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Barra ME, Solt K, Yu X, Edlow BL. Restoring consciousness with pharmacologic therapy: Mechanisms, targets, and future directions. Neurotherapeutics 2024:e00374. [PMID: 39019729 DOI: 10.1016/j.neurot.2024.e00374] [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: 12/01/2023] [Revised: 04/16/2024] [Accepted: 05/03/2024] [Indexed: 07/19/2024] Open
Abstract
Severe brain injury impairs consciousness by disrupting a broad spectrum of neurotransmitter systems. Emerging evidence suggests that pharmacologic modulation of specific neurotransmitter systems, such as dopamine, promotes recovery of consciousness. Clinical guidelines now endorse the use of amantadine in individuals with traumatic disorders of consciousness (DoC) based on level 1 evidence, and multiple neurostimulants are used off-label in clinical practice, including methylphenidate, modafinil, bromocriptine, levodopa, and zolpidem. However, the relative contributions of monoaminergic, glutamatergic, cholinergic, GABAergic, and orexinergic neurotransmitter systems to recovery of consciousness after severe brain injury are unknown, and personalized approaches to targeted therapy have yet to be developed. This review summarizes the state-of-the-science in the neurochemistry and neurobiology of neurotransmitter systems involved in conscious behaviors, followed by a discussion of how pharmacologic therapies may be used to modulate these neurotransmitter systems and promote recovery of consciousness. We consider pharmacologic modulation of consciousness at the synapse, circuit, and network levels, with a focus on the mesocircuit model that has been proposed to explain the consciousness-promoting effects of various monoaminergic, glutamatergic, and paradoxically, GABAergic therapies. Though fundamental questions remain about neurotransmitter mechanisms, target engagement and optimal therapy selection for individual patients, we propose that pharmacologic therapies hold great promise to promote recovery and improve quality of life for patients with severe brain injuries.
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Affiliation(s)
- Megan E Barra
- Department of Pharmacy, Massachusetts General Hospital, Boston, MA, USA; Center for Neurotechnology and Neurorecovery, Massachusetts General Hospital, Boston, MA, USA
| | - Ken Solt
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Xin Yu
- Department of Radiology, Athinoula A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital, Boston, MA, USA
| | - Brian L Edlow
- Center for Neurotechnology and Neurorecovery, Massachusetts General Hospital, Boston, MA, USA; Department of Radiology, Athinoula A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital, Boston, MA, USA; Department of Neurology, Massachusetts General Hospital, Boston, MA, USA.
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2
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Secci S, Liuzzi P, Hakiki B, Burali R, Draghi F, Romoli AM, di Palma A, Scarpino M, Grippo A, Cecchi F, Frosini A, Mannini A. Low-density EEG-based Functional Connectivity Discriminates Minimally Conscious State plus from minus. Clin Neurophysiol 2024; 163:197-208. [PMID: 38761713 DOI: 10.1016/j.clinph.2024.04.021] [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: 05/04/2023] [Revised: 04/03/2024] [Accepted: 04/18/2024] [Indexed: 05/20/2024]
Abstract
OBJECTIVE Within the continuum of consciousness, patients in a Minimally Conscious State (MCS) may exhibit high-level behavioral responses (MCS+) or may not (MCS-). The evaluation of residual consciousness and related classification is crucial to propose tailored rehabilitation and pharmacological treatments, considering the inherent differences among groups in diagnosis and prognosis. Currently, differential diagnosis relies on behavioral assessments posing a relevant risk of misdiagnosis. In this context, EEG offers a non-invasive approach to model the brain as a complex network. The search for discriminating features could reveal whether behavioral responses in post-comatose patients have a defined physiological background. Additionally, it is essential to determine whether the standard behavioral assessment for quantifying responsiveness holds physiological significance. METHODS In this prospective observational study, we investigated whether low-density EEG-based graph metrics could discriminate MCS+/- patients by enrolling 57 MCS patients (MCS-: 30; males: 28). At admission to intensive rehabilitation, 30 min resting-state closed-eyes EEG recordings were performed together with consciousness diagnosis following international guidelines. After EEG preprocessing, graphs' metrics were estimated using different connectivity measures, at multiple connection densities and frequency bands (α,θ,δ). Metrics were also provided to cross-validated Machine Learning (ML) models with outcome MCS+/-. RESULTS A lower level of brain activity integration was found in the MCS- group in the α band. Instead, in the δ band MCS- group presented an higher level of clustering (weighted clustering coefficient) respect to MCS+. The best-performing solution in discriminating MCS+/- through the use of ML was an Elastic-Net regularized logistic regression with a cross-validation accuracy of 79% (sensitivity and specificity of 74% and 85% respectively). CONCLUSION Despite tackling the MCS+/- differential diagnosis is highly challenging, a daily-routine low-density EEG might allow to differentiate across these differently responsive brain networks. SIGNIFICANCE Graph-theoretical features are shown to discriminate between these two neurophysiologically similar conditions, and may thus support the clinical diagnosis.
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Affiliation(s)
- Sara Secci
- IRCCS Fondazione Don Carlo Gnocchi, via di Scandicci 269, Firenze, FI, Italy
| | - Piergiuseppe Liuzzi
- IRCCS Fondazione Don Carlo Gnocchi, via di Scandicci 269, Firenze, FI, Italy; Scuola Superiore Sant'Anna, BioRobotics Institute, Viale Rinaldo Piaggio 34, Pontedera, PI, Italy
| | - Bahia Hakiki
- IRCCS Fondazione Don Carlo Gnocchi, via di Scandicci 269, Firenze, FI, Italy; Dipartimento di Medicina Sperimentale e Clinica, Largo Brambilla 3, FI, Italy.
| | - Rachele Burali
- IRCCS Fondazione Don Carlo Gnocchi, via di Scandicci 269, Firenze, FI, Italy
| | - Francesca Draghi
- IRCCS Fondazione Don Carlo Gnocchi, via di Scandicci 269, Firenze, FI, Italy
| | - Anna Maria Romoli
- IRCCS Fondazione Don Carlo Gnocchi, via di Scandicci 269, Firenze, FI, Italy
| | - Azzurra di Palma
- Dipartimento di Matematica e Informatica, Università di Firenze, Viale Morgagni 65, FI, Italy
| | - Maenia Scarpino
- IRCCS Fondazione Don Carlo Gnocchi, via di Scandicci 269, Firenze, FI, Italy
| | - Antonello Grippo
- IRCCS Fondazione Don Carlo Gnocchi, via di Scandicci 269, Firenze, FI, Italy
| | - Francesca Cecchi
- IRCCS Fondazione Don Carlo Gnocchi, via di Scandicci 269, Firenze, FI, Italy; Dipartimento di Medicina Sperimentale e Clinica, Largo Brambilla 3, FI, Italy
| | - Andrea Frosini
- Dipartimento di Matematica e Informatica, Università di Firenze, Viale Morgagni 65, FI, Italy
| | - Andrea Mannini
- IRCCS Fondazione Don Carlo Gnocchi, via di Scandicci 269, Firenze, FI, Italy
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Ordóñez-Rubiano EG, Castañeda-Duarte MA, Baeza-Antón L, Romo-Quebradas JA, Perilla-Estrada JP, Perilla-Cepeda TA, Enciso-Olivera CO, Rudas J, Marín-Muñoz JH, Pulido C, Gómez F, Martínez D, Zorro O, Garzón E, Patiño-Gómez JG. Resting state networks in patients with acute disorders of consciousness after severe traumatic brain injury. Clin Neurol Neurosurg 2024; 242:108353. [PMID: 38830290 DOI: 10.1016/j.clineuro.2024.108353] [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: 05/20/2024] [Accepted: 05/22/2024] [Indexed: 06/05/2024]
Abstract
OBJECTIVES This study aims to describe resting state networks (RSN) in patients with disorders of consciousness (DOC)s after acute severe traumatic brain injury (TBI). METHODS Adult patients with TBI with a GCS score <8 who remained in a coma, minimally conscious state (MCS), or unresponsive wakefulness syndrome (UWS), between 2017 and 2020 were included. Blood-oxygen-level dependent imaging was performed to compare their RSN with 10 healthy volunteers. RESULTS Of a total of 293 patients evaluated, only 13 patients were included according to inclusion criteria: 7 in coma (54%), 2 in MCS (15%), and 4 (31%) had an UWS. RSN analysis showed that the default mode network (DMN) was present and symmetric in 6 patients (46%), absent in 1 (8%), and asymmetric in 6 (46%). The executive control network (ECN) was present in all patients but was asymmetric in 3 (23%). The right ECN was absent in 2 patients (15%) and the left ECN in 1 (7%). The medial visual network was present in 11 (85%) patients. Finally, the cerebellar network was symmetric in 8 patients (62%), asymmetric in 1 (8%), and absent in 4 (30%). CONCLUSIONS A substantial impairment in activation of RSN is demonstrated in patients with DOC after severe TBI in comparison with healthy subjects. Three patterns of activation were found: normal/complete activation, 2) asymmetric activation or partially absent, and 3) absent activation.
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Affiliation(s)
- Edgar G Ordóñez-Rubiano
- Department of Neurosurgery, Hospital Universitario Fundación Santa Fe de Bogotá, Bogotá, Colombia; Department of Neurosurgery, Hospital de San José, Fundación Universitaria de Ciencias de la Salud (FUCS), Bogotá, Colombia
| | - Marcelo A Castañeda-Duarte
- Department of Neurosurgery, Hospital de San José, Fundación Universitaria de Ciencias de la Salud (FUCS), Bogotá, Colombia; Department of Neurosurgery, Hospital Infantil Universitario de San José, Fundación Universitaria de Ciencias de la Salud (FUCS), Bogotá, Colombia
| | - Laura Baeza-Antón
- Department of Neurological Surgery, Weill Cornell Medicine/NewYork-Presbyterian Hospital, New York, NY, USA.
| | - Jorge A Romo-Quebradas
- Department of Neurosurgery, Hospital de San José, Fundación Universitaria de Ciencias de la Salud (FUCS), Bogotá, Colombia; Department of Neurosurgery, Hospital Infantil Universitario de San José, Fundación Universitaria de Ciencias de la Salud (FUCS), Bogotá, Colombia
| | - Juan P Perilla-Estrada
- Department of Neurosurgery, Hospital de San José, Fundación Universitaria de Ciencias de la Salud (FUCS), Bogotá, Colombia; Department of Neurosurgery, Hospital Infantil Universitario de San José, Fundación Universitaria de Ciencias de la Salud (FUCS), Bogotá, Colombia
| | - Tito A Perilla-Cepeda
- Department of Neurosurgery, Hospital Infantil Universitario de San José, Fundación Universitaria de Ciencias de la Salud (FUCS), Bogotá, Colombia
| | - Cesar O Enciso-Olivera
- Department of Critical Care and Intensive Care Unit, Fundación Universitaria de Ciencias de la Salud (FUCS), Hospital Infantil Universitario de San José, Bogotá, Colombia
| | - Jorge Rudas
- Department of Biotechnology, Universidad Nacional de Colombia, Bogotá, Colombia
| | - Jorge H Marín-Muñoz
- Department of Radiology, Fundación Universitaria de Ciencias de la Salud (FUCS), Hospital Infantil Universitario de San José, Bogotá, Colombia; Innovation and Research Division, Imaging Experts and Healthcare Services (ImexHS), Bogotá, Colombia
| | - Cristian Pulido
- Department of Mathematics, Universidad Nacional de Colombia, Bogotá, Colombia
| | - Francisco Gómez
- Department of Computer Science, Universidad Nacional de Colombia, Bogotá, Colombia
| | - Darwin Martínez
- Department of Computer Science, Universidad Sergio Arboleda, Bogotá, Colombia
| | - Oscar Zorro
- Department of Neurosurgery, Hospital de San José, Fundación Universitaria de Ciencias de la Salud (FUCS), Bogotá, Colombia
| | - Emilio Garzón
- Department of Neurosurgery, Hospital de San José, Fundación Universitaria de Ciencias de la Salud (FUCS), Bogotá, Colombia
| | - Javier G Patiño-Gómez
- Department of Neurosurgery, Hospital de San José, Fundación Universitaria de Ciencias de la Salud (FUCS), Bogotá, Colombia
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Gonçalves ÓF, Sayal J, Lisboa F, Palhares P. The experimental study of consciousness: Is psychology travelling back to the future? Int J Clin Health Psychol 2024; 24:100475. [PMID: 39021679 PMCID: PMC11253270 DOI: 10.1016/j.ijchp.2024.100475] [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: 12/01/2023] [Accepted: 05/29/2024] [Indexed: 07/20/2024] Open
Abstract
It was with the promise of rendering an experimental approach to consciousness that psychology started its trajectory as an independent science more than 150 years ago. Here, we will posit that the neurosciences were instrumental in leading psychology to resume the study of consciousness by projecting an empirical agenda for the future. First, we will start by showing how scientists were able to venture into the consciousness of supposedly unconscious patients, opening the door for the identification of important neural correlates of distinct consciousness states. Then, we will describe how different technological advances and elegant experimental paradigms helped in establishing important neuronal correlates of global consciousness (i.e., being conscious at all), perceptual consciousness (i.e., being conscious of something), and self-consciousness (i.e., being conscious of itself). Finally, we will illustrate how the study of complex consciousness experiences may contribute to the clarification of the mechanisms associated with global consciousness, the relationship between perceptual and self-consciousness, and the interface among distinct self-consciousness domains. In closing, we will elaborate on the road ahead of us for re-establishing psychology as a science of consciousness.
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Affiliation(s)
| | - Joana Sayal
- Proaction Lab – CINEICC, Faculty of Psychology and Educational Sciences, University of Coimbra, Colégio de Jesus, R. Inácio Duarte 65, Coimbra 3000-481, Portugal
| | - Fábio Lisboa
- Proaction Lab – CINEICC, Faculty of Psychology and Educational Sciences, University of Coimbra, Colégio de Jesus, R. Inácio Duarte 65, Coimbra 3000-481, Portugal
| | - Pedro Palhares
- Proaction Lab – CINEICC, Faculty of Psychology and Educational Sciences, University of Coimbra, Colégio de Jesus, R. Inácio Duarte 65, Coimbra 3000-481, Portugal
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Hansen MJ. Modelling developments in consciousness within a multidimensional framework. Neurosci Conscious 2024; 2024:niae026. [PMID: 38895541 PMCID: PMC11184344 DOI: 10.1093/nc/niae026] [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: 08/10/2023] [Revised: 01/17/2024] [Accepted: 06/03/2024] [Indexed: 06/21/2024] Open
Abstract
A recent advancement in consciousness science has been the introduction of a multidimensional framework of consciousness. This framework has been applied to global states of consciousness, including psychedelic states and disorders of consciousness, and the consciousness of non-human animals. The multidimensional framework enables a finer parsing of both various states of consciousness and forms of animal consciousness, paving the way for new scientific investigations into consciousness. In this paper, the multidimensional model is expanded by constructing temporal profiles. This expansion allows for the modelling of changes in consciousness across the life cycles of organisms and the progression over time of disorders of consciousness. The result of this expansion is 2-fold: (i) it enables new modes of comparison, both across stages of development and across species; (ii) it proposes that more attention be given to the various types of fluctuations that occur in patients who are suffering from disorders of consciousness.
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Affiliation(s)
- Mads Jørgensen Hansen
- Department of Philosophy and History of Ideas, School of Culture and Society, Aarhus University, Aarhus 8000, Denmark
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Mahajan C, Prabhakar H, Rass V, McNett M, Kapoor I, Helbok R, Zirpe K. A National Survey on Coma Epidemiology, Evaluation, and Therapy in India: Revisiting the Curing Coma Campaign Come Together Survey. Neurocrit Care 2024; 40:941-952. [PMID: 37821721 DOI: 10.1007/s12028-023-01852-9] [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: 04/20/2023] [Accepted: 08/31/2023] [Indexed: 10/13/2023]
Abstract
BACKGROUND The limited representation from developing countries in the original COME TOGETHER survey gave us an impetus to conduct this survey in the Indian subcontinent. METHODS This cross-sectional online survey was conducted from August through September 2022. Participants were health care physicians caring for patients with coma and disorders of consciousness. Fischer's exact test or the Mann-Whitney U-test was used to compare respondents who agreed or disagreed with the preestablished coma definition. Fleiss κ values were calculated to assess agreement among respondents. A p value less than 0.05 was considered statistically significant. RESULTS The survey was completed by 130 physicians. We found substantial interrater agreement on absence of wakefulness (71.54%; κ = 0.71), Glasgow Coma Score ≤ 8 (78.46%; κ = 0.78), and failure to respond purposefully to visual, verbal, or tactile stimuli (66.15%; κ = 0.66). Reported common etiologies of coma included traumatic brain injury (50.76%), ischemic stroke (30%), and intracerebral hemorrhage (29.23%). The most common clinical assessment tools used for coma included the Glasgow Coma Score (92.3%) and neurological examination (60.8%). Neurological examination was the most common diagnostic tool used (100%), followed by magnetic resonance imaging (89.2%), basic laboratory studies (88.5%), and head computed tomography/angiography (86.9%). Pharmacological interventions used to stimulate arousal in patients with coma were sedation vacation (91.5%), electrolyte/endocrine correction (65.4%), osmotic therapy with mannitol (60%), hypertonic saline (54.6%), modafinil (46.9%), and antidote for drugs (45.4%). Among the nonpharmacological interventions, sensory stimulation (57.7%) was the most commonly used modality. The most common discharge disposition for comatose patients who survived hospitalization were home with or without services (70.0%). CONCLUSIONS Differences from the global survey were noted regarding the following: traumatic brain injury being the most common etiology of coma in India, more frequent practice of sedation interruption, less frequent use of electroencephalography in India, rare use of pharmacological neurostimulants, and home being the most common discharge disposition in India.
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Affiliation(s)
- Charu Mahajan
- Department of Neuroanaesthesiology and Critical Care, All India Institute of Medical Sciences, New Delhi, 110029, India
| | - Hemanshu Prabhakar
- Department of Neuroanaesthesiology and Critical Care, All India Institute of Medical Sciences, New Delhi, 110029, India.
| | - Verena Rass
- Neuro-Intensive Care Unit, Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - Molly McNett
- College of Nursing, The Ohio State University, Columbus, OH, USA
| | - Indu Kapoor
- Department of Neuroanaesthesiology and Critical Care, All India Institute of Medical Sciences, New Delhi, 110029, India
| | - Raimund Helbok
- Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
- Department of Neurology, Johannes Kepler University Linz, Linz, Austria
| | - Kapil Zirpe
- Neurotrauma Unit, Ruby Hall Clinic, Pune, Maharashtra, India
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Yakhkind A, Niznick N, Bodien YG, Hammond FM, Katz D, Luaute J, McNett M, Naccache L, O'Brien K, Schnakers C, Sharshar T, Slomine BS, Giacino JT. Common Data Elements for Disorders of Consciousness: Recommendations from the Working Group on Behavioral Phenotyping. Neurocrit Care 2024; 40:909-917. [PMID: 37726548 DOI: 10.1007/s12028-023-01844-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2023] [Accepted: 07/26/2023] [Indexed: 09/21/2023]
Abstract
BACKGROUND The recent publication of practice guidelines for management of patients with disorders of consciousness (DoC) in the United States and Europe was a major step forward in improving the accuracy and consistency of terminology, diagnostic criteria, and prognostication in this population. There remains a pressing need for a more precise brain injury classification system that combines clinical semiology with neuroimaging, electrophysiologic, and other biomarker data. To address this need, the National Institute of Neurological Disorders and Stroke launched the Common Data Elements (CDEs) initiative to facilitate systematic collection of high-quality research data in studies involving patients with neurological disease. The Neurocritical Care Society's Curing Coma Campaign expanded this effort in 2018 to develop CDEs for DoC. Herein, we present CDE recommendations for behavioral phenotyping of patients with DoC. METHODS The Behavioral Phenotyping Workgroup used a preestablished, five-step process to identify and select candidate CDEs that included review of existing National Institute of Neurological Disorders and Stroke CDEs, nomination and systematic vetting of new CDEs, CDE classification, iterative review, and approval of panel recommendations and development of corresponding case review forms. RESULTS We identified a slate of existing and newly proposed basic, supplemental, and exploratory CDEs that can be used for behavioral phenotyping of adult and pediatric patients with DoC. CONCLUSIONS The proposed behavioral phenotyping CDEs will assist with international harmonization of DoC studies and allow for more precise characterization of study cohorts, favorably impacting observational studies and clinical trials aimed at improving outcome in this population.
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Affiliation(s)
- Aleksandra Yakhkind
- Department of Neurology, Tufts University School of Medicine, Boston, MA, USA
| | - Naomi Niznick
- Department of Medicine (Critical Care), The Ottawa Hospital, Ottawa, Canada
| | - Yelena G Bodien
- Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Charlestown, MA, USA
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Flora M Hammond
- Department of Physical Medicine and Rehabilitation, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Douglas Katz
- Department of Neurology, Boston University Chobanian & Avedisian School of Medicine, and Brain Injury Program, Encompass Health Braintree Rehabilitation Hospital, Braintree, MA, USA
| | - Jacques Luaute
- Department of Neuro-Rehabilitation, Hospices Civils de Lyon, Université Claude Bernard Lyon 1, Lyon, France
| | - Molly McNett
- College of Nursing, The Ohio State University, Columbus, OH, USA
| | - Lionel Naccache
- Sorbonne Université, Paris Brain Institute - Institut du Cerveau, ICM, INSERM, CNRS, AP-HP, Pitié-Salpêtrière Hospital, Paris, France
| | - Katherine O'Brien
- TIRR Disorders of Consciousness Program, TIRR Memorial Hermann Hospital, H. Ben Taub Department of Physical Medicine and Rehabilitation, Baylor College of Medicine, Houston, TX, USA
| | - Caroline Schnakers
- Research Institute, Casa Colina Hospital and Centers for Healthcare, Pomona, CA, USA
| | - Tarek Sharshar
- Neurosciences, Pole Neuro, Sainte-Anne Hospital, Institute of Psychiatry and Neurosciences of Paris, INSERM U1266, Université Paris Cité, Paris, France
| | - Beth S Slomine
- Department of Neuropsychology, Kennedy Krieger Institute, Baltimore, MD, USA
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Joseph T Giacino
- Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Charlestown, MA, USA.
- Department of Physical Medicine and Rehabilitation, Harvard Medical School, Boston, MA, USA.
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Young MJ, Kazazian K, Fischer D, Lissak IA, Bodien YG, Edlow BL. Disclosing Results of Tests for Covert Consciousness: A Framework for Ethical Translation. Neurocrit Care 2024; 40:865-878. [PMID: 38243150 PMCID: PMC11147696 DOI: 10.1007/s12028-023-01899-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Accepted: 11/22/2023] [Indexed: 01/21/2024]
Abstract
The advent of neurotechnologies including advanced functional magnetic resonance imaging and electroencephalography to detect states of awareness not detectable by traditional bedside neurobehavioral techniques (i.e., covert consciousness) promises to transform neuroscience research and clinical practice for patients with brain injury. As these interventions progress from research tools into actionable, guideline-endorsed clinical tests, ethical guidance for clinicians on how to responsibly communicate the sensitive results they yield is crucial yet remains underdeveloped. Drawing on insights from empirical and theoretical neuroethics research and our clinical experience with advanced neurotechnologies to detect consciousness in behaviorally unresponsive patients, we critically evaluate ethical promises and perils associated with disclosing the results of clinical covert consciousness assessments and describe a semistructured approach to responsible data sharing to mitigate potential risks.
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Affiliation(s)
- Michael J Young
- Center for Neurotechnology and Neurorecovery, Department of Neurology, Massachusetts General Hospital and Harvard Medical School, 101 Merrimac Street, Suite 310, Boston, MA, 02114, USA.
| | - Karnig Kazazian
- Center for Neurotechnology and Neurorecovery, Department of Neurology, Massachusetts General Hospital and Harvard Medical School, 101 Merrimac Street, Suite 310, Boston, MA, 02114, USA
- Western Institute of Neuroscience, Western University, London, ON, Canada
| | - David Fischer
- University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - India A Lissak
- Center for Neurotechnology and Neurorecovery, Department of Neurology, Massachusetts General Hospital and Harvard Medical School, 101 Merrimac Street, Suite 310, Boston, MA, 02114, USA
| | - Yelena G Bodien
- Center for Neurotechnology and Neurorecovery, Department of Neurology, Massachusetts General Hospital and Harvard Medical School, 101 Merrimac Street, Suite 310, Boston, MA, 02114, USA
| | - Brian L Edlow
- Center for Neurotechnology and Neurorecovery, Department of Neurology, Massachusetts General Hospital and Harvard Medical School, 101 Merrimac Street, Suite 310, Boston, MA, 02114, USA
- Athinoula A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital and Harvard Medical School, Charlestown, MA, USA
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9
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Edlow BL, Claassen J, Suarez JI. Common data elements for disorders of consciousness. Neurocrit Care 2024; 40:715-717. [PMID: 38291278 DOI: 10.1007/s12028-023-01931-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2024]
Affiliation(s)
- Brian L Edlow
- Center for Neurotechnology and Neurorecovery, Department of Neurology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA.
- Athinoula A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital, Charlestown, MA, USA.
| | - Jan Claassen
- Department of Neurology, Columbia University Medical Center, New York, NY, USA
- NewYork-Presbyterian Hospital, New York, NY, USA
| | - Jose I Suarez
- Division of Neurosciences Critical Care, Departments of Neurology, Neurosurgery, and Anesthesiology and Critical Care Medicine, The Johns Hopkins University and The Johns Hopkins Hospital, Baltimore, MD, USA
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10
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Fischer D, Edlow BL. Coma Prognostication After Acute Brain Injury: A Review. JAMA Neurol 2024:2815829. [PMID: 38436946 DOI: 10.1001/jamaneurol.2023.5634] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/05/2024]
Abstract
Importance Among the most impactful neurologic assessments is that of neuroprognostication, defined here as the prediction of neurologic recovery from disorders of consciousness caused by severe, acute brain injury. Across a range of brain injury etiologies, these determinations often dictate whether life-sustaining treatment is continued or withdrawn; thus, they have major implications for morbidity, mortality, and health care costs. Neuroprognostication relies on a diverse array of tests, including behavioral, radiologic, physiological, and serologic markers, that evaluate the brain's functional and structural integrity. Observations Prognostic markers, such as the neurologic examination, electroencephalography, and conventional computed tomography and magnetic resonance imaging (MRI), have been foundational in assessing a patient's current level of consciousness and capacity for recovery. Emerging techniques, such as functional MRI, diffusion MRI, and advanced forms of electroencephalography, provide new ways of evaluating the brain, leading to evolving schemes for characterizing neurologic function and novel methods for predicting recovery. Conclusions and Relevance Neuroprognostic markers are rapidly evolving as new ways of assessing the brain's structural and functional integrity after brain injury are discovered. Many of these techniques remain in development, and further research is needed to optimize their prognostic utility. However, even as such efforts are underway, a series of promising findings coupled with the imperfect predictive value of conventional prognostic markers and the high stakes of these assessments have prompted clinical guidelines to endorse emerging techniques for neuroprognostication. Thus, clinicians have been thrust into an uncertain predicament in which emerging techniques are not yet perfected but too promising to ignore. This review illustrates the current, and likely future, landscapes of prognostic markers. No matter how much prognostic markers evolve and improve, these assessments must be approached with humility and individualized to reflect each patient's values.
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Affiliation(s)
- David Fischer
- Division of Neurocritical Care, Department of Neurology, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Brian L Edlow
- Center for Neurotechnology and Neurorecovery, Department of Neurology, Massachusetts General Hospital and Harvard Medical School, Boston
- Athinoula A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital and Harvard Medical School, Charlestown
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Young MJ, Fecchio M, Bodien YG, Edlow BL. Covert cortical processing: a diagnosis in search of a definition. Neurosci Conscious 2024; 2024:niad026. [PMID: 38327828 PMCID: PMC10849751 DOI: 10.1093/nc/niad026] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2023] [Revised: 10/22/2023] [Accepted: 12/10/2023] [Indexed: 02/09/2024] Open
Abstract
Historically, clinical evaluation of unresponsive patients following brain injury has relied principally on serial behavioral examination to search for emerging signs of consciousness and track recovery. Advances in neuroimaging and electrophysiologic techniques now enable clinicians to peer into residual brain functions even in the absence of overt behavioral signs. These advances have expanded clinicians' ability to sub-stratify behaviorally unresponsive and seemingly unaware patients following brain injury by querying and classifying covert brain activity made evident through active or passive neuroimaging or electrophysiologic techniques, including functional MRI, electroencephalography (EEG), transcranial magnetic stimulation-EEG, and positron emission tomography. Clinical research has thus reciprocally influenced clinical practice, giving rise to new diagnostic categories including cognitive-motor dissociation (i.e. 'covert consciousness') and covert cortical processing (CCP). While covert consciousness has received extensive attention and study, CCP is relatively less understood. We describe that CCP is an emerging and clinically relevant state of consciousness marked by the presence of intact association cortex responses to environmental stimuli in the absence of behavioral evidence of stimulus processing. CCP is not a monotonic state but rather encapsulates a spectrum of possible association cortex responses from rudimentary to complex and to a range of possible stimuli. In constructing a roadmap for this evolving field, we emphasize that efforts to inform clinicians, philosophers, and researchers of this condition are crucial. Along with strategies to sensitize diagnostic criteria and disorders of consciousness nosology to these vital discoveries, democratizing access to the resources necessary for clinical identification of CCP is an emerging clinical and ethical imperative.
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Affiliation(s)
- Michael J Young
- Center for Neurotechnology and Neurorecovery, Department of Neurology, Massachusetts General Hospital and Harvard Medical School, 101 Merrimac Street, Suite 310, Boston, MA 02114, USA
| | - Matteo Fecchio
- Center for Neurotechnology and Neurorecovery, Department of Neurology, Massachusetts General Hospital and Harvard Medical School, 101 Merrimac Street, Suite 310, Boston, MA 02114, USA
| | - Yelena G Bodien
- Center for Neurotechnology and Neurorecovery, Department of Neurology, Massachusetts General Hospital and Harvard Medical School, 101 Merrimac Street, Suite 310, Boston, MA 02114, USA
- Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Harvard Medical School, 300 1st Ave, Charlestown, Boston, MA 02129, USA
| | - Brian L Edlow
- Center for Neurotechnology and Neurorecovery, Department of Neurology, Massachusetts General Hospital and Harvard Medical School, 101 Merrimac Street, Suite 310, Boston, MA 02114, USA
- Athinoula A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital and Harvard Medical School, 149 13th St, Charlestown, Charlestown, MA 02129, USA
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12
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Marino MH. Pharmacology in Treatment of Patients with Disorders of Consciousness. Phys Med Rehabil Clin N Am 2024; 35:155-165. [PMID: 37993186 DOI: 10.1016/j.pmr.2023.06.023] [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] [Indexed: 11/24/2023]
Abstract
Pharmacologic treatment of disorders of consciousness remains a critical but challenging task for clinicians. Amantadine has been shown to promote the rate of neurologic recovery for patients with traumatic disorders of consciousness when administered between 4 and 16 weeks, as demonstrated by a well-designed randomized control trial. While there are no large, randomized controlled trials to support the use of other dopaminergic medicines (bromocriptine, levodopa, apomorphine), there is a large body of literature implicating their role in improving alertness and responsiveness in disorders of consciousness. Zolpidem can increase the level of consciousness in a small subset of patients. Zolpidem and intrathecal baclofen likely increase the level of consciousness via the mesocircuit pathway. Psychostimulant medications can be initiated in patients, even without strong evidence to support their use, as long as basic principles of brain injury medicine are followed, and there are systems in place to evaluate therapeutic response.
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Affiliation(s)
- Michael H Marino
- Moss Rehab, 60 Township Line Road, Elkins Park, PA 19027, USA; Remed Residential Brain Injury Center.
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13
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Tinti L, Lawson T, Molteni E, Kondziella D, Rass V, Sharshar T, Bodien YG, Giacino JT, Mayer SA, Amiri M, Muehlschlegel S, Venkatasubba Rao CP, Vespa PM, Menon DK, Citerio G, Helbok R, McNett M. Research considerations for prospective studies of patients with coma and disorders of consciousness. Brain Commun 2024; 6:fcae022. [PMID: 38344653 PMCID: PMC10853976 DOI: 10.1093/braincomms/fcae022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Revised: 01/04/2024] [Accepted: 01/26/2024] [Indexed: 03/02/2024] Open
Abstract
Disorders of consciousness are neurological conditions characterized by impaired arousal and awareness of self and environment. Behavioural responses are absent or are present but fluctuate. Disorders of consciousness are commonly encountered as a consequence of both acute and chronic brain injuries, yet reliable epidemiological estimates would require inclusive, operational definitions of the concept, as well as wider knowledge dissemination among involved professionals. Whereas several manifestations have been described, including coma, vegetative state/unresponsive wakefulness syndrome and minimally conscious state, a comprehensive neurobiological definition for disorders of consciousness is still lacking. The scientific literature is primarily observational, and studies-specific aetiologies lead to disorders of consciousness. Despite advances in these disease-related forms, there remains uncertainty about whether disorders of consciousness are a disease-agnostic unitary entity with a common mechanism, prognosis or treatment response paradigm. Our knowledge of disorders of consciousness has also been hampered by heterogeneity of study designs, variables, and outcomes, leading to results that are not comparable for evidence synthesis. The different backgrounds of professionals caring for patients with disorders of consciousness and the different goals at different stages of care could partly explain this variability. The Prospective Studies working group of the Neurocritical Care Society Curing Coma Campaign was established to create a platform for observational studies and future clinical trials on disorders of consciousness and coma across the continuum of care. In this narrative review, the author panel presents limitations of prior observational clinical research and outlines practical considerations for future investigations. A narrative review format was selected to ensure that the full breadth of study design considerations could be addressed and to facilitate a future consensus-based statement (e.g. via a modified Delphi) and series of recommendations. The panel convened weekly online meetings from October 2021 to December 2022. Research considerations addressed the nosographic status of disorders of consciousness, case ascertainment and verification, selection of dependent variables, choice of covariates and measurement and analysis of outcomes and covariates, aiming to promote more homogeneous designs and practices in future observational studies. The goal of this review is to inform a broad community of professionals with different backgrounds and clinical interests to address the methodological challenges imposed by the transition of care from acute to chronic stages and to streamline data gathering for patients with disorders of consciousness. A coordinated effort will be a key to allow reliable observational data synthesis and epidemiological estimates and ultimately inform condition-modifying clinical trials.
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Affiliation(s)
- Lorenzo Tinti
- Department of Neuroscience, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Milan 20156, Italy
| | - Thomas Lawson
- Critical Care, The Ohio State University Wexner Medical Center, Columbus, OH 43210, USA
| | - Erika Molteni
- Biomedical Engineering Department, School of Biomedical Engineering and Imaging Sciences, King’s College London, London SE1 7EU, UK
| | - Daniel Kondziella
- Department of Neurology, Rigshospitalet, Copenhagen University Hospital, Copenhagen 2100, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen 2200, Denmark
| | - Verena Rass
- Department of Neurology, Neuro-Intensive Care Unit, Medical University of Innsbruck, Innsbruck 6020, Austria
| | - Tarek Sharshar
- Neuro-Intensive Care Medicine, Anaesthesiology and ICU Department, GHU-Psychiatry and Neurosciences, Pole Neuro, Sainte-Anne Hospital, Institute of Psychiatry and Neurosciences of Paris, INSERM U1266, Université Paris Cité, Paris 75006, France
| | - Yelena G Bodien
- Department of Neurology, Harvard Medical School, Massachusetts General Hospital, Boston, MA 02114, USA
- Department of Physical Medicine and Rehabilitation, Harvard Medical School, Spaulding Rehabilitation Hospital, Charlestown, MA 02129, USA
| | - Joseph T Giacino
- Department of Physical Medicine and Rehabilitation, Harvard Medical School, Spaulding Rehabilitation Hospital, Charlestown, MA 02129, USA
| | - Stephan A Mayer
- Department of Neurology, New York Medical College, Valhalla, NY 10595, USA
- Department of Neurosurgery, New York Medical College, Valhalla, NY 10595, USA
| | - Moshgan Amiri
- Department of Neurology, Rigshospitalet, Copenhagen University Hospital, Copenhagen 2100, Denmark
| | - Susanne Muehlschlegel
- Department of Neurology and Anesthesiology/Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA
| | - Chethan P Venkatasubba Rao
- Division of Vascular Neurology and Neurocritical Care, Baylor College of Medicine and CHI Baylor St Luke’s Medical Center, Houston, TX 77030, USA
| | - Paul M Vespa
- Department of Neurology, David Geffen School of Medicine at UCLA, Los Angeles, CA 90095, USA
- Department of Neurosurgery, David Geffen School of Medicine at UCLA, Los Angeles, CA 90095, USA
| | - David K Menon
- Division of Anaesthesia, University of Cambridge, Cambridge CB2 1TN, UK
| | - Giuseppe Citerio
- NeuroIntensive Care, IRCSS Fondazione San Gerardo dei Tintori, Monza 20900, Italy
- School of Medicine and Surgery, Università Milano Bicocca, Milan 20854, Italy
| | - Raimund Helbok
- Department of Neurology, Neuro-Intensive Care Unit, Medical University of Innsbruck, Innsbruck 6020, Austria
- Department of Neurology, Johannes Kepler University, Linz 4040, Austria
| | - Molly McNett
- College of Nursing, The Ohio State University, Columbus, OH 43210, USA
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14
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Othman MH, Møller K, Kjaergaard J, Kondziella D. Detecting signatures of consciousness in acute brain injury after stimulation with apomorphine and methylphenidate: protocol for a placebo-controlled, randomized, cross-over study. BMJ Neurol Open 2024; 6:e000584. [PMID: 38268756 PMCID: PMC10806905 DOI: 10.1136/bmjno-2023-000584] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2023] [Accepted: 12/04/2023] [Indexed: 01/26/2024] Open
Abstract
Introduction Acute brain injury can lead to states of decreased consciousness, that is, disorder of consciousness (DoC). Detecting signs of consciousness early is vital for DoC management in the intensive care unit (ICU), neurorehabilitation and long-term prognosis. Our primary objective is to investigate the potential of pharmacological stimulant therapies in eliciting signs of consciousness among unresponsive or low-responsive acute DoC patients. Methods In a placebo-controlled, randomised, cross-over setting, we evaluate the effect of methylphenidate and apomorphine in 50 DoC patients with acute traumatic or non-traumatic brain injury admitted to the ICU. Patients are examined before and after administration of the trial drugs using (1) neurobehavioural scales to determine the clinical level of consciousness, (2) automated pupillometry to record pupillary responses as a signature for awareness and (3) near-infrared spectroscopy combined with electroencephalography to record neurovascular coupling as a measure for cortical activity. Primary outcomes include pupillary dilations and increase in cortical activity during passive and active paradigms. Ethics The study has been approved by the ethics committee (Journal-nr: H-21022096) and follows the principles of the Declaration of Helsinki. It is deemed to pose minimal risks and to hold a significant potential to improve treatment options for DoC patients. If the stimulants are shown to enhance cortical modulation of pupillary function and neurovascular coupling, this would warrant a large multicentre trial to evaluate their clinical impact. Dissemination Results will be available on EudraCT, clinicaltrialsregister.eu and published in an international peer-reviewed journal. Trial registration number EudraCT Number: 2021-001453-31.
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Affiliation(s)
- Marwan H Othman
- Department of Neurology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Kirsten Møller
- Department of Neuroanesthesiology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Jesper Kjaergaard
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
- Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Daniel Kondziella
- Department of Neurology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
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15
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Abstract
Covert consciousness is a state of residual awareness following severe brain injury or neurological disorder that evades routine bedside behavioral detection. Patients with covert consciousness have preserved awareness but are incapable of self-expression through ordinary means of behavior or communication. Growing recognition of the limitations of bedside neurobehavioral examination in reliably detecting consciousness, along with advances in neurotechnologies capable of detecting brain states or subtle signs indicative of consciousness not discernible by routine examination, carry promise to transform approaches to classifying, diagnosing, prognosticating and treating disorders of consciousness. Here we describe and critically evaluate the evolving clinical category of covert consciousness, including approaches to its diagnosis through neuroimaging, electrophysiology, and novel behavioral tools, its prognostic relevance, and open questions pertaining to optimal clinical management of patients with covert consciousness recovering from severe brain injury.
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Affiliation(s)
- Michael J. Young
- Department of Neurology, Center for Neurotechnology and Neurorecovery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Brian L. Edlow
- Department of Neurology, Center for Neurotechnology and Neurorecovery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
- Athinoula A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital, Charlestown, MA, USA
| | - Yelena G. Bodien
- Department of Neurology, Center for Neurotechnology and Neurorecovery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
- Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Harvard Medical School, Boston, MA, USA
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16
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Edlow BL, Boerwinkle VL, Annen J, Boly M, Gosseries O, Laureys S, Mukherjee P, Puybasset L, Stevens RD, Threlkeld ZD, Newcombe VFJ, Fernandez-Espejo D. Common Data Elements for Disorders of Consciousness: Recommendations from the Working Group on Neuroimaging. Neurocrit Care 2023; 39:611-617. [PMID: 37552410 DOI: 10.1007/s12028-023-01794-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2023] [Accepted: 06/22/2023] [Indexed: 08/09/2023]
Abstract
BACKGROUND Over the past 5 decades, advances in neuroimaging have yielded insights into the pathophysiologic mechanisms that cause disorders of consciousness (DoC) in patients with severe brain injuries. Structural, functional, metabolic, and perfusion imaging studies have revealed specific neuroanatomic regions, such as the brainstem tegmentum, thalamus, posterior cingulate cortex, medial prefrontal cortex, and occipital cortex, where lesions correlate with the current or future state of consciousness. Advanced imaging modalities, such as diffusion tensor imaging, resting-state functional magnetic resonance imaging (fMRI), and task-based fMRI, have been used to improve the accuracy of diagnosis and long-term prognosis, culminating in the endorsement of fMRI for the clinical evaluation of patients with DoC in the 2018 US (task-based fMRI) and 2020 European (task-based and resting-state fMRI) guidelines. As diverse neuroimaging techniques are increasingly used for patients with DoC in research and clinical settings, the need for a standardized approach to reporting results is clear. The success of future multicenter collaborations and international trials fundamentally depends on the implementation of a shared nomenclature and infrastructure. METHODS To address this need, the Neurocritical Care Society's Curing Coma Campaign convened an international panel of DoC neuroimaging experts to propose common data elements (CDEs) for data collection and reporting in this field. RESULTS We report the recommendations of this CDE development panel and disseminate CDEs to be used in neuroimaging studies of patients with DoC. CONCLUSIONS These CDEs will support progress in the field of DoC neuroimaging and facilitate international collaboration.
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Affiliation(s)
- Brian L Edlow
- Center for Neurotechnology and Neurorecovery, Department of Neurology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA.
- Athinoula A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital, Charlestown, MA, USA.
| | - Varina L Boerwinkle
- Clinical Resting-State Functional Magnetic Resonance Imaging Laboratory and Service, Department of Neurology, University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | - Jitka Annen
- Coma Science Group, GIGA Consciousness, University of Liège, Liège, Belgium
- Centre de Cerveau2, University Hospital of Liège, Liège, Belgium
| | - Melanie Boly
- Department of Neurology, University of Wisconsin, Madison, WI, USA
- Department of Psychiatry, Wisconsin Institute for Sleep and Consciousness, University of Wisconsin, Madison, WI, USA
| | - Olivia Gosseries
- Coma Science Group, GIGA Consciousness, University of Liège, Liège, Belgium
- Centre de Cerveau2, University Hospital of Liège, Liège, Belgium
| | - Steven Laureys
- Coma Science Group, GIGA Consciousness, University of Liège, Liège, Belgium
- Centre de Cerveau2, University Hospital of Liège, Liège, Belgium
- CERVO Research Institute, Laval University, Quebec, Canada
| | - Pratik Mukherjee
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, San Francisco, CA, USA
| | - Louis Puybasset
- Department of Anesthesiology and Intensive Care, Groupe Hospitalier Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Robert D Stevens
- Departments of Anesthesiology and Critical Care Medicine, Neurology, Radiology, and Biomedical Engineering, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Zachary D Threlkeld
- Department of Neurology, Stanford University School of Medicine, Stanford, CA, USA
| | | | - Davinia Fernandez-Espejo
- School of Psychology and Centre for Human Brain Health, University of Birmingham, Birmingham, UK
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17
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Kolisnyk M, Kazazian K, Rego K, Novi SL, Wild CJ, Gofton TE, Debicki DB, Owen AM, Norton L. Predicting neurologic recovery after severe acute brain injury using resting-state networks. J Neurol 2023; 270:6071-6080. [PMID: 37665382 DOI: 10.1007/s00415-023-11941-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2023] [Revised: 08/13/2023] [Accepted: 08/14/2023] [Indexed: 09/05/2023]
Abstract
OBJECTIVE There is a lack of reliable tools used to predict functional recovery in unresponsive patients following a severe brain injury. The objective of the study is to evaluate the prognostic utility of resting-state functional magnetic resonance imaging for predicting good neurologic recovery in unresponsive patients with severe brain injury in the intensive-care unit. METHODS Each patient underwent a 5.5-min resting-state scan and ten resting-state networks were extracted via independent component analysis. The Glasgow Outcome Scale was used to classify patients into good and poor outcome groups. The Nearest Centroid classifier used each patient's ten resting-state network values to predict best neurologic outcome within 6 months post-injury. RESULTS Of the 25 patients enrolled (mean age = 43.68, range = [19-69]; GCS ≤ 9; 6 females), 10 had good and 15 had poor outcome. The classifier correctly and confidently predicted 8/10 patients with good and 12/15 patients with poor outcome (mean = 0.793, CI = [0.700, 0.886], Z = 2.843, p = 0.002). The prediction performance was largely determined by three visual (medial: Z = 3.11, p = 0.002; occipital pole: Z = 2.44, p = 0.015; lateral: Z = 2.85, p = 0.004) and the left frontoparietal network (Z = 2.179, p = 0.029). DISCUSSION Our approach correctly identified good functional outcome with higher sensitivity (80%) than traditional prognostic measures. By revealing preserved networks in the absence of discernible behavioral signs, functional connectivity may aid in the prognostic process and affect the outcome of discussions surrounding withdrawal of life-sustaining measures.
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Affiliation(s)
- Matthew Kolisnyk
- Western Institute of Neuroscience, Western Interdisciplinary Research Building, Western University, 1151 Richmond Street, London, ON, N6A 3K7, Canada
| | - Karnig Kazazian
- Western Institute of Neuroscience, Western Interdisciplinary Research Building, Western University, 1151 Richmond Street, London, ON, N6A 3K7, Canada.
| | - Karina Rego
- Temerty Faculty of Medicine, University of Toronto, Toronto, Canada
| | - Sergio L Novi
- Western Institute of Neuroscience, Western Interdisciplinary Research Building, Western University, 1151 Richmond Street, London, ON, N6A 3K7, Canada
- Department of Physiology and Pharmacology, Schulich School of Medicine and Dentistry, Western University, London, Canada
| | - Conor J Wild
- Western Institute of Neuroscience, Western Interdisciplinary Research Building, Western University, 1151 Richmond Street, London, ON, N6A 3K7, Canada
| | - Teneille E Gofton
- Department of Clinical Neurological Sciences, Schulich School of Medicine and Dentistry, Western University, London, Canada
| | - Derek B Debicki
- Department of Clinical Neurological Sciences, Schulich School of Medicine and Dentistry, Western University, London, Canada
| | - Adrian M Owen
- Western Institute of Neuroscience, Western Interdisciplinary Research Building, Western University, 1151 Richmond Street, London, ON, N6A 3K7, Canada
- Department of Physiology and Pharmacology, Schulich School of Medicine and Dentistry, Western University, London, Canada
- Department of Psychology, Western University, London, Canada
| | - Loretta Norton
- Western Institute of Neuroscience, Western Interdisciplinary Research Building, Western University, 1151 Richmond Street, London, ON, N6A 3K7, Canada
- Department of Psychology, King's University College at Western University, London, Canada
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18
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Liuzzi P, Mannini A, Hakiki B, Campagnini S, Romoli AM, Draghi F, Burali R, Scarpino M, Cecchi F, Grippo A. Brain microstate spatio-temporal dynamics as a candidate endotype of consciousness. Neuroimage Clin 2023; 41:103540. [PMID: 38101096 PMCID: PMC10727951 DOI: 10.1016/j.nicl.2023.103540] [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: 05/18/2023] [Revised: 10/02/2023] [Accepted: 11/09/2023] [Indexed: 12/17/2023]
Abstract
Consciousness can be defined as a phenomenological experience continuously evolving. Current research showed how conscious mental activity can be subdivided into a series of atomic brain states converging to a discrete spatiotemporal pattern of global neuronal firing. Using the high temporal resolution of EEG recordings in patients with a severe Acquired Brain Injury (sABI) admitted to an Intensive Rehabilitation Unit (IRU), we detected a novel endotype of consciousness from the spatiotemporal brain dynamics identified via microstate analysis. Also, we investigated whether microstate features were associated with common neurophysiological alterations. Finally, the prognostic information comprised in such descriptors was analysed in a sub-cohort of patients with prolonged Disorder of Consciousness (pDoC). Occurrence of frontally-oriented microstates (C microstate), likelihood of maintaining such brain state or transitioning to the C topography and complexity were found to be indicators of consciousness presence and levels. Features of left-right asymmetric microstates and transitions toward them were found to be negatively correlated with antero-posterior brain reorganization and EEG symmetry. Substantial differences in microstates' sequence complexity and presence of C topography were found between groups of patients with alpha dominant background, cortical reactivity and antero-posterior gradient. Also, transitioning from left-right to antero-posterior microstates was found to be an independent predictor of consciousness recovery, stronger than consciousness levels at IRU's admission. In conclusions, global brain dynamics measured with scale-free estimators can be considered an indicator of consciousness presence and a candidate marker of short-term recovery in patients with a pDoC.
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Affiliation(s)
- Piergiuseppe Liuzzi
- IRCCS Don Carlo Gnocchi ONLUS, Firenze, Italy; Istituto di BioRobotica, Scuola Superiore Sant'Anna, Pontedera, Italy
| | | | | | | | | | | | | | | | - Francesca Cecchi
- IRCCS Don Carlo Gnocchi ONLUS, Firenze, Italy; Dipartimento di Medicina Sperimentale e Clinica, Università di Firenze, Firenze, Italy
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19
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Franzova E, Shen Q, Doyle K, Chen JM, Egbebike J, Vrosgou A, Carmona JC, Grobois L, Heinonen GA, Velazquez A, Gonzales IJ, Egawa S, Agarwal S, Roh D, Park S, Connolly ES, Claassen J. Injury patterns associated with cognitive motor dissociation. Brain 2023; 146:4645-4658. [PMID: 37574216 PMCID: PMC10629765 DOI: 10.1093/brain/awad197] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Revised: 04/14/2023] [Accepted: 05/28/2023] [Indexed: 08/15/2023] Open
Abstract
In unconscious appearing patients with acute brain injury, wilful brain activation to motor commands without behavioural signs of command following, known as cognitive motor dissociation (CMD), is associated with functional recovery. CMD can be detected by applying machine learning to EEG recorded during motor command presentation in behaviourally unresponsive patients. Identifying patients with CMD carries clinical implications for patient interactions, communication with families, and guidance of therapeutic decisions but underlying mechanisms of CMD remain unknown. By analysing structural lesion patterns and network level dysfunction we tested the hypothesis that, in cases with preserved arousal and command comprehension, a failure to integrate comprehended motor commands with motor outputs underlies CMD. Manual segmentation of T2-fluid attenuated inversion recovery and diffusion weighted imaging sequences quantifying structural injury was performed in consecutive unresponsive patients with acute brain injury (n = 107) who underwent EEG-based CMD assessments and MRI. Lesion pattern analysis was applied to identify lesion patterns common among patients with (n = 21) and without CMD (n = 86). Thalamocortical and cortico-cortical network connectivity were assessed applying ABCD classification of power spectral density plots and weighted pairwise phase consistency (WPPC) to resting EEG, respectively. Two distinct structural lesion patterns were identified on MRI for CMD and three for non-CMD patients. In non-CMD patients, injury to brainstem arousal pathways including the midbrain were seen, while no CMD patients had midbrain lesions. A group of non-CMD patients was identified with injury to the left thalamus, implicating possible language comprehension difficulties. Shared lesion patterns of globus pallidus and putamen were seen for a group of CMD patients, which have been implicated as part of the anterior forebrain mesocircuit in patients with reversible disorders of consciousness. Thalamocortical network dysfunction was less common in CMD patients [ABCD-index 2.3 (interquartile range, IQR 2.1-3.0) versus 1.4 (IQR 1.0-2.0), P < 0.0001; presence of D 36% versus 3%, P = 0.0006], but WPPC was not different. Bilateral cortical lesions were seen in patients with and without CMD. Thalamocortical disruption did not differ for those with CMD, but long-range WPPC was decreased in 1-4 Hz [odds ratio (OR) 0.8; 95% confidence interval (CI) 0.7-0.9] and increased in 14-30 Hz frequency ranges (OR 1.2; 95% CI 1.0-1.5). These structural and functional data implicate a failure of motor command integration at the anterior forebrain mesocircuit level with preserved thalamocortical network function for CMD patients with subcortical lesions. Amongst patients with bilateral cortical lesions preserved cortico-cortical network function is associated with CMD detection. These data may allow screening for CMD based on widely available structural MRI and resting EEG.
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Affiliation(s)
- Eva Franzova
- Department of Neurology, Columbia University Medical Center, NewYork-Presbyterian Hospital, New York, NY, USA
| | - Qi Shen
- Department of Neurology, Columbia University Medical Center, NewYork-Presbyterian Hospital, New York, NY, USA
| | - Kevin Doyle
- Department of Neurology, Columbia University Medical Center, NewYork-Presbyterian Hospital, New York, NY, USA
| | - Justine M Chen
- Department of Neurology, Columbia University Medical Center, NewYork-Presbyterian Hospital, New York, NY, USA
| | - Jennifer Egbebike
- Department of Neurology, Columbia University Medical Center, NewYork-Presbyterian Hospital, New York, NY, USA
| | - Athina Vrosgou
- Department of Neurology, Columbia University Medical Center, NewYork-Presbyterian Hospital, New York, NY, USA
| | - Jerina C Carmona
- Department of Neurology, Columbia University Medical Center, NewYork-Presbyterian Hospital, New York, NY, USA
| | - Lauren Grobois
- Department of Neurology, Columbia University Medical Center, NewYork-Presbyterian Hospital, New York, NY, USA
| | - Gregory A Heinonen
- Department of Neurology, Columbia University Medical Center, NewYork-Presbyterian Hospital, New York, NY, USA
| | - Angela Velazquez
- Department of Neurology, Columbia University Medical Center, NewYork-Presbyterian Hospital, New York, NY, USA
| | | | - Satoshi Egawa
- Department of Neurology, Columbia University Medical Center, NewYork-Presbyterian Hospital, New York, NY, USA
| | - Sachin Agarwal
- Department of Neurology, Columbia University Medical Center, NewYork-Presbyterian Hospital, New York, NY, USA
| | - David Roh
- Department of Neurology, Columbia University Medical Center, NewYork-Presbyterian Hospital, New York, NY, USA
| | - Soojin Park
- Department of Neurology, Columbia University Medical Center, NewYork-Presbyterian Hospital, New York, NY, USA
| | - E Sander Connolly
- Department of Neurological Surgery, Columbia University Medical Center, NewYork-Presbyterian Hospital, New York, NY, USA
| | - Jan Claassen
- Department of Neurology, Columbia University Medical Center, NewYork-Presbyterian Hospital, New York, NY, USA
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Lewis A, Kirschen MP. Potential Threats and Impediments to the Clinical Practice of Brain Death Determination: The UDDA Revision Series. Neurology 2023; 101:270-279. [PMID: 37429711 PMCID: PMC10424838 DOI: 10.1212/wnl.0000000000207404] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2022] [Accepted: 03/28/2023] [Indexed: 07/12/2023] Open
Abstract
The Uniform Determination of Death Act (UDDA) revision series in Neurology® originated in response to the plan of the Uniform Law Commission to create a revised Uniform Determination of Death Act (rUDDA) to address contemporary controversies associated with brain death/death by neurologic criteria (BD/DNC) determination. This article contextualizes these, and other, controversies and reviews the extent to which they represent potential threats and impediments to the clinical practice of BD/DNC determination. It also explains the reasons that our rapidly evolving understanding of the brain's ability to recover from injury should not influence the clinical practice of BD/DNC determination. Finally, it explores the myriad ways in which the American Academy of Neurology has addressed potential threats and impediments to the clinical practice of BD/DNC determination and the implications potential changes to the UDDA may have on the future of the clinical practice of BD/DNC determination.
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Affiliation(s)
- Ariane Lewis
- From the NYU Langone Medical Center (A.L.), New York, NY; and The Children's Hospital of Philadelphia (M.P.K.), Philadelphia, PA.
| | - Matthew P Kirschen
- From the NYU Langone Medical Center (A.L.), New York, NY; and The Children's Hospital of Philadelphia (M.P.K.), Philadelphia, PA
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21
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Chang CWJ, Provencio JJ, Pascual J, Heavner MS, Olson D, Livesay SL, Kaplan LJ. State-of-the-Art Evaluation of Acute Adult Disorders of Consciousness for the General Intensivist. Crit Care Med 2023; 51:948-963. [PMID: 37070819 DOI: 10.1097/ccm.0000000000005893] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/19/2023]
Abstract
OBJECTIVES To provide a concise review of knowledge and practice pertaining to the diagnosis and initial management of unanticipated adult patient disorders of consciousness (DoC) by the general intensivist. DATA SOURCES Detailed search strategy using PubMed and OVID Medline for English language articles describing adult patient acute DoC diagnostic evaluation and initial management strategies including indications for transfer. STUDY SELECTION Descriptive and interventional studies that address acute adult DoC, their evaluation and initial management, indications for transfer, as well as outcome prognostication. DATA EXTRACTION Relevant descriptions or studies were reviewed, and the following aspects of each manuscript were identified, abstracted, and analyzed: setting, study population, aims, methods, results, and relevant implications for adult critical care practice. DATA SYNTHESIS Acute adult DoC may be categorized by etiology including structural, functional, infectious, inflammatory, and pharmacologic, the understanding of which drives diagnostic investigation, monitoring, acute therapy, and subsequent specialist care decisions including team-based local care as well as intra- and inter-facility transfer. CONCLUSIONS Acute adult DoC may be initially comprehensively addressed by the general intensivist using an etiology-driven and team-based approach. Certain clinical conditions, procedural expertise needs, or resource limitations inform transfer decision-making within a complex care facility or to one with greater complexity. Emerging collaborative science helps improve our current knowledge of acute DoC to better align therapies with underpinning etiologies.
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Affiliation(s)
| | | | - Jose Pascual
- Division of Trauma, Surgical Critical Care and Emergency Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Mojdeh S Heavner
- Department of Practice, Sciences, and Health Outcomes Research, University of Maryland School of Pharmacy, Baltimore, MD
| | - DaiWai Olson
- Departments of Neurology and Neurosurgery, University of Texas Southwestern, Dallas, TX
| | - Sarah L Livesay
- Department of Adult Health and Gerontological Nursing, College of Nursing, Rush University, Chicago, IL
| | - Lewis J Kaplan
- Division of Trauma, Surgical Critical Care and Emergency Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
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22
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Egawa S, Ader J, Shen Q, Nakagawa S, Fujimoto Y, Fujii S, Masuda K, Shirota A, Ota M, Yoshino Y, Amai H, Miyao S, Nakamoto H, Kuroda Y, Doyle K, Grobois L, Vrosgou A, Carmona JC, Velazquez A, Ghoshal S, Roh D, Agarwal S, Park S, Claassen J. Long-Term Outcomes of Patients with Stroke Predicted by Clinicians to have no Chance of Meaningful Recovery: A Japanese Cohort Study. Neurocrit Care 2023; 38:733-740. [PMID: 36450972 PMCID: PMC10227183 DOI: 10.1007/s12028-022-01644-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2022] [Accepted: 11/08/2022] [Indexed: 12/03/2022]
Abstract
BACKGROUND Little is known about the natural history of comatose patients with brain injury, as in many countries most of these patients die in the context of withdrawal of life-sustaining therapies (WLSTs). The accuracy of predicting recovery that is used to guide goals-of-care decisions is uncertain. We examined long-term outcomes of patients with ischemic or hemorrhagic stroke predicted by experienced clinicians to have no chance of meaningful recovery in Japan, where WLST in patients with isolated neurological disease is uncommon. METHODS We retrospectively reviewed the medical records of all patients admitted with acute ischemic stroke, intracerebral hemorrhage, or nontraumatic subarachnoid hemorrhage between January 2018 and December 2020 to a neurocritical care unit at Toda Medical Group Asaka Medical Center in Saitama, Japan. We screened for patients who were predicted by the attending physician on postinjury day 1-4 to have no chance of meaningful recovery. Primary outcome measures were disposition at hospital discharge and the ability to follow commands and functional outcomes measured by the Glasgow Outcome Scale-Extended (GOS-E), which was assessed 6 months after injury. RESULTS From 860 screened patients, we identified 40 patients (14 with acute ischemic stroke, 19 with intracerebral hemorrhage, and 7 with subarachnoid hemorrhage) who were predicted to have no chance of meaningful recovery. Median age was 77 years (interquartile range 64-85), 53% (n = 21) were women, and 80% (n = 32) had no functional deficits prior to hospitalization. Six months after injury, 17 patients were dead, 14 lived in a long-term care hospital, 3 lived at home, 2 lived in a rehabilitation center, and 2 lived in a nursing home. Three patients reliably followed commands, two were in a vegetative state (GOS-E 2), four fully depended on others and required constant assistance (GOS-E 3), one could be left alone independently for 8 h per day but remained dependent (GOS-E 4), and one was independent and able to return to work-like activities (GOS-E 5). CONCLUSIONS In the absence of WLST, almost half of the patients predicted shortly after the injury to have no chance of meaningful recovery were dead 6 months after the injury. A small minority of patients had good functional recovery, highlighting the need for more accurate neurological prognostication.
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Affiliation(s)
- Satoshi Egawa
- Department of Neurology, Columbia University Medical Center, New York-Presbyterian Hospital, 177 Fort Washington Avenue, MHB 8 Center, Room 300, New York, NY, 10032, USA
- Department of Neurointensive Care, Toda Medical Group Asaka Medical Center, Saitama, Japan
- Department of Neurosurgery, Stroke and Epilepsy Center, Toda Medical Group Asaka Medical Center, Saitama, Japan
| | - Jeremy Ader
- Department of Neurology, Columbia University Medical Center, New York-Presbyterian Hospital, 177 Fort Washington Avenue, MHB 8 Center, Room 300, New York, NY, 10032, USA
| | - Qi Shen
- Department of Neurology, Columbia University Medical Center, New York-Presbyterian Hospital, 177 Fort Washington Avenue, MHB 8 Center, Room 300, New York, NY, 10032, USA
| | - Shun Nakagawa
- Department of Neurointensive Care, Toda Medical Group Asaka Medical Center, Saitama, Japan
| | - Yoshihisa Fujimoto
- Department of Neurointensive Care, Toda Medical Group Asaka Medical Center, Saitama, Japan
| | - Shuichi Fujii
- Department of Neurointensive Care, Toda Medical Group Asaka Medical Center, Saitama, Japan
| | - Kenta Masuda
- Department of Rehabilitation, Toda Medical Group Asaka Medical Center, Saitama, Japan
| | - Akira Shirota
- Department of Rehabilitation, Toda Medical Group Asaka Medical Center, Saitama, Japan
| | - Masafumi Ota
- Department of Rehabilitation, Toda Medical Group Asaka Medical Center, Saitama, Japan
| | - Yuji Yoshino
- Department of Rehabilitation, Toda Medical Group Asaka Medical Center, Saitama, Japan
| | - Hitomi Amai
- Department of Social Work, Toda Medical Group Asaka Medical Center, Saitama, Japan
| | - Satoru Miyao
- Department of Neurosurgery, Stroke and Epilepsy Center, Toda Medical Group Asaka Medical Center, Saitama, Japan
| | - Hidetoshi Nakamoto
- Department of Neurosurgery, Stroke and Epilepsy Center, Toda Medical Group Asaka Medical Center, Saitama, Japan
| | - Yasuhiro Kuroda
- Emergency Medical Center, Kagawa University Hospital, Kagawa, Japan
| | - Kevin Doyle
- Department of Neurology, Columbia University Medical Center, New York-Presbyterian Hospital, 177 Fort Washington Avenue, MHB 8 Center, Room 300, New York, NY, 10032, USA
| | - Lauren Grobois
- Department of Neurology, Columbia University Medical Center, New York-Presbyterian Hospital, 177 Fort Washington Avenue, MHB 8 Center, Room 300, New York, NY, 10032, USA
| | - Athina Vrosgou
- Department of Neurology, Columbia University Medical Center, New York-Presbyterian Hospital, 177 Fort Washington Avenue, MHB 8 Center, Room 300, New York, NY, 10032, USA
| | - Jerina C Carmona
- Department of Neurology, Columbia University Medical Center, New York-Presbyterian Hospital, 177 Fort Washington Avenue, MHB 8 Center, Room 300, New York, NY, 10032, USA
| | - Angela Velazquez
- Department of Neurology, Columbia University Medical Center, New York-Presbyterian Hospital, 177 Fort Washington Avenue, MHB 8 Center, Room 300, New York, NY, 10032, USA
| | - Shivani Ghoshal
- Department of Neurology, Columbia University Medical Center, New York-Presbyterian Hospital, 177 Fort Washington Avenue, MHB 8 Center, Room 300, New York, NY, 10032, USA
| | - David Roh
- Department of Neurology, Columbia University Medical Center, New York-Presbyterian Hospital, 177 Fort Washington Avenue, MHB 8 Center, Room 300, New York, NY, 10032, USA
| | - Sachin Agarwal
- Department of Neurology, Columbia University Medical Center, New York-Presbyterian Hospital, 177 Fort Washington Avenue, MHB 8 Center, Room 300, New York, NY, 10032, USA
| | - Soojin Park
- Department of Neurology, Columbia University Medical Center, New York-Presbyterian Hospital, 177 Fort Washington Avenue, MHB 8 Center, Room 300, New York, NY, 10032, USA
- Department of Biomedical Informatics, Columbia University Medical Center, New York-Presbyterian Hospital, New York, NY, USA
| | - Jan Claassen
- Department of Neurology, Columbia University Medical Center, New York-Presbyterian Hospital, 177 Fort Washington Avenue, MHB 8 Center, Room 300, New York, NY, 10032, USA.
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Kumar A, Ridha M, Claassen J. Prognosis of consciousness disorders in the intensive care unit. Presse Med 2023; 52:104180. [PMID: 37805070 PMCID: PMC10995112 DOI: 10.1016/j.lpm.2023.104180] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2023] [Accepted: 10/03/2023] [Indexed: 10/09/2023] Open
Abstract
Assessments of consciousness are a critical part of prognostic algorithms for critically ill patients suffering from severe brain injuries. There have been significant advances in the field of coma science over the past two decades, providing clinicians with more advanced and precise tools for diagnosing and prognosticating disorders of consciousness (DoC). Advanced neuroimaging and electrophysiological techniques have vastly expanded our understanding of the biological mechanisms underlying consciousness, and have helped identify new states of consciousness. One of these, termed cognitive motor dissociation, can predict functional recovery at 1 year post brain injury, and is present in up to 15-20% of patients with DoC. In this chapter, we review several tools that are used to predict DoC, describing their strengths and limitations, from the neurological examination to advanced imaging and electrophysiologic techniques. We also describe multimodal assessment paradigms that can be used to identify covert consciousness and thus help recognize patients with the potential for future recovery and improve our prognostication practices.
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Affiliation(s)
- Aditya Kumar
- Department of Neurology, Columbia University Medical Center, New York-Presbyterian Hospital, New York, NY, USA
| | - Mohamed Ridha
- Department of Neurology, Columbia University Medical Center, New York-Presbyterian Hospital, New York, NY, USA
| | - Jan Claassen
- Department of Neurology, Columbia University Medical Center, New York-Presbyterian Hospital, New York, NY, USA.
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24
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Lewis A. International variability in the diagnosis and management of disorders of consciousness. Presse Med 2023; 52:104162. [PMID: 36564000 DOI: 10.1016/j.lpm.2022.104162] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Revised: 10/31/2022] [Accepted: 12/13/2022] [Indexed: 12/24/2022] Open
Abstract
This manuscript explores the international variability in the diagnosis and management of disorders of consciousness (DoC). The identification, evaluation, intervention, exploration, prognostication and limitation of therapy for patients with DoC is reviewed through an international lens. The myriad factors that impact the diagnosis and management of DoC including 1) financial, 2) legal and regulatory, 3) cultural, 4) religious and 5) psychosocial considerations are discussed. As data comparing patients with DoC internationally are limited, findings from the general critical care or neurocritical care literature are described when information specific to patients with DoC is unavailable. There is a need for improvements in clinical care, education, advocacy and research related to patients with DoC worldwide. It is imperative to standardize methodology to evaluate consciousness and prognosticate outcome. Further, education is needed to 1) generate awareness of the impact of the aforementioned considerations on patients with DoC and 2) develop techniques to optimize communication about DoC with families. It is necessary to promote equity in access to expertise and resources for patients with DoC to enhance the care of patients with DoC worldwide. Improving understanding and management of patients with DoC requires harmonization of existing datasets, development of registries where none exist and establishment of international clinical trial networks that include patients in all phases along the spectrum of care. The work of international organizations like the Curing Coma Campaign can hopefully minimize international variability in the diagnosis and management of DoC and optimize care.
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Affiliation(s)
- Ariane Lewis
- Departments of Neurology and Neurosurgery, NYU Langone Medical Center, New York, NY, United States.
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25
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Marino MH, Koffer J, Nalla S. Update on Disorders of Consciousness. CURRENT PHYSICAL MEDICINE AND REHABILITATION REPORTS 2023. [DOI: 10.1007/s40141-023-00384-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/18/2023]
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26
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Zheng RZ, Qi ZX, Wang Z, Xu ZY, Wu XH, Mao Y. Clinical Decision on Disorders of Consciousness After Acquired Brain Injury: Stepping Forward. Neurosci Bull 2023; 39:138-162. [PMID: 35804219 PMCID: PMC9849546 DOI: 10.1007/s12264-022-00909-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Accepted: 04/10/2022] [Indexed: 01/22/2023] Open
Abstract
Major advances have been made over the past few decades in identifying and managing disorders of consciousness (DOC) in patients with acquired brain injury (ABI), bringing the transformation from a conceptualized definition to a complex clinical scenario worthy of scientific exploration. Given the continuously-evolving framework of precision medicine that integrates valuable behavioral assessment tools, sophisticated neuroimaging, and electrophysiological techniques, a considerably higher diagnostic accuracy rate of DOC may now be reached. During the treatment of patients with DOC, a variety of intervention methods are available, including amantadine and transcranial direct current stimulation, which have both provided class II evidence, zolpidem, which is also of high quality, and non-invasive stimulation, which appears to be more encouraging than pharmacological therapy. However, heterogeneity is profoundly ingrained in study designs, and only rare schemes have been recommended by authoritative institutions. There is still a lack of an effective clinical protocol for managing patients with DOC following ABI. To advance future clinical studies on DOC, we present a comprehensive review of the progress in clinical identification and management as well as some challenges in the pathophysiology of DOC. We propose a preliminary clinical decision protocol, which could serve as an ideal reference tool for many medical institutions.
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Affiliation(s)
- Rui-Zhe Zheng
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, 200040, China
- National Center for Neurological Disorders, Shanghai, 200040, China
- Shanghai Key Laboratory of Brain Function and Restoration and Neural Regeneration, Shanghai, 200040, China
- Neurosurgical Institute of Fudan University, Shanghai, 200040, China
- Shanghai Clinical Medical Center of Neurosurgery, Shanghai, 200040, China
- State Key Laboratory of Medical Neurobiology, MOE Frontiers Center for Brain Science, School of Basic Medical Sciences and Institutes of Brain Science, Fudan University, Shanghai, 200032, China
| | - Zeng-Xin Qi
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, 200040, China
- National Center for Neurological Disorders, Shanghai, 200040, China
- Shanghai Key Laboratory of Brain Function and Restoration and Neural Regeneration, Shanghai, 200040, China
- Neurosurgical Institute of Fudan University, Shanghai, 200040, China
- Shanghai Clinical Medical Center of Neurosurgery, Shanghai, 200040, China
- State Key Laboratory of Medical Neurobiology, MOE Frontiers Center for Brain Science, School of Basic Medical Sciences and Institutes of Brain Science, Fudan University, Shanghai, 200032, China
| | - Zhe Wang
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, 200040, China
- National Center for Neurological Disorders, Shanghai, 200040, China
- Shanghai Key Laboratory of Brain Function and Restoration and Neural Regeneration, Shanghai, 200040, China
- Neurosurgical Institute of Fudan University, Shanghai, 200040, China
- Shanghai Clinical Medical Center of Neurosurgery, Shanghai, 200040, China
- State Key Laboratory of Medical Neurobiology, MOE Frontiers Center for Brain Science, School of Basic Medical Sciences and Institutes of Brain Science, Fudan University, Shanghai, 200032, China
| | - Ze-Yu Xu
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, 200040, China
- National Center for Neurological Disorders, Shanghai, 200040, China
- Shanghai Key Laboratory of Brain Function and Restoration and Neural Regeneration, Shanghai, 200040, China
- Neurosurgical Institute of Fudan University, Shanghai, 200040, China
- Shanghai Clinical Medical Center of Neurosurgery, Shanghai, 200040, China
- State Key Laboratory of Medical Neurobiology, MOE Frontiers Center for Brain Science, School of Basic Medical Sciences and Institutes of Brain Science, Fudan University, Shanghai, 200032, China
| | - Xue-Hai Wu
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, 200040, China.
- National Center for Neurological Disorders, Shanghai, 200040, China.
- Shanghai Key Laboratory of Brain Function and Restoration and Neural Regeneration, Shanghai, 200040, China.
- Neurosurgical Institute of Fudan University, Shanghai, 200040, China.
- Shanghai Clinical Medical Center of Neurosurgery, Shanghai, 200040, China.
- State Key Laboratory of Medical Neurobiology, MOE Frontiers Center for Brain Science, School of Basic Medical Sciences and Institutes of Brain Science, Fudan University, Shanghai, 200032, China.
| | - Ying Mao
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, 200040, China.
- National Center for Neurological Disorders, Shanghai, 200040, China.
- Shanghai Key Laboratory of Brain Function and Restoration and Neural Regeneration, Shanghai, 200040, China.
- Neurosurgical Institute of Fudan University, Shanghai, 200040, China.
- Shanghai Clinical Medical Center of Neurosurgery, Shanghai, 200040, China.
- State Key Laboratory of Medical Neurobiology, MOE Frontiers Center for Brain Science, School of Basic Medical Sciences and Institutes of Brain Science, Fudan University, Shanghai, 200032, China.
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27
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Understanding, detecting, and stimulating consciousness recovery in the ICU. Acta Neurochir (Wien) 2022; 165:809-828. [PMID: 36242637 DOI: 10.1007/s00701-022-05378-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Accepted: 08/07/2022] [Indexed: 11/01/2022]
Abstract
Coma is a medical and socioeconomic emergency. Although underfunded, research on coma and disorders of consciousness has made impressive progress. Lesion-network-mapping studies have delineated the precise brainstem regions that consistently produce coma when damaged. Functional neuroimaging has revealed how mechanisms like "communication through coherence" and "inhibition by gating" work in synergy to enable cortico-cortical processing and how this information transfer is disrupted in brain injury. On the cellular level, break-down of intracellular communication between the layer 5 pyramidal cell soma and the apical dendritic part impairs dendritic information integration, with up-stream effects on microcircuits in local neuronal populations and on large-scale fronto-parietal networks, which correlates with loss of consciousness. A breakthrough in clinical concepts occurred when fMRI, and later EEG, studies revealed that 15% of clinically unresponsive patients in acute and chronic settings are in fact awake and aware, as shown by their command following abilities revealed by brain activation during motor and locomotion imagery tasks. This condition is now termed "cognitive motor dissociation." Furthermore, epidemiological data on coma were literally non-existent until recently because of difficulties related to case ascertainment with traditional methods, but crowdsourcing of family observations enabled the first estimates of how frequent coma is in the general population (pooled annual incidence of 201 coma cases per 100,000 population in the UK and the USA). Diagnostic guidelines on coma and disorders of consciousness by the American Academy of Neurology and the European Academy of Neurology provide ambitious clinical frameworks to accommodate these achievements. As for therapy, a broad range of medical and non-medical treatment options is now being tested in increasingly larger trials; in particular, amantadine and transcranial direct current stimulation appear promising in this regard. Major international initiatives like the Curing Coma Campaign aim to raise awareness for coma and disorders of consciousness in the public, with the ultimate goal to make more brain-injured patients recover consciousness after a coma. To highlight all these accomplishments, this paper provides a comprehensive overview of recent progress and future challenges related to understanding, detecting, and stimulating consciousness recovery in the ICU.
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Provencio JJ. Neurocritical Care Research. Crit Care Clin 2022; 39:47-54. [DOI: 10.1016/j.ccc.2022.08.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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Amiri M, Fisher PM, Raimondo F, Sidaros A, Cacic Hribljan M, Othman MH, Zibrandtsen I, Albrechtsen SS, Bergdal O, Hansen AE, Hassager C, Højgaard JLS, Jakobsen EW, Jensen HR, Møller J, Nersesjan V, Nikolic M, Olsen MH, Sigurdsson ST, Sitt JD, Sølling C, Welling KL, Willumsen LM, Hauerberg J, Larsen VA, Fabricius M, Knudsen GM, Kjaergaard J, Møller K, Kondziella D. Multimodal prediction of residual consciousness in the intensive care unit: the CONNECT-ME study. Brain 2022; 146:50-64. [PMID: 36097353 PMCID: PMC9825454 DOI: 10.1093/brain/awac335] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2022] [Revised: 07/25/2022] [Accepted: 08/14/2022] [Indexed: 01/15/2023] Open
Abstract
Functional MRI (fMRI) and EEG may reveal residual consciousness in patients with disorders of consciousness (DoC), as reflected by a rapidly expanding literature on chronic DoC. However, acute DoC is rarely investigated, although identifying residual consciousness is key to clinical decision-making in the intensive care unit (ICU). Therefore, the objective of the prospective, observational, tertiary centre cohort, diagnostic phase IIb study 'Consciousness in neurocritical care cohort study using EEG and fMRI' (CONNECT-ME, NCT02644265) was to assess the accuracy of fMRI and EEG to identify residual consciousness in acute DoC in the ICU. Between April 2016 and November 2020, 87 acute DoC patients with traumatic or non-traumatic brain injury were examined with repeated clinical assessments, fMRI and EEG. Resting-state EEG and EEG with external stimulations were evaluated by visual analysis, spectral band analysis and a Support Vector Machine (SVM) consciousness classifier. In addition, within- and between-network resting-state connectivity for canonical resting-state fMRI networks was assessed. Next, we used EEG and fMRI data at study enrolment in two different machine-learning algorithms (Random Forest and SVM with a linear kernel) to distinguish patients in a minimally conscious state or better (≥MCS) from those in coma or unresponsive wakefulness state (≤UWS) at time of study enrolment and at ICU discharge (or before death). Prediction performances were assessed with area under the curve (AUC). Of 87 DoC patients (mean age, 50.0 ± 18 years, 43% female), 51 (59%) were ≤UWS and 36 (41%) were ≥ MCS at study enrolment. Thirty-one (36%) patients died in the ICU, including 28 who had life-sustaining therapy withdrawn. EEG and fMRI predicted consciousness levels at study enrolment and ICU discharge, with maximum AUCs of 0.79 (95% CI 0.77-0.80) and 0.71 (95% CI 0.77-0.80), respectively. Models based on combined EEG and fMRI features predicted consciousness levels at study enrolment and ICU discharge with maximum AUCs of 0.78 (95% CI 0.71-0.86) and 0.83 (95% CI 0.75-0.89), respectively, with improved positive predictive value and sensitivity. Overall, both machine-learning algorithms (SVM and Random Forest) performed equally well. In conclusion, we suggest that acute DoC prediction models in the ICU be based on a combination of fMRI and EEG features, regardless of the machine-learning algorithm used.
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Affiliation(s)
| | | | | | - Annette Sidaros
- Department of Neurology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark,Department of Neurophysiology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Melita Cacic Hribljan
- Department of Neurophysiology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Marwan H Othman
- Department of Neurology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Ivan Zibrandtsen
- Department of Neurophysiology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Simon S Albrechtsen
- Department of Neurology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Ove Bergdal
- Department of Neurosurgery, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Adam Espe Hansen
- Department of Radiology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark,Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Christian Hassager
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark,Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Joan Lilja S Højgaard
- Department of Neurology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | | | - Helene Ravnholt Jensen
- Department of Neuroanaesthesiology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Jacob Møller
- Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Vardan Nersesjan
- Department of Neurology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark,Biological and Precision Psychiatry, Copenhagen Research Center for Mental Health, Copenhagen University Hospital, Copenhagen, Denmark
| | - Miki Nikolic
- Department of Neurophysiology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Markus Harboe Olsen
- Department of Neuroanaesthesiology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Sigurdur Thor Sigurdsson
- Department of Neuroanaesthesiology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Jacobo D Sitt
- Sorbonne Université, Institut du Cerveau - Paris Brain Institute - ICM, Inserm, CNRS, APHP, Hôpital de la Pitié Salpêtrière, Paris, France
| | - Christine Sølling
- Department of Neuroanaesthesiology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Karen Lise Welling
- Department of Neuroanaesthesiology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Lisette M Willumsen
- Department of Neurosurgery, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - John Hauerberg
- Department of Neurosurgery, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Vibeke Andrée Larsen
- Department of Radiology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Martin Fabricius
- Department of Neurophysiology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark,Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Gitte Moos Knudsen
- Neurobiology Research Unit, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark,Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Jesper Kjaergaard
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark,Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Kirsten Møller
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark,Department of Neuroanaesthesiology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Daniel Kondziella
- Correspondence to: Daniel Kondziella, MD, MSc, PhD FEBN Department of Neurology Copenhagen University Hospital, Rigshospitalet Blegdamsvej 9, DK-2100 Copenhagen E-mail:
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Lewis A, Claassen J, Illes J, Jox RJ, Kirschen M, Rohaut B, Trevick S, Young MJ, Fins JJ. Ethics Priorities of the Curing Coma Campaign: An Empirical Survey. Neurocrit Care 2022; 37:12-21. [PMID: 35505222 PMCID: PMC10034145 DOI: 10.1007/s12028-022-01506-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2021] [Accepted: 03/31/2022] [Indexed: 11/25/2022]
Abstract
BACKGROUND The Curing Coma Campaign (CCC) is a multidisciplinary global initiative focused on evaluation, diagnosis, treatment, research, and prognostication for patients who are comatose due to any etiology. To support this mission, the CCC Ethics Working Group conducted a survey of CCC collaborators to identify the ethics priorities of the CCC and the variability in priorities based on country of practice. METHODS An electronic survey on the ethics priorities for the CCC was developed using rank-choice questions and distributed between May and July 2021 to a listserv of the 164 collaborators of the CCC. The median rank for each topic and subtopic was determined. Comparisons were made on the basis of country of practice. RESULTS The survey was completed by 93 respondents (57% response rate); 67% practiced in the United States. On the basis of respondent ranking of each topic, the prioritization of ethics topics across respondents was as follows: (1) clinical care, (2) diagnostic definitions, (3) clinical research, (4) implementation/innovation, (5) family, (6) data management, (7) public engagement/perceptions, and (8) equity. Respondents who practiced in the United States were particularly concerned about public engagement, the distinction between clinical care and research, disclosure of results from clinical research to families, the definition of "personhood," and the distinction between the self-fulfilling prophecy/nihilism and medical futility. Respondents who practiced in other countries were particularly concerned about diagnostic modalities for clinical care, investigational drugs/devices for clinical research, translation of research into practice, and the definition of "minimally conscious state." CONCLUSIONS Collaborators of the CCC considered clinical care, diagnostic definitions, and clinical research the top ethics priorities of the CCC. These priorities should be considered as the CCC explores ways to improve evaluation, diagnosis, treatment, research, and prognostication of patients with coma and associated disorders of consciousness. There is some variability in ethics priorities based on country of practice.
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Affiliation(s)
- Ariane Lewis
- Division of Neurocritical Care, Departments of Neurology and Neurosurgery, New York University Langone Medical Center, 530 First Avenue, Skirball-7R , New York, NY, 10016, USA.
| | - Jan Claassen
- Columbia University and NewYork-Presbyterian Hospital, New York, NY, USA
| | - Judy Illes
- University of British Columbia, Vancouver, BC, Canada
| | - Ralf J Jox
- Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | | | - Benjamin Rohaut
- Sorbonne University, Paris Brain Institute - ICM, Inserm, CNRS, APHP - Hôpital de La Pitié Salpêtrière, DMU Neurosciences, Paris, France
| | | | - Michael J Young
- Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Joseph J Fins
- Weill Cornell Medical College, New York, NY, USA
- Yale Law School, New Haven, CT, USA
- Rockefeller University, New York, NY, USA
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Mainali S, Aiyagari V, Alexander S, Bodien Y, Boerwinkle V, Boly M, Brown E, Brown J, Claassen J, Edlow BL, Fink EL, Fins JJ, Foreman B, Frontera J, Geocadin RG, Giacino J, Gilmore EJ, Gosseries O, Hammond F, Helbok R, Claude Hemphill J, Hirsch K, Kim K, Laureys S, Lewis A, Ling G, Livesay SL, McCredie V, McNett M, Menon D, Molteni E, Olson D, O'Phelan K, Park S, Polizzotto L, Javier Provencio J, Puybasset L, Venkatasubba Rao CP, Robertson C, Rohaut B, Rubin M, Sharshar T, Shutter L, Sampaio Silva G, Smith W, Stevens RD, Thibaut A, Vespa P, Wagner AK, Ziai WC, Zink E, I Suarez J. Proceedings of the Second Curing Coma Campaign NIH Symposium: Challenging the Future of Research for Coma and Disorders of Consciousness. Neurocrit Care 2022; 37:326-350. [PMID: 35534661 PMCID: PMC9283342 DOI: 10.1007/s12028-022-01505-3] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2022] [Accepted: 03/29/2022] [Indexed: 12/21/2022]
Abstract
This proceedings article presents actionable research targets on the basis of the presentations and discussions at the 2nd Curing Coma National Institutes of Health (NIH) symposium held from May 3 to May 5, 2021. Here, we summarize the background, research priorities, panel discussions, and deliverables discussed during the symposium across six major domains related to disorders of consciousness. The six domains include (1) Biology of Coma, (2) Coma Database, (3) Neuroprognostication, (4) Care of Comatose Patients, (5) Early Clinical Trials, and (6) Long-term Recovery. Following the 1st Curing Coma NIH virtual symposium held on September 9 to September 10, 2020, six workgroups, each consisting of field experts in respective domains, were formed and tasked with identifying gaps and developing key priorities and deliverables to advance the mission of the Curing Coma Campaign. The highly interactive and inspiring presentations and panel discussions during the 3-day virtual NIH symposium identified several action items for the Curing Coma Campaign mission, which we summarize in this article.
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Affiliation(s)
- Shraddha Mainali
- Department of Neurology, Virginia Commonwealth University School of Medicine, Richmond, VA, USA.
| | - Venkatesh Aiyagari
- Neurological Surgery and Neurology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Sheila Alexander
- School of Nursing, University of Pittsburgh, Pittsburgh, PA, USA
| | - Yelena Bodien
- Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital and Harvard Medical School, Charlestown, MA, USA
| | - Varina Boerwinkle
- Division of Neurology, Barrow Neurological Institute at Phoenix Children's Hospital, Phoenix, AZ, USA
| | - Melanie Boly
- Departments of Neurology and Psychiatry, Wisconsin Institute for Sleep and Consciousness, University of Wisconsin, Madison, WI, USA
| | - Emery Brown
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Jeremy Brown
- Office of Emergency Care Research, Division of Clinical Research, National Institute of Neurological Disorders and Stroke, Bethesda, MD, USA
| | - Jan Claassen
- Department of Neurology, Columbia University Medical Center, New York Presbyterian Hospital, New York, NY, USA
| | - Brian L Edlow
- Department of Neurology, Center for Neurotechnology and Neurorecovery, Massachusetts General Hospital, Boston, MA, USA
- Athinoula A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital, Charlestown, MA, USA
| | - Ericka L Fink
- Department of Critical Care Medicine, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Joseph J Fins
- Division of Medical Ethics, Weill Cornell Medical College, New York, NY, USA
- Yale Law School, New Haven, CT, USA
| | - Brandon Foreman
- Division of Neurocritical Care, Department of Neurology and Rehabilitation Medicine, University of Cincinnati, Cincinnati, OH, USA
| | - Jennifer Frontera
- Department of Neurology, New York University School of Medicine, New York, NY, USA
| | - Romergryko G Geocadin
- Division of Neurosciences Critical Care, Departments of Anesthesiology and Critical Care Medicine, Neurology, and Neurosurgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Joseph Giacino
- Harvard Medical School, Spaulding Rehabilitation Hospital, Boston, MA, USA
| | - Emily J Gilmore
- Comprehensive Epilepsy Center, Department of Neurology, Yale University, New Haven, CT, USA
| | - Olivia Gosseries
- Coma Science Group, GIGA Consciousness, University of Liege, Liege, Belgium
- Centre du Cerveau, University Hospital of Liege, Liege, Belgium
| | - Flora Hammond
- Indiana University Department of Physical Medicine and Rehabilitation, University of Indiana School of Medicine, Indianapolis, IN, USA
| | - Raimund Helbok
- Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - J Claude Hemphill
- Department of Neurology, University of California, San Francisco, CA, USA
| | - Karen Hirsch
- Division of Neurocritical Care, Department of Neurology, Stanford University, Stanford, CA, USA
| | - Keri Kim
- College of Pharmacy, University of Illinois, Chicago, IL, USA
| | - Steven Laureys
- Coma Science Group, Cyclotron Research Center, University of Liege, Liege, Belgium
- Department of Neurology, Centre Hospitalier Universitaire Sart Tilman, University of Liege, Liege, Belgium
| | - Ariane Lewis
- Department of Neurology and Neurosurgery, New York University Langone Health, New York, NY, USA
| | - Geoffrey Ling
- Division of Neurosciences Critical Care, Departments of Anesthesiology and Critical Care Medicine, Neurology, and Neurosurgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Sarah L Livesay
- Department of Adult Health and Gerontological Nursing, College of Nursing, Rush University, Chicago, IL, USA
| | - Victoria McCredie
- Interdepartmental Division of Critical Care, Department of Respirology, University of Toronto, Toronto, ON, Canada
| | - Molly McNett
- College of Nursing, Ohio State University, Columbus, OH, USA
| | - David Menon
- Division of Anaesthesia, University of Cambridge, Cambridge, UK
| | - Erika Molteni
- School of Biomedical Engineering and Imaging Sciences, King's College London, London, UK
| | - DaiWai Olson
- Neuroscience Intensive Care Unit, O'Donnell Brain Institute, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Kristine O'Phelan
- Department of Neurology, Miller School of Medicine, University of Miami, Miami, FL, USA
| | - Soojin Park
- Department of Neurology and Neurocritical Care, Columbia University, New York, NY, USA
| | - Len Polizzotto
- Department of Biomedical Engineering, Worcester Polytechnic Institute, Worcester, MA, USA
| | - Jose Javier Provencio
- Department of Neurology and Neuroscience, University of Virginia, Charlottesville, VA, USA
| | - Louis Puybasset
- Department of Neuroradiology, University of Paris VI, Pierre et Marie Curie, Pitié-Salpêtrière Hospital, Paris, France
| | - Chethan P Venkatasubba Rao
- Division of Vascular Neurology and Neurocritical Care, CHI St. Luke's Health-Baylor St. Luke's Medical Center, Baylor College of Medicine, Houston, TX, USA
| | - Courtney Robertson
- Departments of Anesthesiology and Critical Care Medicine, and Pediatrics, Johns Hopkins Children's Center, The Johns Hopkins University School of Medcine, Baltimore, MD, USA
| | - Benjamin Rohaut
- Neuroscience Intensive Care Unit, Department of Neurology, Sorbonne University, Assistance Publique-Hôpitaux de Paris, Pitié-Salpêtrière Hospital, Paris, France
| | - Michael Rubin
- Neurological Surgery and Neurology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Tarek Sharshar
- Department of Intensive Care, Paris Descartes University, Paris, France
| | | | - Gisele Sampaio Silva
- Hospital Israelita Albert Einstein, Academic Research Organization and Department of Neurology and Neurosurgery, Universidade Federal de São Paulo, São Paulo, Brazil
| | - Wade Smith
- Department of Neurology, University of California, San Francisco, CA, USA
| | - Robert D Stevens
- Division of Neurosciences Critical Care, Departments of Anesthesiology and Critical Care Medicine, Neurology, and Neurosurgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Aurore Thibaut
- Coma Science Group, GIGA Consciousness, University of Liege, Liege, Belgium
- Centre du Cerveau, University Hospital of Liege, Liege, Belgium
| | - Paul Vespa
- Ronald Reagan UCLA Medical Center, UCLA Santa Monica Medical Center, Santa Monica, CA, USA
| | - Amy K Wagner
- Department of Physical Medicine and Rehabilitation, School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Wendy C Ziai
- Division of Neurosciences Critical Care, Departments of Anesthesiology and Critical Care Medicine, Neurology, and Neurosurgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Elizabeth Zink
- Department of Neuroscience Nursing, The Johns Hopkins Hospital, The Johns Hopkins University, Baltimore, MD, USA
| | - Jose I Suarez
- Division of Neurosciences Critical Care, Departments of Anesthesiology and Critical Care Medicine, Neurology, and Neurosurgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
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Olson DM, Hemphill JC, Provencio JJ, Vespa P, Mainali S, Polizzotto L, Kim KS, McNett M, Ziai W, Suarez JI. The Curing Coma Campaign and the Future of Coma Research. Semin Neurol 2022; 42:393-402. [PMID: 35768013 DOI: 10.1055/a-1887-7104] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Affiliation(s)
| | - J Claude Hemphill
- Neurology, University of California San Francisco, San Francisco, United States
| | - J Javier Provencio
- Neurology and Neuroscience, University of Virginia, Charlottesville, United States
| | - Paul Vespa
- Neurosurgery and Neurology, University of California Los Angeles, Los Angeles, United States
| | - Shradda Mainali
- Neurology, Virginia Commonwealth University, Richmond, United States
| | - Len Polizzotto
- Biomedical Engineering, Worcester Polytechnic Institute, Worcester, United States
| | - Keri S Kim
- Pharmacy Practice, University of Illinois Chicago, Chicago, United States
| | - Molly McNett
- College of Nursing, The Ohio State University, Columbus, United States
| | | | - Jose I Suarez
- Anesthesiology and Critical Care Medicine, Johns Hopkins Medicine School of Medicine, Baltimore, United States
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Kondziella D, Stevens RD. Classifying Disorders of Consciousness: Past, Present, and Future. Semin Neurol 2022; 42:239-248. [PMID: 35738291 DOI: 10.1055/a-1883-1021] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
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Azad TD, Shah PP, Kim HB, Stevens RD. Endotypes and the Path to Precision in Moderate and Severe Traumatic Brain Injury. Neurocrit Care 2022; 37:259-266. [PMID: 35314969 DOI: 10.1007/s12028-022-01475-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2021] [Accepted: 02/15/2022] [Indexed: 12/19/2022]
Abstract
Heterogeneity is recognized as a major barrier in efforts to improve the care and outcomes of patients with traumatic brain injury (TBI). Even within the narrower stratum of moderate and severe TBI, current management approaches do not capture the complexity of this condition characterized by manifold clinical, anatomical, and pathophysiologic features. One approach to heterogeneity may be to resolve undifferentiated TBI populations into endotypes, subclasses that are distinguished by shared biological characteristics. The endotype paradigm has been explored in a range of medical domains, including psychiatry, oncology, immunology, and pulmonology. In intensive care, endotypes are being investigated for syndromes such as sepsis and acute respiratory distress syndrome. This review provides an overview of the endotype paradigm as well as some of its methods and use cases. A conceptual framework is proposed for endotype research in moderate and severe TBI, together with a scientific road map for endotype discovery and validation in this population.
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Affiliation(s)
- Tej D Azad
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Pavan P Shah
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Han B Kim
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Phipps Suite 455, Baltimore, MD, 21287, USA
| | - Robert D Stevens
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA. .,Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, USA. .,Department of Radiology, Johns Hopkins University School of Medicine, Baltimore, MD, USA. .,Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Phipps Suite 455, Baltimore, MD, 21287, USA.
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Helbok R, Rass V, Beghi E, Bodien YG, Citerio G, Giacino JT, Kondziella D, Mayer SA, Menon D, Sharshar T, Stevens RD, Ulmer H, Venkatasubba Rao CP, Vespa P, McNett M, Frontera J. The Curing Coma Campaign International Survey on Coma Epidemiology, Evaluation, and Therapy (COME TOGETHER). Neurocrit Care 2022; 37:47-59. [PMID: 35141860 PMCID: PMC9283177 DOI: 10.1007/s12028-021-01425-8] [Citation(s) in RCA: 31] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Accepted: 12/14/2021] [Indexed: 11/29/2022]
Abstract
Background Although coma is commonly encountered in critical care, worldwide variability exists in diagnosis and management practices. We aimed to assess variability in coma definitions, etiologies, treatment strategies, and attitudes toward prognosis. Methods As part of the Neurocritical Care Society Curing Coma Campaign, between September 2020 and January 2021, we conducted an anonymous, international, cross-sectional global survey of health care professionals caring for patients with coma and disorders of consciousness in the acute, subacute, or chronic setting. Survey responses were solicited by sequential emails distributed by international neuroscience societies and social media. Fleiss κ values were calculated to assess agreement among respondents. Results The survey was completed by 258 health care professionals from 41 countries. Respondents predominantly were physicians (n = 213, 83%), were from the United States (n = 141, 55%), and represented academic centers (n = 231, 90%). Among eight predefined items, respondents identified the following cardinal features, in various combinations, that must be present to define coma: absence of wakefulness (81%, κ = 0.764); Glasgow Coma Score (GCS) ≤ 8 (64%, κ = 0.588); failure to respond purposefully to visual, verbal, or tactile stimuli (60%, κ = 0.552); and inability to follow commands (58%, κ = 0.529). Reported etiologies of coma encountered included medically induced coma (24%), traumatic brain injury (24%), intracerebral hemorrhage (21%), and cardiac arrest/hypoxic-ischemic encephalopathy (11%). The most common clinical assessment tools used for coma included the GCS (94%) and neurological examination (78%). Sixty-six percent of respondents routinely performed sedation interruption, in the absence of contraindications, for clinical coma assessments in the intensive care unit. Advanced neurological assessment techniques in comatose patients included quantitative electroencephalography (EEG)/connectivity analysis (16%), functional magnetic resonance imaging (7%), single-photon emission computerized tomography (6%), positron emission tomography (4%), invasive EEG (4%), and cerebral microdialysis (4%). The most commonly used neurostimulants included amantadine (51%), modafinil (37%), and methylphenidate (28%). The leading determinants for prognostication included etiology of coma, neurological examination findings, and neuroimaging. Fewer than 20% of respondents reported routine follow-up of coma survivors after hospital discharge; however, 86% indicated interest in future research initiatives that include postdischarge outcomes at six (85%) and 12 months (65%). Conclusions There is wide heterogeneity among health care professionals regarding the clinical definition of coma and limited routine use of advanced coma assessment techniques in acute care settings. Coma management practices vary across sites, and mechanisms for coordinated and sustained follow-up after acute treatment are inconsistent. There is an urgent need for the development of evidence-based guidelines and a collaborative, coordinated approach to advance both the science and the practice of coma management globally. Supplementary Information The online version contains supplementary material available at 10.1007/s12028-021-01425-8.
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Affiliation(s)
- Raimund Helbok
- Department of Neurology, Neuro-Intensive Care Unit, Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria.
| | - Verena Rass
- Department of Neurology, Neuro-Intensive Care Unit, Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria
| | - Ettore Beghi
- Department of Neuroscience, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Milan, Italy
| | - Yelena G Bodien
- Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Harvard Medical School, Harvard University, Boston, MA, USA.,Center for Neurotechnology and Neurorecovery, Department of Neurology, Massachusetts General Hospital, Boston, MA, USA
| | - Giuseppe Citerio
- Neuro-Intensive Care, ASST Di Monza, Monza, Italy.,School of Medicine and Surgery, Università Milano Bicocca, Milan, Italy
| | - Joseph T Giacino
- Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Harvard Medical School, Harvard University, Boston, MA, USA
| | - Daniel Kondziella
- Department of Neurology, Rigshospitalet, Copenhagen University Hospital and Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Stephan A Mayer
- Department of Neurology, New York Medical College, Valhalla, NY, USA
| | - David Menon
- Division of Anaesthesia, University of Cambridge, Cambridge, UK
| | - Tarek Sharshar
- Neuro-Intensive Care Medicine, Sainte-Anne Hospital, University of Paris, GHU-Psychiatry & Neurosciences, Paris, France
| | - Robert D Stevens
- Departments of Anesthesiology and Critical Care Medicine, Neurology, and Neurosurgery, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Hanno Ulmer
- Director Department of Medical Statistic, Informatics and Health Economics, Medical University of Innsbruck, Innsbruck, Austria
| | - Chethan P Venkatasubba Rao
- Division of Vascular Neurology and Neurocritical Care, Baylor College of Medicine and CHI Baylor St Luke's Medical Center, Houston, TX, USA
| | - Paul Vespa
- Departments of Neurology and Neurosurgery, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, USA
| | - Molly McNett
- College of Nursing, The Ohio State University, Columbus, OH, USA
| | - Jennifer Frontera
- Department of Neurology, Grossman School of Medicine, New York University, New York, NY, USA
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Xiao A, Callaway CW, Coppler PJ. Long-term Outcomes of Post-Cardiac Arrest Patients with Severe Neurological and Functional Impairments at Hospital Discharge. Resuscitation 2022; 174:93-101. [PMID: 35189302 PMCID: PMC10404449 DOI: 10.1016/j.resuscitation.2022.02.011] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2021] [Revised: 02/10/2022] [Accepted: 02/12/2022] [Indexed: 12/22/2022]
Abstract
BACKGROUND Patients resuscitated from cardiac arrest who have severe neurological or functional disability at discharge require high-intensity long-term support. However, few data describe the long-term survival and health-care utilization for these patients. METHODS We identified a cohort of cardiac arrest survivors ≥ 18 years of age, treated at a single center in Western Pennsylvania from January 2010 to December 2019, with a modified Rankin scale (mRS) of 5 at hospital discharge. We recorded demographics, cardiac arrest characteristics, and neurological exam at hospital discharge. We characterized long term survival and mortality through December 31, 2020 through National Death Index query. We described survival time overall and in subgroups using Kaplan-Meier curves and compared using log-rank tests.We linked cases with administrative data to determine 30, 90 day, and one-year hospital readmission rate. For subjects unable to follow commands at discharge, we reviewed records from index hospitalization to the present to describe improvement in neurological status and return home. RESULTS We screened 2,687 patients of which 975 survived to discharge. We identified 190 subjects with mRS of 5 at hospital discharge who were sent to non-hospice settings. Of these, 43 (23%) did not follow commands at discharge. One-year mortality was 38% (n = 71) with a median survival time of 4.2 years (IQR 0.3-10.9). Duration of survival was shorter in older subjects but did not differ based on, sex, or ability to follow commands at hospital discharge. Within the first year of discharge, 58% (n = 111) of subjects had at least one hospitalization with a median length of stay of 8 days [IQR 3-19]. Of subjects who did not follow commands at hospital discharge, 5/43 (11%) followed commands and 9 (21%) were reportedly living at home on subsequent encounters. CONCLUSIONS Of survivors treated over a decade at our institution, 20% (n = 190) were discharged from the hospital with severe functional disability. One-year mortality was 38%, and hospital readmissions were frequent. Few patients discharged unable to follow commands regained the ability over the period of observation, but many did return to living at home. These data can help inform decision maker expectations for patient trajectory and life expectancy.
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Walter J. Consciousness as a multidimensional phenomenon: implications for the assessment of disorders of consciousness. Neurosci Conscious 2021; 2021:niab047. [PMID: 34992792 PMCID: PMC8716840 DOI: 10.1093/nc/niab047] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2021] [Revised: 10/19/2021] [Accepted: 12/10/2021] [Indexed: 01/10/2023] Open
Abstract
Disorders of consciousness (DoCs) pose a significant clinical and ethical challenge because they allow for complex forms of conscious experience in patients where intentional behaviour and communication are highly limited or non-existent. There is a pressing need for brain-based assessments that can precisely and accurately characterize the conscious state of individual DoC patients. There has been an ongoing research effort to develop neural measures of consciousness. However, these measures are challenging to validate not only due to our lack of ground truth about consciousness in many DoC patients but also because there is an open ontological question about consciousness. There is a growing, well-supported view that consciousness is a multidimensional phenomenon that cannot be fully described in terms of the theoretical construct of hierarchical, easily ordered conscious levels. The multidimensional view of consciousness challenges the utility of levels-based neural measures in the context of DoC assessment. To examine how these measures may map onto consciousness as a multidimensional phenomenon, this article will investigate a range of studies where they have been applied in states other than DoC and where more is known about conscious experience. This comparative evidence suggests that measures of conscious level are more sensitive to some dimensions of consciousness than others and cannot be assumed to provide a straightforward hierarchical characterization of conscious states. Elevated levels of brain complexity, for example, are associated with conscious states characterized by a high degree of sensory richness and minimal attentional constraints, but are suboptimal for goal-directed behaviour and external responsiveness. Overall, this comparative analysis indicates that there are currently limitations to the use of these measures as tools to evaluate consciousness as a multidimensional phenomenon and that the relationship between these neural signatures and phenomenology requires closer scrutiny.
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Affiliation(s)
- Jasmine Walter
- Cognition and Philosophy Lab, 21 Chancellor’s Walk, Monash University, Melbourne, VIC 3800, Australia
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Aubinet C, Chatelle C, Gosseries O, Carrière M, Laureys S, Majerus S. Residual implicit and explicit language abilities in patients with disorders of consciousness: A systematic review. Neurosci Biobehav Rev 2021; 132:391-409. [PMID: 34864003 DOI: 10.1016/j.neubiorev.2021.12.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2021] [Revised: 11/13/2021] [Accepted: 12/01/2021] [Indexed: 01/14/2023]
Abstract
Language assessment in post-comatose patients is difficult due to their limited behavioral repertoire; yet associated language deficits might lead to an underestimation of consciousness levels in unresponsive wakefulness syndrome (UWS) or minimally conscious state (MCS; -/+) diagnoses. We present a systematic review of studies from 2002 assessing residual language abilities with neuroimaging, electrophysiological or behavioral measures in patients with severe brain injury. Eighty-five articles including a total of 2278 patients were assessed for quality. The median percentages of patients showing residual implicit language abilities (i.e., cortical responses to specific words/sentences) were 33 % for UWS, 50 % for MCS- and 78 % for MCS + patients, whereas explicit language abilities (i.e., command-following using brain-computer interfaces) were reported in 20 % of UWS, 33 % of MCS- and 50 % of MCS + patients. Cortical responses to verbal stimuli increased along with consciousness levels and the progressive recovery of consciousness after a coma was paralleled by the reappearance of both implicit and explicit language processing. This review highlights the importance of language assessment in patients with disorders of consciousness.
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Affiliation(s)
- Charlène Aubinet
- Coma Science Group, GIGA Consciousness, University of Liège, Belgium; Centre du Cerveau, University Hospital of Liège, Belgium.
| | - Camille Chatelle
- Coma Science Group, GIGA Consciousness, University of Liège, Belgium; Centre du Cerveau, University Hospital of Liège, Belgium
| | - Olivia Gosseries
- Coma Science Group, GIGA Consciousness, University of Liège, Belgium; Centre du Cerveau, University Hospital of Liège, Belgium; Fund for Scientific Research, FNRS, Belgium
| | - Manon Carrière
- Coma Science Group, GIGA Consciousness, University of Liège, Belgium; Centre du Cerveau, University Hospital of Liège, Belgium
| | - Steven Laureys
- Coma Science Group, GIGA Consciousness, University of Liège, Belgium; Centre du Cerveau, University Hospital of Liège, Belgium; Fund for Scientific Research, FNRS, Belgium
| | - Steve Majerus
- Fund for Scientific Research, FNRS, Belgium; Psychology and Neuroscience of Cognition Research Unit, University of Liège, Belgium.
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Therapies to Restore Consciousness in Patients with Severe Brain Injuries: A Gap Analysis and Future Directions. Neurocrit Care 2021; 35:68-85. [PMID: 34236624 PMCID: PMC8266715 DOI: 10.1007/s12028-021-01227-y] [Citation(s) in RCA: 53] [Impact Index Per Article: 17.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2021] [Accepted: 03/04/2021] [Indexed: 02/06/2023]
Abstract
Background/Objective For patients with disorders of consciousness (DoC) and their families, the search for new therapies has been a source of hope and frustration. Almost all clinical trials in patients with DoC have been limited by small sample sizes, lack of placebo groups, and use of heterogeneous outcome measures. As a result, few therapies have strong evidence to support their use; amantadine is the only therapy recommended by current clinical guidelines, specifically for patients with DoC caused by severe traumatic brain injury. To foster and advance development of consciousness-promoting therapies for patients with DoC, the Curing Coma Campaign convened a Coma Science Work Group to perform a gap analysis. Methods We consider five classes of therapies: (1) pharmacologic; (2) electromagnetic; (3) mechanical; (4) sensory; and (5) regenerative. For each class of therapy, we summarize the state of the science, identify gaps in knowledge, and suggest future directions for therapy development. Results Knowledge gaps in all five therapeutic classes can be attributed to the lack of: (1) a unifying conceptual framework for evaluating therapeutic mechanisms of action; (2) large-scale randomized controlled trials; and (3) pharmacodynamic biomarkers that measure subclinical therapeutic effects in early-phase trials. To address these gaps, we propose a precision medicine approach in which clinical trials selectively enroll patients based upon their physiological receptivity to targeted therapies, and therapeutic effects are measured by complementary behavioral, neuroimaging, and electrophysiologic endpoints. Conclusions This personalized approach can be realized through rigorous clinical trial design and international collaboration, both of which will be essential for advancing the development of new therapies and ultimately improving the lives of patients with DoC. Supplementary Information The online version contains supplementary material available at 10.1007/s12028-021-01227-y.
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Coma Science: The Territory and the Map. Neurocrit Care 2021; 35:24-26. [PMID: 34236620 DOI: 10.1007/s12028-021-01292-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2021] [Accepted: 05/28/2021] [Indexed: 10/20/2022]
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