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Shao H, Deng W, Du R, Zhao Y, Jin D, Wei Y. Mismatch Negativity and P300 in the Diagnosis and Prognostic Assessment of Coma and Other Disorders of Consciousness. Neurocrit Care 2024:10.1007/s12028-024-02058-3. [PMID: 39043983 DOI: 10.1007/s12028-024-02058-3] [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: 12/15/2023] [Accepted: 06/25/2024] [Indexed: 07/25/2024]
Abstract
BACKGROUND The objective of this study was to investigate the value of mismatch negativity (MMN) and P300 event-related potentials for discriminating the consciousness state and predicting improvement of consciousness at 6 months in patients with coma and other disorders of consciousness (DOC). METHODS We performed MMN and P300 on 42 patients with DOC with a mean onset time of 40.21 ± 19.43 days. These patients with DOC were categorized into coma, unresponsive wakefulness syndrome (UWS), minimal consciousness minus (MCS-), and minimal consciousness plus (MCS +) groups according to neurobehavioral assessment and the Coma Recovery Scale-Revised score. The primary outcome was the improvement of consciousness at 6 months in patients with DOC. We assessed the efficacy of MMN and P300 in quantitatively predicting the prognosis at 6 months and the capability of MMN and P300 parameters to differentiate between DOC. RESULTS At least one significant difference in either MMN or P300 parameters was displayed among the DOC groups, but not between the MCS- and MCS+ groups (significance level: 0.05). Both MMN and P300 amplitudes showed desirable predictive accuracy at 6 months, with areas under the curve (AUCs) of 0.859 and 0.856, respectively. The optimal thresholds for MMN and P300 amplitudes were 2.044 and 1.095 μV. However, the combined MMN-P300 amplitude showed better 6-month predictive accuracy (AUC 0.934, 95% confidence interval 0.860-1.000), with a sensitivity of 85% and a specificity of 90.9%. CONCLUSIONS MMN and P300 may help discriminate among coma, UWS, and MCS, but not between patients with MCS- and patients with MCS+ . The MMN amplitude, P300 amplitude, and especially combined MMN-P300 amplitude at 6 months may be interesting predictors of consciousness improvement at 6 months in patients with DOC. TRIAL REGISTRATION Chinese Clinical Trial Registry identifier ChiCTR2400083798.
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Affiliation(s)
- Huijie Shao
- Department of Neurology Intensive Care Unit, The First Affiliated Hospital of Zhengzhou University, No.1, Jianshe Road, Zhengzhou, 450052, Henan, China.
| | - Wenjing Deng
- Department of Neurology Intensive Care Unit, The First Affiliated Hospital of Zhengzhou University, No.1, Jianshe Road, Zhengzhou, 450052, Henan, China
| | - Ran Du
- Department of Neurology Intensive Care Unit, The First Affiliated Hospital of Zhengzhou University, No.1, Jianshe Road, Zhengzhou, 450052, Henan, China
| | - Yanan Zhao
- Department of Neurology Intensive Care Unit, The First Affiliated Hospital of Zhengzhou University, No.1, Jianshe Road, Zhengzhou, 450052, Henan, China
| | - Di Jin
- Department of Neurology Intensive Care Unit, The First Affiliated Hospital of Zhengzhou University, No.1, Jianshe Road, Zhengzhou, 450052, Henan, China
| | - Yamin Wei
- Department of Neurology Intensive Care Unit, The First Affiliated Hospital of Zhengzhou University, No.1, Jianshe Road, Zhengzhou, 450052, Henan, China
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Boegle K, Bassi M, Comanducci A, Kuehlmeyer K, Oehl P, Raiser T, Rosenfelder M, Sitt JD, Valota C, Willacker L, Bender A, Grill E. Informal Caregivers of Patients with Disorders of Consciousness: a Qualitative Study of Communication Experiences and Information Needs with Physicians. NEUROETHICS-NETH 2022; 15:24. [PMID: 35912377 PMCID: PMC9307713 DOI: 10.1007/s12152-022-09503-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Accepted: 07/11/2022] [Indexed: 10/27/2022]
Abstract
AbstractDue to improvements in medicine, the figures of patients with disorders of consciousness (DoC) are increasing. Diagnostics of DoC and prognostication of rehabilitation outcome is challenging but necessary to evaluate recovery potential and to decide on treatment options. Such decisions should be made by doctors and patients’ surrogates based on medico-ethical principles. Meeting information needs and communicating effectively with caregivers as the patients´ most common surrogate-decision makers is crucial, and challenging when novel tech-nologies are introduced. This qualitative study aims to explore information needs of informal DoC caregivers, how they manage the obtained information and their perceptions and experiences with caregiver-physician communication in facilities that implemented innovative neurodiagnostics studies. In 2021, we conducted semi-structured interviews with nine caregivers of clinically stable DoC patients in two rehabilitation centers in Italy and Germany. Participants were selected based on consecutive purposeful sampling. Caregivers were recruited at the facilities after written informed consent. All interviews were recorded, transcribed verbatim and translated. For analysis, we used reflexive thematic analysis according to Braun & Clarke (2006). Caregivers experienced the conversations emotionally, generally based on the value of the information provided. They reported to seek positive information, comfort and empathy with-in the communication of results of examinations. They needed detailed information to gain a deep understanding and a clear picture of their loved-one’s condition. The results suggest a mismatch between the perspectives of caregivers and the perspectives of medical profession-als, and stress the need for more elaborate approaches to the communication of results of neu-rodiagnostics studies.
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Liu B, Zhang X, Li Y, Duan G, Hou J, Zhao J, Guo T, Wu D. tDCS-EEG for Predicting Outcome in Patients With Unresponsive Wakefulness Syndrome. Front Neurosci 2022; 16:771393. [PMID: 35812233 PMCID: PMC9263392 DOI: 10.3389/fnins.2022.771393] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2021] [Accepted: 05/30/2022] [Indexed: 11/13/2022] Open
Abstract
Objectives We aimed to assess the role of transcranial direct current stimulation (tDCS) combined with electroencephalogram (EEG) for predicting prognosis in UWS cases. Methods This was a historical control study that enrolled 85 patients with UWS. The subjects were assigned to the control (without tDCS) and tDCS groups. Conventional treatments were implemented in both the control and tDCS groups, along with 40 multi-target tDCS sessions only in the tDCS group. Coma Recovery Scale-Revised (CRS-R) was applied at admission. The non-linear EEG index was evaluated after treatment. The modified Glasgow Outcome Scale (mGOS) was applied 12 months after disease onset. Results The mGOS improvement rate in the tDCS group (37.1%) was higher than the control value (22.0%). Linear regression analysis revealed that the local and remote cortical networks under unaffected pain stimulation conditions and the remote cortical network under affected pain stimulation conditions were the main relevant factors for mGOS improvement. Furthermore, the difference in prefrontal-parietal cortical network was used to examine the sensitivity of prognostic assessment in UWS patients. The results showed that prognostic sensitivity could be increased from 54.5% (control group) to 84.6% (tDCS group). Conclusions This study proposes a tDCS-EEG protocol for predicting the prognosis of UWS. With multi-target tDCS combined with EEG, the sensitivity of prognostic assessment in patients with UWS was improved. The recovery might be related to improved prefrontal-parietal cortical networks of the unaffected hemisphere.
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Affiliation(s)
- Baohu Liu
- Department of Rehabilitation, Wangjing Hospital of China Academy of Chinese Medical Sciences, Beijing, China
| | - Xu Zhang
- Department of Rehabilitation, Wangjing Hospital of China Academy of Chinese Medical Sciences, Beijing, China
| | - Yuanyuan Li
- Department of Rehabilitation, Wangjing Hospital of China Academy of Chinese Medical Sciences, Beijing, China
| | - Guoping Duan
- Department of Rehabilitation, Wangjing Hospital of China Academy of Chinese Medical Sciences, Beijing, China
| | - Jun Hou
- Department of Rehabilitation, Wangjing Hospital of China Academy of Chinese Medical Sciences, Beijing, China
| | - Jiayi Zhao
- Department of Rehabilitation, Wangjing Hospital of China Academy of Chinese Medical Sciences, Beijing, China
| | - Tongtong Guo
- Graduate School, Tianjin University of Traditional Chinese Medicine, Tianjin, China
| | - Dongyu Wu
- Department of Rehabilitation, Wangjing Hospital of China Academy of Chinese Medical Sciences, Beijing, China
- *Correspondence: Dongyu Wu
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Behavioral signs of recovery from unresponsive wakefulness syndrome to emergence of minimally conscious state after severe brain injury. Ann Phys Rehabil Med 2021; 65:101534. [PMID: 33933691 DOI: 10.1016/j.rehab.2021.101534] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2020] [Revised: 03/02/2021] [Accepted: 03/16/2021] [Indexed: 11/22/2022]
Abstract
BACKGROUND A precise description of behavioral signs denoting transition from an unresponsive wakefulness syndrome/vegetative state (UWS/VS) to minimally conscious state (MCS) or emergence from MCS after severe brain injury is crucial for prognostic purposes. A few studies have attempted this goal but involved non-standardized instruments, limited temporal accuracy or samples or focused on patients with (sub)acute condition. OBJECTIVES We aimed to describe the behavioral signs that led to a change in diagnosis as well as the factors affecting this transition in a large sample of patients with chronic disorders of consciousness after severe brain injury. METHODS In this retrospective cohort study, patients in UWS/VS or MCS were assessed with the Coma Recovery Scale Revised (CRS-R) at 5 times within the 2 weeks after their admission to a neurorehabilitation center and then weekly until emergence from MCS, discharge or death. RESULTS Of the 185 patients included, 33 in UWS/VS and 45 in MCS transitioned to another state. Transition to MCS was mostly denoted by one behavioral sign (71%), predominantly visual fixation, followed by localization to noxious stimulation, and visual pursuit, and could be predicted by etiology, time post-injury and age. Emergence from MCS was characterized by one sign in 64% of patients and by 2 signs (functional communication and objects use) in the remaining patients and could be predicted by time post-injury and number of behavioral signs at admission. CONCLUSIONS Transition from UWS to MCS was predominantly signalled by visual fixation and could be predicted by etiology, time post-injury and age. Emergence from MCS was mostly signalled by one sign and could be predicted by time post-injury and number of behavioral signs at admission. Clinicians should pay particular attention to visual and motor subscales of the CRS-R to detect behavioral recovery after severe brain injury. Database registration. ClinicalTrials.gov: NCT04687397.
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Liu B, Zhang X, Wang L, Li Y, Hou J, Duan G, Guo T, Wu D. Outcome Prediction in Unresponsive Wakefulness Syndrome and Minimally Conscious State by Non-linear Dynamic Analysis of the EEG. Front Neurol 2021; 12:510424. [PMID: 33692735 PMCID: PMC7937604 DOI: 10.3389/fneur.2021.510424] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2019] [Accepted: 02/01/2021] [Indexed: 12/12/2022] Open
Abstract
Objectives: This study aimed to investigate the role of non-linear dynamic analysis (NDA) of the electroencephalogram (EEG) in predicting patient outcome in unresponsive wakefulness syndrome (UWS) and minimally conscious state (MCS). Methods: This was a prospective longitudinal cohort study. A total of 98 and 64 UWS and MCS cases, respectively, were assessed. During admission, EEGs were acquired under eyes-closed and pain stimulation conditions. EEG nonlinear indices, including approximate entropy (ApEn) and cross-ApEn, were calculated. The modified Glasgow Outcome Scale (mGOS) was employed to assess functional prognosis 1 year following brain injury. Results: The mGOS scores were improved in 25 (26%) patients with UWS and 42 (66%) with MCS. Under the painful stimulation condition, both non-linear indices were lower in patients with UWS than in those with MCS. The frontal region, periphery of the primary sensory area (S1), and forebrain structure might be the key points modulating disorders of consciousness. The affected local cortical networks connected to S1 and unaffected distant cortical networks connecting S1 to the prefrontal area played important roles in mGOS score improvement. Conclusions: NDA provides an objective assessment of cortical excitability and interconnections of residual cortical functional islands. The impaired interconnection of the residual cortical functional island meant a poorer prognosis. The activation in the affected periphery of the S1 and the increase in the interconnection of affected local cortical areas around the S1 and unaffected S1 to the prefrontal and temporal areas meant a relatively favorable prognosis.
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Affiliation(s)
- Baohu Liu
- Department of Rehabilitation, Wangjing Hospital, China Academy of Chinese Medical Sciences, Beijing, China
| | - Xu Zhang
- Department of Rehabilitation, Wangjing Hospital, China Academy of Chinese Medical Sciences, Beijing, China
| | - Lijia Wang
- Department of Statistics and Actuarial Science, University of Waterloo, Waterloo, ON, Canada
| | - Yuanyuan Li
- Department of Rehabilitation, Wangjing Hospital, China Academy of Chinese Medical Sciences, Beijing, China
| | - Jun Hou
- Department of Rehabilitation, Wangjing Hospital, China Academy of Chinese Medical Sciences, Beijing, China
| | - Guoping Duan
- Department of Rehabilitation, Wangjing Hospital, China Academy of Chinese Medical Sciences, Beijing, China
| | - Tongtong Guo
- Tianjin University of Traditional Chinese Medicine, Tianjin, China
| | - Dongyu Wu
- Department of Rehabilitation, Wangjing Hospital, China Academy of Chinese Medical Sciences, Beijing, China
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Meiron O, Barron J, David J, Jaul E. Neural reactivity parameters of awareness predetermine one-year survival in patients with disorders of consciousness. Brain Inj 2021; 35:453-459. [PMID: 33599140 DOI: 10.1080/02699052.2021.1879398] [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] [Indexed: 10/22/2022]
Abstract
Objective: The current investigation evaluated the sensitivity of neural-reactivity markers of awareness versus standard clinical assessments in predicting 1-year survival in nonresponsive-awake patients with disorders of consciousness (DOC).Methods: Pre-attentive auditory mismatch-negativity (MMN) event-related potentials (ERP's), globally induced electroencephalography (EEG) spectral power following verbal command, and clinical parameters were assessed. The study included 10 patients with DOC with mixed etiology and 10 healthy controls (HC) at baseline. The clinical status of patients with DOC was reassessed after 1 year.Results: Unlike baseline clinical assessment scores, baseline MMN amplitudes of non-survivors and induced theta-power following verbal-command clearly distinguished the non-surviving patients versus surviving patients. Baseline MMN peak-amplitude latencies in survivors with DOC were significantly related to clinical outcome over a 1-year period.Conclusion: Current findings underscore the increased sensitivity of EEG-reactivity markers of awareness versus standard clinical scores in predicting 1-year clinical outcome and survival in patients with DOC. Further longitudinal research in larger DOC samples is needed to confirm the prognostic-reliability, and validity of neural reactivity parameters of awareness in patients with DOC. Current finding may have implications for clinical care and medical-legal decisions in unresponsive-awake patients, and could assist clinicians to predict their survival up to 1 year from admission.
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Affiliation(s)
- Oded Meiron
- Electrophysiology and Neurocognition Lab, Clinical Research Center for Brain Sciences, Herzog Medical Center, Jerusalem, Israel
| | - Jeremy Barron
- Electrophysiology and Neurocognition Lab, Clinical Research Center for Brain Sciences, Herzog Medical Center, Jerusalem, Israel.,Herzog Medical Center, Ventilator Care Department, Jerusalem, Israel.,Johns Hopkins University, Division of Geriatric Medicine, Baltimore, MD, USA
| | - Jonathan David
- Electrophysiology and Neurocognition Lab, Clinical Research Center for Brain Sciences, Herzog Medical Center, Jerusalem, Israel
| | - Efraim Jaul
- Johns Hopkins University, Division of Geriatric Medicine, Baltimore, MD, USA.,Herzog Medical Center, Geriatric Skilled Nursing Department, Jerusalem, Israel.,School of Medicine, The Hebrew University of Jerusalem, Jerusalem, Israel
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7
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Jain R, Ramakrishnan AG. Electrophysiological and Neuroimaging Studies - During Resting State and Sensory Stimulation in Disorders of Consciousness: A Review. Front Neurosci 2020; 14:555093. [PMID: 33041757 PMCID: PMC7522478 DOI: 10.3389/fnins.2020.555093] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Accepted: 08/25/2020] [Indexed: 12/17/2022] Open
Abstract
A severe brain injury may lead to a disorder of consciousness (DOC) such as coma, vegetative state (VS), minimally conscious state (MCS) or locked-in syndrome (LIS). Till date, the diagnosis of DOC relies only on clinical evaluation or subjective scoring systems such as Glasgow coma scale, which fails to detect subtle changes and thereby results in diagnostic errors. The high rate of misdiagnosis and inability to predict the recovery of consciousness for DOC patients have created a huge research interest in the assessment of consciousness. Researchers have explored the use of various stimulation and neuroimaging techniques to improve the diagnosis. In this article, we present the important findings of resting-state as well as sensory stimulation methods and highlight the stimuli proven to be successful in the assessment of consciousness. Primarily, we review the literature based on (a) application/non-use of stimuli (i.e., sensory stimulation/resting state-based), (b) type of stimulation used (i.e., auditory, visual, tactile, olfactory, or mental-imagery), (c) electrophysiological signal used (EEG/ERP, fMRI, PET, EMG, SCL, or ECG). Among the sensory stimulation methods, auditory stimulation has been extensively used, since it is easier to conduct for these patients. Olfactory and tactile stimulation have been less explored and need further research. Emotionally charged stimuli such as subject’s own name or narratives in a familiar voice or subject’s own face/family pictures or music result in stronger responses than neutral stimuli. Studies based on resting state analysis have employed measures like complexity, power spectral features, entropy and functional connectivity patterns to distinguish between the VS and MCS patients. Resting-state EEG and fMRI are the state-of-the-art techniques and have a huge potential in predicting the recovery of coma patients. Further, EMG and mental-imagery based studies attempt to obtain volitional responses from the VS patients and thus could detect their command-following capability. This may provide an effective means to communicate with these patients. Recent studies have employed fMRI and PET to understand the brain-activation patterns corresponding to the mental imagery. This review promotes our knowledge about the techniques used for the diagnosis of patients with DOC and attempts to provide ideas for future research.
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Affiliation(s)
- Ritika Jain
- Medical Intelligence and Language Engineering Laboratory, Department of Electrical Engineering, Indian Institute of Science, Bengaluru, India
| | - Angarai Ganesan Ramakrishnan
- Medical Intelligence and Language Engineering Laboratory, Department of Electrical Engineering, Indian Institute of Science, Bengaluru, India
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Comanducci A, Boly M, Claassen J, De Lucia M, Gibson RM, Juan E, Laureys S, Naccache L, Owen AM, Rosanova M, Rossetti AO, Schnakers C, Sitt JD, Schiff ND, Massimini M. Clinical and advanced neurophysiology in the prognostic and diagnostic evaluation of disorders of consciousness: review of an IFCN-endorsed expert group. Clin Neurophysiol 2020; 131:2736-2765. [PMID: 32917521 DOI: 10.1016/j.clinph.2020.07.015] [Citation(s) in RCA: 96] [Impact Index Per Article: 24.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2019] [Revised: 07/06/2020] [Accepted: 07/26/2020] [Indexed: 12/13/2022]
Abstract
The analysis of spontaneous EEG activity and evoked potentialsis a cornerstone of the instrumental evaluation of patients with disorders of consciousness (DoC). Thepast few years have witnessed an unprecedented surge in EEG-related research applied to the prediction and detection of recovery of consciousness after severe brain injury,opening up the prospect that new concepts and tools may be available at the bedside. This paper provides a comprehensive, critical overview of bothconsolidated and investigational electrophysiological techniquesfor the prognostic and diagnostic assessment of DoC.We describe conventional clinical EEG approaches, then focus on evoked and event-related potentials, and finally we analyze the potential of novel research findings. In doing so, we (i) draw a distinction between acute, prolonged and chronic phases of DoC, (ii) attempt to relate both clinical and research findings to the underlying neuronal processes and (iii) discuss technical and conceptual caveats.The primary aim of this narrative review is to bridge the gap between standard and emerging electrophysiological measures for the detection and prediction of recovery of consciousness. The ultimate scope is to provide a reference and common ground for academic researchers active in the field of neurophysiology and clinicians engaged in intensive care unit and rehabilitation.
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Affiliation(s)
- A Comanducci
- IRCCS Fondazione Don Carlo Gnocchi, Milan, Italy
| | - M Boly
- Department of Neurology and Department of Psychiatry, University of Wisconsin, Madison, USA; Wisconsin Institute for Sleep and Consciousness, Department of Psychiatry, University of Wisconsin-Madison, Madison, USA
| | - J Claassen
- Department of Neurology, Columbia University Medical Center, New York Presbyterian Hospital, New York, NY, USA
| | - M De Lucia
- Laboratoire de Recherche en Neuroimagerie, Department of Clinical Neurosciences, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - R M Gibson
- The Brain and Mind Institute and the Department of Physiology and Pharmacology, Western Interdisciplinary Research Building, N6A 5B7 University of Western Ontario, London, Ontario, Canada
| | - E Juan
- Wisconsin Institute for Sleep and Consciousness, Department of Psychiatry, University of Wisconsin-Madison, Madison, USA; Amsterdam Brain and Cognition, Department of Psychology, University of Amsterdam, Amsterdam, the Netherlands
| | - S Laureys
- Coma Science Group, Centre du Cerveau, GIGA-Consciousness, University and University Hospital of Liège, 4000 Liège, Belgium; Fondazione Europea per la Ricerca Biomedica Onlus, Milan 20063, Italy
| | - L Naccache
- Inserm U 1127, CNRS UMR 7225, Institut du Cerveau et de la Moelle épinière, ICM, Paris, France; Sorbonne Université, UPMC Université Paris 06, Faculté de Médecine Pitié-Salpêtrière, Paris, France
| | - A M Owen
- The Brain and Mind Institute and the Department of Physiology and Pharmacology, Western Interdisciplinary Research Building, N6A 5B7 University of Western Ontario, London, Ontario, Canada
| | - M Rosanova
- Department of Biomedical and Clinical Sciences "L. Sacco", University of Milan, Milan, Italy; Fondazione Europea per la Ricerca Biomedica Onlus, Milan 20063, Italy
| | - A O Rossetti
- Neurology Service, Department of Clinical Neurosciences, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - C Schnakers
- Research Institute, Casa Colina Hospital and Centers for Healthcare, Pomona, CA, USA
| | - J D Sitt
- Inserm U 1127, CNRS UMR 7225, Institut du Cerveau et de la Moelle épinière, ICM, Paris, France
| | - N D Schiff
- Feil Family Brain and Mind Research Institute, Weill Cornell Medical College, 1300 York Avenue, New York, NY 10065, USA
| | - M Massimini
- IRCCS Fondazione Don Carlo Gnocchi, Milan, Italy; Department of Biomedical and Clinical Sciences "L. Sacco", University of Milan, Milan, Italy
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Møller MLH, Højlund A, Jensen M, Gansonre C, Shtyrov Y. Applied potential of task-free event-related paradigms for assessing neurocognitive functions in disorders of consciousness. Brain Commun 2020; 2:fcaa087. [PMID: 33134912 PMCID: PMC7585695 DOI: 10.1093/braincomms/fcaa087] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2019] [Revised: 04/21/2020] [Accepted: 04/29/2020] [Indexed: 12/17/2022] Open
Abstract
Diagnosing patients with disorders of consciousness is immensely difficult and often results in misdiagnoses, which can have fatal consequences. Despite the severity of this well-known issue, a reliable assessment tool has not yet been developed and implemented in the clinic. The main aim of this focused review is to evaluate the various event-related potential paradigms, recorded using EEG, which may be used to improve the assessment of patients with disorders of consciousness; we also provide a brief comparison of these paradigms with other measures. Notably, most event-related potential studies on the topic have focused on testing a small set of components, or even just a single component. However, to be of practical use, we argue that an assessment should probe a range of cognitive and linguistic functions at once. We suggest a novel approach that combines a set of well-tested auditory event-related potential components: N100, mismatch negativity, P3a, N400, early left anterior negativity and lexical response enhancement. Combining these components in a single, task-free design will provide a multidimensional assessment of cognitive and linguistic processes, which may help physicians make a more precise diagnosis.
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Affiliation(s)
- Marie Louise Holm Møller
- Center of Functionally Integrative Neuroscience (CFIN), Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Andreas Højlund
- Center of Functionally Integrative Neuroscience (CFIN), Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Mads Jensen
- Center of Functionally Integrative Neuroscience (CFIN), Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Christelle Gansonre
- Center of Functionally Integrative Neuroscience (CFIN), Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Yury Shtyrov
- Center of Functionally Integrative Neuroscience (CFIN), Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
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How Does Functional Neurodiagnostics Inform Surrogate Decision-Making for Patients with Disorders of Consciousness? A Qualitative Interview Study with Patients’ Next of Kin. NEUROETHICS-NETH 2020. [DOI: 10.1007/s12152-019-09425-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
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André-Obadia N, Zyss J, Gavaret M, Lefaucheur JP, Azabou E, Boulogne S, Guérit JM, McGonigal A, Merle P, Mutschler V, Naccache L, Sabourdy C, Trébuchon A, Tyvaert L, Vercueil L, Rohaut B, Delval A. Recommendations for the use of electroencephalography and evoked potentials in comatose patients. Neurophysiol Clin 2018; 48:143-169. [DOI: 10.1016/j.neucli.2018.05.038] [Citation(s) in RCA: 53] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2018] [Accepted: 05/07/2018] [Indexed: 12/21/2022] Open
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Measuring Depth in Still Water: Electrophysiologic Indicators of Residual Consciousness in the Unresponsive Patient. Epilepsy Curr 2018; 18:147-150. [PMID: 29950932 DOI: 10.5698/1535-7597.18.3.147] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Searching for evidence of consciousness in outwardly unresponsive patients presents significant clinical challenges as the spectrum of disorders of consciousness has become more clearly defined, with clinical examination, functional MRI, and electrophysiologic tests having complementary roles in the investigation of minimally conscious patients, those in a locked-in state, coma, or in a vegetative state. Serial bedside electrophysiologic testing can probe for higher order cortical responses temporally and spatially propagated through cortical networks, while long-latency event-related potentials may help differentiate patients with coma or vegetative state from a state of residual consciousness. Transcranial magnetic stimulation co-registered to high-density EEG may reveal widespread pulse-stimulated cortical activation of various brain regions. These emerging electrophysiologic techniques show promise as powerful diagnostic, prognostic, and therapeutic tools.
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Stefan S, Schorr B, Lopez-Rolon A, Kolassa IT, Shock JP, Rosenfelder M, Heck S, Bender A. Consciousness Indexing and Outcome Prediction with Resting-State EEG in Severe Disorders of Consciousness. Brain Topogr 2018; 31:848-862. [PMID: 29666960 DOI: 10.1007/s10548-018-0643-x] [Citation(s) in RCA: 60] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2017] [Accepted: 04/07/2018] [Indexed: 12/18/2022]
Abstract
We applied the following methods to resting-state EEG data from patients with disorders of consciousness (DOC) for consciousness indexing and outcome prediction: microstates, entropy (i.e. approximate, permutation), power in alpha and delta frequency bands, and connectivity (i.e. weighted symbolic mutual information, symbolic transfer entropy, complex network analysis). Patients with unresponsive wakefulness syndrome (UWS) and patients in a minimally conscious state (MCS) were classified into these two categories by fitting and testing a generalised linear model. We aimed subsequently to develop an automated system for outcome prediction in severe DOC by selecting an optimal subset of features using sequential floating forward selection (SFFS). The two outcome categories were defined as UWS or dead, and MCS or emerged from MCS. Percentage of time spent in microstate D in the alpha frequency band performed best at distinguishing MCS from UWS patients. The average clustering coefficient obtained from thresholding beta coherence performed best at predicting outcome. The optimal subset of features selected with SFFS consisted of the frequency of microstate A in the 2-20 Hz frequency band, path length obtained from thresholding alpha coherence, and average path length obtained from thresholding alpha coherence. Combining these features seemed to afford high prediction power. Python and MATLAB toolboxes for the above calculations are freely available under the GNU public license for non-commercial use ( https://qeeg.wordpress.com ).
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Affiliation(s)
- Sabina Stefan
- School of Engineering, Brown University, 182 Hope Street, Box D, Providence, RI, 02912, USA
| | - Barbara Schorr
- Department of Neurology, Therapiezentrum Burgau, Kapuzinerstrasse 34, 89331, Burgau, Germany.,Clinical and Biological Psychology, Institute of Psychology and Education, Ulm University, 89081, Ulm, Germany
| | - Alex Lopez-Rolon
- Department of Neurology, University of Munich, Marchioninistrasse 15, 81377, Munich, Germany
| | - Iris-Tatjana Kolassa
- Clinical and Biological Psychology, Institute of Psychology and Education, Ulm University, 89081, Ulm, Germany
| | - Jonathan P Shock
- Department of Mathematics and Applied Mathematics, University of Cape Town, Rondebosch, Private Bag X1, Cape Town, 7701, South Africa.
| | - Martin Rosenfelder
- Department of Neurology, Therapiezentrum Burgau, Kapuzinerstrasse 34, 89331, Burgau, Germany.,Clinical and Biological Psychology, Institute of Psychology and Education, Ulm University, 89081, Ulm, Germany
| | - Suzette Heck
- Department of Neurology, University of Munich, Marchioninistrasse 15, 81377, Munich, Germany
| | - Andreas Bender
- Department of Neurology, Therapiezentrum Burgau, Kapuzinerstrasse 34, 89331, Burgau, Germany.,Department of Neurology, University of Munich, Marchioninistrasse 15, 81377, Munich, Germany
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14
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Kotchoubey B. Evoked and event-related potentials in disorders of consciousness: A quantitative review. Conscious Cogn 2017; 54:155-167. [DOI: 10.1016/j.concog.2017.05.002] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2016] [Revised: 04/18/2017] [Accepted: 05/10/2017] [Indexed: 11/25/2022]
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15
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Ragazzoni A, Cincotta M, Giovannelli F, Cruse D, Young GB, Miniussi C, Rossi S. Clinical neurophysiology of prolonged disorders of consciousness: From diagnostic stimulation to therapeutic neuromodulation. Clin Neurophysiol 2017; 128:1629-1646. [DOI: 10.1016/j.clinph.2017.06.037] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2017] [Revised: 05/17/2017] [Accepted: 06/15/2017] [Indexed: 10/19/2022]
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16
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Meiron O, Jaul E. Paroxysmal theta power reactivity is related to survival in anoxic vegetative state patients. Clin Neurophysiol 2017; 128:1255-1257. [DOI: 10.1016/j.clinph.2017.04.019] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2017] [Revised: 04/23/2017] [Accepted: 04/24/2017] [Indexed: 10/19/2022]
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17
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Lugo ZR, Quitadamo LR, Bianchi L, Pellas F, Veser S, Lesenfants D, Real RGL, Herbert C, Guger C, Kotchoubey B, Mattia D, Kübler A, Laureys S, Noirhomme Q. Cognitive Processing in Non-Communicative Patients: What Can Event-Related Potentials Tell Us? Front Hum Neurosci 2016; 10:569. [PMID: 27895567 PMCID: PMC5107572 DOI: 10.3389/fnhum.2016.00569] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2016] [Accepted: 10/26/2016] [Indexed: 12/03/2022] Open
Abstract
Event-related potentials (ERP) have been proposed to improve the differential diagnosis of non-responsive patients. We investigated the potential of the P300 as a reliable marker of conscious processing in patients with locked-in syndrome (LIS). Eleven chronic LIS patients and 10 healthy subjects (HS) listened to a complex-tone auditory oddball paradigm, first in a passive condition (listen to the sounds) and then in an active condition (counting the deviant tones). Seven out of nine HS displayed a P300 waveform in the passive condition and all in the active condition. HS showed statistically significant changes in peak and area amplitude between conditions. Three out of seven LIS patients showed the P3 waveform in the passive condition and five of seven in the active condition. No changes in peak amplitude and only a significant difference at one electrode in area amplitude were observed in this group between conditions. We conclude that, in spite of keeping full consciousness and intact or nearly intact cortical functions, compared to HS, LIS patients present less reliable results when testing with ERP, specifically in the passive condition. We thus strongly recommend applying ERP paradigms in an active condition when evaluating consciousness in non-responsive patients.
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Affiliation(s)
- Zulay R Lugo
- Coma Science Group, University and University Hospital of Liège, GIGALiège, Belgium; Institute of Psychology, University of WürzburgWürzburg, Germany; French Association of Locked-in Syndrome (ALIS)Paris, France
| | - Lucia R Quitadamo
- Neuroelectrical Imaging and BCI Laboratory, Fondazione Santa Lucia, IRCCSRome, Italy; School of Life and Health Sciences, Aston Brain Centre, Aston UniversityBirmingham, UK
| | - Luigi Bianchi
- Department of Civil Engineering and Computer Science, University of Rome Tor Vergata Rome, Italy
| | - Fréderic Pellas
- French Association of Locked-in Syndrome (ALIS)Paris, France; Coma Arousal Unit - PMR Department, Nîmes University HospitalNîmes, France
| | - Sandra Veser
- Institute for Medical Psychology and Behavioural Neurobiology, University of Tübingen Tübingen, Germany
| | - Damien Lesenfants
- Coma Science Group, University and University Hospital of Liège, GIGA Liège, Belgium
| | - Ruben G L Real
- Institute of Psychology, University of Würzburg Würzburg, Germany
| | - Cornelia Herbert
- Institute of Psychology, University of WürzburgWürzburg, Germany; Department of Psychiatry, University of TübingenTübingen, Germany; Department of Biomedical Resonance, University of TübingenTübingen, Germany
| | - Christoph Guger
- G.Tec Medical Engineering GmbH/Guger Technologies OG Graz, Austria
| | - Boris Kotchoubey
- Institute for Medical Psychology and Behavioural Neurobiology, University of Tübingen Tübingen, Germany
| | - Donatella Mattia
- Neuroelectrical Imaging and BCI Laboratory, Fondazione Santa Lucia, IRCCS Rome, Italy
| | - Andrea Kübler
- Institute of Psychology, University of Würzburg Würzburg, Germany
| | - Steven Laureys
- Coma Science Group, University and University Hospital of Liège, GIGA Liège, Belgium
| | - Quentin Noirhomme
- Coma Science Group, University and University Hospital of Liège, GIGALiège, Belgium; Department of Cognitive Neuroscience, Maastricht UniversityMaastricht, Netherlands; Brain Innovation B.V.Maastricht, Netherlands
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18
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Kondziella D, Friberg CK, Frokjaer VG, Fabricius M, Møller K. Preserved consciousness in vegetative and minimal conscious states: systematic review and meta-analysis. J Neurol Neurosurg Psychiatry 2016; 87:485-92. [PMID: 26139551 DOI: 10.1136/jnnp-2015-310958] [Citation(s) in RCA: 169] [Impact Index Per Article: 21.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2015] [Accepted: 06/18/2015] [Indexed: 11/04/2022]
Abstract
Active, passive and resting state paradigms using functional MRI (fMRI) or EEG may reveal consciousness in the vegetative (VS) and the minimal conscious state (MCS). A meta-analysis was performed to assess the prevalence of preserved consciousness in VS and MCS as revealed by fMRI and EEG, including command following (active paradigms), cortical functional connectivity elicited by external stimuli (passive paradigms) and default mode networks (resting state). Studies were selected from multiple indexing databases until February 2015 and evaluated using the Quality Assessment of Diagnostic Accuracy Studies-2. 37 studies were identified, including 1041 patients (mean age 43 years, range 16-89; male/female 2.1:1; 39.5% traumatic brain injuries). MCS patients were more likely than VS patients to follow commands during active paradigms (32% vs 14%; OR 2.85 (95% CI 1.90 to 4.27; p<0.0001)) and to show preserved functional cortical connectivity during passive paradigms (55% vs 26%; OR 3.53 (95% CI 2.49 to 4.99; p<0.0001)). Passive paradigms suggested preserved consciousness more often than active paradigms (38% vs 24%; OR 1.98 (95% CI 1.54 to 2.54; p<0.0001)). Data on resting state paradigms were insufficient for statistical evaluation. In conclusion, active paradigms may underestimate the degree of consciousness as compared to passive paradigms. While MCS patients show signs of preserved consciousness more frequently in both paradigms, roughly 15% of patients with a clinical diagnosis of VS are able to follow commands by modifying their brain activity. However, there remain important limitations at the single-subject level; for example, patients from both categories may show command following despite negative passive paradigms.
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Affiliation(s)
- Daniel Kondziella
- Department of Neurology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark Institute of Neuroscience, Norwegian University of Science and Technology, Trondheim, Norway
| | - Christian K Friberg
- Department of Clinical Neurophysiology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Vibe G Frokjaer
- Neurobiology Research Unit, Copenhagen University Hospital and Center for Integrated Molecular Brain Imaging, Copenhagen, Denmark
| | - Martin Fabricius
- Department of Clinical Neurophysiology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Kirsten Møller
- Department of Neuroanesthesiology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
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19
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Schorr B, Schlee W, Arndt M, Bender A. Coherence in resting-state EEG as a predictor for the recovery from unresponsive wakefulness syndrome. J Neurol 2016; 263:937-953. [PMID: 26984609 DOI: 10.1007/s00415-016-8084-5] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2015] [Revised: 02/18/2016] [Accepted: 02/28/2016] [Indexed: 12/27/2022]
Abstract
We investigated differences of EEG coherence within (short-range), and between (long-range) specified brain areas as diagnostic markers for different states in disorders of consciousness (DOC), and their predictive value for recovery from unresponsive wakefulness syndrome (UWS). EEGs of 73 patients and 24 controls were recorded and coma recovery scale- revised (CRS-R) scores were assessed. CRS-R of UWS patients was collected after 12 months and divided into two groups (improved/unimproved). Frontal, parietal, fronto-parietal, fronto-temporal, and fronto-occipital coherence was computed, as well as EEG power over frontal, parietal, occipital, and temporal areas. Minimally conscious patients (MCS) and UWS patients could not be differentiated based on their coherence patterns or on EEG power. Fronto-parietal and parietal coherence could positively predict improvement of UWS patients, i.e. recovery from UWS to MCS. Parietal coherence was significantly higher in delta and theta frequencies in the improved group, as well as the coherence between frontal and parietal regions in delta, theta, alpha, and beta frequencies. High parietal delta and theta, and high fronto-parietal theta and alpha coherence appear to provide strong early evidence for recovery from UWS with high predictive sensitivity and specificity. Short and long-range coherence can have a diagnostic value in the prognosis of recovery from UWS.
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Affiliation(s)
- Barbara Schorr
- Therapiezentrum Burgau, Kapuzinerstraße 34, 89331, Burgau, Germany. .,Clinical and Biological Psychology, Institute of Psychology and Education, Ulm University, Albert-Einstein-Allee 47, 89069, Ulm, Germany.
| | - Winfried Schlee
- Institute for Psychiatry and Psychotherapy, University of Regensburg, Universitätsstraße 84, 93053, Regensburg, Germany
| | - Marion Arndt
- Therapiezentrum Burgau, Kapuzinerstraße 34, 89331, Burgau, Germany
| | - Andreas Bender
- Therapiezentrum Burgau, Kapuzinerstraße 34, 89331, Burgau, Germany.,Department of Neurology, Klinikum Grosshadern, University of Munich, Marchioninistraße 15, 81377, Munich, Germany
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