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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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Kim KS, Polizzotto L, Suarez JI, Olson DM, Hemphill JC, Mainali S. An Update on Curing Coma Campaign. Semin Neurol 2024; 44:389-397. [PMID: 38631382 DOI: 10.1055/s-0044-1785478] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/19/2024]
Abstract
The Curing Coma Campaign (CCC) and its contributing collaborators identified multiple key areas of knowledge and research gaps in coma and disorders of consciousness (DoC). This step was a crucial effort and essential to prioritize future educational and research efforts. These key areas include defining categories of DoC, assessing DoC using multimodal approach (e.g., behavioral assessment tools, advanced neuroimaging studies), discussing optimal clinical trials' design and exploring computational models to conduct clinical trials in patients with DoC, and establishing common data elements to standardize data collection. Other key areas focused on creating coma care registry and educating clinicians and patients and promoting awareness of DoC to improve care in patients with DoC. The ongoing efforts in these key areas are discussed.
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Affiliation(s)
- Keri S Kim
- Department of Pharmacy Practice, University of Illinois Chicago, Chicago, Illinois
| | - Leonard Polizzotto
- Department of Biomedical Engineering, Worcester Polytechnic Institute, Worcester, Massachusetts
| | - 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, Maryland
| | - DaiWai M Olson
- Department of Neurology, University of Texas Southwestern, Dallas, Texas
| | - J Claude Hemphill
- Department of Neurology, University of California, San Francisco, California
| | - Shraddha Mainali
- Department of Neurology, Virginia Commonwealth University School of Medicine, Richmond, Virginia
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Hwang DY, Bannon SM, Meurer K, Kubota R, Baskaran N, Kim J, Zhang Q, Reichman M, Fishbein NS, Lichstein K, Motta M, Muehlschlegel S, Reznik ME, Jaffa MN, Creutzfeldt CJ, Fehnel CR, Tomlinson AD, Williamson CA, Vranceanu AM. Thematic Analysis of Psychosocial Stressors and Adaptive Coping Strategies Among Informal Caregivers of Patients Surviving ICU Admission for Coma. Neurocrit Care 2024; 40:674-688. [PMID: 37523110 DOI: 10.1007/s12028-023-01804-3] [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: 02/02/2023] [Accepted: 07/10/2023] [Indexed: 08/01/2023]
Abstract
BACKGROUND Family caregivers of patients with severe acute brain injury (SABI) admitted to intensive care units (ICUs) with coma experience heightened emotional distress stemming from simultaneous stressors. Stress and coping frameworks can inform psychosocial intervention development by elucidating common challenges and ways of navigating such experiences but have yet to be employed with this population. The present study therefore sought to use a stress and coping framework to characterize the stressors and coping behaviors of family caregivers of patients with SABI hospitalized in ICUs and recovering after coma. METHODS Our qualitative study recruited a convenience sample from 14 US neuroscience ICUs. Participants were family caregivers of patients who were admitted with ischemic stroke, intracerebral hemorrhage, subarachnoid hemorrhage, traumatic brain injury, or hypoxic-ischemic encephalopathy; had experienced a comatose state for > 24 h; and completed or were scheduled for tracheostomy and/or gastrostomy tube placement. Participants were recruited < 7 days after transfer out of the neuroscience ICU. We conducted live online video interviews from May 2021 to January 2022. One semistructured interview per participant was recorded and subsequently transcribed. Recruitment was stopped when thematic saturation was reached. We deductively derived two domains using a stress and coping framework to guide thematic analysis. Within each domain, we inductively derived themes to comprehensively characterize caregivers' experiences. RESULTS We interviewed 30 caregivers. We identified 18 themes within the two theory-driven domains, including ten themes describing practical, social, and emotional stressors experienced by caregivers and eight themes describing the psychological and behavioral coping strategies that caregivers attempted to enact. Nearly all caregivers described using avoidance or distraction as an initial coping strategy to manage overwhelming emotions. Caregivers also expressed awareness of more adaptive strategies (e.g., cultivation of positive emotions, acceptance, self-education, and soliciting social and medical support) but had challenges employing them because of their heightened emotional distress. CONCLUSIONS In response to substantial stressors, family caregivers of patients with SABI attempted to enact various psychological and behavioral coping strategies. They described avoidance and distraction as less helpful than other coping strategies but had difficulty engaging in alternative strategies because of their emotional distress. These findings can directly inform the development of additional resources to mitigate the long-term impact of acute psychological distress among this caregiver population.
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Affiliation(s)
- David Y Hwang
- Division of Neurocritical Care, Department of Neurology, University of North Carolina School of Medicine, 170 Manning Drive, CB# 7025, Chapel Hill, NC, 27599-7025, USA.
| | - Sarah M Bannon
- Department of Psychiatry, Center for Health Outcomes and Interdisciplinary Research, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Kate Meurer
- Division of Neurocritical Care and Emergency Neurology, Department of Neurology, Yale School of Medicine, New Haven, CT, USA
| | - Rina Kubota
- Division of Neurocritical Care and Emergency Neurology, Department of Neurology, Yale School of Medicine, New Haven, CT, USA
| | - Nithyashri Baskaran
- Division of Neurocritical Care and Emergency Neurology, Department of Neurology, Yale School of Medicine, New Haven, CT, USA
| | - Jisoo Kim
- Division of Neurocritical Care and Emergency Neurology, Department of Neurology, Yale School of Medicine, New Haven, CT, USA
| | - Qiang Zhang
- David Geffen School of Medicine at the University of California, Los Angeles, Los Angeles, CA, USA
| | - Mira Reichman
- Department of Psychology, University of Washington, Seattle, WA, USA
| | - Nathan S Fishbein
- Department of Psychiatry, Center for Health Outcomes and Interdisciplinary Research, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Kaitlyn Lichstein
- Department of Psychiatry, Center for Health Outcomes and Interdisciplinary Research, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Melissa Motta
- Program in Trauma, Department of Neurology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Susanne Muehlschlegel
- Department of Neurology, University of Massachusetts Chan Medical School, Worcester, MA, USA
| | - Michael E Reznik
- Department of Neurology, Alpert Medical School, Brown University, Providence, RI, USA
| | - Matthew N Jaffa
- Department of Neurointensive Care, Hartford Hospital, Hartford, CT, USA
| | - Claire J Creutzfeldt
- Department of Neurology, University of Washington and Harborview Medical Center, Seattle, WA, USA
| | - Corey R Fehnel
- Department of Neurology, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA
| | - Amanda D Tomlinson
- Department of Critical Care Medicine, College of Medicine, Mayo Clinic, Jacksonville, FL, USA
| | | | - Ana-Maria Vranceanu
- Department of Psychiatry, Center for Health Outcomes and Interdisciplinary Research, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
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4
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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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5
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Monti MM, Beekman R, Spivak NM, Thibaut A, Schnakers C, Whyte J, Molteni E. Common Data Element for Disorders of Consciousness: Recommendations from the Working Group on Therapeutic Interventions. Neurocrit Care 2024; 40:51-57. [PMID: 38030874 DOI: 10.1007/s12028-023-01873-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2023] [Accepted: 09/29/2023] [Indexed: 12/01/2023]
Abstract
BACKGROUND Over the past 30 years, there have been significant advances in the understanding of the mechanisms associated with loss and recovery of consciousness following severe brain injury. This work has provided a strong grounding for the development of novel restorative therapeutic interventions. Although all interventions are aimed at modulating and thereby restoring brain function, the landscape of existing interventions encompasses a very wide scope of techniques and protocols. Despite vigorous research efforts, few approaches have been assessed with rigorous, high-quality randomized controlled trials. As a growing number of exploratory interventions emerge, it is paramount to develop standardized approaches to reporting results. The successful evaluation of novel interventions depends on implementation of shared nomenclature and infrastructure. To address this gap, the Neurocritical Care Society's Curing Coma Campaign convened nine working groups and charged them with developing common data elements (CDEs). Here, we report the work of the Therapeutic Interventions Working Group. METHODS The working group reviewed existing CDEs relevant to therapeutic interventions within the National Institutes of Health National Institute of Neurological Disorders and Stroke database and reviewed the literature for assessing key areas of research in the intervention space. CDEs were then proposed, iteratively discussed and reviewed, classified, and organized in a case report form (CRF). RESULTS We developed a unified CRF, including CDEs and key design elements (i.e., methodological or protocol parameters), divided into five sections: (1) patient information, (2) general study information, (3) behavioral interventions, (4) pharmacological interventions, and (5) device interventions. CONCLUSIONS The newly created CRF enhances systematization of future work by proposing a portfolio of measures that should be collected in the development and implementation of studies assessing novel interventions intended to increase the level of consciousness or rate of recovery of consciousness in patients with disorders of consciousness.
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Affiliation(s)
- Martin M Monti
- Department of Psychology, University of California Los Angeles, 6522 Pritzker Hall, Los Angeles, CA, USA.
| | - Rachel Beekman
- Department of Neurology, Yale University School of Medicine, New Haven, CT, USA
| | - Norman M Spivak
- David Geffen School of Medicine, University of California, Los Angeles, CA, USA
| | - Aurore Thibaut
- Coma Science Group, GIGA-Consciousness, University of Liège, Liège, Belgium
| | | | - John Whyte
- Moss Rehabilitation Research Institute, Elkins Park, PA, USA
| | - Erika Molteni
- School of Biomedical Engineering and Imaging Sciences, Faculty of Life Sciences and Medicine, School of Life Course Sciences, King's College London, London, UK
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Abstract
In this article, we discuss the taxonomy associated with the four major disorders of consciousness (DoC): coma, vegetative state or unresponsive wakefulness syndrome, minimally conscious state, and post-traumatic confusional state. We briefly review the history of each disorder and then provide operational definitions and diagnostic criteria for each one. We rely heavily on recently released practice guidelines and, where appropriate, identify knowledge gaps and discuss future directions to advance DoC research and practice.
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Affiliation(s)
- Katherine Golden
- School of Health & Rehabilitation Sciences, MGH Institute of Health Professions, 36 1st Avenue, Boston, MA 02129, USA
| | - Yelena G Bodien
- Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, 300 1st Avenue, Charlestown, MA, 02129, USA; Center for Neurotechnology and Neurorecovery, Department of Neurology, Massachusetts General Hospital and Harvard Medical School, 55 Fruit Street, Boston, MA 02114, USA; Department of Physical Medicine and Rehabilitation, Harvard Medical School, 25 Shattuck Street, Boston, MA, USA
| | - Joseph T Giacino
- Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, 300 1st Avenue, Charlestown, MA, 02129, USA; Center for Neurotechnology and Neurorecovery, Department of Neurology, Massachusetts General Hospital and Harvard Medical School, 55 Fruit Street, Boston, MA 02114, USA.
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7
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Cho SM, Robba C, Diringer MN, Hanley DF, Hemphill JC, Horn J, Lewis A, Livesay SL, Menon D, Sharshar T, Stevens RD, Torner J, Vespa PM, Ziai WC, Spann M, Helbok R, Suarez JI. Optimal Design of Clinical Trials Involving Persons with Disorders of Consciousness. Neurocrit Care 2024; 40:74-80. [PMID: 37535178 DOI: 10.1007/s12028-023-01813-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2023] [Accepted: 07/11/2023] [Indexed: 08/04/2023]
Abstract
BACKGROUND Limited data exist regarding the optimal clinical trial design for studies involving persons with disorders of consciousness (DoC), and only a few therapies have been tested in high-quality clinical trials. To address this, the Curing Coma Campaign Clinical Trial Working Group performed a gap analysis on the current state of clinical trials in DoC to identify the optimal clinical design for studies involving persons with DoC. METHODS The Curing Coma Campaign Clinical Trial Working Group was divided into three subgroups to (1) review clinical trials involving persons with DoC, (2) identify unique challenges in the design of clinical trials involving persons with DoC, and (3) recommend optimal clinical trial designs for DoC. RESULTS There were 3055 studies screened, and 66 were included in this review. Several knowledge gaps and unique challenges were identified. There is a lack of high-quality clinical trials, and most data regarding patients with DoC are based on observational studies focusing on patients with traumatic brain injury and cardiac arrest. There is a lack of a structured long-term outcome assessment with significant heterogeneity in the methodology, definitions of outcomes, and conduct of studies, especially for long-term follow-up. Another major barrier to conducting clinical trials is the lack of resources, especially in low-income countries. Based on the available data, we recommend incorporating trial designs that use master protocols, sequential multiple assessment randomized trials, and comparative effectiveness research. Adaptive platform trials using a multiarm, multistage approach offer substantial advantages and should make use of biomarkers to assess treatment responses to increase trial efficiency. Finally, sound infrastructure and international collaboration are essential to facilitate the conduct of trials in patients with DoC. CONCLUSIONS Conduct of trials in patients with DoC should make use of master protocols and adaptive design and establish international registries incorporating standardized assessment tools. This will allow the establishment of evidence-based practice recommendations and decrease variations in care.
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Affiliation(s)
- Sung-Min Cho
- Neuroscience Critical Care Division, Departments of Neurology, and Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, 600 N. Wolfe Street , Baltimore, MD, 21287, USA
| | - Chiara Robba
- IRCCS for Oncology and Neuroscience and Department of Surgical Science and Integrated Diagnostic, San Martino Policlinico Hospital, University of Genoa, Genoa, Italy
| | - Michael N Diringer
- Departments of Neurology, Washington University in St. Louis, St. Louis, MO, USA
| | - Daniel F Hanley
- Neuroscience Critical Care Division, Departments of Neurology, and Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, 600 N. Wolfe Street , Baltimore, MD, 21287, USA
| | - J Claude Hemphill
- Weill Institute for Neurosciences, University of California, San Francisco, San Francisco, CA, USA
| | | | - Ariane Lewis
- Division of Neurocritical Care, Department of Neurology and Neurosurgery, New York University, New York, NY, USA
| | - Sarah L Livesay
- Department of Adult Health and Gerontological Nursing, College of Nursing, Rush University, Chicago, IL, USA
| | - David Menon
- Department of Medicine, University of Cambridge, Cambridge, UK
| | - Tarek Sharshar
- Departments of Neurology and Intensive Care Medicine, Paris-Descartes University, Paris, France
| | - Robert D Stevens
- Neuroscience Critical Care Division, Departments of Neurology, and Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, 600 N. Wolfe Street , Baltimore, MD, 21287, USA
| | - James Torner
- Department of Epidemiology, University of Iowa, Iowa City, IA, USA
| | - Paul M Vespa
- Departments of Neurology and Neurosurgery, University of California, Los Angeles, Los Angeles, CA, USA
| | - Wendy C Ziai
- Neuroscience Critical Care Division, Departments of Neurology, and Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, 600 N. Wolfe Street , Baltimore, MD, 21287, USA
| | - Marcus Spann
- Neuroscience Critical Care Division, Departments of Neurology, and Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, 600 N. Wolfe Street , Baltimore, MD, 21287, USA
| | - Raimund Helbok
- Departments of Neurology and Medicine, Innsbruck Medical University, Innsbruck, Austria
| | - Jose I Suarez
- Neuroscience Critical Care Division, Departments of Neurology, and Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, 600 N. Wolfe Street , Baltimore, MD, 21287, USA.
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8
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Shah VA, Hinson HE, Reznik ME, Hahn CD, Alexander S, Elmer J, Chou SHY. Common Data Elements for Disorders of Consciousness: Recommendations from the Working Group on Biospecimens and Biomarkers. Neurocrit Care 2024; 40:58-64. [PMID: 38087173 DOI: 10.1007/s12028-023-01883-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2023] [Accepted: 10/18/2023] [Indexed: 02/15/2024]
Abstract
BACKGROUND In patients with disorders of consciousness (DoC), laboratory and molecular biomarkers may help define endotypes, identify therapeutic targets, prognosticate outcomes, and guide patient selection in clinical trials. We performed a systematic review to identify common data elements (CDEs) and key design elements (KDEs) for future coma and DoC research. METHODS The Curing Coma Campaign Biospecimens and Biomarkers work group, composed of seven invited members, reviewed existing biomarker and biospecimens CDEs and conducted a systematic literature review for laboratory and molecular biomarkers using predetermined search words and standardized methodology. Identified CDEs and KDEs were adjudicated into core, basic, supplemental, or experimental CDEs per National Institutes of Health classification based on level of evidence, reproducibility, and generalizability across different diseases through a consensus process. RESULTS Among existing National Institutes of Health CDEs, those developed for ischemic stroke, traumatic brain injury, and subarachnoid hemorrhage were most relevant to DoC and included. KDEs were common to all disease states and included biospecimen collection time points, baseline indicator, biological source, anatomical location of collection, collection method, and processing and storage methodology. Additionally, two disease core, nine basic, 24 supplemental, and 59 exploratory biomarker CDEs were identified. Results were summarized and generated into a Laboratory Data and Biospecimens Case Report Form (CRF) and underwent public review. A final CRF version 1.0 is reported here. CONCLUSIONS Exponential growth in biomarkers development has generated a growing number of potential experimental biomarkers associated with DoC, but few meet the quality, reproducibility, and generalizability criteria to be classified as core and basic biomarker and biospecimen CDEs. Identification and adaptation of KDEs, however, contribute to standardizing methodology to promote harmonization of future biomarker and biospecimens studies in DoC. Development of this CRF serves as a basic building block for future DoC studies.
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Affiliation(s)
- Vishank A Shah
- Departments of Anesthesiology and Critical Care Medicine, Neurology, Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - H E Hinson
- Department of Neurology, University of California San Francisco, San Francisco, CA, USA
| | - Michael E Reznik
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- Department of Neurology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Cecil D Hahn
- Division of Neurology, Department of Paediatrics, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - Sheila Alexander
- School of Nursing, University of Pittsburgh, Pittsburgh, PA, USA
| | - Jonathan Elmer
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- Department of Neurology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Sherry H-Y Chou
- Department of Neurology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.
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9
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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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10
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Cruse D, Ragazinskaite K, Chinner A, Bareham C, Roberts N, Banner R, Chennu S, Villa D. Family caregivers' sense-making of the results of functional neurodiagnostics for patients with Prolonged Disorders of Consciousness. Neuropsychol Rehabil 2024:1-22. [PMID: 38230516 DOI: 10.1080/09602011.2023.2299448] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2023] [Accepted: 12/06/2023] [Indexed: 01/18/2024]
Abstract
Functional neuroimaging and electrophysiological assessments can identify evidence of residual consciousness and cognition in patients with prolonged disorders of consciousness (PDOC) who are otherwise behaviourally unresponsive. These functional neurodiagnostics are increasingly available in clinical settings and are recommended by international clinical guidelines to reduce diagnostic and prognostic uncertainty, and thereby assist family caregivers in their best-interests decision-making. Nevertheless, little is known about how family caregivers make sense of the results of these state-of-the-art functional neurodiagnostics. By applying Interpretative Phenomenological Analysis (IPA) to interviews with family caregivers of patients with diagnoses of PDOC who had received a functional neurodiagnostic assessment, we identify three primary themes of sense-making: The special significance of "brain scans"; A dynamic sense-making process; Holding on to hope and holding on to the person. These themes highlight the challenges of helping family caregivers to balance the relative importance of functional neurodiagnostic results with other clinical assessments and identify an ability of family caregivers to hold a contradiction in which they hope for recovery but simultaneously express a rational understanding of evidence to the contrary. We offer several recommendations for the ways in which family caregivers can be better supported to make sense of the results of functional neurodiagnostics.
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Affiliation(s)
- Damian Cruse
- Centre for Human Brain Health, University of Birmingham, Edgbaston, UK
- School of Psychology, University of Birmingham, Edgbaston, UK
| | | | - Amy Chinner
- School of Psychology, University of Birmingham, Edgbaston, UK
| | | | - Neil Roberts
- Sawbridgeworth Medical Services, Jacobs & Gardens Neuro Centres, Sawbridgeworth, UK
| | - Ruth Banner
- Birmingham Community Healthcare NHS Foundation Trust, Birmingham, UK
| | - Srivas Chennu
- School of Computing, University of Kent, Canterbury, UK
| | - Darrelle Villa
- School of Psychology, University of Birmingham, Edgbaston, UK
- Centre for Applied Psychology, University of Birmingham, Edgbaston, UK
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11
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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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12
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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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13
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Barra ME, Zink EK, Bleck TP, Cáceres E, Farrokh S, Foreman B, Cediel EG, Hemphill JC, Nagayama M, Olson DM, Suarez JI. Common Data Elements for Disorders of Consciousness: Recommendations from the Working Group on Hospital Course, Confounders, and Medications. Neurocrit Care 2023; 39:586-592. [PMID: 37610641 DOI: 10.1007/s12028-023-01803-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Accepted: 07/05/2023] [Indexed: 08/24/2023]
Abstract
The convergence of an interdisciplinary team of neurocritical care specialists to organize the Curing Coma Campaign is the first effort of its kind to coordinate national and international research efforts aimed at a deeper understanding of disorders of consciousness (DoC). This process of understanding includes translational research from bench to bedside, descriptions of systems of care delivery, diagnosis, treatment, rehabilitation, and ethical frameworks. The description and measurement of varying confounding factors related to hospital care was thought to be critical in furthering meaningful research in patients with DoC. Interdisciplinary hospital care is inherently varied across geographical areas as well as community and academic medical centers. Access to monitoring technologies, specialist consultation (medical, nursing, pharmacy, respiratory, and rehabilitation), staffing resources, specialty intensive and acute care units, specialty medications and specific surgical, diagnostic and interventional procedures, and imaging is variable, and the impact on patient outcome in terms of DoC is largely unknown. The heterogeneity of causes in DoC is the source of some expected variability in care and treatment of patients, which necessitated the development of a common nomenclature and set of data elements for meaningful measurement across studies. Guideline adherence in hemorrhagic stroke and severe traumatic brain injury may also be variable due to moderate or low levels of evidence for many recommendations. This article outlines the process of the development of common data elements for hospital course, confounders, and medications to streamline definitions and variables to collect for clinical studies of DoC.
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Affiliation(s)
| | - Elizabeth K Zink
- 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
| | - Thomas P Bleck
- Department of Neurology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | | | - Salia Farrokh
- 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
| | - Brandon Foreman
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Emilio Garzón Cediel
- Division of Neurosurgery, Clínica de Marly Jorge Cavelier Gaviria, Chía, Colombia
| | - J Claude Hemphill
- Department of Neurology, UCSF Weill Institute for Neurosciences, San Francisco, CA, USA
| | - Masao Nagayama
- Department of Neurology, International University of Health and Welfare Graduate School of Medicine, Narita, Japan
| | - DaiWai M Olson
- Department of Neurology and Neurosurgery, UT Southwestern, Dallas, TX, 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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14
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Lewis A, Young MJ, Rohaut B, Jox RJ, Claassen J, Creutzfeldt CJ, Illes J, Kirschen M, Trevick S, Fins JJ. Ethics Along the Continuum of Research Involving Persons with Disorders of Consciousness. Neurocrit Care 2023; 39:565-577. [PMID: 36977963 PMCID: PMC11023737 DOI: 10.1007/s12028-023-01708-2] [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: 12/16/2022] [Accepted: 02/23/2023] [Indexed: 03/30/2023]
Abstract
Interest in disorders of consciousness (DoC) has grown substantially over the past decade and has illuminated the importance of improving understanding of DoC biology; care needs (use of monitoring, performance of interventions, and provision of emotional support); treatment options to promote recovery; and outcome prediction. Exploration of these topics requires awareness of numerous ethics considerations related to rights and resources. The Curing Coma Campaign Ethics Working Group used its expertise in neurocritical care, neuropalliative care, neuroethics, neuroscience, philosophy, and research to formulate an informal review of ethics considerations along the continuum of research involving persons with DoC related to the following: (1) study design; (2) comparison of risks versus benefits; (3) selection of inclusion and exclusion criteria; (4) screening, recruitment, and enrollment; (5) consent; (6) data protection; (7) disclosure of results to surrogates and/or legally authorized representatives; (8) translation of research into practice; (9) identification and management of conflicts of interest; (10) equity and resource availability; and (11) inclusion of minors with DoC in research. Awareness of these ethics considerations when planning and performing research involving persons with DoC will ensure that the participant rights are respected while maximizing the impact and meaningfulness of the research, interpretation of outcomes, and communication of results.
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Affiliation(s)
- Ariane Lewis
- NYU Langone Medical Center, 530 First Avenue, Skirball-7R, New York, NY, 10016, USA.
| | - Michael J Young
- Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Benjamin Rohaut
- Inserm, CNRS, APHP - Hôpital de la Pitié Salpêtrière, Paris Brain Institute - ICM, DMU Neuroscience, Sorbonne University, Paris, France
| | - Ralf J Jox
- Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Jan Claassen
- New York Presbyterian Hospital, Columbia University, New York, NY, USA
| | - Claire J Creutzfeldt
- Harborview Medical Center, Seattle, WA, USA
- University of Washington, Seattle, WA, USA
- Cambia Palliative Care Center of Excellence, Seattle, WA, USA
| | - Judy Illes
- University of British Columbia, Vancouver, BC, Canada
| | | | | | - 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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15
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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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16
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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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17
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Presciutti AM, Woodworth E, Rochon E, Neale M, Motta M, Piazza J, Vranceanu AM, Hwang DYG. A Mindfulness-Based Resiliency Program for Caregivers of Patients With Severe Acute Brain Injury Transitioning Out of Critical Care: Protocol for an Open Pilot Trial. JMIR Res Protoc 2023; 12:e50860. [PMID: 37878376 PMCID: PMC10632918 DOI: 10.2196/50860] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Accepted: 09/27/2023] [Indexed: 10/26/2023] Open
Abstract
BACKGROUND Caregivers of patients with severe acute brain injuries (SABI) that lead to coma and require intensive care unit (ICU) treatment often experience chronic emotional distress. To address this need, we developed the Coma Family (COMA-F) program, a mindfulness-based resiliency intervention for these caregivers. OBJECTIVE We will conduct an open pilot trial of COMA-F (National Institutes of Health Stage IA). Here we describe our study protocol and proposed intervention content. METHODS We will enroll 15 caregivers of patients with SABIs during their loved one's hospital course from 3 enrollment centers. A clinical psychologist will deliver the COMA-F intervention (6 sessions) over Zoom (Zoom Video Communications, Inc) or in person. We will iterate COMA-F after each caregiver completes the intervention and an exit interview. English-speaking adults who have emotional distress confirmed by the clinical team and are the primary caregivers of a patient with SABI are eligible. The adult patient must have been admitted to the neuro-ICU for SABI and (1) have had a Glasgow Coma Scale score below 9 while not intubated or an inability to follow meaningful commands while intubated at any point during their hospitalization for >24 hours due to SABI; (2) will be undergoing either tracheostomy or percutaneous endoscopic or surgical gastrostomy tube placement or have already received one or both; and (3) have a prognosis of survival >3 months. We will identify eligible caregivers through screening patients' medical records and through direct referrals from clinicians in the neuro-ICU. During the intervention we will teach caregivers mind-body and resilience skills, including deep breathing, mindfulness, meditation, dialectical thinking, acceptance, cognitive restructuring, effective communication, behavioral activation, and meaning-making. Caregivers will complete self-report assessments (measures of emotional distress and resilience) before and after the intervention. Primary outcomes are feasibility (recruitment, quantitative measures, adherence, and therapist fidelity) and acceptability (treatment satisfaction, credibility, and expectancy). We will conduct brief qualitative exit interviews to gather feedback on refining the program and study procedures. We will examine frequencies and proportions to determine feasibility and acceptability and will analyze qualitative exit interview data using thematic analysis. We will also conduct 2-tailed t tests to explore signals of improvement in emotional distress and treatment targets. We will then conduct an explanatory-sequential mixed methods analysis to integrate quantitative and qualitative data to refine the COMA-F manual and study procedures. RESULTS This study has been approved by the institutional review board at 1 of the 3 enrollment centers (2023P000536), with approvals at the other 2 centers pending. We anticipate that the study will be completed by late 2024. CONCLUSIONS We will use our findings to refine the COMA-F intervention and prepare for a feasibility randomized controlled trial. TRIAL REGISTRATION ClinicalTrials.gov NCT05761925; https://clinicaltrials.gov/study/NCT05761925. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) PRR1-10.2196/50860.
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Affiliation(s)
- Alexander Mattia Presciutti
- Department of Psychiatry, Center for Health Outcomes and Interdisciplinary Research, Massachusetts General Hospital, Boston, MA, United States
- Department of Psychiatry, Harvard Medical School, Boston, MA, United States
| | - Emily Woodworth
- Department of Psychiatry, Center for Health Outcomes and Interdisciplinary Research, Massachusetts General Hospital, Boston, MA, United States
| | - Elizabeth Rochon
- Department of Psychiatry, Center for Health Outcomes and Interdisciplinary Research, Massachusetts General Hospital, Boston, MA, United States
| | - Molly Neale
- Department of Neurology, Division of Neurocritical Care, University of North Carolina School of Medicine, Chapel Hill, NC, United States
| | - Melissa Motta
- Program in Trauma, Department of Neurology, University of Maryland School of Medicine, Baltimore, MD, United States
| | - Joseph Piazza
- Program in Trauma, Department of Neurology, University of Maryland School of Medicine, Baltimore, MD, United States
| | - Ana-Maria Vranceanu
- Department of Psychiatry, Center for Health Outcomes and Interdisciplinary Research, Massachusetts General Hospital, Boston, MA, United States
- Department of Psychiatry, Harvard Medical School, Boston, MA, United States
| | - David Yi-Gin Hwang
- Department of Neurology, Division of Neurocritical Care, University of North Carolina School of Medicine, Chapel Hill, NC, United States
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18
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Gao Q, Hao J, Kang X, Yuan F, Liu Y, Chen R, Liu X, Li R, Jiang W. EEG dynamics induced by zolpidem forecast consciousness evolution in prolonged disorders of consciousness. Clin Neurophysiol 2023; 153:46-56. [PMID: 37454563 DOI: 10.1016/j.clinph.2023.06.012] [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: 10/31/2022] [Revised: 05/19/2023] [Accepted: 06/11/2023] [Indexed: 07/18/2023]
Abstract
OBJECTIVE To explore whether the EEG dynamics induced by zolpidem can predict consciousness evolution in patients with prolonged disorders of consciousness (PDOC). METHODS We conducted a prospective explorative analysis on thirty-six patients with PDOC and eleven healthy controls. The EEG power spectrum was analyzed and categorized into 'ABCD' patterns at baseline and one hour after zolpidem administration at 10 mg. The clinical outcome was defined as consciousness improvement and no improvement six months after enrollment using the Coma Recovery Scale-Revised (CRS-R) score. RESULTS Zolpidem administration significantly increased the EEG power in the delta & theta bands and decreased EEG power in the beta bands in healthy controls. Further follow-up studies indicated that the increased EEG beta-band power induced by zolpidem can predict an improved consciousness six months after enrollment with an area under the receiver operating characteristic curve (AUC) of 0.829, the sensitivity of 94.38% and an accuracy of 81.48%. CONCLUSIONS Our work revealed that the specific EEG responses to zolpidem can predict consciousness recovery in PDOC patients. SIGNIFICANCE The zolpidem-induced specific EEG responses could potentially predict the recovery of PDOC patients, which may help clinicians and patients' families in their decision-making process.
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Affiliation(s)
- Qiong Gao
- Department of Neurology, Xijing Hospital, Fourth Military Medical University, Xi'an 710032, China.
| | - Jianmin Hao
- Department of Neurology, Xijing Hospital, Fourth Military Medical University, Xi'an 710032, China
| | - Xiaogang Kang
- Department of Neurology, Xijing Hospital, Fourth Military Medical University, Xi'an 710032, China
| | - Fang Yuan
- Department of Neurology, Xijing Hospital, Fourth Military Medical University, Xi'an 710032, China; Department of Neurology, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou 510000, China.
| | - Yu Liu
- Department of Neurology, Xijing Hospital, Fourth Military Medical University, Xi'an 710032, China.
| | - Rong Chen
- Department of Neurology, Xijing Hospital, Fourth Military Medical University, Xi'an 710032, China
| | - Xiuyun Liu
- Department of Biomedical Engineering, College of Precision Instruments and Optoelectronics Engineering, Tianjin University, Tianjin 300072, China; Academy of Medical Engineering and Translational Medicine, Tianjin University, Tianjin 300072, China.
| | - Rui Li
- Department of Neurology, Xijing Hospital, Fourth Military Medical University, Xi'an 710032, China.
| | - Wen Jiang
- Department of Neurology, Xijing Hospital, Fourth Military Medical University, Xi'an 710032, China.
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19
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Liuzzi P, Hakiki B, Scarpino M, Burali R, Maiorelli A, Draghi F, Romoli AM, Grippo A, Cecchi F, Mannini A. Neural coding of autonomic functions in different states of consciousness. J Neuroeng Rehabil 2023; 20:96. [PMID: 37491259 PMCID: PMC10369699 DOI: 10.1186/s12984-023-01216-6] [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: 03/17/2023] [Accepted: 07/10/2023] [Indexed: 07/27/2023] Open
Abstract
Detecting signs of residual neural activity in patients with altered states of consciousness is a crucial issue for the customization of neurorehabilitation treatments and clinical decision-making. With this large observational prospective study, we propose an innovative approach to detect residual signs of consciousness via the assessment of the amount of autonomic information coded within the brain. The latter was estimated by computing the mutual information (MI) between preprocessed EEG and ECG signals, to be then compared across consciousness groups, together with the absolute power and an international qualitative labeling. One-hundred seventy-four patients (73 females, 42%) were included in the study (median age of 65 years [IQR = 20], MCS +: 29, MCS -: 23, UWS: 29). Electroencephalography (EEG) information content was found to be mostly related to the coding of electrocardiography (ECG) activity, i.e., with higher MI (p < 0.05), in Unresponsive Wakefulness Syndrome and Minimally Consciousness State minus (MCS -). EEG-ECG MI, besides clearly discriminating patients in an MCS - and +, significantly differed between lesioned areas (sides) in a subgroup of unilateral hemorrhagic patients. Crucially, such an accessible and non-invasive measure of residual consciousness signs was robust across electrodes and patient groups. Consequently, exiting from a strictly neuro-centric consciousness detection approach may be the key to provide complementary insights for the objective assessment of patients' consciousness levels and for the patient-specific planning of rehabilitative interventions.
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Affiliation(s)
- Piergiuseppe Liuzzi
- Sant’Anna School of Advanced Studies, The BioRobotics Institute, Viale Rinaldo Piaggio 69, 56025 Pontedera, PI Italy
- IRCSS Fondazione Don Carlo Gnocchi ONLUS, Via di Scandicci 269, FI 50143 Florence, Italy
| | - Bahia Hakiki
- IRCSS Fondazione Don Carlo Gnocchi ONLUS, Via di Scandicci 269, FI 50143 Florence, Italy
| | - Maenia Scarpino
- IRCSS Fondazione Don Carlo Gnocchi ONLUS, Via di Scandicci 269, FI 50143 Florence, Italy
| | - Rachele Burali
- IRCSS Fondazione Don Carlo Gnocchi ONLUS, Via di Scandicci 269, FI 50143 Florence, Italy
| | - Antonio Maiorelli
- IRCSS Fondazione Don Carlo Gnocchi ONLUS, Via di Scandicci 269, FI 50143 Florence, Italy
| | - Francesca Draghi
- IRCSS Fondazione Don Carlo Gnocchi ONLUS, Via di Scandicci 269, FI 50143 Florence, Italy
| | - Anna Maria Romoli
- IRCSS Fondazione Don Carlo Gnocchi ONLUS, Via di Scandicci 269, FI 50143 Florence, Italy
| | - Antonello Grippo
- IRCSS Fondazione Don Carlo Gnocchi ONLUS, Via di Scandicci 269, FI 50143 Florence, Italy
| | - Francesca Cecchi
- IRCSS Fondazione Don Carlo Gnocchi ONLUS, Via di Scandicci 269, FI 50143 Florence, Italy
- Department of Experimental and Clinical Medicine, University of Florence, Largo Brambilla 3, 50143 Florence, FI Italy
| | - Andrea Mannini
- IRCSS Fondazione Don Carlo Gnocchi ONLUS, Via di Scandicci 269, FI 50143 Florence, Italy
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20
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Luppi AI, Cabral J, Cofre R, Mediano PAM, Rosas FE, Qureshi AY, Kuceyeski A, Tagliazucchi E, Raimondo F, Deco G, Shine JM, Kringelbach ML, Orio P, Ching S, Sanz Perl Y, Diringer MN, Stevens RD, Sitt JD. Computational modelling in disorders of consciousness: Closing the gap towards personalised models for restoring consciousness. Neuroimage 2023; 275:120162. [PMID: 37196986 PMCID: PMC10262065 DOI: 10.1016/j.neuroimage.2023.120162] [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: 01/15/2023] [Revised: 04/16/2023] [Accepted: 05/09/2023] [Indexed: 05/19/2023] Open
Abstract
Disorders of consciousness are complex conditions characterised by persistent loss of responsiveness due to brain injury. They present diagnostic challenges and limited options for treatment, and highlight the urgent need for a more thorough understanding of how human consciousness arises from coordinated neural activity. The increasing availability of multimodal neuroimaging data has given rise to a wide range of clinically- and scientifically-motivated modelling efforts, seeking to improve data-driven stratification of patients, to identify causal mechanisms for patient pathophysiology and loss of consciousness more broadly, and to develop simulations as a means of testing in silico potential treatment avenues to restore consciousness. As a dedicated Working Group of clinicians and neuroscientists of the international Curing Coma Campaign, here we provide our framework and vision to understand the diverse statistical and generative computational modelling approaches that are being employed in this fast-growing field. We identify the gaps that exist between the current state-of-the-art in statistical and biophysical computational modelling in human neuroscience, and the aspirational goal of a mature field of modelling disorders of consciousness; which might drive improved treatments and outcomes in the clinic. Finally, we make several recommendations for how the field as a whole can work together to address these challenges.
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Affiliation(s)
- Andrea I Luppi
- Division of Anaesthesia and Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK; Montreal Neurological Institute, McGill University, Montreal, Quebec, Canada.
| | - Joana Cabral
- Life and Health Sciences Research Institute, University of Minho, Portugal
| | - Rodrigo Cofre
- CIMFAV-Ingemat, Facultad de Ingeniería, Universidad de Valparaíso, Valparaíso, Chile; Centre National de la Recherche Scientifique (CNRS), Institute of Neuroscience (NeuroPSI), Paris-Saclay University, Gif-sur-Yvette, France
| | - Pedro A M Mediano
- Department of Computing, Imperial College London, London, UK; Department of Psychology, University of Cambridge, Cambridge, UK
| | - Fernando E Rosas
- Department of Informatics, University of Sussex, Brighton, UK; Centre for Psychedelic Research, Department of Brain Sciences, Imperial College London, London, UK; Centre for Complexity Science, Imperial College London, London, UK; Centre for Eudaimonia and Human Flourishing, Linacre College, University of Oxford, Oxford, UK
| | - Abid Y Qureshi
- University of Kansas Medical Center, Kansas City, MO, USA
| | - Amy Kuceyeski
- Department of Radiology, Weill Cornell Medicine, New York, USA
| | - Enzo Tagliazucchi
- Departamento de Física (UBA) e Instituto de Fisica de Buenos Aires (CONICET), Buenos Aires, Argentina; Latin American Brain Health Institute (BrainLat), Universidad Adolfo Ibáñez, Santiago, Chile
| | - Federico Raimondo
- Institute of Neuroscience and Medicine (INM-7: Brain and Behaviour), Research Centre Jülich, Germany; Institute of Systems Neuroscience, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Gustavo Deco
- Center for Brain and Cognition, Department of Information and Communication Technologies, Universitat Pompeu Fabra, Barcelona, Spain; Department of Neuropsychology, Max Planck Institute for Human Cognitive and Brain Sciences, Leipzig, Germany; Institució Catalana de Recerca i Estudis Avançats (ICREA), Barcelona, Spain; Turner Institute for Brain and Mental Health, Monash University, Melbourne, VIC, Australia
| | - James M Shine
- Brain and Mind Center, The University of Sydney, Sydney, Australia
| | - Morten L Kringelbach
- Centre for Eudaimonia and Human Flourishing, Linacre College, University of Oxford, Oxford, UK; Department of Psychiatry, University of Oxford, Oxford, UK; Center for Music in the Brain, Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Patricio Orio
- Centro Interdisciplinario de Neurociencia de Valparaíso and Instituto de Neurociencia, Universidad de Valparaíso, Valparaíso, Chile
| | - ShiNung Ching
- Electrical and Systems Engineering, Washington University in St. Louis, St. Louis, MO, USA
| | - Yonatan Sanz Perl
- Center for Brain and Cognition, Department of Information and Communication Technologies, Universitat Pompeu Fabra, Barcelona, Spain; Institut du Cerveau et de la Moelle épinière - Paris Brain Institute, ICM, Paris, France; National Scientific and Technical Research Council (CONICET), Godoy Cruz, CABA 2290, Argentina
| | - Michael N Diringer
- Department of Neurology and Neurosurgery, Washington University in St. Louis, St. Louis, MO, USA
| | - Robert D Stevens
- Departments of Anesthesiology and Critical Care Medicine, Neurology, and Biomedical Engineering, Johns Hopkins University, Baltimore, MD, USA
| | - Jacobo Diego Sitt
- Institut du Cerveau et de la Moelle épinière - Paris Brain Institute, ICM, Paris, France; Sorbonne Université, Inserm, CNRS, APHP, Hôpital de la Pitié Salpêtrière, Paris, France.
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21
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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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22
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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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23
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O'Donnell JC, Browne KD, Kvint S, Makaron L, Grovola MR, Karandikar S, Kilbaugh TJ, Cullen DK, Petrov D. Multimodal Neuromonitoring and Neurocritical Care in Swine to Enhance Translational Relevance in Brain Trauma Research. Biomedicines 2023; 11:biomedicines11051336. [PMID: 37239007 DOI: 10.3390/biomedicines11051336] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Revised: 04/19/2023] [Accepted: 04/21/2023] [Indexed: 05/28/2023] Open
Abstract
Neurocritical care significantly impacts outcomes after moderate-to-severe acquired brain injury, but it is rarely applied in preclinical studies. We created a comprehensive neurointensive care unit (neuroICU) for use in swine to account for the influence of neurocritical care, collect clinically relevant monitoring data, and create a paradigm that is capable of validating therapeutics/diagnostics in the unique neurocritical care space. Our multidisciplinary team of neuroscientists, neurointensivists, and veterinarians adapted/optimized the clinical neuroICU (e.g., multimodal neuromonitoring) and critical care pathways (e.g., managing cerebral perfusion pressure with sedation, ventilation, and hypertonic saline) for use in swine. Moreover, this neurocritical care paradigm enabled the first demonstration of an extended preclinical study period for moderate-to-severe traumatic brain injury with coma beyond 8 h. There are many similarities with humans that make swine an ideal model species for brain injury studies, including a large brain mass, gyrencephalic cortex, high white matter volume, and topography of basal cisterns, amongst other critical factors. Here we describe the neurocritical care techniques we developed and the medical management of swine following subarachnoid hemorrhage and traumatic brain injury with coma. Incorporating neurocritical care in swine studies will reduce the translational gap for therapeutics and diagnostics specifically tailored for moderate-to-severe acquired brain injury.
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Affiliation(s)
- John C O'Donnell
- Center for Neurotrauma, Neurodegeneration & Restoration, Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, PA 19104, USA
- Center for Brain Injury & Repair, Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Kevin D Browne
- Center for Neurotrauma, Neurodegeneration & Restoration, Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, PA 19104, USA
- Center for Brain Injury & Repair, Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Svetlana Kvint
- Center for Brain Injury & Repair, Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Leah Makaron
- University Laboratory Animal Resources, Department of Pathobiology, School of Veterinary Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Michael R Grovola
- Center for Neurotrauma, Neurodegeneration & Restoration, Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, PA 19104, USA
- Center for Brain Injury & Repair, Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Saarang Karandikar
- Center for Neurotrauma, Neurodegeneration & Restoration, Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, PA 19104, USA
- Department of Bioengineering, School of Engineering and Applied Science, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Todd J Kilbaugh
- Center for Brain Injury & Repair, Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
- Department of Anesthesiology and Critical Care Medicine, Perelman School of Medicine, University of Pennsylvania, The Children's Hospital of Philadelphia, Philadelphia, PA 19104, USA
| | - D Kacy Cullen
- Center for Neurotrauma, Neurodegeneration & Restoration, Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, PA 19104, USA
- Center for Brain Injury & Repair, Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
- Department of Bioengineering, School of Engineering and Applied Science, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Dmitriy Petrov
- Center for Brain Injury & Repair, Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
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24
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Luppi AI, Mediano PAM, Rosas FE, Allanson J, Pickard JD, Williams GB, Craig MM, Finoia P, Peattie ARD, Coppola P, Menon DK, Bor D, Stamatakis EA. Reduced emergent character of neural dynamics in patients with a disrupted connectome. Neuroimage 2023; 269:119926. [PMID: 36740030 PMCID: PMC9989666 DOI: 10.1016/j.neuroimage.2023.119926] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Revised: 01/23/2023] [Accepted: 02/02/2023] [Indexed: 02/05/2023] Open
Abstract
High-level brain functions are widely believed to emerge from the orchestrated activity of multiple neural systems. However, lacking a formal definition and practical quantification of emergence for experimental data, neuroscientists have been unable to empirically test this long-standing conjecture. Here we investigate this fundamental question by leveraging a recently proposed framework known as "Integrated Information Decomposition," which establishes a principled information-theoretic approach to operationalise and quantify emergence in dynamical systems - including the human brain. By analysing functional MRI data, our results show that the emergent and hierarchical character of neural dynamics is significantly diminished in chronically unresponsive patients suffering from severe brain injury. At a functional level, we demonstrate that emergence capacity is positively correlated with the extent of hierarchical organisation in brain activity. Furthermore, by combining computational approaches from network control theory and whole-brain biophysical modelling, we show that the reduced capacity for emergent and hierarchical dynamics in severely brain-injured patients can be mechanistically explained by disruptions in the patients' structural connectome. Overall, our results suggest that chronic unresponsiveness resulting from severe brain injury may be related to structural impairment of the fundamental neural infrastructures required for brain dynamics to support emergence.
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Affiliation(s)
- Andrea I Luppi
- Division of Anaesthesia, School of Clinical Medicine, University of Cambridge, UK; Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK; Leverhulme Centre for the Future of Intelligence, Cambridge, UK; The Alan Turing Institute, London, UK.
| | - Pedro A M Mediano
- Department of Computing, Imperial College London, London, UK; Department of Psychology, University of Cambridge, Cambridge, UK
| | - Fernando E Rosas
- Department of Brain Science, Center for Psychedelic Research, Imperial College London, London, UK; Data Science Institute, Imperial College London, London, UK; Centre for Complexity Science, Imperial College London, London, UK; Center for Eudaimonia and Human Flourishing, University of Oxford, Oxford, UK; Department of Informatics, University of Sussex, Brighton, UK
| | - Judith Allanson
- Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK; Department of Neurosciences, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation, Cambridge, UK
| | - John D Pickard
- Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| | - Guy B Williams
- Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK; Wolfson Brain Imaging Centre, University of Cambridge, Cambridge, UK
| | - Michael M Craig
- Division of Anaesthesia, School of Clinical Medicine, University of Cambridge, UK; Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| | - Paola Finoia
- Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| | - Alexander R D Peattie
- Division of Anaesthesia, School of Clinical Medicine, University of Cambridge, UK; Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| | - Peter Coppola
- Division of Anaesthesia, School of Clinical Medicine, University of Cambridge, UK; Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| | - David K Menon
- Division of Anaesthesia, School of Clinical Medicine, University of Cambridge, UK; Wolfson Brain Imaging Centre, University of Cambridge, Cambridge, UK
| | - Daniel Bor
- Department of Psychology, University of Cambridge, Cambridge, UK; Department of Psychology, Queen Mary University of London, UK
| | - Emmanuel A Stamatakis
- Division of Anaesthesia, School of Clinical Medicine, University of Cambridge, UK; Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
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25
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Hudson AE. Presumption of insensibility during general anaesthesia. Br J Anaesth 2023; 130:e209-e212. [PMID: 36344330 DOI: 10.1016/j.bja.2022.09.010] [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: 08/03/2022] [Revised: 09/05/2022] [Accepted: 09/17/2022] [Indexed: 11/06/2022] Open
Abstract
Whilst the general presumption of the public is that general anaesthesia prevents awareness of any sensory stimuli, Lennertz and colleagues have shown in this issue of the British Journal of Anaesthesia that 11% of young adults were able to respond to auditory commands when neuromuscular blocking drugs were prevented from reaching one arm using the isolated forearm technique. This occurred with anaesthetic regimens that followed usual clinical practice in each of the 10 countries that enrolled patients, and it was significantly more common in women than in men. This high incidence demands attention. Further characterisation of the experience of these patients is essential to our understanding of the state of general anaesthesia.
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Affiliation(s)
- Andrew E Hudson
- Department of Anesthesiology, Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, CA, USA; Department of Anesthesiology and Perioperative Medicine, University of California, Los Angeles, Los Angeles, CA, USA.
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26
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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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27
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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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28
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Sangare A, Marois C, Perlbarg V, Pyatigorskaya N, Valente M, Zyss J, Borden A, Lambrecq V, Le Guennec L, Sitt J, Weiss N, Rohaut B, Demeret S, Puybasset L, Demoule A, Naccache L. Description and Outcome of Severe Hypoglycemic Encephalopathy in the Intensive Care Unit. Neurocrit Care 2022; 38:365-377. [PMID: 36109449 DOI: 10.1007/s12028-022-01594-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2022] [Accepted: 08/18/2022] [Indexed: 11/28/2022]
Abstract
BACKGROUND Disorders of consciousness due to severe hypoglycemia are rare but challenging to treat. The aim of this retrospective cohort study was to describe our multimodal neurological assessment of patients with hypoglycemic encephalopathy hospitalized in the intensive care unit and their neurological outcomes. METHODS Consecutive patients with disorders of consciousness related to hypoglycemia admitted for neuroprognostication from 2010 to 2020 were included. Multimodal neurological assessment included electroencephalography, somatosensory and cognitive event-related potentials, and morphological and quantitative magnetic resonance imaging (MRI) with quantification of fractional anisotropy. Neurological outcomes at 28 days, 3 months, 6 months, 1 year, and 2 years after hypoglycemia were retrieved. RESULTS Twenty patients were included. After 2 years, 75% of patients had died, 5% remained in a permanent vegetative state, 10% were in a minimally conscious state, and 10% were conscious but with severe disabilities (Glasgow Outcome Scale-Extended scores 3 and 4). All patients showed pathologic electroencephalography findings with heterogenous patterns. Morphological brain MRI revealed abnormalities in 95% of patients, with various localizations including cortical atrophy in 65% of patients. When performed, quantitative MRI showed decreased fractional anisotropy affecting widespread white matter tracts in all patients. CONCLUSIONS The overall prognosis of patients with severe hypoglycemic encephalopathy was poor, with only a small fraction of patients who slowly improved after intensive care unit discharge. Of note, patients who did not improve during the first 6 months did not recover consciousness. This study suggests that a multimodal approach capitalizing on advanced brain imaging and bedside electrophysiology techniques could improve diagnostic and prognostic performance in severe hypoglycemic encephalopathy.
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Affiliation(s)
- Aude Sangare
- Physiological Investigayions of Clinically Normal and Impaired Cognition Lab, Institut du Cerveau et de la Moelle épinière, Sorbonne Université, Paris, France.
- Département de Neurophysiologie, Assistance Publique-Hôpitaux de Paris, Groupe Hospitalier Pitié-Salpêtrière Charles Foix, Sorbonne Université, Paris, France.
- Institut de Neurosciences Translationnelles, Paris, France.
- Brain Institute - ICM, Sorbonne Université, Inserm U1127, CNRS UMR 7225, 47 Boulevard de l'Hôpital, 75013, Paris, France.
| | - Clémence Marois
- Groupe Hospitalier Pitié-Salpêtrière Charles Foix, Département de Neurologie, Médecine Intensive et Réanimation à Orientation Neurologique, Assistance Publique-Hôpitaux de Paris, Sorbonne Université, Paris, France
- Groupe de Recherche Clinique en Reanimation et Soins Intensifs du Patient en Insuffisance Respiratoire Aigue Assistance Publique, Sorbonne Université, Paris, France
| | | | - Nadya Pyatigorskaya
- Département de Neuroradiologie, Assistance Publique-Hôpitaux de Paris, Groupe Hospitalier Pitié-Salpêtrière Charles Foix, Sorbonne Université, Paris, France
| | - Mélanie Valente
- Physiological Investigayions of Clinically Normal and Impaired Cognition Lab, Institut du Cerveau et de la Moelle épinière, Sorbonne Université, Paris, France
- Département de Neurophysiologie, Assistance Publique-Hôpitaux de Paris, Groupe Hospitalier Pitié-Salpêtrière Charles Foix, Sorbonne Université, Paris, France
- Institut de Neurosciences Translationnelles, Paris, France
| | - Julie Zyss
- Département de Neurophysiologie, Assistance Publique-Hôpitaux de Paris, Groupe Hospitalier Pitié-Salpêtrière Charles Foix, Sorbonne Université, Paris, France
- Institut de Neurosciences Translationnelles, Paris, France
| | - Alaina Borden
- Département de Neurophysiologie, Assistance Publique-Hôpitaux de Paris, Groupe Hospitalier Pitié-Salpêtrière Charles Foix, Sorbonne Université, Paris, France
- Institut de Neurosciences Translationnelles, Paris, France
| | - Virginie Lambrecq
- Département de Neurophysiologie, Assistance Publique-Hôpitaux de Paris, Groupe Hospitalier Pitié-Salpêtrière Charles Foix, Sorbonne Université, Paris, France
- Institut de Neurosciences Translationnelles, Paris, France
| | - Loic Le Guennec
- Groupe Hospitalier Pitié-Salpêtrière Charles Foix, Département de Neurologie, Médecine Intensive et Réanimation à Orientation Neurologique, Assistance Publique-Hôpitaux de Paris, Sorbonne Université, Paris, France
| | - Jacobo Sitt
- Physiological Investigayions of Clinically Normal and Impaired Cognition Lab, Institut du Cerveau et de la Moelle épinière, Sorbonne Université, Paris, France
| | - Nicolas Weiss
- Groupe Hospitalier Pitié-Salpêtrière Charles Foix, Département de Neurologie, Médecine Intensive et Réanimation à Orientation Neurologique, Assistance Publique-Hôpitaux de Paris, Sorbonne Université, Paris, France
- Groupe de Recherche Clinique en Reanimation et Soins Intensifs du Patient en Insuffisance Respiratoire Aigue Assistance Publique, Sorbonne Université, Paris, France
- Brain Liver Pitié-Salpêtrière Study Group, Centre de Recherche Saint-Antoine, Maladies Métaboliques, Biliaires et Fibro-Inflammatoire du Foie & Institute of Cardiometabolism and Nutrition, Sorbonne Université, Paris, France
| | - Benjamin Rohaut
- Physiological Investigayions of Clinically Normal and Impaired Cognition Lab, Institut du Cerveau et de la Moelle épinière, Sorbonne Université, Paris, France
- Groupe Hospitalier Pitié-Salpêtrière Charles Foix, Département de Neurologie, Médecine Intensive et Réanimation à Orientation Neurologique, Assistance Publique-Hôpitaux de Paris, Sorbonne Université, Paris, France
| | - Sophie Demeret
- Groupe Hospitalier Pitié-Salpêtrière Charles Foix, Département de Neurologie, Médecine Intensive et Réanimation à Orientation Neurologique, Assistance Publique-Hôpitaux de Paris, Sorbonne Université, Paris, France
| | - Louis Puybasset
- Laboratoire d'Imagerie Biomédicale, Centre National de la Recherche Scientifique, Institut National de la Santé et de la Recherche Médicale, Assistance Publique-Hôpitaux de Paris, Départements Médico-Universitaires Diagnostic, Radiologie, Explorations fonctionnelles, Anatomo-pathologie, Médecine nucléaire, Paris, France
- Department of Anesthesiology and Critical Care, Pitié-Salpêtrière Hospital, Paris, France
| | - Alexandre Demoule
- Neurophysiologie Respiratoire Expérimentale et Clinique, Institut National de la Santé et de la Recherche Médicale, Sorbonne Université, Paris, France
- Service Médecine Intensive-Réanimation, Groupe Hospitalier Pitié-Salpêtrière Charles Foix, Assistance Publique-Hôpitaux de Paris, Sorbonne Université, Paris, France
| | - Lionel Naccache
- Physiological Investigayions of Clinically Normal and Impaired Cognition Lab, Institut du Cerveau et de la Moelle épinière, Sorbonne Université, Paris, France
- Département de Neurophysiologie, Assistance Publique-Hôpitaux de Paris, Groupe Hospitalier Pitié-Salpêtrière Charles Foix, Sorbonne Université, Paris, France
- Institut de Neurosciences Translationnelles, Paris, France
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Weaver JA, Cogan AM, Watters K. Mobility Interventions for Patients With Disorders of Consciousness Following a Traumatic Brain Injury (June 2013-October 2020). Am J Occup Ther 2022; 76:23915. [PMID: 36165887 DOI: 10.5014/ajot.2022/76s2003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Systematic Review Briefs provide a summary of the findings from systematic reviews developed in conjunction with the American Occupational Therapy Association's Evidence-Based Practice Program. Each Systematic Review Brief summarizes the evidence on a theme related to a systematic review topic. This Systematic Review Brief presents findings from the systematic review on the effectiveness of mobility interventions to improve arousal and awareness in people with disorders of consciousness following a traumatic brain injury.
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Affiliation(s)
- Jennifer A Weaver
- Jennifer A. Weaver, PhD, OTR/L, CBIS, is Associate Professor, Department of Occupational Therapy, Colorado State University
| | - Alison M Cogan
- Alison M. Cogan, PhD, OTR/L, is PROVEN Project Director, VA Greater Los Angeles Healthcare System and Adjunct Assistant Professor, George Washington University School of Medicine and Health Sciences
| | - Kelsey Watters
- Kelsey Watters, MS, OTR/L, BCPR, CBIS, is Clinical Practice Leader, Shirley Ryan AbilityLab
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30
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Kondziella D, Amiri M, Othman MH, Beghi E, Bodien YG, Citerio G, Giacino JT, Mayer SA, Lawson TN, Menon DK, Rass V, Sharshar T, Stevens RD, Tinti L, Vespa P, McNett M, Venkatasubba Rao CP, Helbok R. Incidence and prevalence of coma in the UK and the USA. Brain Commun 2022; 4:fcac188. [PMID: 36132425 PMCID: PMC9486895 DOI: 10.1093/braincomms/fcac188] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Revised: 05/19/2022] [Accepted: 07/14/2022] [Indexed: 11/14/2022] Open
Abstract
The epidemiology of coma is unknown because case ascertainment with traditional methods is difficult. Here, we used crowdsourcing methodology to estimate the incidence and prevalence of coma in the UK and the USA. We recruited UK and US laypeople (aged ≥18 years) who were nationally representative (i.e. matched for age, gender and ethnicity according to census data) of the UK and the USA, respectively, utilizing a crowdsourcing platform. We provided a description of coma and asked survey participants if they-'right now' or 'within the last year'-had a family member in coma. These participants (UK n = 994, USA n = 977) provided data on 30 387 family members (UK n = 14 124, USA n = 16 263). We found more coma cases in the USA (n = 47) than in the UK (n = 20; P = 0.009). We identified one coma case in the UK (0.007%, 95% confidence interval 0.00-0.04%) on the day of the survey and 19 new coma cases (0.13%, 95% confidence interval 0.08-0.21%) within the preceding year, resulting in an annual incidence of 135/100 000 (95% confidence interval 81-210) and a point prevalence of 7 cases per 100 000 population (95% confidence interval 0.18-39.44) in the UK. We identified five cases in the USA (0.031%, 95% confidence interval 0.01-0.07%) on the day of the survey and 42 new cases (0.26%, 95% confidence interval 0.19-0.35%) within the preceding year, resulting in an annual incidence of 258/100 000 (95% confidence interval 186-349) and a point prevalence of 31 cases per 100 000 population (95% confidence interval 9.98-71.73) in the USA. The five most common causes were stroke, medically induced coma, COVID-19, traumatic brain injury and cardiac arrest. To summarize, for the first time, we report incidence and prevalence estimates for coma across diagnosis types and settings in the UK and the USA using crowdsourcing methods. Coma may be more prevalent in the USA than in the UK, which requires further investigation. These data are urgently needed to expand the public health perspective on coma and disorders of consciousness.
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Affiliation(s)
- Daniel Kondziella
- Department of Neurology, Rigshospitalet, Copenhagen University Hospital, Blegdamsvej 9, DK-2100 Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen 2100, Denmark
| | - Moshgan Amiri
- Department of Neurology, Rigshospitalet, Copenhagen University Hospital, Blegdamsvej 9, DK-2100 Copenhagen, Denmark
| | - Marwan H Othman
- Department of Neurology, Rigshospitalet, Copenhagen University Hospital, Blegdamsvej 9, DK-2100 Copenhagen, Denmark
| | - Ettore Beghi
- Department of Neuroscience, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Milan 20156, Italy
| | - Yelena G Bodien
- Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Harvard Medical School, Boston, MA 02115, USA
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA
| | - Giuseppe Citerio
- NeuroIntensive Care, ASST di Monza, Monza 20900, Italy
- School of Medicine and Surgery, Università Milano Bicocca, Milan 20100, Italy
| | - Joseph T Giacino
- Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Harvard Medical School, Boston, MA 02115, USA
| | - Stephan A Mayer
- Department of Neurology, New York Medical College, Valhalla, NY 10595, USA
| | - Thomas N Lawson
- College of Nursing, The Ohio State University, Columbus, OH 43210, USA
| | - David K Menon
- Division of Anaesthesia, University of Cambridge, Cambridge CB2 2QQ, UK
| | - Verena Rass
- Department of Neurology, Neuro-Intensive Care Unit, Medical University of Innsbruck, Innsbruck 6020, Austria
| | - Tarek Sharshar
- Neuro-anesthesiology and Intensive Care Medicine, Sainte-Anne Hospital, Paris-Descartes University, Paris 75006, France
- Experimental Neuropathology, Infection and Epidemiology Department, Institut Pasteur, Paris 75015, France
| | - Robert D Stevens
- Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
- Department of Neurology, The Johns Hopkins University School of Medicine, Baltimore, MD 21218, USA
- Department of Neurosurgery, The Johns Hopkins University School of Medicine, Baltimore 21287, MD, USA
| | - Lorenzo Tinti
- Department of Neuroscience, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Milan 20156, Italy
| | - Paul 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
| | - Molly McNett
- College of Nursing, The Ohio State University, Columbus, OH 43210, 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
| | - Raimund Helbok
- Department of Neurology, Neuro-Intensive Care Unit, Medical University of Innsbruck, Innsbruck 6020, Austria
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Weaver JA, Cogan AM, Watters K. Noninvasive Nerve Stimulation for Patients With Disorders of Consciousness Following a Traumatic Brain Injury (June 2013-October 2020). Am J Occup Ther 2022; 76:23914. [PMID: 36165886 DOI: 10.5014/ajot.2022/76s2001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Systematic Review Briefs provide a summary of the findings from systematic reviews developed in conjunction with the American Occupational Therapy Association's Evidence-Based Practice Program. Each Systematic Review Brief summarizes the evidence on a theme related to a systematic review topic. This Systematic Review Brief presents findings from the systematic review on the effectiveness of noninvasive nerve stimulation to improve arousal and awareness in people with disorders of consciousness following a traumatic brain injury.
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Affiliation(s)
- Jennifer A Weaver
- Jennifer A. Weaver, PhD, OTR/L, CBIS, is Associate Professor, Department of Occupational Therapy, Colorado State University
| | - Alison M Cogan
- Alison M. Cogan, PhD, OTR/L, is PROVEN Project Director, VA Greater Los Angeles Healthcare System and Adjunct Assistant Professor, George Washington University School of Medicine and Health Sciences
| | - Kelsey Watters
- Kelsey Watters, MS, OTR/L, BCPR, CBIS, is Clinical Practice Leader, Shirley Ryan AbilityLab
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Weaver JA, Cogan AM, Watters K. Animal-Assisted Therapy for Patients With Disorders of Consciousness Following a Traumatic Brain Injury (June 2013-October 2020). Am J Occup Ther 2022; 76:23920. [PMID: 36165890 DOI: 10.5014/ajot.2022/76s2002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Systematic Review Briefs provide a summary of the findings from systematic reviews developed in conjunction with the American Occupational Therapy Association's Evidence-Based Practice Program. Each Systematic Review Brief summarizes the evidence on a theme related to a systematic review topic. This Systematic Review Brief presents findings from the systematic review on the effectiveness of animal-assisted therapy to improve arousal and awareness for people with disorders of consciousness following a traumatic brain injury.
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Affiliation(s)
- Jennifer A Weaver
- Jennifer A. Weaver, PhD, OTR/L, CBIS, is Associate Professor, Department of Occupational Therapy, Colorado State University
| | - Alison M Cogan
- Alison M. Cogan, PhD, OTR/L, is PROVEN Project Director, VA Greater Los Angeles Healthcare System and Adjunct Assistant Professor, George Washington University School of Medicine and Health Sciences
| | - Kelsey Watters
- Kelsey Watters, MS, OTR/L, BCPR, CBIS, is Clinical Practice Leader, Shirley Ryan Ability Lab
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33
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Weaver JA, Cogan AM, Watters K. Sensory Stimulation for Patients With Disorders of Consciousness Following a Traumatic Brain Injury (June 2013-October 2020). Am J Occup Ther 2022; 76:23928. [PMID: 36165891 DOI: 10.5014/ajot.2022/76s2004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Systematic Review Briefs provide a summary of the findings from systematic reviews developed in conjunction with the American Occupational Therapy Association's Evidence-Based Practice Program. Each Systematic Review Brief summarizes the evidence on a theme related to a systematic review topic. This Systematic Review Brief presents findings from the systematic review on the effectiveness of sensory stimulation interventions to improve arousal and awareness in people with disorders of consciousness following a TBI.
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Affiliation(s)
- Jennifer A Weaver
- Jennifer A. Weaver, PhD, OTR/L, CBIS, is Associate Professor, Department of Occupational Therapy, Colorado State University
| | - Alison M Cogan
- Alison M. Cogan, PhD, OTR/L, is PROVEN Project Director, VA Greater Los Angeles Healthcare System and Adjunct Assistant Professor, George Washington University School of Medicine and Health Sciences
| | - Kelsey Watters
- Kelsey Watters, MS, OTR/L, BCPR, CBIS, is Clinical Practice Leader, Shirley Ryan AbilityLab
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34
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Egbebike J, Shen Q, Doyle K, Der-Nigoghossian CA, Panicker L, Gonzales IJ, Grobois L, Carmona JC, Vrosgou A, Kaur A, Boehme A, Velazquez A, Rohaut B, Roh D, Agarwal S, Park S, Connolly ES, Claassen J. Cognitive-motor dissociation and time to functional recovery in patients with acute brain injury in the USA: a prospective observational cohort study. Lancet Neurol 2022; 21:704-713. [PMID: 35841909 PMCID: PMC9476646 DOI: 10.1016/s1474-4422(22)00212-5] [Citation(s) in RCA: 54] [Impact Index Per Article: 27.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2021] [Revised: 04/19/2022] [Accepted: 05/04/2022] [Indexed: 12/30/2022]
Abstract
BACKGROUND Recovery trajectories of clinically unresponsive patients with acute brain injury are largely uncertain. Brain activation in the absence of a behavioural response to spoken motor commands can be detected by EEG, also known as cognitive-motor dissociation. We aimed to explore the role of cognitive-motor dissociation in predicting time to recovery in patients with acute brain injury. METHODS In this observational cohort study, we prospectively studied two independent cohorts of clinically unresponsive patients (aged ≥18 years) with acute brain injury. Machine learning was applied to EEG recordings to diagnose cognitive-motor dissociation by detecting brain activation in response to verbal commands. Survival statistics and shift analyses were applied to the data to identify an association between cognitive-motor dissociation and time to and magnitude of recovery. The prediction accuracy of the model that was built using the derivation cohort was assessed using the validation cohort. Functional outcomes of all patients were assessed with the Glasgow Outcome Scale-Extended (GOS-E) at hospital discharge and at 3, 6, and 12 months after injury. Patients who underwent withdrawal of life-sustaining therapies were censored, and death was treated as a competing risk. FINDINGS Between July 1, 2014, and Sept 30, 2021, we screened 598 patients with acute brain injury and included 193 (32%) patients, of whom 100 were in the derivation cohort and 93 were in the validation cohort. At 12 months, 28 (15%) of 193 unresponsive patients had a GOS-E score of 4 or above. Cognitive-motor dissociation was seen in 27 (14%) patients and was an independent predictor of shorter time to good recovery (hazard ratio 5·6 [95% CI 2·5-12·5]), as was underlying traumatic brain injury or subdural haematoma (4·4 [1·4-14·0]), a Glasgow Coma Scale score on admission of greater than or equal to 8 (2·2 [1·0-4·7]), and younger age (1·0 [1·0-1·1]). Among patients discharged home or to a rehabilitation setting, those diagnosed with cognitive-motor dissociation consistently had higher scores on GOS-E indicating better functional recovery compared with those without cognitive-motor dissociation, which was seen as early as 3 months after the injury (odds ratio 4·5 [95% CI 2·0-33·6]). INTERPRETATION Recovery trajectories of clinically unresponsive patients diagnosed with cognitive-motor dissociation early after brain injury are distinctly different from those without cognitive-motor dissociation. A diagnosis of cognitive-motor dissociation could inform the counselling of families of clinically unresponsive patients, and it could help clinicians to identify patients who will benefit from rehabilitation. FUNDING US National Institutes of Health.
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35
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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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Weaver J, Cogan A, Bhandari P, Zainab BEA, Jacobs E, Pape A, Nguyen C, Guernon A, Harrod T, Bender Pape T, Mallinson T. Mapping outcomes for recovery of consciousness in studies from 1986 to 2020: a scoping review protocol. BMJ Open 2022; 12:e056538. [PMID: 35772816 PMCID: PMC9247663 DOI: 10.1136/bmjopen-2021-056538] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
INTRODUCTION Historically, heterogeneous outcome assessments have been used to measure recovery of consciousness in patients with disorders of consciousness (DoC) following traumatic brain injury (TBI), making it difficult to compare across studies. To date, however, there is no comprehensive review of clinical outcome assessments that are used in intervention studies of adults with DoC. The objective of this scoping review is to develop a comprehensive inventory of clinical outcome assessments for recovery of consciousness that have been used in clinical studies of adults with DoC following TBI. METHODS AND ANALYSIS The methodological framework for this review is: (1) identify the research questions, (2) identify relevant studies, (3) select studies, (4) chart the data, (5) collate, summarise and report results and (6) consult stakeholders to drive knowledge translation. We will identify relevant studies by searching the following electronic bibliographic databases: PubMed, Scopus, EMBASE, PsycINFO and The Cochrane Library (including Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials and Cochrane Methodology Register). Criteria for article inclusion are published in the English-language, peer-reviewed studies of interventions aimed at facilitating recovery of consciousness among adults (> 18 years) with DoC following a severe TBI, published from January 1986 to December 2020. Articles meeting inclusion criteria at this stage will undergo a full text review. We will chart the data by applying the WHO International Classification of Functioning, Disability and Health Framework to identify the content areas of clinical outcome assessments. To support knowledge translation efforts, we will involve clinicians and researchers experienced in TBI care throughout the project from conceptualisation of the study through dissemination of results. ETHICS AND DISSEMINATION No ethical approval is required for this study as it is not determined to be human subjects research. Results will be presented at national conferences and published in peer-reviewed journals. TRIAL REGISTRATION NUMBER CRD42017058383.
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Affiliation(s)
- Jennifer Weaver
- Department of Occupational Therapy, Colorado State University College of Health and Human Sciences, Fort Collins, Colorado, USA
- Department of Clinical Research and Leadership, The George Washington University School of Medicine and Health Sciences, Washington, District of Columbia, USA
| | - Alison Cogan
- Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, California, USA
| | - Parie Bhandari
- Department of Clinical Research and Leadership, The George Washington University School of Medicine and Health Sciences, Washington, District of Columbia, USA
| | - Bint-E Awan Zainab
- Department of Clinical Research and Leadership, The George Washington University School of Medicine and Health Sciences, Washington, District of Columbia, USA
| | - Erica Jacobs
- Department of Clinical Research and Leadership, The George Washington University School of Medicine and Health Sciences, Washington, District of Columbia, USA
| | - Ariana Pape
- Department of Clinical Research and Leadership, The George Washington University School of Medicine and Health Sciences, Washington, District of Columbia, USA
| | - Chantal Nguyen
- Department of Clinical Research and Leadership, The George Washington University School of Medicine and Health Sciences, Washington, District of Columbia, USA
| | - Ann Guernon
- Department of Speech Language Pathology, Lewis University - College of Nursing and Health Professions, Romeoville, Illinois, USA
- Center for Innovation in Complex Chronic Healthcare and Research Service, Hines Veterans Affairs Hospital, Hines, Illinois, USA
| | - Tom Harrod
- Department of Clinical Research and Leadership, The George Washington University School of Medicine and Health Sciences, Washington, District of Columbia, USA
| | - Theresa Bender Pape
- Center for Innovation in Complex Chronic Healthcare and Research Service, Hines Veterans Affairs Hospital, Hines, Illinois, USA
| | - Trudy Mallinson
- Department of Clinical Research and Leadership, The George Washington University School of Medicine and Health Sciences, Washington, District of Columbia, 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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Treatment Trials in Disorders of Consciousness: Challenges and Future Directions. Brain Sci 2022; 12:brainsci12050569. [PMID: 35624956 PMCID: PMC9139017 DOI: 10.3390/brainsci12050569] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2022] [Revised: 04/23/2022] [Accepted: 04/25/2022] [Indexed: 11/29/2022] Open
Abstract
The evidence base supporting treatment interventions for patients with disorders of consciousness is limited, and rigorous treatment trials are needed to guide future management of this complex patient population. There are many potential study designs that can be employed to develop this evidence, but the process of selecting the optimal study design is challenging. This article reviews common obstacles that impede research progress in this population and a range of study designs that may be employed. In addition, we consider how the particular practical and scientific obstacles may drive selection of the optimal design and, in particular, how the optimal design changes as treatment research proceeds along the translational continuum from mechanistic discovery to real-world clinical impact.
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Mainali S, Cardim D, Sarwal A, Merck LH, Yeatts SD, Czosnyka M, Shutter L. Prolonged Automated Robotic TCD Monitoring in Acute Severe TBI: Study Design and Rationale. Neurocrit Care 2022; 37:267-275. [PMID: 35381966 DOI: 10.1007/s12028-022-01483-6] [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: 12/01/2021] [Accepted: 03/01/2022] [Indexed: 10/18/2022]
Abstract
BACKGROUND Transcranial Doppler ultrasonography (TCD) is a portable, bedside, noninvasive diagnostic tool used for the real-time assessment of cerebral hemodynamics. Despite the evident utility of TCD and the ability of this technique to function as a stethoscope to the brain, its use has been limited to specialized centers because of the dearth of technical and clinical expertise required to acquire and interpret the cerebrovascular parameters. Additionally, the conventional pragmatic episodic TCD monitoring protocols lack dynamic real-time feedback to guide time-critical clinical interventions. Fortunately, with the recent advent of automated robotic TCD technology in conjunction with the automated software for TCD data processing, we now have the technology to automatically acquire TCD data and obtain clinically relevant information in real-time. By obviating the need for highly trained clinical personnel, this technology shows great promise toward a future of widespread noninvasive monitoring to guide clinical care in patients with acute brain injury. METHODS Here, we describe a proposal for a prospective observational multicenter clinical trial to evaluate the safety and feasibility of prolonged automated robotic TCD monitoring in patients with severe acute traumatic brain injury (TBI). We will enroll patients with severe non-penetrating TBI with concomitant invasive multimodal monitoring including, intracranial pressure, brain tissue oxygenation, and brain temperature monitoring as part of standard of care in centers with varying degrees of TCD availability and experience. Additionally, we propose to evaluate the correlation of pertinent TCD-based cerebral autoregulation indices such as the critical closing pressure, and the pressure reactivity index with the brain tissue oxygenation values obtained invasively. CONCLUSIONS The overarching goal of this study is to establish safety and feasibility of prolonged automated TCD monitoring for patients with TBI in the intensive care unit and identify clinically meaningful and pragmatic noninvasive targets for future interventions.
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Affiliation(s)
- Shraddha Mainali
- Department of Neurology, Virginial Commonwealth University, Richmond, VA, USA.
| | - Danilo Cardim
- Department of Neurology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Aarti Sarwal
- Department of Neurology, Wake Forest School of Medicine, Winston Salem, NC, USA
| | - Lisa H Merck
- Departments of Emergency Medicine and Neurology, University of Florida College of Medicine, Gainesville, FL, USA
| | - Sharon D Yeatts
- Department of Public Health Sciences, Medical University of South Carolina, Charleston, SC, USA
| | - Marek Czosnyka
- Brain Physics Laboratory, Neurosurgical Unit, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| | - Lori Shutter
- Department of Critical Care Medicine, Neurology, and Neurosurgery, University of Pittsburgh, Pittsburgh, PA, USA
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