Cognition, Netherlands Institute for Neuroscience, Meibergdreef 47, 1105 BA Amsterdam, the Netherlands.
| | - Jean-François Aubry
- Physics for Medicine Paris, Inserm U1273, CNRS UMR 8063, ESPCI Paris, PSL University, Paris, France
| | - Vincent P Ferrera
- Department of Neuroscience & Department of Psychiatry, Columbia University Medical Center, New York, NY, USA; Zuckerman Mind Brain Behavior Institute, Columbia University, New York, NY, USA
| | - Andrew S Fox
- Department of Psychology & California National Primate Research Center, University of California, Davis, CA, USA
| | | | - Béchir Jarraya
- NeuroSpin, Commissariat à l'Énergie Atomique et aux Énergies Alternatives (CEA), Institut National de la Santé et de la Recherche Médicale (INSERM), Cognitive Neuroimaging Unit, Université Paris-Saclay, France; Foch Hospital, UVSQ, Suresnes, France
| | - Elisa E Konofagou
- Ultrasound and Elasticity Imaging Laboratory, Department of Biomedical Engineering, Columbia University, New York, NY, USA; Department of Radiology, Columbia University, New York, NY, USA
| | - Richard J Krauzlis
- Laboratory of Sensorimotor Research, National Eye Institute, Bethesda, MD, USA
| | - Adam Messinger
- Laboratory of Brain and Cognition, National Institute of Mental Health, Bethesda, MD, USA
| | - Anna S Mitchell
- Department of Experimental Psychology, Oxford University, Oxford, United Kingdom
| | - Michael Ortiz-Rios
- Newcastle University Medical School, Newcastle upon Tyne NE1 7RU, United Kingdom; German Primate Center, Leibniz Institute for Primate Research, Kellnerweg 4, 37077 Göttingen, Germany
| | - Hiroyuki Oya
- Iowa Neuroscience Institute, Carver College of Medicine, University of Iowa, Iowa City, IA, USA; Department of Neurosurgery, University of Iowa, Iowa city, IA, USA
| | - Angela C Roberts
- Department of Physiology, Development and Neuroscience, Cambridge University, Cambridge, United Kingdom
| | - Anna Wang Roe
- Interdisciplinary Institute of Neuroscience and Technology, School of Medicine, Zhejiang University, Hangzhou 310029, China
| | | | - Jérôme Sallet
- Department of Experimental Psychology, Oxford University, Oxford, United Kingdom; Univ Lyon, Université Lyon 1, Inserm, Stem Cell and Brain Research Institute, U1208 Bron, France; Wellcome Centre for Integrative Neuroimaging, Department of Experimental Psychology, University of Oxford, Oxford, United Kingdom
| | - Michael Christoph Schmid
- Newcastle University Medical School, Newcastle upon Tyne NE1 7RU, United Kingdom; Faculty of Science and Medicine, University of Fribourg, Chemin du Musée 5, CH-1700 Fribourg, Switzerland
| | - Charles E Schroeder
- Nathan Kline Institute, Orangeburg, NY, USA; Columbia University, New York, NY, USA
| | - Jordy Tasserie
- NeuroSpin, Commissariat à l'Énergie Atomique et aux Énergies Alternatives (CEA), Institut National de la Santé et de la Recherche Médicale (INSERM), Cognitive Neuroimaging Unit, Université Paris-Saclay, France
| | - Doris Y Tsao
- Division of Biology and Biological Engineering, Tianqiao and Chrissy Chen Institute for Neuroscience; Howard Hughes Medical Institute; Computation and Neural Systems, Caltech, Pasadena, CA, USA
| | - Lynn Uhrig
- NeuroSpin, Commissariat à l'Énergie Atomique et aux Énergies Alternatives (CEA), Institut National de la Santé et de la Recherche Médicale (INSERM), Cognitive Neuroimaging Unit, Université Paris-Saclay, France
| | - Wim Vanduffel
- Laboratory for Neuro- and Psychophysiology, Neurosciences Department, KU Leuven Medical School, Leuven, Belgium; Leuven Brain Institute, KU Leuven, Leuven Belgium; Harvard Medical School, Boston, MA, USA; Massachusetts General Hospital, Martinos Center for Biomedical Imaging, Charlestown, MA, USA
| | - Melanie Wilke
- German Primate Center, Leibniz Institute for Primate Research, Kellnerweg 4, 37077 Göttingen, Germany; Department of Cognitive Neurology, University Medicine Göttingen, Göttingen, Germany
| | - Igor Kagan
- German Primate Center, Leibniz Institute for Primate Research, Kellnerweg 4, 37077 Göttingen, Germany.
| | - Christopher I Petkov
- Newcastle University Medical School, Newcastle upon Tyne NE1 7RU, United Kingdom.
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Martens G, Ibáñez-Soria D, Barra A, Soria-Frisch A, Piarulli A, Gosseries O, Salvador R, Rojas A, Nitsche MA, Kroupi E, Laureys S, Ruffini G, Thibaut A. A novel closed-loop EEG-tDCS approach to promote responsiveness of patients in minimally conscious state: A study protocol. Behav Brain Res 2021; 409:113311. [PMID: 33878429 DOI: 10.1016/j.bbr.2021.113311] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2020] [Revised: 03/10/2021] [Accepted: 04/15/2021] [Indexed: 01/28/2023]
Abstract
Transcranial direct current stimulation (tDCS) applied over the prefrontal cortex has been shown to improve behavioral responsiveness in patients with disorders of consciousness following severe brain injury, especially those in minimally conscious state (MCS). However, one potential barrier of clinical response to tDCS is the timing of stimulation with regard to the fluctuations of vigilance that characterize this population. Indeed, a previous study showed that the vigilance of MCS patients has periodic average cycles of 70 min (range 57-80 min), potentially preventing them to be in an optimal neural state to benefit from tDCS when applied randomly. To tackle this issue, we propose a new protocol to optimize the application of tDCS by selectively stimulating at high and low vigilance states. Electroencephalography (EEG) real-time spectral entropy will be used as a marker of vigilance and to trigger tDCS, in a closed-loop fashion. We will conduct a randomized controlled crossover clinical trial on 16 patients in prolonged MCS who will undergo three EEG-tDCS sessions 5 days apart (1. tDCS applied at high vigilance; 2. tDCS applied at low vigilance; 3. tDCS applied at a random moment). Behavioral effects will be assessed using the Coma Recovery Scale-Revised at baseline and right after the stimulations. EEG will be recorded throughout the session and for 30 min after the end of the stimulation. This unique and novel approach will provide patients' tailored treatment options, currently lacking in the field of disorders of consciousness.
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Affiliation(s)
- Géraldine Martens
- 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
| | | | - Andrea Piarulli
- Department of Surgical, Medical, Molecular and Critical Area Pathology, University of Pisa, Italy
| | - Olivia Gosseries
- Coma Science Group, GIGA Consciousness, University of Liège, Liège, Belgium; Centre du cerveau², University Hospital of Liège, Liège, Belgium
| | | | | | - Michael A Nitsche
- Dept. Psychology and Neurosciences, Leibniz Research Centre for Working Environment and Human Factors, Dortmund, Germany; Dept. Neurology, University Medical Hospital Bergmannsheil, Bochum, Germany
| | | | - Steven Laureys
- Coma Science Group, GIGA Consciousness, University of Liège, Liège, Belgium; Centre du cerveau², University Hospital of Liège, Liège, Belgium
| | | | - Aurore Thibaut
- Coma Science Group, GIGA Consciousness, University of Liège, Liège, Belgium; Centre du cerveau², University Hospital of Liège, Liège, Belgium
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134
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Therapies to Restore Consciousness in Patients with Severe Brain Injuries: A Gap Analysis and Future Directions. Neurocrit Care 2021; 35:68-85. [PMID: 34236624 PMCID: PMC8266715 DOI: 10.1007/s12028-021-01227-y] [Citation(s) in RCA: 53] [Impact Index Per Article: 17.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2021] [Accepted: 03/04/2021] [Indexed: 02/06/2023]
Abstract
Background/Objective For patients with disorders of consciousness (DoC) and their families, the search for new therapies has been a source of hope and frustration. Almost all clinical trials in patients with DoC have been limited by small sample sizes, lack of placebo groups, and use of heterogeneous outcome measures. As a result, few therapies have strong evidence to support their use; amantadine is the only therapy recommended by current clinical guidelines, specifically for patients with DoC caused by severe traumatic brain injury. To foster and advance development of consciousness-promoting therapies for patients with DoC, the Curing Coma Campaign convened a Coma Science Work Group to perform a gap analysis. Methods We consider five classes of therapies: (1) pharmacologic; (2) electromagnetic; (3) mechanical; (4) sensory; and (5) regenerative. For each class of therapy, we summarize the state of the science, identify gaps in knowledge, and suggest future directions for therapy development. Results Knowledge gaps in all five therapeutic classes can be attributed to the lack of: (1) a unifying conceptual framework for evaluating therapeutic mechanisms of action; (2) large-scale randomized controlled trials; and (3) pharmacodynamic biomarkers that measure subclinical therapeutic effects in early-phase trials. To address these gaps, we propose a precision medicine approach in which clinical trials selectively enroll patients based upon their physiological receptivity to targeted therapies, and therapeutic effects are measured by complementary behavioral, neuroimaging, and electrophysiologic endpoints. Conclusions This personalized approach can be realized through rigorous clinical trial design and international collaboration, both of which will be essential for advancing the development of new therapies and ultimately improving the lives of patients with DoC. Supplementary Information The online version contains supplementary material available at 10.1007/s12028-021-01227-y.
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Claassen J, Akbari Y, Alexander S, Bader MK, Bell K, Bleck TP, Boly M, Brown J, Chou SHY, Diringer MN, Edlow BL, Foreman B, Giacino JT, Gosseries O, Green T, Greer DM, Hanley DF, Hartings JA, Helbok R, Hemphill JC, Hinson HE, Hirsch K, Human T, James ML, Ko N, Kondziella D, Livesay S, Madden LK, Mainali S, Mayer SA, McCredie V, McNett MM, Meyfroidt G, Monti MM, Muehlschlegel S, Murthy S, Nyquist P, Olson DM, Provencio JJ, Rosenthal E, Sampaio Silva G, Sarasso S, Schiff ND, Sharshar T, Shutter L, Stevens RD, Vespa P, Videtta W, Wagner A, Ziai W, Whyte J, Zink E, Suarez JI. Proceedings of the First Curing Coma Campaign NIH Symposium: Challenging the Future of Research for Coma and Disorders of Consciousness. Neurocrit Care 2021; 35:4-23. [PMID: 34236619 PMCID: PMC8264966 DOI: 10.1007/s12028-021-01260-x] [Citation(s) in RCA: 40] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2021] [Accepted: 04/15/2021] [Indexed: 01/04/2023]
Abstract
Coma and disorders of consciousness (DoC) are highly prevalent and constitute a burden for patients, families, and society worldwide. As part of the Curing Coma Campaign, the Neurocritical Care Society partnered with the National Institutes of Health to organize a symposium bringing together experts from all over the world to develop research targets for DoC. The conference was structured along six domains: (1) defining endotype/phenotypes, (2) biomarkers, (3) proof-of-concept clinical trials, (4) neuroprognostication, (5) long-term recovery, and (6) large datasets. This proceedings paper presents actionable research targets based on the presentations and discussions that occurred at the conference. We summarize the background, main research gaps, overall goals, the panel discussion of the approach, limitations and challenges, and deliverables that were identified.
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Affiliation(s)
- Jan Claassen
- Department of Neurology, Columbia University and New York-Presbyterian Hospital, 177 Fort Washington Avenue, MHB 8 Center, Room 300, New York City, NY, 10032, USA.
| | - Yama Akbari
- Departments of Neurology, Neurological Surgery, and Anatomy & Neurobiology and Beckman Laser Institute and Medical Clinic, University of California, Irvine, Irvine, CA, USA
| | - Sheila Alexander
- Acute and Tertiary Care, School of Nursing and Critical Care Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | | | - Kathleen Bell
- Department of Physical Medicine and Rehabilitation, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Thomas P Bleck
- Davee Department of Neurology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Melanie Boly
- Department of Neurology, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, WI, USA
| | - Jeremy Brown
- Office of Emergency Care Research, Division of Clinical Research, National Institute of Neurological Disorders and Stroke, Bethesda, MD, USA
| | - Sherry H-Y Chou
- Departments of Critical Care Medicine, Neurology, and Neurosurgery, School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Michael N Diringer
- Department of Neurology, Washington University in St. Louis, St. Louis, MO, USA
| | - Brian L Edlow
- Department of Neurology, Center for Neurotechnology and Neurorecovery, Massachusetts General Hospital and Harvard Medical School, Harvard University, Boston, MA, USA
| | - Brandon Foreman
- Departments of Neurology and Rehabilitation Medicine, College of Medicine, University of Cincinnati, Cincinnati, OH, USA
| | - Joseph T Giacino
- Department of Physical Medicine and Rehabilitation, Harvard Medical School, Harvard University, Boston, MA, USA
| | - Olivia Gosseries
- GIGA Consciousness After Coma Science Group, University of Liege, Liege, Belgium
| | - Theresa Green
- School of Nursing, Queensland University of Technology, Kelvin Grove, QLD, Australia
| | - David M Greer
- Department of Neurology, School of Medicine, Boston University, Boston, MA, USA
| | - Daniel F Hanley
- Division of Brain Injury Outcomes, Department of Neurology, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Jed A Hartings
- Department of Neurosurgery, College of Medicine, University of Cincinnati, Cincinnati, OH, USA
| | - Raimund Helbok
- Neurocritical Care Unit, Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - J Claude Hemphill
- Department of Neurology, Weill Institute for Neurosciences, School of Medicine, University of California, San Francisco, San Francisco, CA, USA
| | - H E Hinson
- Department of Neurology, School of Medicine, Oregon Health & Science University, Portland, OR, USA
| | - Karen Hirsch
- Department of Neurology, Stanford University, Palo Alto, CA, USA
| | - Theresa Human
- Department of Pharmacy, Barnes Jewish Hospital, St. Louis, MO, USA
| | - Michael L James
- Departments of Anesthesiology and Neurology, Duke University, Durham, NC, USA
| | - Nerissa Ko
- Department of Neurology, Weill Institute for Neurosciences, School of Medicine, University of California, San Francisco, San Francisco, CA, USA
| | - Daniel Kondziella
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
- Department of Neurology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Sarah Livesay
- College of Nursing, Rush University, Chicago, IL, USA
| | - Lori K Madden
- Center for Nursing Science, University of California, Davis, Sacramento, CA, USA
| | - Shraddha Mainali
- Department of Neurology, The Ohio State University, Columbus, OH, USA
| | - Stephan A Mayer
- Department of Neurology, New York Medical College, Valhalla, NY, USA
| | - Victoria McCredie
- Interdepartmental Division of Critical Care, Department of Respirology, University of Toronto, Toronto, ON, Canada
| | - Molly M McNett
- College of Nursing, The Ohio State University, Columbus, OH, USA
| | - Geert Meyfroidt
- Department of Intensive Care Medicine, University Hospitals Leuven and University of Leuven, Leuven, Belgium
| | - Martin M Monti
- Departments of Neurosurgery and Psychology, Brain Injury Research Center, University of California, Los Angeles, Los Angeles, CA, USA
| | - Susanne Muehlschlegel
- Departments of Neurology, Anesthesiology/Critical Care, and Surgery, Medical School, University of Massachusetts, Worcester, MA, USA
| | - Santosh Murthy
- Department of Neurology, Weill Cornell Medical College, New York City, NY, USA
| | - Paul Nyquist
- Division of Neurosciences Critical Care, Departments of Anesthesiology and Critical Care Medicine, Neurology, and Neurosurgery, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - DaiWai M Olson
- Departments of Neurology and Neurosurgery, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - J Javier Provencio
- Departments of Neurology and Neuroscience, School of Medicine, University of Virginia, Charlottesville, VA, USA
| | - Eric Rosenthal
- Department of Neurology, Harvard Medical School, Harvard University, Boston, MA, USA
| | - Gisele Sampaio Silva
- Department of Neurology, Albert Einstein Israelite Hospital and Universidade Federal de São Paulo, São Paulo, Brazil
| | - Simone Sarasso
- Department of Biomedical and Clinical Sciences "L. Sacco", Università degli Studi di Milano, Milan, Italy
| | - Nicholas D Schiff
- Department of Neurology and Brain Mind Research Institute, Weill Cornell Medicine, Cornell University, New York City, NY, USA
| | - Tarek Sharshar
- Department of Intensive Care, Paris Descartes University, Paris, France
| | - Lori Shutter
- Departments of Critical Care Medicine, Neurology, and Neurosurgery, School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Robert D Stevens
- Division of Neurosciences Critical Care, Departments of Anesthesiology and Critical Care Medicine, Neurology, and Neurosurgery, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Paul Vespa
- Departments of Neurosurgery and Neurology, University of California, Los Angeles, Los Angeles, CA, USA
| | - Walter Videtta
- National Hospital Alejandro Posadas, Buenos Aires, Argentina
| | - Amy Wagner
- Department of Physical Medicine and Rehabilitation, School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Wendy Ziai
- Division of Neurosciences Critical Care, Departments of Anesthesiology and Critical Care Medicine, Neurology, and Neurosurgery, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - John Whyte
- Moss Rehabilitation Research Institute, Elkins Park, PA, USA
| | - Elizabeth Zink
- Division of Neurosciences Critical Care, Department of Neurology, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Jose I Suarez
- Division of Neurosciences Critical Care, Departments of Anesthesiology and Critical Care Medicine, Neurology, and Neurosurgery, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
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Luppi AI, Cain J, Spindler LRB, Górska UJ, Toker D, Hudson AE, Brown EN, Diringer MN, Stevens RD, Massimini M, Monti MM, Stamatakis EA, Boly M. Mechanisms Underlying Disorders of Consciousness: Bridging Gaps to Move Toward an Integrated Translational Science. Neurocrit Care 2021; 35:37-54. [PMID: 34236622 PMCID: PMC8266690 DOI: 10.1007/s12028-021-01281-6] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2021] [Accepted: 05/17/2021] [Indexed: 01/08/2023]
Abstract
AIM In order to successfully detect, classify, prognosticate, and develop targeted therapies for patients with disorders of consciousness (DOC), it is crucial to improve our mechanistic understanding of how severe brain injuries result in these disorders. METHODS To address this need, the Curing Coma Campaign convened a Mechanisms Sub-Group of the Coma Science Work Group (CSWG), aiming to identify the most pressing knowledge gaps and the most promising approaches to bridge them. RESULTS We identified a key conceptual gap in the need to differentiate the neural mechanisms of consciousness per se, from those underpinning connectedness to the environment and behavioral responsiveness. Further, we characterised three fundamental gaps in DOC research: (1) a lack of mechanistic integration between structural brain damage and abnormal brain function in DOC; (2) a lack of translational bridges between micro- and macro-scale neural phenomena; and (3) an incomplete exploration of possible synergies between data-driven and theory-driven approaches. CONCLUSION In this white paper, we discuss research priorities that would enable us to begin to close these knowledge gaps. We propose that a fundamental step towards this goal will be to combine translational, multi-scale, and multimodal data, with new biomarkers, theory-driven approaches, and computational models, to produce an integrated account of neural mechanisms in DOC. Importantly, we envision that reciprocal interaction between domains will establish a "virtuous cycle," leading towards a critical vantage point of integrated knowledge that will enable the advancement of the scientific understanding of DOC and consequently, an improvement of clinical practice.
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Affiliation(s)
- Andrea I Luppi
- Division of Anaesthesia, School of Clinical Medicine, University of Cambridge, Cambridge, UK.
- Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK.
| | - Joshua Cain
- Department of Psychology, University of California, Los Angeles, Los Angeles, CA, USA.
| | - Lennart R B Spindler
- Division of Anaesthesia, School of Clinical Medicine, University of Cambridge, Cambridge, UK.
- Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK.
| | - Urszula J Górska
- Department of Psychiatry, University of Wisconsin-Madison, Madison, WI, USA.
| | - Daniel Toker
- Department of Psychology, University of California, Los Angeles, Los Angeles, CA, USA
| | - Andrew E Hudson
- Department of Anesthesia and Perioperative Medicine, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, USA
| | - Emery N Brown
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital and Harvard Medical School, Harvard University, Boston, MA, USA
- Department of Brain and Cognitive Sciences, Massachusetts Institute of Technology, Cambridge, MA, USA
| | - Michael N Diringer
- Department of Neurology and Neurosurgery, Washington University in St. Louis, St. Louis, MO, USA
| | - Robert D Stevens
- Departments of Anesthesiology and Critical Care Medicine, Neurology and Neurosurgery, and Radiology, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Marcello Massimini
- Dipartimento di Scienze Biomediche e Cliniche "L. Sacco", Università Degli Studi Di Milano, Milan, Italy
- Istituto Di Ricovero e Cura a Carattere Scientifico, Fondazione Don Carlo Gnocchi, Milan, Italy
| | - Martin M Monti
- Department of Psychology, University of California, Los Angeles, Los Angeles, CA, USA
- Brain Injury Research Center, Department of Neurosurgery, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, USA
| | - Emmanuel A Stamatakis
- Division of Anaesthesia, School of Clinical Medicine, University of Cambridge, Cambridge, UK
- Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| | - Melanie Boly
- Department of Psychiatry, University of Wisconsin-Madison, Madison, WI, USA
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Sleep in disorders of consciousness: diagnostic, prognostic, and therapeutic considerations. Curr Opin Neurol 2021; 33:684-690. [PMID: 33177374 DOI: 10.1097/wco.0000000000000870] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
PURPOSE OF REVIEW Sleep is important in the evaluation of patients with disorders of consciousness (DOC). However, it remains unclear whether reconstitution of sleep could enable consciousness or vice versa. Here we synthesize recent evidence on natural recovery of sleep in DOC, and sleep-promoting therapeutic interventions for recovery of consciousness. RECENT FINDINGS In subacute DOC, physiological sleep--wake cycles and complex sleep patterns are related to better outcomes. Moreover, structured rapid-eye-movement (REM), non-REM (NREM) stages, and presence of sleep spindles correlate with full or partial recovery. In chronic DOC, sleep organization may reflect both integrity of consciousness-supporting brain networks and engagement of those networks during wakefulness. Therapeutic strategies have integrated improvement of sleep and sleep--wake cycles in DOC patients; use of bright light stimulation or drugs enhancing sleep and/or vigilance, treatment of sleep apneas, and neuromodulatory stimulations are promising tools to promote healthy sleep architecture and wakeful recovery. SUMMARY Sleep features and sleep--wake cycles are important prognostic markers in subacute DOC and can provide insight into covert recovery in chronic DOC. Although large-scale studies are needed, preliminary studies in limited patients suggest that therapeutic options restoring sleep and/or sleep--wake cycles may improve cognitive function and outcomes in DOC.
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138
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Phillips JM, Kambi NA, Redinbaugh MJ, Mohanta S, Saalmann YB. Disentangling the influences of multiple thalamic nuclei on prefrontal cortex and cognitive control. Neurosci Biobehav Rev 2021; 128:487-510. [PMID: 34216654 DOI: 10.1016/j.neubiorev.2021.06.042] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Revised: 04/13/2021] [Accepted: 06/09/2021] [Indexed: 10/21/2022]
Abstract
The prefrontal cortex (PFC) has a complex relationship with the thalamus, involving many nuclei which occupy predominantly medial zones along its anterior-to-posterior extent. Thalamocortical neurons in most of these nuclei are modulated by the affective and cognitive signals which funnel through the basal ganglia. We review how PFC-connected thalamic nuclei likely contribute to all aspects of cognitive control: from the processing of information on internal states and goals, facilitating its interactions with mnemonic information and learned values of stimuli and actions, to their influence on high-level cognitive processes, attentional allocation and goal-directed behavior. This includes contributions to transformations such as rule-to-choice (parvocellular mediodorsal nucleus), value-to-choice (magnocellular mediodorsal nucleus), mnemonic-to-choice (anteromedial nucleus) and sensory-to-choice (medial pulvinar). Common mechanisms appear to be thalamic modulation of cortical gain and cortico-cortical functional connectivity. The anatomy also implies a unique role for medial PFC in modulating processing in thalamocortical circuits involving other orbital and lateral PFC regions. We further discuss how cortico-basal ganglia circuits may provide a mechanism through which PFC controls cortico-cortical functional connectivity.
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Affiliation(s)
- Jessica M Phillips
- Department of Psychology, University of Wisconsin-Madison, 1202 W Johnson St., Madison, WI 53706, United States.
| | - Niranjan A Kambi
- Department of Psychology, University of Wisconsin-Madison, 1202 W Johnson St., Madison, WI 53706, United States
| | - Michelle J Redinbaugh
- Department of Psychology, University of Wisconsin-Madison, 1202 W Johnson St., Madison, WI 53706, United States
| | - Sounak Mohanta
- Department of Psychology, University of Wisconsin-Madison, 1202 W Johnson St., Madison, WI 53706, United States
| | - Yuri B Saalmann
- Department of Psychology, University of Wisconsin-Madison, 1202 W Johnson St., Madison, WI 53706, United States; Wisconsin National Primate Research Center, University of Wisconsin-Madison, 1202 Capitol Ct., Madison, WI 53715, United States.
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Lemaire JJ, Pontier B, Chaix R, El Ouadih Y, Khalil T, Sinardet D, Achim V, Postelnicu A, Coste J, Germain V, Sarret C, Sontheimer A. Neural correlates of consciousness and related disorders: From phenotypic descriptors of behavioral and relative consciousness to cortico-subcortical circuitry. Neurochirurgie 2021; 68:212-222. [PMID: 34051246 DOI: 10.1016/j.neuchi.2021.05.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Revised: 04/13/2021] [Accepted: 05/09/2021] [Indexed: 01/01/2023]
Abstract
We report a review of medical aspects of the consciousness. The behavioral dimension, phenotypic descriptors, relative consciousness and neural correlates of consciousness and related disorders were addressed successively in a holistic and chronological approach. Consciousness is relative, specific to each individual across time and space. Historically defined as the perception of the self and the environment, it cannot be separated from behaviors, entailing an idea of conscious behavior with metapractic and metagnostic aspects. Observation of spontaneous and evoked overt behavior distinguishes three main types of disorder of consciousness (DoC): coma, vegetative state or unresponsive wakefulness, and minimally conscious or relationally impoverished state. Modern functional exploration techniques, such as imaging, increase the understanding of DoCs and consciousness. Whether consciousness is a superior function and/or an instrumental function is discussed. Neural correlates can be subdivided into two wakefulness pathways (superior thalamic cholinergic and inferior extra-thalamic), and cortico-subcortical circuitry. The deep brain structures are those described in the well-known sensorimotor, associative and limbic loops, as illustrated in the mesolimbic model of DoC. The cortices can be segregated into several overlapping networks: (1) a global workspace including thalamo-cortical loops; (2) the default mode network (DMN) and related intrinsic connectivity networks (i.e., central executive, medial DMN and salience networks); (3) a 3-fold network comprising the fronto-parietal control system and its dorsal and ventral attentional sub-networks, the fronto-parietal executive control network, and the cingulo-opercular salience network; (4) the internal and external cortices, respectively medial, turned toward the self, and lateral, turned toward the environment. The network dynamics is the reflection of consciousness, notably anticorrelations such as the decrease in activity of the posterior cingulate-precuneus regions during attentional tasks. Thanks to recent advances in DoC pathophysiology, further significative therapeutic progress is expected, taking into account the societal context. This depends notably on the dissemination of medical knowledge and its transfer to a wider public.
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Affiliation(s)
- J-J Lemaire
- Service de neurochirurgie, CHU Clermont-Ferrand, Clermont-Ferrand, France; Institut Pascal, université Clermont Auvergne CNRS SIGMA, Clermont-Ferrand, France.
| | - B Pontier
- Service de neurochirurgie, CHU Clermont-Ferrand, Clermont-Ferrand, France; Institut Pascal, université Clermont Auvergne CNRS SIGMA, Clermont-Ferrand, France
| | - R Chaix
- Service de neurochirurgie, CHU Clermont-Ferrand, Clermont-Ferrand, France
| | - Y El Ouadih
- Service de neurochirurgie, CHU Clermont-Ferrand, Clermont-Ferrand, France
| | - T Khalil
- Service de neurochirurgie, CHU Clermont-Ferrand, Clermont-Ferrand, France; Institut Pascal, université Clermont Auvergne CNRS SIGMA, Clermont-Ferrand, France
| | - D Sinardet
- Service de neurochirurgie, CHU Clermont-Ferrand, Clermont-Ferrand, France
| | - V Achim
- Service de neurochirurgie, CHU Clermont-Ferrand, Clermont-Ferrand, France
| | - A Postelnicu
- Service de neurochirurgie, CHU Clermont-Ferrand, Clermont-Ferrand, France
| | - J Coste
- Service de neurochirurgie, CHU Clermont-Ferrand, Clermont-Ferrand, France; Institut Pascal, université Clermont Auvergne CNRS SIGMA, Clermont-Ferrand, France
| | - V Germain
- Service de neurochirurgie, CHU Clermont-Ferrand, Clermont-Ferrand, France; Institut Pascal, université Clermont Auvergne CNRS SIGMA, Clermont-Ferrand, France
| | - C Sarret
- Institut Pascal, université Clermont Auvergne CNRS SIGMA, Clermont-Ferrand, France
| | - A Sontheimer
- Service de neurochirurgie, CHU Clermont-Ferrand, Clermont-Ferrand, France; Institut Pascal, université Clermont Auvergne CNRS SIGMA, Clermont-Ferrand, France
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140
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Bastos AM, Donoghue JA, Brincat SL, Mahnke M, Yanar J, Correa J, Waite AS, Lundqvist M, Roy J, Brown EN, Miller EK. Neural effects of propofol-induced unconsciousness and its reversal using thalamic stimulation. eLife 2021; 10:60824. [PMID: 33904411 PMCID: PMC8079153 DOI: 10.7554/elife.60824] [Citation(s) in RCA: 61] [Impact Index Per Article: 20.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2020] [Accepted: 03/28/2021] [Indexed: 01/05/2023] Open
Abstract
The specific circuit mechanisms through which anesthetics induce unconsciousness have not been completely characterized. We recorded neural activity from the frontal, parietal, and temporal cortices and thalamus while maintaining unconsciousness in non-human primates (NHPs) with the anesthetic propofol. Unconsciousness was marked by slow frequency (~1 Hz) oscillations in local field potentials, entrainment of local spiking to Up states alternating with Down states of little or no spiking activity, and decreased coherence in frequencies above 4 Hz. Thalamic stimulation ‘awakened’ anesthetized NHPs and reversed the electrophysiologic features of unconsciousness. Unconsciousness is linked to cortical and thalamic slow frequency synchrony coupled with decreased spiking, and loss of higher-frequency dynamics. This may disrupt cortical communication/integration.
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Affiliation(s)
- André M Bastos
- The Picower Institute for Learning and Memory and Department of Brain and Cognitive Sciences, Massachusetts Institute of Technology, Cambridge, United States
| | - Jacob A Donoghue
- The Picower Institute for Learning and Memory and Department of Brain and Cognitive Sciences, Massachusetts Institute of Technology, Cambridge, United States
| | - Scott L Brincat
- The Picower Institute for Learning and Memory and Department of Brain and Cognitive Sciences, Massachusetts Institute of Technology, Cambridge, United States
| | - Meredith Mahnke
- The Picower Institute for Learning and Memory and Department of Brain and Cognitive Sciences, Massachusetts Institute of Technology, Cambridge, United States
| | - Jorge Yanar
- The Picower Institute for Learning and Memory and Department of Brain and Cognitive Sciences, Massachusetts Institute of Technology, Cambridge, United States
| | - Josefina Correa
- The Picower Institute for Learning and Memory and Department of Brain and Cognitive Sciences, Massachusetts Institute of Technology, Cambridge, United States
| | - Ayan S Waite
- The Picower Institute for Learning and Memory and Department of Brain and Cognitive Sciences, Massachusetts Institute of Technology, Cambridge, United States
| | - Mikael Lundqvist
- The Picower Institute for Learning and Memory and Department of Brain and Cognitive Sciences, Massachusetts Institute of Technology, Cambridge, United States
| | - Jefferson Roy
- The Picower Institute for Learning and Memory and Department of Brain and Cognitive Sciences, Massachusetts Institute of Technology, Cambridge, United States
| | - Emery N Brown
- The Picower Institute for Learning and Memory and Department of Brain and Cognitive Sciences, Massachusetts Institute of Technology, Cambridge, United States.,The Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital/Harvard Medical School, Boston, United States.,The Institute for Medical Engineering and Science, Massachusetts Institute of Technology, Cambridge, United States
| | - Earl K Miller
- The Picower Institute for Learning and Memory and Department of Brain and Cognitive Sciences, Massachusetts Institute of Technology, Cambridge, United States
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141
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Afrasiabi M, Redinbaugh MJ, Phillips JM, Kambi NA, Mohanta S, Raz A, Haun AM, Saalmann YB. Consciousness depends on integration between parietal cortex, striatum, and thalamus. Cell Syst 2021; 12:363-373.e11. [PMID: 33730543 PMCID: PMC8084606 DOI: 10.1016/j.cels.2021.02.003] [Citation(s) in RCA: 45] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Revised: 11/10/2020] [Accepted: 02/18/2021] [Indexed: 11/19/2022]
Abstract
The neural substrates of consciousness remain elusive. Competing theories that attempt to explain consciousness disagree on the contribution of frontal versus posterior cortex and omit subcortical influences. This lack of understanding impedes the ability to monitor consciousness, which can lead to adverse clinical consequences. To test substrates and measures of consciousness, we recorded simultaneously from frontal cortex, parietal cortex, and subcortical structures, the striatum and thalamus, in awake, sleeping, and anesthetized macaques. We manipulated consciousness on a finer scale using thalamic stimulation, rousing macaques from continuously administered anesthesia. Our results show that, unlike measures targeting complexity, a measure additionally capturing neural integration (Φ∗) robustly correlated with changes in consciousness. Machine learning approaches show parietal cortex, striatum, and thalamus contributed more than frontal cortex to decoding differences in consciousness. These findings highlight the importance of integration between parietal and subcortical structures and challenge a key role for frontal cortex in consciousness.
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Affiliation(s)
- Mohsen Afrasiabi
- Department of Psychology, University of Wisconsin-Madison, Madison, WI 53705, USA.
| | | | - Jessica M Phillips
- Department of Psychology, University of Wisconsin-Madison, Madison, WI 53705, USA
| | - Niranjan A Kambi
- Department of Psychology, University of Wisconsin-Madison, Madison, WI 53705, USA
| | - Sounak Mohanta
- Department of Psychology, University of Wisconsin-Madison, Madison, WI 53705, USA
| | - Aeyal Raz
- Department of Anesthesiology, Rambam Health Care Campus, Haifa 3109601, Israel; The Ruth and Bruce Rappaport Faculty of Medicine, Technion - Israel Institute of Technology, Haifa 3200003, Israel
| | - Andrew M Haun
- Department of Psychiatry, University of Wisconsin-Madison, Madison, WI 53705, USA
| | - Yuri B Saalmann
- Department of Psychology, University of Wisconsin-Madison, Madison, WI 53705, USA; Wisconsin National Primate Research Center, Madison, WI 53705, USA.
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142
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Cover KK, Mathur BN. Rostral Intralaminar Thalamus Engagement in Cognition and Behavior. Front Behav Neurosci 2021; 15:652764. [PMID: 33935663 PMCID: PMC8082140 DOI: 10.3389/fnbeh.2021.652764] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2021] [Accepted: 03/22/2021] [Indexed: 11/25/2022] Open
Abstract
The thalamic rostral intralaminar nuclei (rILN) are a contiguous band of neurons that include the central medial, paracentral, and central lateral nuclei. The rILN differ from both thalamic relay nuclei, such as the lateral geniculate nucleus, and caudal intralaminar nuclei, such as the parafascicular nucleus, in afferent and efferent connectivity as well as physiological and synaptic properties. rILN activity is associated with a range of neural functions and behaviors, including arousal, pain, executive function, and action control. Here, we review this evidence supporting a role for the rILN in integrating arousal, executive and motor feedback information. In light of rILN projections out to the striatum, amygdala, and sensory as well as executive cortices, we propose that such a function enables the rILN to modulate cognitive and motor resources to meet task-dependent behavioral engagement demands.
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Affiliation(s)
- Kara K Cover
- Department of Pharmacology, University of Maryland School of Medicine, Baltimore, MD, United States
| | - Brian N Mathur
- Department of Pharmacology, University of Maryland School of Medicine, Baltimore, MD, United States
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143
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Fins JJ, Wright MS, Giacino JT, Henderson J, Schiff ND. In Pursuit of Agency Ex Machina: Expanding the Map in Severe Brain Injury. AJOB Neurosci 2021; 12:200-202. [PMID: 33960894 PMCID: PMC8496492 DOI: 10.1080/21507740.2021.1904050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Affiliation(s)
- Joseph J. Fins
- Weill Cornell Medical College
- Yale Law School
- The Rockefeller University
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144
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Park E, Lyon JG, Alvarado-Velez M, Betancur MI, Mokarram N, Shin JH, Bellamkonda RV. Enriching neural stem cell and anti-inflammatory glial phenotypes with electrical stimulation after traumatic brain injury in male rats. J Neurosci Res 2021; 99:1864-1884. [PMID: 33772860 PMCID: PMC8360147 DOI: 10.1002/jnr.24834] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2021] [Accepted: 03/08/2021] [Indexed: 12/26/2022]
Abstract
Traumatic brain injury (TBI) by an external physical impact results in compromised brain function via undesired neuronal death. Following the injury, resident and peripheral immune cells, astrocytes, and neural stem cells (NSCs) cooperatively contribute to the recovery of the neuronal function after TBI. However, excessive pro‐inflammatory responses of immune cells, and the disappearance of endogenous NSCs at the injury site during the acute phase of TBI, can exacerbate TBI progression leading to incomplete healing. Therefore, positive outcomes may depend on early interventions to control the injury‐associated cellular milieu in the early phase of injury. Here, we explore electrical stimulation (ES) of the injury site in a rodent model (male Sprague–Dawley rats) to investigate its overall effect on the constituent brain cell phenotype and composition during the acute phase of TBI. Our data showed that a brief ES for 1 hr on day 2 of TBI promoted anti‐inflammatory phenotypes of microglia as assessed by CD206 expression and increased the population of NSCs and Nestin+ astrocytes at 7 days post‐TBI. Also, ES effectively increased the number of viable neurons when compared to the unstimulated control group. Given the salience of microglia and neural stem cells for healing after TBI, our results strongly support the potential benefit of the therapeutic use of ES during the acute phase of TBI to regulate neuroinflammation and to enhance neuroregeneration.
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Affiliation(s)
- Eunyoung Park
- Department of Mechanical Engineering, Korea Advanced Institute of Science and Technology, Daejeon, Republic of Korea
| | - Johnathan G Lyon
- Department of Biomedical Engineering, Pratt School of Engineering, Duke University, Durham, NC, USA
| | - Melissa Alvarado-Velez
- The Wallace H. Coulter Department of Biomedical Engineering, Georgia Institute of Technology, Atlanta, GA, USA
| | - Martha I Betancur
- Department of Biomedical Engineering, Pratt School of Engineering, Duke University, Durham, NC, USA
| | - Nassir Mokarram
- Department of Biomedical Engineering, Pratt School of Engineering, Duke University, Durham, NC, USA
| | - Jennifer H Shin
- Department of Mechanical Engineering, Korea Advanced Institute of Science and Technology, Daejeon, Republic of Korea
| | - Ravi V Bellamkonda
- Department of Biomedical Engineering, Pratt School of Engineering, Duke University, Durham, NC, USA
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145
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O’Donnell A, Pauli R, Banellis L, Sokoliuk R, Hayton T, Sturman S, Veenith T, Yakoub KM, Belli A, Chennu S, Cruse D. The prognostic value of resting-state EEG in acute post-traumatic unresponsive states. Brain Commun 2021; 3:fcab017. [PMID: 33855295 PMCID: PMC8023635 DOI: 10.1093/braincomms/fcab017] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2020] [Revised: 12/08/2020] [Accepted: 12/08/2020] [Indexed: 11/27/2022] Open
Abstract
Accurate early prognostication is vital for appropriate long-term care decisions after traumatic brain injury. While measures of resting-state EEG oscillations and their network properties, derived from graph theory, have been shown to provide clinically useful information regarding diagnosis and recovery in patients with chronic disorders of consciousness, little is known about the value of these network measures when calculated from a standard clinical low-density EEG in the acute phase post-injury. To investigate this link, we first validated a set of measures of oscillatory network features between high-density and low-density resting-state EEG in healthy individuals, thus ensuring accurate estimation of underlying cortical function in clinical recordings from patients. Next, we investigated the relationship between these features and the clinical picture and outcome of a group of 18 patients in acute post-traumatic unresponsive states who were not following commands 2 days+ after sedation hold. While the complexity of the alpha network, as indexed by the standard deviation of the participation coefficients, was significantly related to the patients' clinical picture at the time of EEG, no network features were significantly related to outcome at 3 or 6 months post-injury. Rather, mean relative alpha power across all electrodes improved the accuracy of outcome prediction at 3 months relative to clinical features alone. These results highlight the link between the alpha rhythm and clinical signs of consciousness and suggest the potential for simple measures of resting-state EEG band power to provide a coarse snapshot of brain health for stratification of patients for rehabilitation, therapy and assessments of both covert and overt cognition.
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Affiliation(s)
- Alice O’Donnell
- Birmingham Medical School, University of Birmingham, Edgbaston B15 2TT, UK
- Centre for Human Brain Health, University of Birmingham, Edgbaston B15 2TT, UK
- School of Psychology, University of Birmingham, Edgbaston B15 2TT, UK
| | - Ruth Pauli
- Centre for Human Brain Health, University of Birmingham, Edgbaston B15 2TT, UK
- School of Psychology, University of Birmingham, Edgbaston B15 2TT, UK
| | - Leah Banellis
- Centre for Human Brain Health, University of Birmingham, Edgbaston B15 2TT, UK
- School of Psychology, University of Birmingham, Edgbaston B15 2TT, UK
| | - Rodika Sokoliuk
- Centre for Human Brain Health, University of Birmingham, Edgbaston B15 2TT, UK
- School of Psychology, University of Birmingham, Edgbaston B15 2TT, UK
| | - Tom Hayton
- National Institute for Health Research Surgical Reconstruction and Microbiology Research Centre, Birmingham B15 2TH, UK
| | - Steve Sturman
- National Institute for Health Research Surgical Reconstruction and Microbiology Research Centre, Birmingham B15 2TH, UK
| | - Tonny Veenith
- National Institute for Health Research Surgical Reconstruction and Microbiology Research Centre, Birmingham B15 2TH, UK
- Birmingham Acute Care Research Group, Institute of Inflammation and Ageing, University of Birmingham, Edgbaston B15 2TT, UK
| | - Kamal M Yakoub
- National Institute for Health Research Surgical Reconstruction and Microbiology Research Centre, Birmingham B15 2TH, UK
| | - Antonio Belli
- National Institute for Health Research Surgical Reconstruction and Microbiology Research Centre, Birmingham B15 2TH, UK
| | - Srivas Chennu
- School of Computing, University of Kent, Canterbury CT2 7NZ, UK
| | - Damian Cruse
- Centre for Human Brain Health, University of Birmingham, Edgbaston B15 2TT, UK
- School of Psychology, University of Birmingham, Edgbaston B15 2TT, UK
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146
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Yao L, Baker JL, Schiff ND, Purpura KP, Shoaran M. Predicting task performance from biomarkers of mental fatigue in global brain activity. J Neural Eng 2021; 18. [PMID: 33108778 PMCID: PMC8122624 DOI: 10.1088/1741-2552/abc529] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2020] [Accepted: 10/27/2020] [Indexed: 11/23/2022]
Abstract
Objective. Detection and early prediction of mental fatigue (i.e. shifts in vigilance), could be used to adapt neuromodulation strategies to effectively treat patients suffering from brain injury and other indications with prominent chronic mental fatigue. Approach. In this study, we analyzed electrocorticography (ECoG) signals chronically recorded from two healthy non-human primates (NHP) as they performed a sustained attention task over extended periods of time. We employed a set of spectrotemporal and connectivity biomarkers of the ECoG signals to identify periods of mental fatigue and a gradient boosting classifier to predict performance, up to several seconds prior to the behavioral response. Main results. Wavelet entropy and the instantaneous amplitude and frequency were among the best single features across sessions in both NHPs. The classification performance using higher order spectral-temporal (HOST) features was significantly higher than that of conventional spectral power features in both NHPs. Across the 99 sessions analyzed, average F1 scores of 77.5%±8.2% and 91.2%±3.6%, and accuracy of 79.5%±8.9% and 87.6%±3.9 % for the classifier were obtained for each animal, respectively. Significance. Our results here demonstrate the feasibility of predicting performance and detecting periods of mental fatigue by analyzing ECoG signals, and that this general approach, in principle, could be used for closed-loop control of neuromodulation strategies.
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Affiliation(s)
- Lin Yao
- Frontiers Science Center for Brain&Brain-machine Integration, Zhejiang University, Hangzhou, Zhejiang 310000, People's Republic of China.,College of Computer Science, Zhejiang University, Hangzhou, Zhejiang 310000, People's Republic of China.,School of Electrical and Computer Engineering, Cornell University, Ithaca, NY 14850, United States of America
| | - Jonathan L Baker
- Feil Family Brain and Mind Research Institute, Weill Cornell Medicine, New York, NY 10021, United States of America
| | - Nicholas D Schiff
- Feil Family Brain and Mind Research Institute, Weill Cornell Medicine, New York, NY 10021, United States of America
| | - Keith P Purpura
- Feil Family Brain and Mind Research Institute, Weill Cornell Medicine, New York, NY 10021, United States of America
| | - Mahsa Shoaran
- School of Electrical and Computer Engineering, Cornell University, Ithaca, NY 14850, United States of America.,Institute of Electrical Engineering and Center for Neuroprosthetics, Swiss Federal Institute of Technology (EPFL), Geneva 1202, Switzerland
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147
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Katz DI, Dwyer B. Clinical Neurorehabilitation: Using Principles of Neurological Diagnosis, Prognosis, and Neuroplasticity in Assessment and Treatment Planning. Semin Neurol 2021; 41:111-123. [PMID: 33663002 DOI: 10.1055/s-0041-1725132] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Neurorehabilitation aspires to restore a person to his or her fullest potential after incurring neurological dysfunction. In medical rehabilitation, diagnosis involves assessment of medical conditions and their effects on functioning. It is usually a team effort that involves an amalgam of diagnostic assessments by multiple disciplines, leading to a collection of rehabilitative treatment plans and goals. This article discusses a clinical neurological paradigm, using rigorous clinical assessment of neuropathological and clinical diagnosis, along with prognostication of natural history and recovery. In the context of the role of neuroplasticity in recovery, this paradigm can add significant value to rehabilitation team management and planning. It contributes to enhanced understanding of neurological impairments and syndromes as they relate to functional disability, aiding in targeting deficits and setting treatment goals. Rehabilitation strategies and goals should be informed by natural history and prognosis, and viewed in the framework of the stage of recovery. Prognostic formulations should suggest an emphasis on restorative versus compensatory strategies for functional problems. Treatment planning should be informed by evidence on how interventions modulate brain reorganization in promoting recovery. Strategies that promote adaptive neuroplasticity should be favored, especially with restorative efforts, and evidence supporting optimal techniques, timing, and dosing of rehabilitation should be considered in treatment planning.
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Affiliation(s)
- Douglas I Katz
- Department of Neurology, Boston University School of Medicine, Boston, Massachusetts.,Encompass Health Braintree Rehabilitation Hospital, Braintree, Massachusetts
| | - Brigid Dwyer
- Department of Neurology, Boston University School of Medicine, Boston, Massachusetts.,Encompass Health Braintree Rehabilitation Hospital, Braintree, Massachusetts
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148
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Edlow BL, Claassen J, Schiff ND, Greer DM. Recovery from disorders of consciousness: mechanisms, prognosis and emerging therapies. Nat Rev Neurol 2021; 17:135-156. [PMID: 33318675 PMCID: PMC7734616 DOI: 10.1038/s41582-020-00428-x] [Citation(s) in RCA: 280] [Impact Index Per Article: 93.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/23/2020] [Indexed: 12/16/2022]
Abstract
Substantial progress has been made over the past two decades in detecting, predicting and promoting recovery of consciousness in patients with disorders of consciousness (DoC) caused by severe brain injuries. Advanced neuroimaging and electrophysiological techniques have revealed new insights into the biological mechanisms underlying recovery of consciousness and have enabled the identification of preserved brain networks in patients who seem unresponsive, thus raising hope for more accurate diagnosis and prognosis. Emerging evidence suggests that covert consciousness, or cognitive motor dissociation (CMD), is present in up to 15-20% of patients with DoC and that detection of CMD in the intensive care unit can predict functional recovery at 1 year post injury. Although fundamental questions remain about which patients with DoC have the potential for recovery, novel pharmacological and electrophysiological therapies have shown the potential to reactivate injured neural networks and promote re-emergence of consciousness. In this Review, we focus on mechanisms of recovery from DoC in the acute and subacute-to-chronic stages, and we discuss recent progress in detecting and predicting recovery of consciousness. We also describe the developments in pharmacological and electrophysiological therapies that are creating new opportunities to improve the lives of patients with DoC.
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Affiliation(s)
- Brian L Edlow
- Center for Neurotechnology and Neurorecovery, Department of Neurology, Massachusetts General Hospital, Boston, MA, USA
- Athinoula A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital, Charlestown, MA, USA
| | - Jan Claassen
- Department of Neurology, Columbia University Medical Center, New York Presbyterian Hospital, New York, NY, USA
| | - Nicholas D Schiff
- Feil Family Brain Mind Research Institute, Weill Cornell Medical College, New York, NY, USA
| | - David M Greer
- Department of Neurology, Boston University School of Medicine, Boston, MA, USA.
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149
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Abstract
Consciousness has evolved and is a feature of all animals with sufficiently complex nervous systems. It is, therefore, primarily a problem for biology, rather than physics. In this review, I will consider three aspects of consciousness: level of consciousness, whether we are awake or in a coma; the contents of consciousness, what determines how a small amount of sensory information is associated with subjective experience, while the rest is not; and meta-consciousness, the ability to reflect upon our subjective experiences and, importantly, to share them with others. I will discuss and compare current theories of the neural and cognitive mechanisms involved in producing these three aspects of consciousness and conclude that the research in this area is flourishing and has already succeeded to delineate these mechanisms in surprising detail.
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Affiliation(s)
- Chris D Frith
- Wellcome Centre for Human Neuroimaging at University College London, UK
- Institute of Philosophy, Institute of Advanced Study, University of London, UK
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150
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Abstract
Background: Reviving patients with prolonged disorders of consciousness (DOCs) has always been focused and challenging in medical research. Owing to the limited effectiveness of available medicine, recent research has increasingly turned towards neuromodulatory therapies, involving the stimulation of neural circuits. We summarised the progression of research regarding neuromodulatory therapies in the field of DOCs, compared the differences among different studies, in an attempt to explore optimal stimulation patterns and parameters, and analyzed the major limitations of the relevant studies to facilitate future research. Methods: We performed a search in the PubMed database, using the concepts of DOCs and neuromodulation. Inclusion criteria were: articles in English, published after 2002, and reporting clinical trials of neuromodulatory therapies in human patients with DOCs. Results: Overall, 187 published articles met the search criteria, and 60 articles met the inclusion criteria. There are differences among these studies regarding the clinical efficacies of neurostimulation techniques for patients with DOCs, and large-sample studies are still lacking. Conclusions: Neuromodulatory techniques were used as trial therapies for DOCs wherein their curative effects were controversial. The difficulties in detecting residual consciousness, the confounding effect between the natural course of the disease and therapeutic effect, and the heterogeneity across patients are the major limitations. Large-sample, well-designed studies, and innovations for both treatment and assessment are anticipated in future research.
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