Risk factors for mortality in 600 patients in vegetative and minimally conscious states

Long-Term Outcomes among Patients with Prolonged Disorders of Consciousness

PURPOSE

To evaluate the long-term survival and functional outcomes of patients with prolonged disorders of consciousness (pDoC) 1-8 years after brain injuries.

METHODS

Retrospective study to assess the long-term survival and functional outcomes of patients with pDoC was conducted. We performed Cox regression and multivariate logistic regression to calculate hazard ratios (HRs) for the outcome of survival and to identify risk factors of the functional outcome.

RESULTS

We recruited 154 patients with pDoC. The duration of follow-up from disease onset was 1-8 years. The median age was 46 years (IQR, 32-59), and 65.6% (n = 101) of them were men. During the follow-up period, one hundred and ten patients (71.4%) survived; among them, 52 patients had a good outcome. From the overall survival curve, the 1-, 3-, and 8-year survival rates of patients were about 80.5%, 72.0%, and 69.7%, respectively. Cox regression analysis revealed a significant association between the lower APACHE II score (p = 0.005) (cut-off score ≥ 18) and the presence of sleep spindles (p = 0.001) with survival. Logistic regression analysis demonstrated a higher CRS-R score (cut-off score ≥ 7), and presence of sleep spindles were related to a favorable outcome among patients with pDoC.

CONCLUSIONS

Sleep spindles are correlated with both long-term survival and long-term functional outcome in pDoC patients.

Insights of neurophysiology on unconscious state using combined transcranial magnetic stimulation and electroencephalography: A systematic review

Unconscious state has been investigated in numerous studies so far, but pathophysiology of this state is not fully understood. Recently, combined transcranial magnetic stimulation (TMS) and electroencephalography (EEG) has been developed to allow for non-invasive assessment of neurophysiology in the cerebral cortex. We conducted a systematic literature search for TMS-EEG studies on human unconscious state using PubMed with cross-reference and manual searches. The initial search yielded 137 articles, and 19 of them were identified as relevant, including one article found by manual search. This review included 10 studies for unresponsive wakefulness syndrome (UWS), 9 for minimally conscious states (MCS), 5 for medication-induced unconscious states, and 6 for natural non-rapid eye movement states. These studies analyzed TMS-evoked potential to calculate perturbational complexity index (PCI) and OFF-periods. In particular, PCI was found to be a potentially useful marker to differentiate between UWS and MCS. This review demonstrated that TMS-EEG could represent a promising neuroscientific tool to investigate various unconscious states. Further TMS-EEG research may help elucidate the neural basis of unconscious state.

Looking toward predicting functional recovery in disorders of consciousness: can sensorimotor integration help us?

PRIMARY OBJECTIVE

Only a few objective prognostic markers are available for patients with disorders of consciousness (DoC). We assessed whether the magnitude of short-latency afferent inhibition (SAI) might be a useful predictor of responsiveness recovery and functional outcome in patients with DoC.

RESEARCH DESIGN

We enrolled 40 patients with prolonged Minimally Conscious State (MCS) and Unresponsive Wakefulness Syndrome (UWS) in a longitudinal, observational study.

METHODS AND PROCEDURES

Clinical features (including Coma Recovery Scale-Revised, CRS-R, and Glasgow Outcome Scale, GOS) and SAI were collected at the study entry and after 18 months from study inclusion, to assess a correlation between SAI and the clinical outcome.

MAIN OUTCOMES AND RESULTS

At the follow-up, 19 patients remained in their baseline condition, whereas 7 UWS evolved into MCS or emerged-from-MCS (EMCS), eight MCS evolved into EMCS, and two MCS- evolved into MCS+. Two UWS and one MCS+ died for cardiopulmonary complications. The patients who showed the highest GOS, the highest CRS-R and the lowest SAI strength at study entry, improved at the follow-up.

CONCLUSIONS

Our findings suggest that an objective and simple neurophysiologic measure as SAI strength could provide useful information to predict the outcome and the behavioral responsiveness of patients with DoC.

Do Medical Complications Impact Long-Term Outcomes in Prolonged Disorders of Consciousness?

OBJECTIVE

To investigate medical complications (MCs) occurring within 6 months postinjury in brain-injured patients with prolonged disorders of consciousness (DoC) and to evaluate impact of MC on mortality and long-term clinical outcomes.

DESIGN

Prospective observational cohort study.

SETTING

Rehabilitation unit for acquired DoC.

PARTICIPANTS

Patients (N=194) with DoC (142 in vegetative state [VS], 52 in minimally conscious state; traumatic etiology 43, anoxic 69, vascular 82) consecutively admitted to a neurorehabilitation unit within 1-3 months postonset.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Mortality and improvements in clinical diagnosis and functional disability level (assessed by Coma Recovery Scale-Revised [CRS-R] and Disability Rating Scale) at 12, 24, and 36 months postonset.

RESULTS

Within 6 months postinjury, 188 of 194 patients (>95%) developed at least 1 MC and 142 of them (73%) showed at least 1 severe MC. Respiratory and musculoskeletal-cutaneous MCs were the most frequent, followed by endocrino-metabolic abnormalities. Follow-up, complete in 189 of 194 patients, showed that male sex and endocrine-metabolic MCs were associated with higher risk of mortality at all timepoints. Old age, anoxic etiology, lower CRS-R total scores, and diagnosis of VS at study entry predicted no clinical and functional improvements at most timepoints; however, epilepsy predicted no improvement in diagnosis at 24 months postonset only.

CONCLUSIONS

MCs are very frequent in patients with DoC within at least 6 months after brain injury, regardless of clinical diagnosis, etiology, and age. Endocrino-metabolic MCs are independent predictors of mortality at all timepoints; however,epilepsy predicted poor long-term outcome. Occurrence and severity of MCs in patients with DoC call for long-term appropriate levels of care after the postacute phase.

Effects on the diagnosis change and on the disability level for individuals with disorder of consciousness: which predictors?

Prediction of the functional recovery in patients with disorders of consciousness (DOC) is still complex because of the different numbers of variables that influence the possibility of observing changes in clinical outcome. The aim of the present study is to identify the best set of predictors of the change in DOC diagnosis among different pharmacotherapy and nonpharmacotherapy indicators. This study analyzed data collected in a longitudinal, two-evaluation, multicenter project conducted in 90 centers. We analyzed the predictor effects of physical and cognitive treatments, duration of disease, etiology, age, and sex (nonpharmacological treatments) as well as the use of antiparkinson, psycholeptic, psychoanaleptic, and muscle-relaxant drugs (pharmacological variables). Ordered logistic models, linear regression models with bootstrap estimation, and model averaging procedures were used. The results showed that physical and cognitive treatments [best predictor: odds ratio (OR)=413.3, P<0.001], age (OR=0.964, P<0.001), and use of psycholeptic drugs (negative effect: OR=0.373, P=0.039) were the variables that contributed in general toward a change in diagnosis. Notably, the use of psycholeptic drugs seemed to impede the functional recovery in patients with DOC, so serious reflections on its use will be made.

Vegetative state outcomes improved over the last two decades

OBJECTIVE

To describe late outcomes in patients with prolonged unawareness, and factors affecting them.

DESIGN

A retrospective study of 154 patients with traumatic brain injury (TBI) and 52 with non-traumatic brain injury (NTBI), admitted for intensive care and consciousness rehabilitation (ICCR), in a vegetative state (VS) lasting over 1 month.

RESULTS

Survival rate (67% total) was higher than in past studies carried out at the same facility (p < 0.01). Consciousness recovery rate (54% total) was higher in NTBI VS patients (p < 0.01) than in earlier cohorts, and similar in TBI VS patients, despite their older age than that of earlier cohorts. No meaningful differences were found in characteristics or in outcomes between the TBI and NTBI groups. Age, length of stay in ICCR, and hydrocephalus were found to affect survival (p < 0.001). Younger age, absence of hydrocephalus, and anti-Parkinsonian medication contributed to consciousness recovery after VS (p < 0.05).

CONCLUSIONS

The present study demonstrated an improvement in survival and recovery of consciousness in VS patients over the last two decades, and similar outcomes for both TBI and NTBI VS. Outcomes suggest that acute medical care and ICCR have contributed to advances in VS care.

Caregiver's burden in disorders of consciousness: a longitudinal study

OBJECTIVES

To study the changes in the burden of informal caregivers of patients with disorders of consciousness (DOC) over time.

MATERIALS AND METHODS

Short Form-12, Family Strain Questionnaire, Beck Depression Inventory and Coping Orientations to Problem Experiences were administered.

RESULTS

Data collected on 216 informal caregivers of patients with DOC (59.6% females, mean age 53.4 ± 12.7 years old) were analysed at two time-points (mean distance is 2.7 years). Results of the national study revealed that caregivers' mental health improved (T0: M = 41.1, SD = 11.8; T1: M = 45.8, SD = 11.7), whereas the emotional burden (T0: M = 7.4, SD = 3.6; T1: M = 6.6, SD = 3.9) and the presence of depressive symptoms (T0: M = 14.3, SD = 9.3; T1: M = 11.7, SD = 10.2) as well as the need for information about the disease (T0: M = 2.7, SD = 1.2; T1: M = 2.2, SD = 1.4), thoughts of death (T0: M = 3.6, SD = 1.5; T1: M = 3.1, SD = 1.6) and the use of avoiding coping strategy (T0: M = 7.8, SD = 1.0; T1: M = 6.0, SD = 1.3) decreased at T1. Furthermore, depressive symptoms positively correlated with the emotional burden (0.580) and negatively with the mental health component of caregivers' self-perceived health condition (-0.473). Physical (-0.308) and mental health (-0.444) negatively correlated with emotional burden. Finally, the acute event and patients' health condition still have a deep impact on the economic situation of the family.

CONCLUSION

Although high level of burden was observed, it tends to decrease over time, except for financial burden. Hence, this study suggests the importance to plan strategies or targeted interventions in order to reduce the psychosocial and financial burden associated with caregiving.

LOCFAS-Assessed Evolution of Cognitive and Behavioral Functioning in a Sample of Pediatric Patients With Severe Acquired Brain Injury in the Postacute Phase

We studied 86 patients with severe acquired brain injuries of different etiology, aged 0 to 18 years, in a condition of vegetative state or minimally conscious state. During neurorehabilitation, we administered the Level of Cognitive Functioning Assessment Scale every 2 weeks in order to describe and compare the progressive improvement in their cognitive-behavioral functioning and responsiveness in different etiologies. Patients with traumatic brain injury showed more favorable clinical outcomes. The higher the level of functioning at the first evaluation, the better the outcome, and the higher the Glasgow Coma Scale score, the higher the Level of Cognitive Functioning Assessment Scale level reached at the end of hospitalization. Patients with an apparently stable clinical picture, too, showed a change in their ability to interact with the environment. This study underlines the importance of an individualized and early cognitive-behavioral intervention protocol that can reveal minimal and fluctuating responses.