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Tao T, Lu S, Hu N, Xu D, Xu C, Li F, Wang Q, Peng Y. Prognosis of comatose patients with reduced EEG montage by combining quantitative EEG features in various domains. Front Neurosci 2023; 17:1302318. [PMID: 38144206 PMCID: PMC10748426 DOI: 10.3389/fnins.2023.1302318] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2023] [Accepted: 11/20/2023] [Indexed: 12/26/2023] Open
Abstract
Objective As the frontoparietal network underlies recovery from coma, a limited frontoparietal montage was used, and the prognostic values of EEG features for comatose patients were assessed. Methods Collected with a limited frontoparietal EEG montage, continuous EEG recordings of 81 comatose patients in ICU were used retrospectively. By the 60-day Glasgow outcome scale (GOS), the patients were dichotomized into favorable and unfavorable outcome groups. Temporal-, frequency-, and spatial-domain features were automatically extracted for comparison. Partial correlation analysis was applied to eliminate redundant factors, and multiple correspondence analysis was used to explore discrimination between groups. Prognostic characteristics were calculated to assess the performance of EEG feature-based predictors established by logistic regression. Analyses were performed on all-patients group, strokes subgroup, and traumatic brain injury (TBI) subgroup. Results By analysis of all patients, raised burst suppression ratio (BSR), suppressed root mean square (RMS), raised power ratio of β to α rhythm (β/α), and suppressed phase-lag index between F3 and P4 (PLI [F3, P4]) were associated with unfavorable outcome, and yielded AUC of 0.790, 0.811, 0.722, and 0.844, respectively. For the strokes subgroup, the significant variables were BSR, RMS, θ/total, θ/δ, and PLI (F3, P4), while for the TBI subgroup, only PLI (F3, P4) was significant. BSR combined with PLI (F3, P4) gave the best predictor by cross-validation analysis in the all-patients group (AUC = 0.889, 95% CI: 0.819-0.960). Conclusion Features extracted from limited frontoparietal montage EEG served as valuable coma prognostic tools, where PLI (F3, P4) was always significant. Combining PLI (F3, P4) with features in other domains may achieve better performance. Significance A limited-montage EEG coupled with an automated algorithm is valuable for coma prognosis.
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Affiliation(s)
- Tao Tao
- Intensive Care Unit, The First People’s Hospital of Kunshan, Kunshan Affiliated Hospital of Jiangsu University, Kunshan, Jiangsu, China
| | - Shiqi Lu
- Emergency Department, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu, China
| | - Nan Hu
- School of Electronics and Information Engineering, Soochow University, Suzhou, Jiangsu, China
| | - Dongyang Xu
- Center for Intelligent Acoustics and Signal Processing, Huzhou Institute of Zhejiang University, Huzhou, China
| | - Chenyang Xu
- Intensive Care Unit, The First People’s Hospital of Kunshan, Kunshan Affiliated Hospital of Jiangsu University, Kunshan, Jiangsu, China
| | - Fajun Li
- Intensive Care Unit, The First People’s Hospital of Kunshan, Kunshan Affiliated Hospital of Jiangsu University, Kunshan, Jiangsu, China
| | - Qin Wang
- Intensive Care Unit, The First People’s Hospital of Kunshan, Kunshan Affiliated Hospital of Jiangsu University, Kunshan, Jiangsu, China
| | - Yuan Peng
- Intensive Care Unit, The First People’s Hospital of Kunshan, Kunshan Affiliated Hospital of Jiangsu University, Kunshan, Jiangsu, China
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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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3
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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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Communicating With Unconscious Patients. Dimens Crit Care Nurs 2023; 42:3-11. [DOI: 10.1097/dcc.0000000000000561] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
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5
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Pozeg P, Alemán-Goméz Y, Jöhr J, Muresanu D, Pincherle A, Ryvlin P, Hagmann P, Diserens K, Dunet V. Structural connectivity in recovery after coma: Connectome atlas approach. Neuroimage Clin 2023; 37:103358. [PMID: 36868043 PMCID: PMC9996111 DOI: 10.1016/j.nicl.2023.103358] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2022] [Revised: 02/06/2023] [Accepted: 02/20/2023] [Indexed: 03/05/2023]
Abstract
AIM Pathological states of recovery after coma as a result of a severe brain injury are marked with changes in structural connectivity of the brain. This study aimed to identify a topological correlation between white matter integrity and the level of functional and cognitive impairment in patients recovering after coma. METHODS Structural connectomes were computed based on fractional anisotropy maps from 40 patients using a probabilistic human connectome atlas. We used a network based statistics approach to identify potential brain networks associated with a more favorable outcome, assessed with clinical neurobehavioral scores at the patient's discharge from the acute neurorehabilitation unit. RESULTS We identified a subnetwork whose strength of connectivity correlated with a more favorable outcome as measured with the Disability Rating Scale (network based statistics: t >3.5, P =.010). The subnetwork predominated in the left hemisphere and included the thalamic nuclei, putamen, precentral and postcentral gyri, and medial parietal regions. Spearman correlation between the mean fractional anisotropy value of the subnetwork and the score was ρ = -0.60 (P <.0001). A less extensive overlapping subnetwork correlated with the Coma Recovery Scale Revised score, consisting mostly of the left hemisphere connectivity between the thalamic nuclei and pre- and post-central gyri (network based statistics: t >3.5, P =.033; Spearman's ρ = 0.58, P <.0001). CONCLUSION The present findings suggest an important role of structural connectivity between the thalamus, putamen and somatomotor cortex in the recovery from coma as evaluated with neurobehavioral scores. These structures are part of the motor circuit involved in the generation and modulation of voluntary movement, as well as the forebrain mesocircuit supposedly underlying the maintenance of consciousness. As behavioural assessment of consciousness depends heavily on the signs of voluntary motor behaviour, further work will elucidate whether the identified subnetwork reflects the structural architecture underlying the recovery of consciousness or rather the ability to communicate its content.
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Affiliation(s)
- Polona Pozeg
- Department of Radiology, Lausanne University Hospital and University of Lausanne (CHUV-UNIL), Lausanne 1011, Switzerland; Connectomics Lab, Department of Radiology, Lausanne University Hospital and University of Lausanne (CHUV-UNIL), Lausanne 1011, Switzerland
| | - Yasser Alemán-Goméz
- Department of Radiology, Lausanne University Hospital and University of Lausanne (CHUV-UNIL), Lausanne 1011, Switzerland; Connectomics Lab, Department of Radiology, Lausanne University Hospital and University of Lausanne (CHUV-UNIL), Lausanne 1011, Switzerland
| | - Jane Jöhr
- Neurology and Acute Neurorehabilitation Unit, Department of Clinical Neurosciences, Lausanne University Hospital and University of Lausanne (CHUV-UNIL), Lausanne 1011, Switzerland
| | - Dafin Muresanu
- Department of Neuroscience, Luliu Hatieganu University of Medicine and Pharmacy, Cluj-Napoca 400347, Romania
| | - Alessandro Pincherle
- Neurology Unit, Department of Medicine, Hôpitaux Robert Schuman, Luxembourg 2540, Luxembourg
| | - Philippe Ryvlin
- Laboratory of Cortical Excitability and Arousal Disorders, Department of Clinical Neurosciences, Lausanne University Hospital and University of Lausanne (CHUV-UNIL), Lausanne 1011, Switzerland
| | - Patric Hagmann
- Department of Radiology, Lausanne University Hospital and University of Lausanne (CHUV-UNIL), Lausanne 1011, Switzerland; Connectomics Lab, Department of Radiology, Lausanne University Hospital and University of Lausanne (CHUV-UNIL), Lausanne 1011, Switzerland
| | - Karin Diserens
- Neurology and Acute Neurorehabilitation Unit, Department of Clinical Neurosciences, Lausanne University Hospital and University of Lausanne (CHUV-UNIL), Lausanne 1011, Switzerland
| | - Vincent Dunet
- Department of Radiology, Lausanne University Hospital and University of Lausanne (CHUV-UNIL), Lausanne 1011, Switzerland.
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Ablat N, Ablimit M, Sun Y, Zhao X, Pu X. Application of new imaging methods in the development of Chinese medicine. Biomed Pharmacother 2022; 153:113470. [DOI: 10.1016/j.biopha.2022.113470] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2022] [Revised: 07/21/2022] [Accepted: 07/23/2022] [Indexed: 11/27/2022] Open
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7
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Schnakers C, Bauer C, Formisano R, Noé E, Llorens R, Lejeune N, Farisco M, Teixeira L, Morrissey AM, De Marco S, Veeramuthu V, Ilina K, Edlow BL, Gosseries O, Zandalasini M, De Bellis F, Thibaut A, Estraneo A. What names for covert awareness? A systematic review. Front Hum Neurosci 2022; 16:971315. [PMID: 35992948 PMCID: PMC9389234 DOI: 10.3389/fnhum.2022.971315] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2022] [Accepted: 07/15/2022] [Indexed: 12/14/2022] Open
Abstract
Background With the emergence of Brain Computer Interfaces (BCI), clinicians have been facing a new group of patients with severe acquired brain injury who are unable to show any behavioral sign of consciousness but respond to active neuroimaging or electrophysiological paradigms. However, even though well documented, there is still no consensus regarding the nomenclature for this clinical entity. Objectives This systematic review aims to 1) identify the terms used to indicate the presence of this entity through the years, and 2) promote an informed discussion regarding the rationale for these names and the best candidates to name this fascinating disorder. Methods The Disorders of Consciousness Special Interest Group (DoC SIG) of the International Brain Injury Association (IBIA) launched a search on Pubmed and Google scholar following PRISMA guidelines to collect peer-reviewed articles and reviews on human adults (>18 years) published in English between 2006 and 2021. Results The search launched in January 2021 identified 4,089 potentially relevant titles. After screening, 1,126 abstracts were found relevant. Finally, 161 manuscripts were included in our analyses. Only 58% of the manuscripts used a specific name to discuss this clinical entity, among which 32% used several names interchangeably throughout the text. We found 25 different names given to this entity. The five following names were the ones the most frequently used: covert awareness, cognitive motor dissociation, functional locked-in, non-behavioral MCS (MCS*) and higher-order cortex motor dissociation. Conclusion Since 2006, there has been no agreement regarding the taxonomy to use for unresponsive patients who are able to respond to active neuroimaging or electrophysiological paradigms. Developing a standard taxonomy is an important goal for future research studies and clinical translation. We recommend a Delphi study in order to build such a consensus.
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Affiliation(s)
- Caroline Schnakers
- Research Institute, Casa Colina Hospital and Centers for Healthcare, Pomona, CA, United States
- *Correspondence: Caroline Schnakers
| | - Chase Bauer
- College of Osteopathic Medicine, Western University of Health Sciences, Pomona, CA, United States
| | | | - Enrique Noé
- Vithas Neuro Rehab Human Brain, Fundación Hospitales Vithas, Valencia, Spain
| | - Roberto Llorens
- Vithas Neuro Rehab Human Brain, Fundación Hospitales Vithas, Valencia, Spain
- Neurorehabilitation and Brain Research Group, Instituto de Investigación e Innovación en Bioingeniería, Universitat Politècnica de València, Valencia, Spain
| | - Nicolas Lejeune
- Centre Hospitalier Neurologique William Lennox, Ottignies-Louvain-la-Neuve, Belgium
- GIGA-Consciousness, Coma Science Group, University of Liège, Liege, Belgium
| | - Michele Farisco
- Centre for Research Ethics and Bioethics, Uppsala University, Uppsala, Sweden
- Science and Society Unit, Biogem, Biology and Molecular Genetics Research Institute, Ariano Irpino, Italy
| | - Liliana Teixeira
- Center for Innovative Care and Health Technology, School of Health Sciences, Polytechnic of Leiria, Leiria, Portugal
| | - Ann-Marie Morrissey
- Ageing Research Centre, School of Allied Health, Health Research Institute, University of Limerick, Limerick, Ireland
| | - Sabrina De Marco
- Clínica Universitaria Reina Fabiola, Universidad Católica de Córdoba, Córdoba, Argentina
| | | | - Kseniya Ilina
- Research Center of Neurology, Moscow, Russia
- Faculty of Fundamental Medicine, Lomonosov Moscow State University, Moscow, Russia
| | - Brian L. Edlow
- Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
| | - Olivia Gosseries
- GIGA-Consciousness, Coma Science Group, University of Liège, Liege, Belgium
- Centre du Cerveau, University Hospital of Liege, Liege, Belgium
| | - Matteo Zandalasini
- Unità Spinale, Neuroriabilitazione e Medicina Riabilitativa Intensiva, Dipartimento di Medicina Riabilitativa, Azienda USL di Piacenza, Piacenza, Italy
| | | | - Aurore Thibaut
- GIGA-Consciousness, Coma Science Group, University of Liège, Liege, Belgium
- Centre du Cerveau, University Hospital of Liege, Liege, Belgium
| | - Anna Estraneo
- IRCCS Fondazione Don Carlo Gnocchi, Florence, Italy
- Neurology Unit, SM della Pietà General Hospital, Nola, Italy
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Affiliation(s)
- George A. Mashour
- From the Departments of Anesthesiology and Pharmacology, Center for Consciousness Science, Michigan Neuroscience Institute, Neuroscience Graduate Program, University of Michigan, Ann Arbor, Michigan
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Picozzi M, Panzeri L, Torri D, Sattin D. Analyzing the paradigmatic cases of two persons with a disorder of consciousness: reflections on the legal and ethical perspectives. BMC Med Ethics 2021; 22:88. [PMID: 34238274 PMCID: PMC8268180 DOI: 10.1186/s12910-021-00656-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2020] [Accepted: 06/30/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Media have increasingly reported on the difficulties associated with end-of-life decision-making in patients with Disorders of Consciousness (DOC), contextualizing such dilemma in detailed accounts of the patient's life. Two of the first stories debated in the scientific community were those related to the cases of two women, one American, the other Italian, who captured attention of millions of people in the first years of this third millennium. METHODS Much has been written about the challenges of surrogate decision-making for patients in DOC, but less has been written comparing these challenges across legal systems and cultures. In our paper, we propose a systematic analysis of the final legal documents written by the American and Italian Courts in relation to the two cases, developing our discussion around three areas: the level of certainty/reliability of diagnosis and prognosis, the reconstruction of self-expression, time of illness and time of care. They are examples of the typical issues discussed by legal authors and allow us to understand the link and the difference between the legal and ethical perspectives. RESULTS The legal approach to the two cases has some common elements: the need to be certain about the diagnosis and prognosis and the fact that the clinical criteria are necessary in determining the most appropriate treatments, although these criteria are not sufficient unless they are supplemented by the patient's will. The issue of relations takes on importance both from a legal and an ethical point of view, but from two different perspectives. While ethics safeguards relationships by guaranteeing their differences and makes them reconcilable, law safeguards relationships by guaranteeing the cold forms of respect, equality, impartiality, symmetry, reciprocity, and irreversibility. In this perspective, the link between the time of care and the decision of the family members assumes importance. CONCLUSIONS The most interesting point that emerges from our analysis is the issue of relationships and how they affect decisions, both from a legal and ethical point of view. For this reason, during the patients' hospitalization, it is necessary to identify ways in which they might give their opinion about the moral issues underlying their choices.
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Affiliation(s)
- Mario Picozzi
- Center for Clinical Ethics, Biotechnology and Life Sciences Department, University of Insubria, Varese, Italy.
- Clinical and Experimental Medicine and Medical Humanities-PhD Program, Via Ottorino Rossi 9, 21100, Varese, Italy.
| | - Lino Panzeri
- Department of Law, Economics and Cultures, University of Insubria, Via Sant'Abbondio 12, 22100, Como, Italy
| | - Davide Torri
- ASST Dei Sette Laghi - S.C. Medicina Legale, Viale Borri, 57, 21100, Varese, Italy
| | - Davide Sattin
- Clinical and Experimental Medicine and Medical Humanities-PhD Program, Via Ottorino Rossi 9, 21100, Varese, Italy
- Neurology Public Health and Disability Unit, Fondazione IRCCS Istituto Neurologico C. Besta, Via Celoria 11, 20133, Milan, Italy
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Pozeg P, Jöhr J, Pincherle A, Marie G, Ryvlin P, Meuli R, Hagmann P, Diserens K, Dunet V. Discriminating cognitive motor dissociation from disorders of consciousness using structural MRI. Neuroimage Clin 2021; 30:102651. [PMID: 33836454 PMCID: PMC8056460 DOI: 10.1016/j.nicl.2021.102651] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Revised: 03/12/2021] [Accepted: 03/26/2021] [Indexed: 11/18/2022]
Abstract
An accurate evaluation and detection of awareness after a severe brain injury is crucial to a patient's diagnosis, therapy, and end-of-life decisions. Misdiagnosis is frequent as behavior-based assessments often overlook subtle signs of consciousness. This study aimed to identify brain MRI characteristics of patients with residual consciousness after a severe brain injury and to develop a simple MRI-based scoring system according to the findings. We retrieved data from 128 patients and split them into a development or validation set. Structural brain MRIs were qualitatively assessed for lesions in 18 brain regions. We used logistic regression and support vector machine algorithms to first identify the most relevant brain regions predicting a patient's outcome in the development set. We next built a diagnostic MRI-based score and estimated its optimal diagnostic cut-off point. The classifiers were then tested on the validation set and their performance compared using the receiver operating characteristic curve. Relevant brain regions predicting negative outcome highly overlapped between both classifiers and included the left mesencephalon, right basal ganglia, right thalamus, right parietal cortex, and left frontal cortex. The support vector machine classifier showed higher accuracy (0.93, 95% CI: 0.81-0.96) and specificity (0.97, 95% CI: 0.85-1) than logistic regression (accuracy: 0.87, 95% CI: 0.73 - 0.95; specificity: 0.90, 95% CI: 0.75-0.97), but equal sensitivity (0.67, 95% CI: 0.24-0.94 and 0.22-0.96, respectively) for distinguishing patients with and without residual consciousness. The novel MRI-based score assessing brain lesions in patients with disorders of consciousness accurately detects patients with residual consciousness. It could complement valuably behavioral evaluation as it is time-efficient and requires only conventional MRI.
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Affiliation(s)
- Polona Pozeg
- Department of Radiology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Jane Jöhr
- Neurology and Acute Neurorehabilitation Unit, Department of Clinical Neurosciences, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Alessandro Pincherle
- Neurology and Acute Neurorehabilitation Unit, Department of Clinical Neurosciences, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland; Neurology Unit, Department of Medicine, Hopitaux Robert Schuman, Luxembourg, Luxembourg
| | - Guillaume Marie
- Department of Radiology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Philippe Ryvlin
- Neurology and Acute Neurorehabilitation Unit, Department of Clinical Neurosciences, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Reto Meuli
- Department of Radiology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Patric Hagmann
- Department of Radiology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Karin Diserens
- Neurology and Acute Neurorehabilitation Unit, Department of Clinical Neurosciences, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland.
| | - Vincent Dunet
- Department of Radiology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland.
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Chen T, Lu S, Qian P, Chen G, Hu N. An automatic detection method for 40-Hz auditory steady state response and its application in prognosis of comatose patients. Clin Neurophysiol 2020; 131:703-715. [PMID: 31991313 DOI: 10.1016/j.clinph.2020.01.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2018] [Revised: 12/03/2019] [Accepted: 01/01/2020] [Indexed: 12/16/2022]
Abstract
OBJECTIVE We proposed a 40-Hz auditory steady-state response (ASSR) automatic detection method, and studied the prognosis of comatose patients by combining the 40-Hz ASSR detection results of multiple paradigms of auditory stimulation. METHODS The 40-Hz ASSR elicitation experiments were carried out on 32 comatose patients, with the detection results used as prognosis predictors. To achieve automatic detection, the detection was modeled as a binary hypothesis test for a sinusoidal waveform with unknown amplitude and phase, based on the generalized likelihood ratio test (GLRT). The patients were followed up for 6 months, and each patient's outcome was classified as either favorable outcome (severe disability, moderate disability or good recovery) or unfavorable outcome (vegetative state/unresponsive wakefulness syndrome or death) according to the Glasgow outcome scale (GOS). The performance of the prognosis predictors was assessed using the area under the receiver operating characteristic curve (AUC-ROC). RESULTS The largest AUC in univariate analysis involving a single stimulation paradigm was 0.849, while the AUC obtained by combining multiple predictors was increased to 0.966. CONCLUSIONS For comatose patients, the absence of 40-Hz ASSR in multiple stimulation paradigms may indicate an unfavorable prognosis. Furthermore, the combination of multiple auditory stimulation paradigms may increase the outcome prediction accuracy. SIGNIFICANCE The combination of multi-paradigm 40-Hz ASSR automatic detection results may provide a feasible automatic outcome prediction method for comatose patients.
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Affiliation(s)
- Tingting Chen
- School of Electronic and Information Engineering, Soochow University, Suzhou, Jiangsu 215006, China
| | - Shiqi Lu
- Emergency Department, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu 215006, China
| | - Ping Qian
- Emergency Department, The First People's Hospital of Taicang, Taicang Affiliated Hospital of Soochow University, Taicang, Jiangsu 215400, China
| | - Guolin Chen
- Emergency Department, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu 215006, China
| | - Nan Hu
- School of Electronic and Information Engineering, Soochow University, Suzhou, Jiangsu 215006, China.
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Towards a Clinical Neuroethics for Brain Injury Practice: An Introduction to a New Special Feature for Ethics in JHTR. J Head Trauma Rehabil 2019; 33:283-284. [PMID: 29975255 DOI: 10.1097/htr.0000000000000416] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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13
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Pennartz CMA, Farisco M, Evers K. Indicators and Criteria of Consciousness in Animals and Intelligent Machines: An Inside-Out Approach. Front Syst Neurosci 2019; 13:25. [PMID: 31379521 PMCID: PMC6660257 DOI: 10.3389/fnsys.2019.00025] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2019] [Accepted: 06/24/2019] [Indexed: 01/02/2023] Open
Abstract
In today's society, it becomes increasingly important to assess which non-human and non-verbal beings possess consciousness. This review article aims to delineate criteria for consciousness especially in animals, while also taking into account intelligent artifacts. First, we circumscribe what we mean with "consciousness" and describe key features of subjective experience: qualitative richness, situatedness, intentionality and interpretation, integration and the combination of dynamic and stabilizing properties. We argue that consciousness has a biological function, which is to present the subject with a multimodal, situational survey of the surrounding world and body, subserving complex decision-making and goal-directed behavior. This survey reflects the brain's capacity for internal modeling of external events underlying changes in sensory state. Next, we follow an inside-out approach: how can the features of conscious experience, correlating to mechanisms inside the brain, be logically coupled to externally observable ("outside") properties? Instead of proposing criteria that would each define a "hard" threshold for consciousness, we outline six indicators: (i) goal-directed behavior and model-based learning; (ii) anatomic and physiological substrates for generating integrative multimodal representations; (iii) psychometrics and meta-cognition; (iv) episodic memory; (v) susceptibility to illusions and multistable perception; and (vi) specific visuospatial behaviors. Rather than emphasizing a particular indicator as being decisive, we propose that the consistency amongst these indicators can serve to assess consciousness in particular species. The integration of scores on the various indicators yields an overall, graded criterion for consciousness, somewhat comparable to the Glasgow Coma Scale for unresponsive patients. When considering theoretically derived measures of consciousness, it is argued that their validity should not be assessed on the basis of a single quantifiable measure, but requires cross-examination across multiple pieces of evidence, including the indicators proposed here. Current intelligent machines, including deep learning neural networks (DLNNs) and agile robots, are not indicated to be conscious yet. Instead of assessing machine consciousness by a brief Turing-type of test, evidence for it may gradually accumulate when we study machines ethologically and across time, considering multiple behaviors that require flexibility, improvisation, spontaneous problem-solving and the situational conspectus typically associated with conscious experience.
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Affiliation(s)
- Cyriel M. A. Pennartz
- Department of Cognitive and Systems Neuroscience, Swammerdam Institute for Life Sciences, University of Amsterdam, Amsterdam, Netherlands
- Research Priority Area, Brain and Cognition, University of Amsterdam, Amsterdam, Netherlands
| | - Michele Farisco
- Centre for Research Ethics and Bioethics, Uppsala University, Uppsala, Sweden
- Biogem, Biology and Molecular Genetics Institute, Ariano Irpino, Italy
| | - Kathinka Evers
- Centre for Research Ethics and Bioethics, Uppsala University, Uppsala, Sweden
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Berlucchi G. Wandering thoughts about consciousness, the brain, and the commentary system of Larry Weiskrantz. Neuropsychologia 2019; 128:266-269. [DOI: 10.1016/j.neuropsychologia.2017.10.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2017] [Revised: 10/06/2017] [Accepted: 10/08/2017] [Indexed: 11/15/2022]
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Hauger SL, Schanke AK, Andersson S, Chatelle C, Schnakers C, Løvstad M. The Clinical Diagnostic Utility of Electrophysiological Techniques in Assessment of Patients With Disorders of Consciousness Following Acquired Brain Injury: A Systematic Review. J Head Trauma Rehabil 2018; 32:185-196. [PMID: 27831962 DOI: 10.1097/htr.0000000000000267] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
OBJECTIVE To investigate the diagnostic utility of electrophysiological recordings during active cognitive tasks in detecting residual cognitive capacities in patients with disorders of consciousness (DoC) after severe acquired brain injury. DESIGN Systematic review of empirical research in MEDLINE, Embase, PsycINFO, and Cochrane from January 2002 to March 2016. MAIN MEASURES Data extracted included sample size, type of electrophysiological technique and task design, rate of cognitive responders, false negatives and positives, and excluded subjects from the study analysis. The Quality Assessment of Diagnostic Accuracy Studies-2 (QUADAS-2) was used for quality appraisal of the retrieved literature. RESULTS Twenty-four studies examining electrophysiological signs of command-following in patients with DoC were identified. Sensitivity rates in healthy controls demonstrated variable accuracy across the studies, ranging from 71% to 100%. In patients with DoC, specificity and sensitivity rates varied in the included studies, ranging from 0% to 100%. Pronounced heterogeneity was found between studies regarding methodological approaches, task design, and procedures of analysis, rendering comparison between studies challenging. CONCLUSION We are still far from establishing precise recommendations for standardized electrophysiological diagnostic procedures in DoC, but electrophysiological methods may add supplemental diagnostic information of covert cognition in some patients with DoC.
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Affiliation(s)
- S L Hauger
- Department of Research, Sunnaas Rehabilitation Hospital, Norway (Mrs Hauger and Drs Løvstad and Schanke); Department of Psychology, University of Oslo, Oslo, Norway (Drs Andersson, Løvstad, and Schanke); Laboratory for NeuroImaging of Coma and Consciousness, Massachusetts General Hospital, Boston, and Acute Neurorehabilitation Unit, Department of Clinical Neurosciences, University Hospital of Lausanne, Switzerland (Dr Chatelle); and Department of Neurosurgery, University of California, Los Angeles (Dr Schnakers)
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Do ICP-Derived Parameters Differ in Vegetative State from Other Outcome Groups After Traumatic Brain Injury? ACTA NEUROCHIRURGICA. SUPPLEMENT 2018. [PMID: 29492524 DOI: 10.1007/978-3-319-65798-1_4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register]
Abstract
OBJECTIVE In nearly 1,000 traumatic brain injury (TBI) patients monitored in the years 1992-2014, we identified 18 vegetative state (VS) cases. Our database provided access to continuous computer-recorded signals, which we used to compare primary signals, intracranial pressure (ICP)-derived indices and demographic data between VS patients, patients who survived but who were not VS (S), and patients who died (D). METHOD Mean values of ICP, arterial blood pressure (ABP) and cerebral perfusion pressure (CPP) from the whole monitoring periods were compared between the different outcome groups. Secondary indices included pressure reactivity index (PRx), the magnitude of slow ICP vasogenic waves, the pulse amplitude of the first harmonic component of the ICP waveform and heart rate (HR). RESULTS Mean blood pressure was lowest in the VS group-significantly in comparison to those who died (p = 0.02) and almost significantly (p = 0.1) in comparison to the patients who survived. Mean ICP in VS patients was lower than those who died (VS, 13 ± 5 mmHg; D, 22 ± 14 mmHg; p < 0.001), but not significantly different from those who survived (p > 0.05). The magnitude of slow vasogenic ICP waves was the same in VS patients and those who died, but significantly lower than in those who survived (S, 1.04 ± 0.57 mmHg; VS, 0.74 ± 0.45; p = 0.01). CONCLUSION Patients who progress to a VS differ from non-VS survivors in displaying decreased power of slow vasogenic waves and from those who die by not experiencing as high a burden of intracranial hypertension.
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Bailey J, Pereira S. Advances in neuroscience imply that harmful experiments in dogs are unethical. JOURNAL OF MEDICAL ETHICS 2018; 44:47-52. [PMID: 28739639 PMCID: PMC5749309 DOI: 10.1136/medethics-2016-103630] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 04/18/2016] [Revised: 05/18/2017] [Accepted: 06/09/2017] [Indexed: 06/07/2023]
Abstract
Functional MRI (fMRI) of fully awake and unrestrained dog 'volunteers' has been proven an effective tool to understand the neural circuitry and functioning of the canine brain. Although every dog owner would vouch that dogs are perceptive, cognitive, intuitive and capable of positive emotions/empathy, as indeed substantiated by ethological studies for some time, neurological investigations now corroborate this. These studies show that there exists a striking similarity between dogs and humans in the functioning of the caudate nucleus (associated with pleasure and emotion), and dogs experience positive emotions, empathic-like responses and demonstrate human bonding which, some scientists claim, may be at least comparable with human children. There exists an area analogous to the 'voice area' in the canine brain, enabling dogs to comprehend and respond to emotional cues/valence in human voices, and evidence of a region in the temporal cortex of dogs involved in the processing of faces, as also observed in humans and monkeys. We therefore contend that using dogs in invasive and/or harmful research, and toxicity testing, cannot be ethically justifiable.
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Chandler JA, Sun JA, Racine E. Online public reactions to fMRI communication with patients with disorders of consciousness: Quality of life, end-of-life decision making, and concerns with misdiagnosis. AJOB Empir Bioeth 2017; 8:40-51. [PMID: 28949872 DOI: 10.1080/23294515.2016.1226199] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
BACKGROUND Recently, the news media have reported on the discovery of covert awareness and the establishment of limited communication using a functional magnetic resonance imaging (fMRI) neuroimaging technique with several brain-injured patients thought to have been in a vegetative state. This discovery has raised many ethical, legal, and social questions related to quality of life, end-of-life decision making, diagnostic and prognostic accuracy in disorders of consciousness, resource allocation, and other issues. This project inquires into the public responses to these discoveries. METHODS We conducted a thematic analysis of online comments (n = 779) posted in response to 15 news articles and blog posts regarding the case of a Canadian patient diagnosed for 12 years as in a vegetative state, but who was reported in 2012 as having been able to communicate via fMRI. The online comments were coded using an iteratively refined codebook structured around 14 main themes. RESULTS Among the most frequent public reactions revealed in the online comments were discussions of the quality of life of patients with disorders of consciousness, whether life-sustaining treatment should be withdrawn (and whether the fMRI communication technique should be used to ask patients about this), and misgivings about the accuracy of diagnosis in disorders of consciousness and brain death. CONCLUSIONS These public perspectives are relevant to the obligations of clinicians, lawyers, and public policymakers to patients, families, and the public. Future work should consider how best to alleviate families' concerns as this type of research shakes their faith in diagnostic accuracy, to clarify the legal rules relating to advance directives in this context, and to address the manner in which public messaging might help to alleviate any indirect impact on confidence in the organ donation system.
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Affiliation(s)
| | | | - Eric Racine
- b Institut de Recherches Cliniques de Montreal (IRCM) , Neuroethics Research Unit
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