Against the odds: a case study of recovery from coma after devastating prognosis

Predicting outcome in disorders of consciousness: A mega-analysis

OBJECTIVE

Assessing recovery potential in patients with disorders of consciousness (DoC) is pivotal for guiding clinical and ethical decisions. We conducted a mega-analysis of individual patient data to understand (1) if a time threshold exists, beyond which regaining consciousness is almost impossible, and (2) how recovery varies based on factors such as diagnosis, etiology, age, sex, and neuropsychological status.

METHODS

A systematic literature search revealed a total of 3290 patients. In this sample, we performed a Cox proportional hazards analysis for interval censored data.

RESULTS

We observed a late saturation of probability to regain consciousness in Kaplan-Meier curves, and the annual rate of recovery was remarkably stable, in that approximately 35% of patients regained consciousness per year. Patients in minimally conscious state (MCS) recovered more frequently than patients in unresponsive wakefulness syndrome (UWS). No significant difference was observed between the recovery dynamics of MCS subgroups: MCS+ and MCS-. Patients with hypoxic brain lesions showed worse recovery rate than patients with traumatic brain injury and patients with vascular brain lesions, while the latter two categories did not differ from each other. Male patients had moderately better chance to regain consciousness. While younger UWS patients recovered more frequently than older patients, it was not the case in MCS.

INTERPRETATION

Our findings highlight the necessity for neurologists to exercise caution when making negative predictions in individual cases, challenge traditional beliefs regarding recovery timelines, and underscore the importance of conducting detailed and prolonged assessments to better understand recovery prospects in DoC.

Resting-State Functional Magnetic Resonance Imaging Network Association With Mortality, Epilepsy, Cognition, and Motor Two-Year Outcomes in Suspected Severe Neonatal Acute Brain Injury

BACKGROUND AND OBJECTIVES

In acute brain injury of neonates, resting-state functional magnetic resonance imaging (MRI) (RS) showed incremental association with consciousness, mortality, cognitive and motor development, and epilepsy, with correction for multiple comparisons, at six months postgestation in neonates with suspected acute brain injury (ABI). However, there are relatively few developmental milestones at six months to benchmark against, thus, we extended this cohort study to evaluate two-year outcomes.

METHODS

In 40 consecutive neonates with ABI and RS, ordinal scores of resting-state networks; MRI, magnetic resonance spectroscopy, and electroencephalography; and up to 42-month outcomes of mortality, general and motor development, Pediatric Cerebral Performance Category Scale (PCPC), and epilepsy informed associations between tests and outcomes.

RESULTS

Mean gestational age was 37.8 weeks, 68% were male, and 60% had hypoxic-ischemic encephalopathy. Three died in-hospital, four at six to 42 months, and five were lost to follow-up. Associations included basal ganglia network with PCPC (P = 0.0003), all-mortality (P = 0.005), and motor (P = 0.0004); language/frontoparietal network with developmental delay (P = 0.009), PCPC (P = 0.006), and all-mortality (P = 0.01); default mode network with developmental delay (P = 0.003), PCPC (P = 0.004), neonatal intensive care unit mortality (P = 0.01), and motor (P = 0.009); RS seizure onset zone with epilepsy (P = 0.01); and anatomic MRI with epilepsy (P = 0.01).

CONCLUSION

For the first time, at any age, resting state functional MRI in ABI is associated with long-term epilepsy and RSNs predicted mortality in neonates. Severity of RSN abnormality was associated with incrementally worsened neurodevelopment including cognition, language, and motor function over two years.

Whole-brain traumatic controlled cortical impact to the left frontal lobe: Magnetic resonance image-based texture analysis

This research assesses the capability of texture analysis (TA) derived from high-resolution (HR) T2-weighted magnetic resonance imaging to identify primary sequelae following 1-5 hours of controlled cortical impact mild or severe traumatic brain injury (TBI) to the left frontal cortex (focal impact) and secondary (diffuse) sequelae in the right frontal cortex, bilateral corpus callosum, and hippocampus in rats. The TA technique comprised first-order (histogram-based) and second-order statistics (including gray-level co-occurrence matrix, gray-level run length matrix, and neighborhood gray-level difference matrix). Edema in the left frontal impact region developed within 1 hour and continued throughout the 5-hour assessments. The TA features from HR images confirmed the focal injury. There was no significant difference among radiomics features between the left and right corpus callosum or hippocampus from 1 to 5 hours following a mild or severe impact. The adjacent corpus callosum region and the distal hippocampus region (s), showed no diffuse injury 1-5 hours after mild or severe TBI. These results suggest that combining HR images with TA may enhance detection of early primary and secondary sequelae following TBI.

Scoping Review on the Diagnosis, Prognosis, and Treatment of Pediatric Disorders of Consciousness

BACKGROUND AND OBJECTIVES

Comprehensive guidelines for the diagnosis, prognosis, and treatment of disorders of consciousness (DoC) in pediatric patients have not yet been released. We aimed to summarize available evidence for DoC with >14 days duration to support the future development of guidelines for children, adolescents and young adults aged 6 months-18 years.

METHODS

This scoping review was reported based on Preferred Reporting Items for Systematic reviews and Meta-Analyses-extension for Scoping Reviews guidelines. A systematic search identified records from 4 databases: PubMed, Embase, Cochrane Library, and Web of Science. Abstracts received 3 blind reviews. Corresponding full-text articles rated as "in-scope" and reporting data not published in any other retained article (i.e., no double reporting) were identified and assigned to 5 thematic evaluating teams. Full-text articles were reviewed using a double-blind standardized form. Level of evidence was graded, and summative statements were generated.

RESULTS

On November 9, 2022, 2,167 documents had been identified; 132 articles were retained, of which 33 (25%) were published over the past 5 years. Overall, 2,161 individuals met the inclusion criteria; female patients were 527 of 1,554 (33.9%) cases included, whose sex was identifiable. Of 132 articles, 57 (43.2%) were single case reports and only 5 (3.8%) clinical trials; the level of evidence was prevalently low (80/132; 60.6%). Most studies included neurobehavioral measures (84/127; 66.1%) and neuroimaging (81/127; 63.8%); 59 (46.5%) were mainly related to diagnosis, 56 (44.1%) to prognosis, and 44 (34.6%) to treatment. Most frequently used neurobehavioral tools included the Coma Recovery Scale-Revised, Coma/Near-Coma Scale, Level of Cognitive Functioning Assessment Scale, and Post-Acute Level of Consciousness scale. EEG, event-related potentials, structural CT, and MRI were the most frequently used instrumental techniques. In 29/53 (54.7%) cases, DoC improvement was observed, which was associated with treatment with amantadine.

DISCUSSION

The literature on pediatric DoCs is mainly observational, and clinical details are either inconsistently presented or absent. Conclusions drawn from many studies convey insubstantial evidence and have limited validity and low potential for translation in clinical practice. Despite these limitations, our work summarizes the extant literature and constitutes a base for future guidelines related to the diagnosis, prognosis, and treatment of pediatric DoC.

The effect of neural pre-stimulus oscillations on post-stimulus somatosensory event-related potentials in disorders of consciousness

Brain activity of people in a disorder of consciousness (DoC) is diffuse and different from healthy people. In order to get a better understanding of their cognitive processes and functions, electroencephalographic activity has often been examined in patients with DoC, including detection of event-related potentials (ERPs) and spectral power analysis. However, the relationship between pre-stimulus oscillations and post-stimulus ERPs has rarely been explored in DoC, although it is known from healthy participants that pre-stimulus oscillations predispose subsequent stimulus detection. Here, we examine to what extent pre-stimulus electroencephalography band power in DoC relates to post-stimulus ERPs in a similar way as previously documented in healthy people. 14 DoC patients in an unresponsive wakefulness syndrome (UWS, N = 2) or a minimally conscious state (MCS, N = 12) participated in this study. In an active oddball paradigm patients received vibrotactile stimuli. Significant post-stimulus differences between brain responses to deviant and standard stimulation could be found in six MCS patients (42.86%). Regarding relative pre-stimulus frequency bands, delta oscillations predominated in most patients, followed by theta and alpha, although two patients showed a relatively normal power spectrum. The statistical analysis of the relationship between pre-stimulus power and post-stimulus event-related brain response showed multiple significant correlations in five out of the six patients. Individual results sometimes showed similar correlation patterns as in healthy subjects primarily between the relative pre-stimulus alpha power and post-stimulus variables in later time-intervals. However, opposite effects were also found, indicating high inter-individual variability in DoC patients´ functional brain activity. Future studies should determine on an individual level to what extent the relationship between pre- and post-stimulus brain activity could relate to the course of the disorder.

A Long Short-Term Memory Network Using Resting-State Electroencephalogram to Predict Outcomes Following Moderate Traumatic Brain Injury

Although traumatic brain injury (TBI) is a global public health issue, not all injuries necessitate additional hospitalisation. Thinking, memory, attention, personality, and movement can all be negatively impacted by TBI. However, only a small proportion of nonsevere TBIs necessitate prolonged observation. Clinicians would benefit from an electroencephalography (EEG)-based computational intelligence model for outcome prediction by having access to an evidence-based analysis that would allow them to securely discharge patients who are at minimal risk of TBI-related mortality. Despite the increasing popularity of EEG-based deep learning research to create predictive models with breakthrough performance, particularly in epilepsy prediction, its use in clinical decision making for the diagnosis and prognosis of TBI has not been as widely exploited. Therefore, utilising 60s segments of unprocessed resting-state EEG data as input, we suggest a long short-term memory (LSTM) network that can distinguish between improved and unimproved outcomes in moderate TBI patients. Complex feature extraction and selection are avoided in this architecture. The experimental results show that, with a classification accuracy of 87.50 ± 0.05%, the proposed prognostic model outperforms three related works. The results suggest that the proposed methodology is an efficient and reliable strategy to assist clinicians in creating an automated tool for predicting treatment outcomes from EEG signals.

Misconceptions About Traumatic Brain Injuries in Five Sub-Saharan African Countries

Background Traumatic Brain Injury (TBI) remains a significant problem in certain regions of the world but receives little attention despite its enormous burden. This discrepancy could consequently lead to various misconceptions among the general public. This study evaluated misconceptions about TBI in five African countries. Methods Data for this cross-sectional study were collected using the Common Misconception about Traumatic Brain Injury (CM-TBI) questionnaire, which was electronically disseminated from January 16 to February 6, 2021. Associations between the percentage of correct answers and independent variables (i.e., sociodemographic characteristics and experience with TBI) were evaluated with the ANOVA test. Additionally, answers to the question items were compared against independent variables using the Chi-Square test. A P-value <0.05 was considered statistically significant. Results A total of 817 adults, 50.2% female (n=410), aged 24.3 ± 4.3 years, and majoritarily urban dwellers (94.6%, n=773) responded to the survey. They had received tertiary education (79.2%, n=647) and were from Nigeria (77.7%, n=635). Respondents had few misconceptions (mean correct answers=71.7%, 95% CI=71.0-72.4%) and the amnesia domain had the highest level of misconception (39.3%, 95% CI=37.7-40.8%). Surveyees whose friends had TBI were more knowledgeable about TBI (mean score difference=4.1%, 95% CI=1.2-6.9, P=0.01). Additionally, surveyees whose family members had experienced TBI had a better understanding of brain damage (mean score difference=5.7%, 95% CI=2.1-9.2%, P=0.002) and recovery (mean score difference=4.3%, 95% CI=0.40-8.2%, P=0.03). Conclusion This study identified some misconceptions about TBI among young adult Africans. This at-risk population should benefit from targeted education strategies to prevent TBI and reduce TBI patients' stigmatization in Africa.

Combining scoping review and concept analysis methodologies to clarify the meaning of rehabilitation potential after acquired brain injury

Purpose: Clinicians make judgments about patients' rehabilitation potential because it is considered by many as a prerequisite for referral to rehabilitation. However, the concept is rarely defined. This research aimed to clarify the concept of rehabilitation potential in the context of acquired brain injury patient referral to post-acute rehabilitation.Method: Literature search (conducted in Medline, CINAHL and Embase) and article selection followed a scoping review methodology while a concept analysis methodology guided data extraction and analysis.Results: Eighteen documents met inclusion criteria. Findings suggest four defining attributes of the concept. Rehabilitation potential (1) emerges from clinicians' interpretation of patient characteristics and is influenced by the health care environment, (2) involves the prediction of how a patient might improve with rehabilitation interventions, (3) is a multi-level concept and (4) can change over time. The most critical consequence to assessing a patient's rehabilitation potential is the impact on the patient's opportunity to access post-acute rehabilitation services.Conclusion: Rehabilitation potential is a concept rooted in clinical reasoning. We propose an operational definition and a conceptual model to provide a solid foundation for future research to advance policy and clinical decision-making regarding equitable access to post-acute rehabilitation.IMPLICATIONS FOR REHABILITATIONRehabilitation potential is a concept rooted in clinical reasoning and emerges from clinicians' prediction of how a patient might improve with rehabilitation interventions.Rehabilitation potential is not a dichotomous concept but a multi-level concept with each level falling along a continuum.It may be inaccurate/inappropriate to definitively state that a patient has or does not have rehabilitation potential, as patients may demonstrate varying levels of rehabilitation potential.Rehabilitation potential can change with time requiring re-assessment to readjust recommendations accordingly with regards to appropriate rehabilitation interventions at any given time.

No language unification without neural feedback: How awareness affects sentence processing

How does the human brain combine a finite number of words to form an infinite variety of sentences? According to the Memory, Unification and Control (MUC) model, sentence processing requires long-range feedback from the left inferior frontal cortex (LIFC) to left posterior temporal cortex (LPTC). Single word processing however may only require feedforward propagation of semantic information from sensory regions to LPTC. Here we tested the claim that long-range feedback is required for sentence processing by reducing visual awareness of words using a masking technique. Masking disrupts feedback processing while leaving feedforward processing relatively intact. Previous studies have shown that masked single words still elicit an N400 ERP effect, a neural signature of semantic incongruency. However, whether multiple words can be combined to form a sentence under reduced levels of awareness is controversial. To investigate this issue, we performed two experiments in which we measured electroencephalography (EEG) while 40 subjects performed a masked priming task. Words were presented either successively or simultaneously, thereby forming a short sentence that could be congruent or incongruent with a target picture. This sentence condition was compared with a typical single word condition. In the masked condition we only found an N400 effect for single words, whereas in the unmasked condition we observed an N400 effect for both unmasked sentences and single words. Our findings suggest that long-range feedback processing is required for sentence processing, but not for single word processing.

Coma with Glasgow Coma Scale Score 3 at Admission following Acute Head Injury: Experiencing the Complete Recovery Supported through Ayurveda - A Case Report

Road traffic accidents (RTAs) are a common cause of untimely death, particularly of youth. RTA mortality and morbidity are predominantly associated with trauma to the brain tissue resulting in traumatic brain injury (TBI). The Glasgow Coma Scale (GCS) is commonly employed to predict the prognosis of such cases at the time of hospital admission. A lower GCS score is invariably found to be associated with poor prognosis, often resulting in death or severely com-promised recovery. A 17-year-old male suffering from TBI due to a RTA was treated with Ayurveda after initially been kept under modern neurological care. The whole course of Ayurvedic therapy began 2 weeks after the initial trauma, continued for about 3 months, and resulted in coma reversal with near complete recovery. This case is one among few reports describing a complete recovery despite presence of bad prognostic predictors in TBI. This is the first such case reported where Ayurveda was used as the intervention in case of TBI, resulting in coma reversal and near complete recovery of neurological deficits.

Withdrawal of Life-Sustaining Treatments in Perceived Devastating Brain Injury: The Key Role of Uncertainty

BACKGROUND

Withdrawal of life-sustaining treatment (WOLST) is the leading proximate cause of death in patients with perceived devastating brain injury (PDBI). There are reasons to believe that a potentially significant proportion of WOLST decisions, in this setting, are premature and guided by a number of assumptions that falsely confer a sense of certainty.

METHOD

This manuscript proposes that these assumptions face serious challenges, and that we should replace unwarranted certainty with an appreciation for the great degree of multi-dimensional uncertainty involved. The article proceeds by offering a taxonomy of uncertainty in PDBI and explores the key role that uncertainty as a cognitive state, may play into how WOLST decisions are reached.

CONCLUSION

In order to properly share decision-making with families and surrogates of patients with PDBI, we will have to acknowledge, understand, and be able to communicate the great degree of uncertainty involved.

Prospective Study of Nonbeneficial Care in Neurocritical Care Unit

OBJECTIVE

We sought to determine whether a set of simple criteria can identify patients in the neuroscience intensive care unit (NICU) at high risk of poor outcome and delivery of nonbeneficial care early in the course of their illness. Secondarily, factors affecting limitation of care protocols were assessed.

METHODS

We prospectively identified patients who were admitted to the NICU with partial loss of brainstem reflexes persisting for >24 hours due to an intrinsic lesion of the brain (trauma, stroke, hemorrhage, etc.).

RESULTS

The study included 102 patients. Seventy-two of them died after a mean of 16 days (median: 8 days), and 23 remained comatose, locked-in, or in a vegetative state. Four were conscious and following commands, while 3 were minimally conscious, episodically obeying simple commands. Three out of 4 conscious patients were young males with traumatic brain injuries. Patients who remained full code spent a mean of 22.2 days in the NICU, compared with 10.4 for those who had withdrawal of care (P = 0.022) and 11.9 for patients who received a do-not-resuscitate order (P = 0.045). Time to death did not differ significantly between the groups. Overall, institution of various limitations of care protocols correlated positively with older age (odds ratio [OR] = 1.07, P = 0.0008), being treated on the neurology service (OR = 4.4, P = 0.043), and having health insurance (OR = 5.4, P = 0.03).

CONCLUSIONS

We identified simple criteria that can be used to identify patients in the NICU setting for whom continued aggressive care is likely nonbeneficial. Our analysis revealed demographic, social, and economic factors correlating with proxies' willingness to consider limitation of care.

The living dead? Perception of persons in the unresponsive wakefulness syndrome in Germany compared to the USA

BACKGROUND

The extent to which people ascribe mind to others has been shown to predict the extent to which human rights are conferred. Therefore, in the context of disorders of consciousness (DOC), mind ascription can influence end of life decisions. A previous US-American study indicated that participants ascribed even less mind to patients with unresponsive-wakefulness-syndrome (UWS) than to the dead. Results were explained in terms of implicit dualism and religious beliefs, as highly religious people ascribed least mind to UWS. Here, we addresses mind ascription to UWS patients in Germany.

METHODS

We investigate the perception of UWS patients in a large German sample (N = 910) and compare the results to the previous US data, addressing possible cultural differences. We further assess effects of medical expertise, age, gender, socio-economic status and subjective knowledge about UWS in the German sample.

RESULTS

Unlike the US sample, German participants did not perceive UWS patients as "more dead than dead", ascribing either equal (on 3 of 5 items) or more (on 2 items) mental abilities to UWS patients than to the dead. Likewise, an effect of implicit dualism was not replicated and German medically trained participants ascribed more capabilities to UWS patients than did a non-medical sample. Within the German sample, age, gender, religiosity and socio-economic status explained about 15% of the variability of mind ascription. Age and religiosity were individually significant predictors, younger and more religious people ascribing more mind. Gender had no effect.

CONCLUSION

Results are consistent with cross-cultural differences in the perception of UWS between Germany and the USA, Germans ascribing more mind to UWS patients. The German sample ascribed as much or more but not less mind to a UWS patient than to a deceased, although within group variance was large, calling for further research. Mind ascription is vital, because, in times of declining resources for healthcare systems, and an increasing legalization of euthanasia, public opinion will influence UWS patients' rights and whether 'the right to die' will be the only right conceded to them.