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Edlow BL, Menon DK. Covert Consciousness in the ICU. Crit Care Med 2024; 52:1414-1426. [PMID: 39145701 DOI: 10.1097/ccm.0000000000006372] [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: 08/16/2024]
Abstract
OBJECTIVES For critically ill patients with acute severe brain injuries, consciousness may reemerge before behavioral responsiveness. The phenomenon of covert consciousness (i.e., cognitive motor dissociation) may be detected by advanced neurotechnologies such as task-based functional MRI (fMRI) and electroencephalography (EEG) in patients who appear unresponsive on the bedside behavioral examination. In this narrative review, we summarize the state-of-the-science in ICU detection of covert consciousness. Further, we consider the prognostic and therapeutic implications of diagnosing covert consciousness in the ICU, as well as its potential to inform discussions about continuation of life-sustaining therapy for patients with severe brain injuries. DATA SOURCES We reviewed salient medical literature regarding covert consciousness. STUDY SELECTION We included clinical studies investigating the diagnostic performance characteristics and prognostic utility of advanced neurotechnologies such as task-based fMRI and EEG. We focus on clinical guidelines, professional society scientific statements, and neuroethical analyses pertaining to the implementation of advanced neurotechnologies in the ICU to detect covert consciousness. DATA EXTRACTION AND DATA SYNTHESIS We extracted study results, guideline recommendations, and society scientific statement recommendations regarding the diagnostic, prognostic, and therapeutic relevance of covert consciousness to the clinical care of ICU patients with severe brain injuries. CONCLUSIONS Emerging evidence indicates that covert consciousness is present in approximately 15-20% of ICU patients who appear unresponsive on behavioral examination. Covert consciousness may be detected in patients with traumatic and nontraumatic brain injuries, including patients whose behavioral examination suggests a comatose state. The presence of covert consciousness in the ICU may predict the pace and extent of long-term functional recovery. Professional society guidelines now recommend assessment of covert consciousness using task-based fMRI and EEG. However, the clinical criteria for patient selection for such investigations are uncertain and global access to advanced neurotechnologies is limited.
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Affiliation(s)
- Brian L Edlow
- Center for Neurotechnology and Neurorecovery, Department of Neurology, Massachusetts General Hospital and Harvard Medical School, Boston, MA
- Athinoula A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital, Charlestown, MA
| | - David K Menon
- University Division of Anaesthesia, University of Cambridge, Addenbrooke's Hospital Cambridge, Cambridge, United Kingdom
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Othman MH, Olsen MH, Hansen KIT, Amiri M, Jensen HR, Nyholm B, Møller K, Kjaergaard J, Kondziella D. Covert Consciousness in Acute Brain Injury Revealed by Automated Pupillometry and Cognitive Paradigms. Neurocrit Care 2024; 41:218-227. [PMID: 38605221 DOI: 10.1007/s12028-024-01983-7] [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: 02/02/2024] [Accepted: 03/12/2024] [Indexed: 04/13/2024]
Abstract
BACKGROUND Identifying covert consciousness in intensive care unit (ICU) patients with coma and other disorders of consciousness (DoC) is crucial for treatment decisions, but sensitive low-cost bedside markers are missing. We investigated whether automated pupillometry combined with passive and active cognitive paradigms can detect residual consciousness in ICU patients with DoC. METHODS We prospectively enrolled clinically low-response or unresponsive patients with traumatic or nontraumatic DoC from ICUs of a tertiary referral center. Age-matched and sex-matched healthy volunteers served as controls. Patients were categorized into clinically unresponsive (coma or unresponsive wakefulness syndrome) or clinically low-responsive (minimally conscious state or better). Using automated pupillometry, we recorded pupillary dilation to passive (visual and auditory stimuli) and active (mental arithmetic) cognitive paradigms, with task-specific success criteria (e.g., ≥ 3 of 5 pupillary dilations on five consecutive mental arithmetic tasks). RESULTS We obtained 699 pupillometry recordings at 178 time points from 91 ICU patients with brain injury (mean age 60 ± 13.8 years, 31% women, and 49.5% nontraumatic brain injuries). Recordings were also obtained from 26 matched controls (59 ± 14.8 years, 38% women). Passive paradigms yielded limited distinctions between patients and controls. However, active paradigms enabled discrimination between different states of consciousness. With mental arithmetic of moderate complexity, ≥ 3 pupillary dilations were seen in 17.8% of clinically unresponsive patients and 50.0% of clinically low-responsive patients (odds ratio 4.56, 95% confidence interval 2.09-10.10; p < 0.001). In comparison, 76.9% healthy controls responded with ≥ 3 pupillary dilations (p = 0.028). Results remained consistent across sensitivity analyses using different thresholds for success. Spearman's rank analysis underscored the robust association between pupillary dilations during mental arithmetic and consciousness levels (rho = 1, p = 0.017). Notably, one behaviorally unresponsive patient demonstrated persistent command-following behavior 2 weeks before overt signs of awareness, suggesting prolonged cognitive motor dissociation. CONCLUSIONS Automated pupillometry combined with mental arithmetic can identify cognitive efforts, and hence covert consciousness, in ICU patients with acute DoC.
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Affiliation(s)
- Marwan H Othman
- Department of Neurology, Rigshospitalet, Copenhagen University Hospital, Inge Lehmanns Vej 8, 2100, Copenhagen, Denmark
| | - Markus Harboe Olsen
- Department of Neuroanesthesiology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Karen Irgens Tanderup Hansen
- Department of Neurology, Rigshospitalet, Copenhagen University Hospital, Inge Lehmanns Vej 8, 2100, Copenhagen, Denmark
- Faculty of Health Science, University of Southern Denmark, Odense, Denmark
| | - Moshgan Amiri
- Department of Neurology, Rigshospitalet, Copenhagen University Hospital, Inge Lehmanns Vej 8, 2100, Copenhagen, Denmark
| | - Helene Ravnholt Jensen
- Department of Neuroanesthesiology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Benjamin Nyholm
- Department of Cardiology, 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 Cardiology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Daniel Kondziella
- Department of Neurology, Rigshospitalet, Copenhagen University Hospital, Inge Lehmanns Vej 8, 2100, Copenhagen, Denmark.
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark.
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Thibaut A, Martens G. Neuromodulation for severe brain injury: time for a paradigm shift? Nat Rev Neurol 2024; 20:441-442. [PMID: 38945982 DOI: 10.1038/s41582-024-00980-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/02/2024]
Affiliation(s)
- Aurore Thibaut
- GIGA-Consciousness, University of Liège, Liège, Belgium.
- Centre du Cerveau², University Hospital of Liège, Liège, Belgium.
| | - Géraldine Martens
- GIGA-Consciousness, University of Liège, Liège, Belgium
- Sport and Trauma Applied Research Lab, Department of Surgery, University of Montreal, Montreal, Quebec, Canada
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Kondziella D, Othman MH. Response to Letter to the Editor for: "Covert Consciousness in Acute Brain Injury Revealed by Automated Pupillometry and Cognitive Paradigms". Neurocrit Care 2024; 41:316-317. [PMID: 38872032 DOI: 10.1007/s12028-024-02024-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2024] [Accepted: 05/23/2024] [Indexed: 06/15/2024]
Affiliation(s)
- Daniel Kondziella
- Department of Neurology, Copenhagen University Hospital -Rigshospitalet, Copenhagen, Denmark.
| | - Marwan H Othman
- Department of Neurology, Copenhagen University Hospital -Rigshospitalet, Copenhagen, Denmark
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5
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De Koninck BP, Brazeau D, Deshaies AA, Briand MM, Maschke C, Williams V, Arbour C, Williamson D, Duclos C, Bernard F, Blain-Moraes S, De Beaumont L. Modulation of brain activity in brain-injured patients with a disorder of consciousness in intensive care with repeated 10-Hz transcranial alternating current stimulation (tACS): a randomised controlled trial protocol. BMJ Open 2024; 14:e078281. [PMID: 38991682 PMCID: PMC11243138 DOI: 10.1136/bmjopen-2023-078281] [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] [Indexed: 07/13/2024] Open
Abstract
INTRODUCTION Therapeutic interventions for disorders of consciousness lack consistency; evidence supports non-invasive brain stimulation, but few studies assess neuromodulation in acute-to-subacute brain-injured patients. This study aims to validate the feasibility and assess the effect of a multi-session transcranial alternating current stimulation (tACS) intervention in subacute brain-injured patients on recovery of consciousness, related brain oscillations and brain network dynamics. METHODS AND ANALYSES The study is comprised of two phases: a validation phase (n=12) and a randomised controlled trial (n=138). Both phases will be conducted in medically stable brain-injured adult patients (traumatic brain injury and hypoxic-ischaemic encephalopathy), with a Glasgow Coma Scale score ≤12 after continuous sedation withdrawal. Recruitment will occur at the intensive care unit of a Level 1 Trauma Centre in Montreal, Quebec, Canada. The intervention includes a 20 min 10 Hz tACS at 1 mA intensity or a sham session over parieto-occipital cortical sites, repeated over five consecutive days. The current's frequency targets alpha brain oscillations (8-13 Hz), known to be associated with consciousness. Resting-state electroencephalogram (EEG) will be recorded four times daily for five consecutive days: pre and post-intervention, at 60 and 120 min post-tACS. Two additional recordings will be included: 24 hours and 1-week post-protocol. Multimodal measures (blood samples, pupillometry, behavioural consciousness assessments (Coma Recovery Scale-revised), actigraphy measures) will be acquired from baseline up to 1 week after the stimulation. EEG signal analysis will focus on the alpha bandwidth (8-13 Hz) using spectral and functional network analyses. Phone assessments at 3, 6 and 12 months post-tACS, will measure long-term functional recovery, quality of life and caregivers' burden. ETHICS AND DISSEMINATION Ethical approval for this study has been granted by the Research Ethics Board of the CIUSSS du Nord-de-l'Île-de-Montréal (Project ID 2021-2279). The findings of this two-phase study will be submitted for publication in a peer-reviewed academic journal and submitted for presentation at conferences. The trial's results will be published on a public trial registry database (ClinicalTrials.gov). TRIAL REGISTRATION NUMBER NCT05833568.
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Affiliation(s)
- Béatrice P De Koninck
- Psychology, University of Montreal, Montreal, Quebec, Canada
- Research Center, Hopital du Sacre-Coeur de Montreal, Montreal, Quebec, Canada
| | - Daphnee Brazeau
- Psychology, University of Montreal, Montreal, Quebec, Canada
- Research Center, Hopital du Sacre-Coeur de Montreal, Montreal, Quebec, Canada
| | | | - Marie-Michele Briand
- CIUSSS du Nord-de-l'Ile-de-Montreal, Montreal, Quebec, Canada
- IRDPQ, Montreal, Quebec, Canada
| | - Charlotte Maschke
- McGill University, Montreal, Quebec, Canada
- Montreal General Hospital, Montreal, Quebec, Canada
| | - Virginie Williams
- Research Center, Hopital du Sacre-Coeur de Montreal, Montreal, Quebec, Canada
| | - Caroline Arbour
- Research Center, Hopital du Sacre-Coeur de Montreal, Montreal, Quebec, Canada
- University of Montreal, Montreal, Quebec, Canada
| | | | - Catherine Duclos
- Research Center, Hopital du Sacre-Coeur de Montreal, Montreal, Quebec, Canada
- Anesthesiology and Pain Medicine, University of Montreal, Montreal, Quebec, Canada
| | - Francis Bernard
- Research Center, Hopital du Sacre-Coeur de Montreal, Montreal, Quebec, Canada
- Medicine, University of Montreal, Montreal, Quebec, Canada
| | - Stefanie Blain-Moraes
- Montreal General Hospital, Montreal, Quebec, Canada
- Physical and Occupational Therapy, McGill University, Montreal, Quebec, Canada
| | - Louis De Beaumont
- Research Center, Hopital du Sacre-Coeur de Montreal, Montreal, Quebec, Canada
- Surgery, University of Montreal, Montreal, Quebec, Canada
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Fins JJ, Shulman KS. Neuroethics, Covert Consciousness, and Disability Rights: What Happens When Artificial Intelligence Meets Cognitive Motor Dissociation? J Cogn Neurosci 2024; 36:1667-1674. [PMID: 38579252 DOI: 10.1162/jocn_a_02157] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/07/2024]
Abstract
In this article, we consider the intersection of cognitive motor dissociation (CMD) and artificial intelligence (AI), hence when CMD meets AI. In covert consciousness, there is a discordance between the observed behavior, the traditional bedside mode of assessment, and the response to volitional commands as depicted by neuroimaging or EEG studies. This alphabet soup of acronyms represents both the promise and peril of nascent technology in covert consciousness. On the diagnostic side, there is the complexity and uncertainty of identifying the discordance between cognitive activity and overt behavior. On the therapeutic side, when AI is used to generate speech, there is the possibility of misrepresenting the thoughts and intentions of those who are otherwise voiceless. This concordance of factors makes the application of AI to CMD worthy of deeper consideration. We offer this analysis in the spirit of anticipatory governance, a prudential process by which one plans to prevent or mitigate unintended consequences of novel technology. We first consider the normative challenges posed by CMD for clinical practice, neuroethics, and the law. We then explore the history of covert consciousness and the relationship of severe brain injury to the right-to-die movement, before introducing three biographies of brain injury that highlight the potential impact of disability bias or ableism in clinical practice, assistive technology, and translational research. Subsequently, we explore how AI might give voice to conscious individuals who are unable to communicate and the ethical challenges that this technology must overcome to promote human flourishing drawing upon what Nussbaum and Sen have described as a "capabilities approach" to promote normative reasoning.
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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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8
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Lejeune N, Fritz P, Cardone P, Szymkowicz E, Vitello MM, Martial C, Thibaut A, Gosseries O. Exploring the Significance of Cognitive Motor Dissociation on Patient Outcome in Acute Disorders of Consciousness. Semin Neurol 2024; 44:271-280. [PMID: 38604229 DOI: 10.1055/s-0044-1785507] [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: 04/13/2024]
Abstract
Cognitive motor dissociation (CMD) is characterized by a dissociation between volitional brain responses and motor control, detectable only through techniques such as electroencephalography (EEG) and functional magnetic resonance imaging. Hence, it has recently emerged as a major challenge in the assessment of patients with disorders of consciousness. Specifically, this review focuses on the prognostic implications of CMD detection during the acute stage of brain injury. CMD patients were identified in each diagnostic category (coma, unresponsive wakefulness syndrome/vegetative state, minimally conscious state minus) with a relatively similar prevalence of around 20%. Current knowledge tends to indicate that the diagnosis of CMD in the acute phase often predicts a more favorable clinical outcome compared with other unresponsive non-CMD patients. Nevertheless, the review underscores the limited research in this domain, probably at least partially explained by its nascent nature and the lack of uniformity in the nomenclature for CMD-related disorders, hindering the impact of the literature in the field.
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Affiliation(s)
- Nicolas Lejeune
- Coma Science Group, GIGA-Consciousness, University of Liège, Liège, Belgium
- Centre du Cerveau, University Hospital of Liège, Liège, Belgium
- DoC Care Unit, Centre Hospitalier Neurologique William Lennox, Ottignies-Louvain-la-Neuve, Belgium
- Institute of NeuroScience, UCLouvain, Brussels, Belgium
| | - Pauline Fritz
- Coma Science Group, GIGA-Consciousness, University of Liège, Liège, Belgium
- Centre du Cerveau, University Hospital of Liège, Liège, Belgium
| | - Paolo Cardone
- Coma Science Group, GIGA-Consciousness, University of Liège, Liège, Belgium
- Centre du Cerveau, University Hospital of Liège, Liège, Belgium
| | - Emilie Szymkowicz
- Coma Science Group, GIGA-Consciousness, University of Liège, Liège, Belgium
- Centre du Cerveau, University Hospital of Liège, Liège, Belgium
| | - Marie M Vitello
- Coma Science Group, GIGA-Consciousness, University of Liège, Liège, Belgium
- Centre du Cerveau, University Hospital of Liège, Liège, Belgium
| | - Charlotte Martial
- Coma Science Group, GIGA-Consciousness, University of Liège, Liège, Belgium
- Centre du Cerveau, University Hospital of Liège, Liège, Belgium
| | - Aurore Thibaut
- Coma Science Group, GIGA-Consciousness, University of Liège, Liège, Belgium
- Centre du Cerveau, University Hospital of Liège, Liège, Belgium
| | - Olivia Gosseries
- Coma Science Group, GIGA-Consciousness, University of Liège, Liège, Belgium
- Centre du Cerveau, University Hospital of Liège, Liège, Belgium
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9
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Young MJ, Kazazian K, Fischer D, Lissak IA, Bodien YG, Edlow BL. Disclosing Results of Tests for Covert Consciousness: A Framework for Ethical Translation. Neurocrit Care 2024; 40:865-878. [PMID: 38243150 PMCID: PMC11147696 DOI: 10.1007/s12028-023-01899-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Accepted: 11/22/2023] [Indexed: 01/21/2024]
Abstract
The advent of neurotechnologies including advanced functional magnetic resonance imaging and electroencephalography to detect states of awareness not detectable by traditional bedside neurobehavioral techniques (i.e., covert consciousness) promises to transform neuroscience research and clinical practice for patients with brain injury. As these interventions progress from research tools into actionable, guideline-endorsed clinical tests, ethical guidance for clinicians on how to responsibly communicate the sensitive results they yield is crucial yet remains underdeveloped. Drawing on insights from empirical and theoretical neuroethics research and our clinical experience with advanced neurotechnologies to detect consciousness in behaviorally unresponsive patients, we critically evaluate ethical promises and perils associated with disclosing the results of clinical covert consciousness assessments and describe a semistructured approach to responsible data sharing to mitigate potential risks.
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Affiliation(s)
- Michael J Young
- Center for Neurotechnology and Neurorecovery, Department of Neurology, Massachusetts General Hospital and Harvard Medical School, 101 Merrimac Street, Suite 310, Boston, MA, 02114, USA.
| | - Karnig Kazazian
- Center for Neurotechnology and Neurorecovery, Department of Neurology, Massachusetts General Hospital and Harvard Medical School, 101 Merrimac Street, Suite 310, Boston, MA, 02114, USA
- Western Institute of Neuroscience, Western University, London, ON, Canada
| | - David Fischer
- University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - India A Lissak
- Center for Neurotechnology and Neurorecovery, Department of Neurology, Massachusetts General Hospital and Harvard Medical School, 101 Merrimac Street, Suite 310, Boston, MA, 02114, USA
| | - Yelena G Bodien
- Center for Neurotechnology and Neurorecovery, Department of Neurology, Massachusetts General Hospital and Harvard Medical School, 101 Merrimac Street, Suite 310, Boston, MA, 02114, USA
| | - Brian L Edlow
- Center for Neurotechnology and Neurorecovery, Department of Neurology, Massachusetts General Hospital and Harvard Medical School, 101 Merrimac Street, Suite 310, Boston, MA, 02114, USA
- Athinoula A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital and Harvard Medical School, Charlestown, MA, USA
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Lo CCH, Woo PYM, Cheung VCK. Task-based EEG and fMRI paradigms in a multimodal clinical diagnostic framework for disorders of consciousness. Rev Neurosci 2024; 0:revneuro-2023-0159. [PMID: 38804042 DOI: 10.1515/revneuro-2023-0159] [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: 12/20/2023] [Accepted: 05/09/2024] [Indexed: 05/29/2024]
Abstract
Disorders of consciousness (DoC) are generally diagnosed by clinical assessment, which is a predominantly motor-driven process and accounts for up to 40 % of non-communication being misdiagnosed as unresponsive wakefulness syndrome (UWS) (previously known as prolonged/persistent vegetative state). Given the consequences of misdiagnosis, a more reliable and objective multimodal protocol to diagnosing DoC is needed, but has not been produced due to concerns regarding their interpretation and reliability. Of the techniques commonly used to detect consciousness in DoC, task-based paradigms (active paradigms) produce the most unequivocal result when findings are positive. It is well-established that command following (CF) reliably reflects preserved consciousness. Task-based electroencephalography (EEG) and functional magnetic resonance imaging (fMRI) can detect motor-independent CF and reveal preserved covert consciousness in up to 14 % of UWS patients. Accordingly, to improve the diagnostic accuracy of DoC, we propose a practical multimodal clinical decision framework centered on task-based EEG and fMRI, and complemented by measures like transcranial magnetic stimulation (TMS-EEG).
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Affiliation(s)
- Chris Chun Hei Lo
- School of Biomedical Sciences, and Gerald Choa Neuroscience Institute, The Chinese University of Hong Kong, Shatin, New Territories, Hong Kong, China
| | - Peter Yat Ming Woo
- Division of Neurosurgery, Department of Surgery, Faculty of Medicine, The Chinese University of Hong Kong, Shatin, New Territories, Hong Kong, China
| | - Vincent C K Cheung
- School of Biomedical Sciences, and Gerald Choa Neuroscience Institute, The Chinese University of Hong Kong, Shatin, New Territories, Hong Kong, China
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11
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Schiff ND. Toward an interventional science of recovery after coma. Neuron 2024; 112:1595-1610. [PMID: 38754372 DOI: 10.1016/j.neuron.2024.04.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2024] [Revised: 04/04/2024] [Accepted: 04/24/2024] [Indexed: 05/18/2024]
Abstract
Recovery of consciousness after coma remains one of the most challenging areas for accurate diagnosis and effective therapeutic engagement in the clinical neurosciences. Recovery depends on preservation of neuronal integrity and evolving changes in network function that re-establish environmental responsiveness. It typically occurs in defined steps: it begins with eye opening and unresponsiveness in a vegetative state, then limited recovery of responsiveness characterizes the minimally conscious state, and this is followed by recovery of reliable communication. This review considers several points for novel interventions, for example, in persons with cognitive motor dissociation in whom a hidden cognitive reserve is revealed. Circuit mechanisms underlying restoration of behavioral responsiveness and communication are discussed. An emerging theme is the possibility to rescue latent capacities in partially damaged human networks across time. These opportunities should be exploited for therapeutic engagement to achieve individualized solutions for restoration of communication and environmental interaction across varying levels of recovery.
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Affiliation(s)
- Nicholas D Schiff
- Jerold B. Katz Professor of Neurology and Neuroscience, Weill Cornell Medicine, New York, NY, USA.
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12
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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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13
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Fischer D, Edlow BL. Coma Prognostication After Acute Brain Injury: A Review. JAMA Neurol 2024:2815829. [PMID: 38436946 DOI: 10.1001/jamaneurol.2023.5634] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/05/2024]
Abstract
Importance Among the most impactful neurologic assessments is that of neuroprognostication, defined here as the prediction of neurologic recovery from disorders of consciousness caused by severe, acute brain injury. Across a range of brain injury etiologies, these determinations often dictate whether life-sustaining treatment is continued or withdrawn; thus, they have major implications for morbidity, mortality, and health care costs. Neuroprognostication relies on a diverse array of tests, including behavioral, radiologic, physiological, and serologic markers, that evaluate the brain's functional and structural integrity. Observations Prognostic markers, such as the neurologic examination, electroencephalography, and conventional computed tomography and magnetic resonance imaging (MRI), have been foundational in assessing a patient's current level of consciousness and capacity for recovery. Emerging techniques, such as functional MRI, diffusion MRI, and advanced forms of electroencephalography, provide new ways of evaluating the brain, leading to evolving schemes for characterizing neurologic function and novel methods for predicting recovery. Conclusions and Relevance Neuroprognostic markers are rapidly evolving as new ways of assessing the brain's structural and functional integrity after brain injury are discovered. Many of these techniques remain in development, and further research is needed to optimize their prognostic utility. However, even as such efforts are underway, a series of promising findings coupled with the imperfect predictive value of conventional prognostic markers and the high stakes of these assessments have prompted clinical guidelines to endorse emerging techniques for neuroprognostication. Thus, clinicians have been thrust into an uncertain predicament in which emerging techniques are not yet perfected but too promising to ignore. This review illustrates the current, and likely future, landscapes of prognostic markers. No matter how much prognostic markers evolve and improve, these assessments must be approached with humility and individualized to reflect each patient's values.
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Affiliation(s)
- David Fischer
- Division of Neurocritical Care, Department of Neurology, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Brian L Edlow
- Center for Neurotechnology and Neurorecovery, Department of Neurology, Massachusetts General Hospital and Harvard Medical School, Boston
- Athinoula A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital and Harvard Medical School, Charlestown
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