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Xiao X, Ding J, Yu M, Dong Z, Cruz S, Ding N, Aubinet C, Laureys S, Di H, Chen Y. Exploring the clinical diagnostic value of linguistic learning ability in patients with disorders of consciousness using electrooculography. Neuroimage 2024; 297:120753. [PMID: 39053636 DOI: 10.1016/j.neuroimage.2024.120753] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2024] [Revised: 07/15/2024] [Accepted: 07/23/2024] [Indexed: 07/27/2024] Open
Abstract
For patients with disorders of consciousness (DoC), accurate assessment of residual consciousness levels and cognitive abilities is critical for developing appropriate rehabilitation interventions. In this study, we investigated the potential of electrooculography (EOG) in assessing language processing abilities and consciousness levels. Patients' EOG data and related electrophysiological data were analysed before and after explicit language learning. The results showed distinct differences in vocabulary learning patterns among patients with varying levels of consciousness. While minimally conscious patients showed significant neural tracking of artificial words and notable learning effects similar to those observed in healthy controls, whereas patients with unresponsive wakefulness syndrome did not show such effects. Correlation analysis further indicated that EOG detected vocabulary learning effects with comparable validity to electroencephalography, reinforcing the credibility of EOG indicator as a diagnostic tool. Critically, EOG also revealed significant correlations between individual patients' linguistic learning performance and their Oromotor/verbal function as assessed through behavioural scales. In conclusion, this study explored the differences in language processing abilities among patients with varying consciousness levels. By demonstrating the utility of EOG in evaluating consciousness and detecting vocabulary learning effects, as well as its potential to guide personalised rehabilitation, our findings indicate that EOG indicators show promise as a rapid, accurate and effective additional tool for diagnosing and managing patients with DoC.
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Affiliation(s)
- Xiangyue Xiao
- International Unresponsive Wakefulness Syndrome and Consciousness Science Institute, Hangzhou Normal University, Hangzhou 311121, China; Key Laboratory of Ageing and Cancer Biology of Zhejiang Province, School of Basic Medical Sciences, Hangzhou Normal University, Hangzhou 311121, China
| | - Junhua Ding
- Department of Psychology, University of Edinburgh, Edinburgh EH8 9YL, UK
| | - Mingyan Yu
- International Unresponsive Wakefulness Syndrome and Consciousness Science Institute, Hangzhou Normal University, Hangzhou 311121, China; Key Laboratory of Ageing and Cancer Biology of Zhejiang Province, School of Basic Medical Sciences, Hangzhou Normal University, Hangzhou 311121, China
| | - Zhicai Dong
- International Unresponsive Wakefulness Syndrome and Consciousness Science Institute, Hangzhou Normal University, Hangzhou 311121, China; Key Laboratory of Ageing and Cancer Biology of Zhejiang Province, School of Basic Medical Sciences, Hangzhou Normal University, Hangzhou 311121, China
| | - Sara Cruz
- The Psychology for Development Research Centre, Lusiada University Porto, Porto 4100-348, Portugal
| | - Nai Ding
- Key Laboratory for Biomedical Engineering of Ministry of Education, College of Biomedical Engineering and Instrument Sciences, Zhejiang University, Hangzhou 310027, China
| | - Charlène Aubinet
- Coma Science Group, GIGA Consciousness & Centre du Cerveau, University and University Hospital of Liège, Liège 4000, Belgium; Psychology & Neuroscience of Cognition Research Unit, University of Liège, Liège 4000, Belgium
| | - Steven Laureys
- Coma Science Group, GIGA Consciousness & Centre du Cerveau, University and University Hospital of Liège, Liège 4000, Belgium
| | - Haibo Di
- International Unresponsive Wakefulness Syndrome and Consciousness Science Institute, Hangzhou Normal University, Hangzhou 311121, China; Key Laboratory of Ageing and Cancer Biology of Zhejiang Province, School of Basic Medical Sciences, Hangzhou Normal University, Hangzhou 311121, China.
| | - Yan Chen
- International Unresponsive Wakefulness Syndrome and Consciousness Science Institute, Hangzhou Normal University, Hangzhou 311121, China; Key Laboratory of Ageing and Cancer Biology of Zhejiang Province, School of Basic Medical Sciences, Hangzhou Normal University, Hangzhou 311121, China.
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You Y, Li Y, Yu B, Ying A, Zhou H, Zuo G, Xu J. A study on EEG differences between active counting and focused breathing tasks for more sensitive detection of consciousness. Front Neurosci 2024; 18:1341986. [PMID: 38533445 PMCID: PMC10963484 DOI: 10.3389/fnins.2024.1341986] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2023] [Accepted: 02/26/2024] [Indexed: 03/28/2024] Open
Abstract
Introduction In studies on consciousness detection for patients with disorders of consciousness, difference comparison of EEG responses based on active and passive task modes is difficult to sensitively detect patients' consciousness, while a single potential analysis of EEG responses cannot comprehensively and accurately determine patients' consciousness status. Therefore, in this paper, we designed a new consciousness detection paradigm based on a multi-stage cognitive task that could induce a series of event-related potentials and ERD/ERS phenomena reflecting different consciousness contents. A simple and direct task of paying attention to breathing was designed, and a comprehensive evaluation of consciousness level was conducted using multi-feature joint analysis. Methods We recorded the EEG responses of 20 healthy subjects in three modes and reported the consciousness-related mean event-related potential amplitude, ERD/ERS phenomena, and the classification accuracy, sensitivity, and specificity of the EEG responses under different conditions. Results The results showed that the EEG responses of the subjects under different conditions were significantly different in the time domain and time-frequency domain. Compared with the passive mode, the amplitudes of the event-related potentials in the breathing mode were further reduced, and the theta-ERS and alpha-ERD phenomena in the frontal region were further weakened. The breathing mode showed greater distinguishability from the active mode in machine learning-based classification. Discussion By analyzing multiple features of EEG responses in different modes and stimuli, it is expected to achieve more sensitive and accurate consciousness detection. This study can provide a new idea for the design of consciousness detection methods.
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Affiliation(s)
- Yimeng You
- Cixi Biomedical Research Institute, Wenzhou Medical University, Ningbo, Zhejiang, China
- Ningbo Institute of Materials Technology and Engineering, Chinese Academy of Sciences, Ningbo, Zhejiang, China
- Ningbo Cixi Institute of Biomedical Engineering, Ningbo, Zhejiang, China
| | - Yahui Li
- Cixi Biomedical Research Institute, Wenzhou Medical University, Ningbo, Zhejiang, China
- Ningbo Institute of Materials Technology and Engineering, Chinese Academy of Sciences, Ningbo, Zhejiang, China
- Ningbo Cixi Institute of Biomedical Engineering, Ningbo, Zhejiang, China
| | - Baobao Yu
- Cixi Biomedical Research Institute, Wenzhou Medical University, Ningbo, Zhejiang, China
- Ningbo Institute of Materials Technology and Engineering, Chinese Academy of Sciences, Ningbo, Zhejiang, China
- Ningbo Cixi Institute of Biomedical Engineering, Ningbo, Zhejiang, China
| | - Ankai Ying
- Cixi Biomedical Research Institute, Wenzhou Medical University, Ningbo, Zhejiang, China
- Ningbo Institute of Materials Technology and Engineering, Chinese Academy of Sciences, Ningbo, Zhejiang, China
- Ningbo Cixi Institute of Biomedical Engineering, Ningbo, Zhejiang, China
| | - Huilin Zhou
- Ningbo Institute of Materials Technology and Engineering, Chinese Academy of Sciences, Ningbo, Zhejiang, China
- Ningbo Cixi Institute of Biomedical Engineering, Ningbo, Zhejiang, China
| | - Guokun Zuo
- Cixi Biomedical Research Institute, Wenzhou Medical University, Ningbo, Zhejiang, China
- Ningbo Institute of Materials Technology and Engineering, Chinese Academy of Sciences, Ningbo, Zhejiang, China
- Ningbo Cixi Institute of Biomedical Engineering, Ningbo, Zhejiang, China
- University of Chinese Academy of Sciences, Beijing, China
| | - Jialin Xu
- Cixi Biomedical Research Institute, Wenzhou Medical University, Ningbo, Zhejiang, China
- Ningbo Institute of Materials Technology and Engineering, Chinese Academy of Sciences, Ningbo, Zhejiang, China
- Ningbo Cixi Institute of Biomedical Engineering, Ningbo, Zhejiang, China
- University of Chinese Academy of Sciences, Beijing, China
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Yang Z, Yue T, Zschorlich VR, Li D, Wang D, Qi F. Behavioral Effects of Repetitive Transcranial Magnetic Stimulation in Disorders of Consciousness: A Systematic Review and Meta-Analysis. Brain Sci 2023; 13:1362. [PMID: 37891731 PMCID: PMC10605911 DOI: 10.3390/brainsci13101362] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Revised: 09/12/2023] [Accepted: 09/20/2023] [Indexed: 10/29/2023] Open
Abstract
Traumatic brain injury, cardiac arrest, intracerebral hemorrhage, and ischemic stroke may cause disorders of consciousness (DoC). Repetitive transcranial magnetic stimulation (rTMS) has been used to promote the recovery of disorders of consciousness (DoC) patients. In this meta-analysis, we examined whether rTMS can relieve DoC patient symptoms. We searched through journal articles indexed in PubMed, the Web of Science, Embase, Scopus, and the Cochrane Library until 20 April 2023. We assessed whether studies used rTMS as an intervention and reported the pre- and post-rTMS coma recovery scale-revised (CRS-R) scores. A total of 207 patients from seven trials were included. rTMS significantly improved the recovery degree of patients; the weighted mean difference (WMD) of the change in the CRS-R score was 1.89 (95% confidence interval (CI): 1.39-2.39; p < 0.00001) in comparison with controls. The subgroup analysis showed a significant improvement in CRS-R scores in rTMS over the dorsolateral prefrontal cortex (WMD = 2.24; 95% CI: 1.55-2.92; p < 0.00001; I2 = 31%) and the primary motor cortex (WMD = 1.63; 95% CI: 0.69-2.57; p = 0.0007; I2 = 14%). Twenty-hertz rTMS significantly improved CRS-R scores in patients with DoC (WMD = 1.61; 95% CI: 0.39-2.83; p = 0.010; I2 = 31%). Furthermore, CRS-R scores in rTMS over 20 sessions significantly improved (WMD = 1.75; 95% CI: 0.95-2.55; p < 0.0001; I2 = 12%). rTMS improved the symptoms of DoC patients; however, the available evidence remains limited and inadequate.
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Affiliation(s)
- Zihan Yang
- School of Sports Medicine and Rehabilitation, Beijing Sport University, Beijing 100084, China
| | - Tian Yue
- School of Sports Medicine and Rehabilitation, Beijing Sport University, Beijing 100084, China
| | - Volker R. Zschorlich
- Institute of Sport Science, Carl von Ossietzky Universität Oldenburg, 26129 Oldenburg, Germany
| | - Dai Li
- Department of Sports Medicine, Peking University Third Hospital, Institute of Sports Medicine of Peking University, Beijing 100191, China
- Beijing Key Laboratory of Sports Injuries, Beijing 100191, China
- Engineering Research Center of Sports Trauma Treatment Technology and Devices, Ministry of Education, Beijing 100191, China
| | - Duanwei Wang
- Shandong Mental Health Center, Shandong University, Jinan 250012, China
| | - Fengxue Qi
- Sports, Exercise and Brain Sciences Laboratory, Beijing Sport University, Beijing 100084, China
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Zhang J, Zhang H, Yan F, Zhang H, Zhang E, Wang X, Wei M, Pei Y, Yang Z, Li Y, Dong L, Wang X. Investigating the mechanism and prognosis of patients with disorders of consciousness on the basis of brain networks between the thalamus and whole-brain. Front Neurol 2022; 13:990686. [PMID: 36237619 PMCID: PMC9552841 DOI: 10.3389/fneur.2022.990686] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2022] [Accepted: 09/05/2022] [Indexed: 11/13/2022] Open
Abstract
PurposeThis study aimed to investigate the changes in the functional connectivity between the bilateral thalamus and the whole-brain in patients with severe traumatic brain injury (sTBI) patients suffering from disorders of consciousness (DOC) and to explore their potential prognostic representation capacity.MethodsThe sTBI patients suffering from DOC and healthy controls underwent functional magnetic resonance imaging. We defined patients with the Extended Glasgow Outcome Score (GOS-E) ≥ 3 as the wake group and GOS-E = 2 as the coma group. The differences in functional connectivity between sTBI and healthy controls and between wake and coma groups were compared. Based on the brain regions with altered functional connectivity between wake and coma groups, they were divided into 26 regions of interest. Based on the Z-values of regions of interest, the receiver operating characteristic analysis was conducted to classify the prognosis of patients.ResultsA total of 28 patients and 15 healthy controls were finally included. Patients who had DOC indicated a significant disruption of functional connectivity between the bilateral thalamus and the whole-brain (FDR corrected, P < 0.0007). The functional connectivity strength (bilateral thalamus to whole-brain) was significantly different between coma patients who went on to wake and those who were eventually non-awake at 6 months after sTBI (Alphasim corrected, P < 0.05). Furthermore, the 26 regions of interest had a similar or even better prognostic distinction ability than the admission Glasgow coma score.ConclusionThe thalamus-based system of consciousness of sTBI patients suffering from DOC is disrupted. There are differences in the thalamus-to-whole-brain network between wake and coma groups and these differences have potential prognostic characterization capability.
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Affiliation(s)
- Jun Zhang
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China
- Department of Neurosurgery, Clinical Medical College of Yangzhou University, Yangzhou, China
| | - Hongying Zhang
- Department of Radiology, Clinical Medical College of Yangzhou University, Yangzhou, China
| | - Fuli Yan
- Department of Neurosurgery, Clinical Medical College of Yangzhou University, Yangzhou, China
| | - Hengzhu Zhang
- Department of Neurosurgery, Clinical Medical College of Yangzhou University, Yangzhou, China
| | - Enpeng Zhang
- Department of Neurosurgery, Clinical Medical College of Yangzhou University, Yangzhou, China
| | - Xingdong Wang
- Department of Neurosurgery, Clinical Medical College of Yangzhou University, Yangzhou, China
| | - Min Wei
- Department of Neurosurgery, Clinical Medical College of Yangzhou University, Yangzhou, China
| | - Yunlong Pei
- Department of Neurosurgery, Clinical Medical College of Yangzhou University, Yangzhou, China
| | - Zhijie Yang
- Department of Neurosurgery, Clinical Medical College of Yangzhou University, Yangzhou, China
| | - Yuping Li
- Department of Neurosurgery, Clinical Medical College of Yangzhou University, Yangzhou, China
| | - Lun Dong
- Department of Neurosurgery, Clinical Medical College of Yangzhou University, Yangzhou, China
- Lun Dong
| | - Xiaodong Wang
- Department of Neurosurgery, Clinical Medical College of Yangzhou University, Yangzhou, China
- *Correspondence: Xiaodong Wang
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Arnts H, Tewarie P, van Erp WS, Overbeek BU, Stam CJ, Lavrijsen JCM, Booij J, Vandertop WP, Schuurman R, Hillebrand A, van den Munckhof P. Clinical and neurophysiological effects of central thalamic deep brain stimulation in the minimally conscious state after severe brain injury. Sci Rep 2022; 12:12932. [PMID: 35902627 PMCID: PMC9334292 DOI: 10.1038/s41598-022-16470-2] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Accepted: 07/11/2022] [Indexed: 12/01/2022] Open
Abstract
Deep brain stimulation (DBS) of the central thalamus is an experimental treatment for restoration of impaired consciousness in patients with severe acquired brain injury. Previous results of experimental DBS are heterogeneous, but significant improvements in consciousness have been reported. However, the mechanism of action of DBS remains unknown. We used magnetoencephalography to study the direct effects of DBS of the central thalamus on oscillatory activity and functional connectivity throughout the brain in a patient with a prolonged minimally conscious state. Different DBS settings were used to improve consciousness, including two different stimulation frequencies (50 Hz and 130 Hz) with different effective volumes of tissue activation within the central thalamus. While both types of DBS resulted in a direct increase in arousal, we found that DBS with a lower frequency (50 Hz) and larger volume of tissue activation was associated with a stronger increase in functional connectivity and neural variability throughout the brain. Moreover, this form of DBS was associated with improvements in visual pursuit, a reduction in spasticity, and improvement of swallowing, eight years after loss of consciousness. However, after DBS, all neurophysiological markers remained significantly lower than in healthy controls and objective increases in consciousness remained limited. Our findings provide new insights on the mechanistic understanding of neuromodulatory effects of DBS of the central thalamus in humans and suggest that DBS can re-activate dormant functional brain networks, but that the severely injured stimulated brain still lacks the ability to serve cognitive demands.
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Affiliation(s)
- Hisse Arnts
- Department of Neurosurgery, Amsterdam Neurosciences, Systems & Network Neurosciences, Amsterdam UMC (Location AMC), University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands.
| | - Prejaas Tewarie
- Department of Clinical Neurophysiology and MEG Center, Amsterdam Neuroscience, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
- Sir Peter Mansfield Imaging Centre, School of Physics and Astronomy, University of Nottingham, Nottingham, UK
| | - Willemijn S van Erp
- Department of Primary and Community Care, Center for Family Medicine, Geriatric Care and Public Health, Radboud University Medical Center, Nijmegen, The Netherlands
- Accolade Zorg, Bosch en Duin, The Netherlands
- Libra Rehabilitation & Audiology, Tilburg, The Netherlands
| | - Berno U Overbeek
- Department of Primary and Community Care, Center for Family Medicine, Geriatric Care and Public Health, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Cornelis J Stam
- Department of Clinical Neurophysiology and MEG Center, Amsterdam Neuroscience, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Jan C M Lavrijsen
- Department of Primary and Community Care, Center for Family Medicine, Geriatric Care and Public Health, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Jan Booij
- Department of Radiology and Nuclear Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - William P Vandertop
- Department of Neurosurgery, Amsterdam Neurosciences, Systems & Network Neurosciences, Amsterdam UMC (Location AMC), University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - Rick Schuurman
- Department of Neurosurgery, Amsterdam Neurosciences, Systems & Network Neurosciences, Amsterdam UMC (Location AMC), University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - Arjan Hillebrand
- Department of Clinical Neurophysiology and MEG Center, Amsterdam Neuroscience, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Pepijn van den Munckhof
- Department of Neurosurgery, Amsterdam Neurosciences, Systems & Network Neurosciences, Amsterdam UMC (Location AMC), University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
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Cacciatore M, Magnani FG, Leonardi M, Rossi Sebastiano D, Sattin D. Sleep Treatments in Disorders of Consciousness: A Systematic Review. Diagnostics (Basel) 2021; 12:diagnostics12010088. [PMID: 35054255 PMCID: PMC8775271 DOI: 10.3390/diagnostics12010088] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Revised: 12/24/2021] [Accepted: 12/30/2021] [Indexed: 12/23/2022] Open
Abstract
Sleep disorders are among the main comorbidities in patients with a Disorder of Consciousness (DOC). Given the key role of sleep in neural and cognitive functioning, detecting and treating sleep disorders in DOCs might be an effective therapeutic strategy to boost consciousness recovery and levels of awareness. To date, no systematic reviews have been conducted that explore the effect of sleep treatments in DOCs; thus, we systematically reviewed the existing studies on both pharmacological and non-pharmacological treatments for sleep disorders in DOCs. Among 2267 assessed articles, only 7 were included in the systematic review. The studies focused on two sleep disorder categories (sleep-related breathing disorders and circadian rhythm dysregulation) treated with both pharmacological (Modafinil and Intrathecal Baclofen) and non-pharmacological (positive airway pressure, bright light stimulation, and central thalamic deep brain stimulation) interventions. Although the limited number of studies and their heterogeneity do not allow generalized conclusions, all the studies highlighted the effectiveness of treatments on both sleep disorders and levels of awareness. For this reason, clinical and diagnostic evaluations able to detect sleep disorders in DOC patients should be adopted in the clinical routine for the purpose of intervening promptly with the most appropriate treatment.
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Affiliation(s)
- Martina Cacciatore
- UOC Neurologia, Salute Pubblica, Disabilità, Fondazione IRCCS Istituto Neurologico Carlo Besta, 20133 Milan, Italy; (M.C.); (M.L.)
| | - Francesca G. Magnani
- UOC Neurologia, Salute Pubblica, Disabilità, Fondazione IRCCS Istituto Neurologico Carlo Besta, 20133 Milan, Italy; (M.C.); (M.L.)
- Correspondence: ; Tel.: +39-02-23942188
| | - Matilde Leonardi
- UOC Neurologia, Salute Pubblica, Disabilità, Fondazione IRCCS Istituto Neurologico Carlo Besta, 20133 Milan, Italy; (M.C.); (M.L.)
| | - Davide Rossi Sebastiano
- Unità di Neurofisiopatologia, Fondazione IRCCS Istituto Neurologico Carlo Besta, 20133 Milan, Italy;
| | - Davide Sattin
- IRCCS Istituti Clinici Scientifici Maugeri di Milano, 20138 Milan, Italy;
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Stephens TM, Young IM, O'Neal CM, Dadario NB, Briggs RG, Teo C, Sughrue ME. Akinetic mutism reversed by inferior parietal lobule repetitive theta burst stimulation: Can we restore default mode network function for therapeutic benefit? Brain Behav 2021; 11:e02180. [PMID: 34145791 PMCID: PMC8413751 DOI: 10.1002/brb3.2180] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2020] [Revised: 03/24/2021] [Accepted: 04/06/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Transcranial magnetic stimulation is a noninvasive treatment used to modulate cortical excitability. Its use over the last two decades has expanded, ranging from psychiatric disorders to traumatic brain injury and poststroke rehabilitation. OBJECTIVES We present the case of a 59-year-old male patient who presented in a decreased state of consciousness due to a right frontal glioblastoma, wherein his state was not improved by a successful surgery and could not be explained by any other condition. Due to his poor prognosis, we examine the benefits of receiving transcranial magnetic stimulation treatment to improve his akinetic mutism. METHODS We utilized independent component analysis with resting-state functional magnetic resonance imaging (rsfMRI) to better understand his cortical functionality. The imaging suggested absence of the default mode network (DMN). The patient underwent five sessions of navigated intermittent theta burst stimulation to the ipsilesional inferior parietal lobule and inferior frontal gyrus, with the aim of improving his default mode network functionality. RESULTS No other treatments resulted in an improvement of this patient's condition; however, 3 weeks following transcranial magnetic stimulation treatment, the patient was more alert and interactive, and his follow-up rsfMRI scan demonstrated a partially intact default mode network. CONCLUSION This case raises important questions regarding the clinical utility of transcranial magnetic stimulation to improve the connectivity of important cerebral networks and subsequent related functional recovery.
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Affiliation(s)
- Tressie M Stephens
- Department of Neurosurgery, University of Oklahoma Health Sciences Center, Oklahoma City, Japan
| | | | - Christen M O'Neal
- Department of Neurosurgery, University of Oklahoma Health Sciences Center, Oklahoma City, Japan
| | | | - Robert G Briggs
- Department of Neurosurgery, University of Oklahoma Health Sciences Center, Oklahoma City, Japan
| | - Charles Teo
- Centre for Minimally Invasive Neurosurgery, Prince of Wales Private Hospital, Sydney, NSW, Australia
| | - Michael E Sughrue
- Centre for Minimally Invasive Neurosurgery, Prince of Wales Private Hospital, Sydney, NSW, Australia
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8
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Xu C, Zou J, He F, Wen X, Li J, Gao J, Ding N, Luo B. Neural Tracking of Sound Rhythms Correlates With Diagnosis, Severity, and Prognosis of Disorders of Consciousness. Front Neurosci 2021; 15:646543. [PMID: 33994924 PMCID: PMC8113690 DOI: 10.3389/fnins.2021.646543] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2020] [Accepted: 03/19/2021] [Indexed: 12/03/2022] Open
Abstract
Effective diagnosis and prognosis of patients with disorders of consciousness (DOC) provides a basis for family counseling, decision-making, and the design of rehabilitation programs. However, effective and objective bedside evaluation is a challenging problem. In this study, we explored electroencephalography (EEG) response tracking sound rhythms as potential neural markers for DOC evaluation. We analyzed the responses to natural speech and tones modulated at 2 and 41 Hz. At the population level, patients with positive outcomes (DOC-P) showed higher cortical synchronization to modulated tones at 41 Hz compared with patients with negative outcomes (DOC-N). At the individual level, phase coherence to modulated tones at 41 Hz was significantly correlated with Coma Recovery Scale-Revised (CRS-R) and Glasgow Outcome Scale-Extended (GOS-E) scores. Furthermore, SVM classifiers, trained using phase coherences in higher frequency bands or combination of the low frequency aSSR and speech tracking responses, performed very well in diagnosis and prognosis of DOC. These findings show that EEG response to auditory rhythms is a potential tool for diagnosis, severity, and prognosis of DOC.
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Affiliation(s)
- Chuan Xu
- Department of Neurology, First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Jiajie Zou
- Key Laboratory for Biomedical Engineering of Ministry of Education, College of Biomedical Engineering and Instrument Sciences, Zhejiang University, Hangzhou, China.,Research Center for Advanced Artificial Intelligence Theory Zhejiang Lab, Hangzhou, China
| | - Fangping He
- Department of Neurology, First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Xinrui Wen
- Department of Neurology, First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Jingqi Li
- Department of Rehabilitation, Hangzhou Mingzhou Brain Rehabilitation Hospital, Hangzhou, China
| | - Jian Gao
- Department of Rehabilitation, Hangzhou Mingzhou Brain Rehabilitation Hospital, Hangzhou, China
| | - Nai Ding
- Key Laboratory for Biomedical Engineering of Ministry of Education, College of Biomedical Engineering and Instrument Sciences, Zhejiang University, Hangzhou, China.,Research Center for Advanced Artificial Intelligence Theory Zhejiang Lab, Hangzhou, China
| | - Benyan Luo
- Department of Neurology, First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
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Golaszewski SM, Wutzl B, Unterrainer AF, Florea C, Schwenker K, Frey VN, Kronbichler M, Rattay F, Nardone R, Hauer L, Sellner J, Trinka E. Functional Magnetic Resonance Imaging in the Final Stage of Creutzfeldt-Jakob Disease. Diagnostics (Basel) 2020; 10:diagnostics10050309. [PMID: 32429303 PMCID: PMC7277986 DOI: 10.3390/diagnostics10050309] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2020] [Revised: 05/06/2020] [Accepted: 05/12/2020] [Indexed: 11/16/2022] Open
Abstract
Sporadic Creutzfeldt-Jakob disease (sCJD) is a rare fatal degenerative disease of the central nervous system. The clinical course is characterized by rapid progression of neurological and neuromuscular symptoms. The late stage with loss of consciousness is not well characterized. We report a 62-year-old male patient with sCJD with the clinical picture of a vegetative state/apallic syndrome, in whom we studied cortical responses using a vibration paradigm. The functional magnetic resonance imaging (fMRI) investigation demonstrated a clear response within the sensorimotor cortex, the cerebellum, the parietal cortex, the insular, and frontal inferior region. The finding of persistent cortical activity on fMRI in a patient with CJD in a state of unconsciousness has implications for the clinical management and for ethical considerations.
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Affiliation(s)
- Stefan M. Golaszewski
- Department of Neurology, Christian Doppler Medical Center, Paracelsus Medical University, 5020 Salzburg, Austria; (B.W.); (C.F.); (K.S.); (V.N.F.); (R.N.); (J.S.); (E.T.)
- Karl Landsteiner Institute for Neurorehabilitation and Space Neurology, 5020 Salzburg, Austria
- Neuroscience Institute, Christian Doppler Medical Center, Paracelsus Medical University, 5020 Salzburg, Austria;
- Correspondence: ; Tel.: +43-(0)5-7255-34600; Fax: +43-(0)5-7255-34899
| | - Bettina Wutzl
- Department of Neurology, Christian Doppler Medical Center, Paracelsus Medical University, 5020 Salzburg, Austria; (B.W.); (C.F.); (K.S.); (V.N.F.); (R.N.); (J.S.); (E.T.)
- Karl Landsteiner Institute for Neurorehabilitation and Space Neurology, 5020 Salzburg, Austria
- Institute for Analysis and Scientific Computing, Technical University of Vienna, 1040 Vienna, Austria;
| | - Axel F. Unterrainer
- Institute of Neuroanesthesiology, Christian Doppler Medical Center, Paracelsus Medical University, 5020 Salzburg, Austria;
| | - Cristina Florea
- Department of Neurology, Christian Doppler Medical Center, Paracelsus Medical University, 5020 Salzburg, Austria; (B.W.); (C.F.); (K.S.); (V.N.F.); (R.N.); (J.S.); (E.T.)
| | - Kerstin Schwenker
- Department of Neurology, Christian Doppler Medical Center, Paracelsus Medical University, 5020 Salzburg, Austria; (B.W.); (C.F.); (K.S.); (V.N.F.); (R.N.); (J.S.); (E.T.)
- Karl Landsteiner Institute for Neurorehabilitation and Space Neurology, 5020 Salzburg, Austria
| | - Vanessa N. Frey
- Department of Neurology, Christian Doppler Medical Center, Paracelsus Medical University, 5020 Salzburg, Austria; (B.W.); (C.F.); (K.S.); (V.N.F.); (R.N.); (J.S.); (E.T.)
| | - Martin Kronbichler
- Neuroscience Institute, Christian Doppler Medical Center, Paracelsus Medical University, 5020 Salzburg, Austria;
- Centre for Cognitive Neuroscience and Department of Psychology, University of Salzburg, 5020 Salzburg, Austria
| | - Frank Rattay
- Institute for Analysis and Scientific Computing, Technical University of Vienna, 1040 Vienna, Austria;
| | - Raffaele Nardone
- Department of Neurology, Christian Doppler Medical Center, Paracelsus Medical University, 5020 Salzburg, Austria; (B.W.); (C.F.); (K.S.); (V.N.F.); (R.N.); (J.S.); (E.T.)
- Department of Neurology, Franz-Tappeiner-Hospital, 39012 Merano, Italy
| | - Larissa Hauer
- Department of Psychiatry, Psychotherapy and Psychosomatic Medicine, Christian Doppler Medical Center, Paracelsus Medical University, 5020 Salzburg, Austria;
| | - Johann Sellner
- Department of Neurology, Christian Doppler Medical Center, Paracelsus Medical University, 5020 Salzburg, Austria; (B.W.); (C.F.); (K.S.); (V.N.F.); (R.N.); (J.S.); (E.T.)
- Department of Neurology, Landesklinikum Mistelbach-Gänserndorf, 2130 Mistelbach, Austria
- Department of Neurology, Klinikum rechts der Isar, Technische Universität München, 81675 München, Germany
| | - Eugen Trinka
- Department of Neurology, Christian Doppler Medical Center, Paracelsus Medical University, 5020 Salzburg, Austria; (B.W.); (C.F.); (K.S.); (V.N.F.); (R.N.); (J.S.); (E.T.)
- Institute for Analysis and Scientific Computing, Technical University of Vienna, 1040 Vienna, Austria;
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10
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Modolo J, Hassan M, Wendling F, Benquet P. Decoding the circuitry of consciousness: From local microcircuits to brain-scale networks. Netw Neurosci 2020; 4:315-337. [PMID: 32537530 PMCID: PMC7286300 DOI: 10.1162/netn_a_00119] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2019] [Accepted: 12/09/2019] [Indexed: 01/25/2023] Open
Abstract
Identifying the physiological processes underlying the emergence and maintenance of consciousness is one of the most fundamental problems of neuroscience, with implications ranging from fundamental neuroscience to the treatment of patients with disorders of consciousness (DOCs). One major challenge is to understand how cortical circuits at drastically different spatial scales, from local networks to brain-scale networks, operate in concert to enable consciousness, and how those processes are impaired in DOC patients. In this review, we attempt to relate available neurophysiological and clinical data with existing theoretical models of consciousness, while linking the micro- and macrocircuit levels. First, we address the relationships between awareness and wakefulness on the one hand, and cortico-cortical and thalamo-cortical connectivity on the other hand. Second, we discuss the role of three main types of GABAergic interneurons in specific circuits responsible for the dynamical reorganization of functional networks. Third, we explore advances in the functional role of nested oscillations for neural synchronization and communication, emphasizing the importance of the balance between local (high-frequency) and distant (low-frequency) activity for efficient information processing. The clinical implications of these theoretical considerations are presented. We propose that such cellular-scale mechanisms could extend current theories of consciousness.
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Affiliation(s)
- Julien Modolo
- University of Rennes, INSERM, LTSI-U1099, Rennes, France
| | - Mahmoud Hassan
- University of Rennes, INSERM, LTSI-U1099, Rennes, France
| | | | - Pascal Benquet
- University of Rennes, INSERM, LTSI-U1099, Rennes, France
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11
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Rudas J, Martínez D, Castellanos G, Demertzi A, Martial C, Carriére M, Aubinet C, Soddu A, Laureys S, Gómez F. Time-Delay Latency of Resting-State Blood Oxygen Level-Dependent Signal Related to the Level of Consciousness in Patients with Severe Consciousness Impairment. Brain Connect 2020; 10:83-94. [DOI: 10.1089/brain.2019.0716] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Affiliation(s)
- Jorge Rudas
- Institute of Biotechnology, Universidad Nacional de Colombia, Bogotá, Colombia
| | - Darwin Martínez
- Department of Computer Science, Universidad Nacional de Colombia, Bogotá, Colombia
- Department of Computer Science, Universidad Central de Colombia, Bogotá, Colombia
| | - Gabriel Castellanos
- Department of Physiological Sciences, Facultad de Medicina, Pontificia Universidad Javeriana, Bogotá, Colombia
| | - Athena Demertzi
- Physiology of Cognition Research Lab, GIGA-Consciousness, GIGA Institute, University of Liege, Liège, Belgium
| | - Charlotte Martial
- Coma Science Group, GIGA Consciousness, University of Liège, Liège, Belgium
| | - Manon Carriére
- Coma Science Group, GIGA Consciousness, University of Liège, Liège, Belgium
| | - Charlène Aubinet
- Coma Science Group, GIGA Consciousness, University of Liège, Liège, Belgium
| | - Andrea Soddu
- Department of Physics and Astronomy, University of Western Ontario, London, Ontario
| | - Steven Laureys
- Coma Science Group, GIGA Consciousness, University of Liège, Liège, Belgium
| | - Francisco Gómez
- Department of Mathematics, Universidad Nacional de Colombia, Bogotá, Colombia
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12
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Kondziella D, Bender A, Diserens K, van Erp W, Estraneo A, Formisano R, Laureys S, Naccache L, Ozturk S, Rohaut B, Sitt JD, Stender J, Tiainen M, Rossetti AO, Gosseries O, Chatelle C. European Academy of Neurology guideline on the diagnosis of coma and other disorders of consciousness. Eur J Neurol 2020; 27:741-756. [PMID: 32090418 DOI: 10.1111/ene.14151] [Citation(s) in RCA: 313] [Impact Index Per Article: 78.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2019] [Accepted: 01/09/2020] [Indexed: 12/20/2022]
Abstract
BACKGROUND AND PURPOSE Patients with acquired brain injury and acute or prolonged disorders of consciousness (DoC) are challenging. Evidence to support diagnostic decisions on coma and other DoC is limited but accumulating. This guideline provides the state-of-the-art evidence regarding the diagnosis of DoC, summarizing data from bedside examination techniques, functional neuroimaging and electroencephalography (EEG). METHODS Sixteen members of the European Academy of Neurology (EAN) Scientific Panel on Coma and Chronic Disorders of Consciousness, representing 10 European countries, reviewed the scientific evidence for the evaluation of coma and other DoC using standard bibliographic measures. Recommendations followed the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system. The guideline was endorsed by the EAN. RESULTS Besides a comprehensive neurological examination, the following suggestions are made: probe for voluntary eye movements using a mirror; repeat clinical assessments in the subacute and chronic setting, using the Coma Recovery Scale - Revised; use the Full Outline of Unresponsiveness score instead of the Glasgow Coma Scale in the acute setting; obtain clinical standard EEG; search for sleep patterns on EEG, particularly rapid eye movement sleep and slow-wave sleep; and, whenever feasible, consider positron emission tomography, resting state functional magnetic resonance imaging (fMRI), active fMRI or EEG paradigms and quantitative analysis of high-density EEG to complement behavioral assessment in patients without command following at the bedside. CONCLUSIONS Standardized clinical evaluation, EEG-based techniques and functional neuroimaging should be integrated for multimodal evaluation of patients with DoC. The state of consciousness should be classified according to the highest level revealed by any of these three approaches.
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Affiliation(s)
- D Kondziella
- Department of Neurology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark.,Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark.,Department of Neurosciences, Norwegian University of Science and Technology, Trondheim, Norway
| | - A Bender
- Department of Neurology, Ludwig-Maximilians-Universität München, Munich, Germany.,Therapiezentrum Burgau, Burgau, Germany
| | - K Diserens
- Department of Clinical Neurosciences, Centre Hospitalier Universitaire Vaudois and University of Lausanne, Lausanne, Switzerland
| | - W van Erp
- Coma Science Group, GIGA Consciousness, University and University Hospital of Liège, Liège, Belgium.,Department of Primary Care, Radboud University Medical Center, Nijmegen, The Netherlands
| | - A Estraneo
- Neurology Unit, Santa Maria della Pietà General Hospital, Nola, Italy.,IRCCS Fondazione don Carlo Gnocchi ONLUS, Florence, Italy
| | - R Formisano
- Post-Coma Unit, Neurorehabilitation Hospital and Research Institution, Santa Lucia Foundation, Rome, Italy
| | - S Laureys
- Coma Science Group, GIGA Consciousness, University and University Hospital of Liège, Liège, Belgium
| | - L Naccache
- Department of Neurology, AP-HP, Groupe hospitalier Pitié-Salpêtrière, Paris, France.,Sorbonne Université, UPMC Univ Paris 06, Faculté de Médecine Pitié-Salpêtrière, Paris, France
| | - S Ozturk
- Department of Neurology, Faculty of Medicine, Selcuk University, Konya, Turkey
| | - B Rohaut
- Department of Neurology, AP-HP, Groupe hospitalier Pitié-Salpêtrière, Paris, France.,Sorbonne Université, UPMC Univ Paris 06, Faculté de Médecine Pitié-Salpêtrière, Paris, France.,Neuro-ICU, Department of Neurology, Columbia University, New York, NY, USA
| | - J D Sitt
- Sorbonne Université, UPMC Univ Paris 06, Faculté de Médecine Pitié-Salpêtrière, Paris, France
| | - J Stender
- Department of Neurosurgery, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - M Tiainen
- Department of Neurology, Helsinki University Hospital, Helsinki, Finland
| | - A O Rossetti
- Department of Clinical Neurosciences, Centre Hospitalier Universitaire Vaudois and University of Lausanne, Lausanne, Switzerland
| | - O Gosseries
- Coma Science Group, GIGA Consciousness, University and University Hospital of Liège, Liège, Belgium
| | - C Chatelle
- Coma Science Group, GIGA Consciousness, University and University Hospital of Liège, Liège, Belgium.,Laboratory for NeuroImaging of Coma and Consciousness - Department of Neurology, Harvard Medical School, Massachusetts General Hospital, Boston, MA, USA
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13
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Prefrontal neural dynamics in consciousness. Neuropsychologia 2019; 131:25-41. [DOI: 10.1016/j.neuropsychologia.2019.05.018] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2018] [Revised: 05/17/2019] [Accepted: 05/20/2019] [Indexed: 12/11/2022]
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14
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Marino S, Bonanno L, Ciurleo R, Baglieri A, Morabito R, Guerrera S, Rifici C, Giorgio A, Bramanti P, De Stefano N. Functional Evaluation of Awareness in Vegetative and Minimally Conscious State. Open Neuroimag J 2017; 11:17-25. [PMID: 28553427 PMCID: PMC5427708 DOI: 10.2174/1874440001711010017] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2017] [Revised: 01/31/2017] [Accepted: 03/21/2017] [Indexed: 11/30/2022] Open
Abstract
Objective: The aim of this study was to assess differences in brain activation in a large sample of Vegetative State (VS) and Minimally Conscious State (MCS) patients, using functional magnetic resonance imaging (fMRI). Methods: We studied 50 patients four to seven months after brain injury. By using international clinical criteria and validated behavioural scales such as the Glasgow Coma Scale and the Clinical Unawareness Assessment Scale, the patients were grouped into VS (n=23) and MCS (n=27). All patients underwent to fMRI examination. After 6 months, the patients were reassessed using Glasgow Outcome Scale and Revised Coma Recovery Scale. Results: fMRI showed significant (p<0.01, cluster-corrected) brain activation in the primary auditory cortex bilaterally during the acoustic stimuli in patients with both VS and MCS. However, ten patients clinically classified as VS, showed a pattern of brain activation very similar to that of MCS patients. Six months later, these ten VS patients had significant clinical improvement, evolving into MCS, whereas the other VS patients and patients with MCS remained clinically stable. Conclusion: Brain activity could help in discerning whether the status of wakefulness in VS is also accompanied by partial awareness, as occurs in MCS. This may have very important prognostic implications.
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Affiliation(s)
- Silvia Marino
- IRCCS Centro Neurolesi "Bonino Pulejo", Messina, Italy.,Department of Biomedical and Dental Sciences and Morphofunctional Imaging, University of Messina, Italy
| | - Lilla Bonanno
- IRCCS Centro Neurolesi "Bonino Pulejo", Messina, Italy
| | | | | | - Rosa Morabito
- IRCCS Centro Neurolesi "Bonino Pulejo", Messina, Italy
| | | | | | - Antonio Giorgio
- UOSA Experimental Neurology, Dept. of Medicine, Surgery & Neuroscience, University of Siena, Italy
| | | | - Nicola De Stefano
- UOSA Experimental Neurology, Dept. of Medicine, Surgery & Neuroscience, University of Siena, Italy
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15
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Numan T, Slooter AJC, van der Kooi AW, Hoekman AML, Suyker WJL, Stam CJ, van Dellen E. Functional connectivity and network analysis during hypoactive delirium and recovery from anesthesia. Clin Neurophysiol 2017; 128:914-924. [PMID: 28402867 DOI: 10.1016/j.clinph.2017.02.022] [Citation(s) in RCA: 68] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2016] [Revised: 02/08/2017] [Accepted: 02/25/2017] [Indexed: 01/02/2023]
Abstract
OBJECTIVE To gain insight in the underlying mechanism of reduced levels of consciousness due to hypoactive delirium versus recovery from anesthesia, we studied functional connectivity and network topology using electroencephalography (EEG). METHODS EEG recordings were performed in age and sex-matched patients with hypoactive delirium (n=18), patients recovering from anesthesia (n=20), and non-delirious control patients (n=20), all after cardiac surgery. Functional and directed connectivity were studied with phase lag index and directed phase transfer entropy. Network topology was characterized using the minimum spanning tree (MST). A random forest classifier was calculated based on all measures to obtain discriminative ability between the three groups. RESULTS Non-delirious control subjects showed a back-to-front information flow, which was lost during hypoactive delirium (p=0.01) and recovery from anesthesia (p<0.01). The recovery from anesthesia group had more integrated network in the delta band compared to non-delirious controls. In contrast, hypoactive delirium showed a less integrated network in the alpha band. High accuracy for discrimination between hypoactive delirious patients and controls (86%) and recovery from anesthesia and controls (95%) were found. Accuracy for discrimination between hypoactive delirium and recovery from anesthesia was 73%. CONCLUSION Loss of functional and directed connectivity were observed in both hypoactive delirium and recovery from anesthesia, which might be related to the reduced level of consciousness in both states. These states could be distinguished in topology, which was a less integrated network during hypoactive delirium. SIGNIFICANCE Functional and directed connectivity are similarly disturbed during a reduced level of consciousness due to hypoactive delirium and sedatives, however topology was differently affected.
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Affiliation(s)
- Tianne Numan
- Department of Intensive Care Medicine, Brain Center Rudolf Magnus, University Medical Center Utrecht, Heidelberglaan 100, Utrecht, The Netherlands.
| | - Arjen J C Slooter
- Department of Intensive Care Medicine, Brain Center Rudolf Magnus, University Medical Center Utrecht, Heidelberglaan 100, Utrecht, The Netherlands
| | - Arendina W van der Kooi
- Department of Intensive Care Medicine, Brain Center Rudolf Magnus, University Medical Center Utrecht, Heidelberglaan 100, Utrecht, The Netherlands
| | - Annemieke M L Hoekman
- Department of Intensive Care Medicine, Brain Center Rudolf Magnus, University Medical Center Utrecht, Heidelberglaan 100, Utrecht, The Netherlands
| | - Willem J L Suyker
- Department of Cardiothoracic Surgery, University Medical Center Utrecht, Heidelberglaan 100, The Netherlands
| | - Cornelis J Stam
- Department of Clinical Neurophysiology and MEG Center, Neuroscience Campus Amsterdam, VU University Medical Center, De Boelelaan 1085, Amsterdam, The Netherlands
| | - Edwin van Dellen
- Department of Psychiatry, Brain Center Rudolf Magnus, University Medical Center Utrecht, Heidelberglaan 100, Utrecht, The Netherlands
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