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Colomer C, Llorens R, Navarro MD, Noé E, Ferri J. Neurobehavioral Progress and Signs of Transition in Children With Prolonged Disorders of Consciousness: A Retrospective Longitudinal Study With the Coma Recovery Scale-Revised. Pediatr Neurol 2024; 155:187-192. [PMID: 38677241 DOI: 10.1016/j.pediatrneurol.2024.03.029] [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: 03/15/2023] [Revised: 05/05/2023] [Accepted: 03/31/2024] [Indexed: 04/29/2024]
Abstract
BACKGROUND Research on disorders of consciousness in children is scarce and includes disparate and barely comparable participants and assessment instruments and therefore provides inconclusive information on the clinical progress and recovery in this population. This study retrospectively investigated the neurobehavioral progress and the signs of transition between states of consciousness in a group of children admitted to a rehabilitation program either with an unresponsive wakefulness syndrome (UWS) or in a minimally conscious state (MCS). METHODS Systematic weekly assessments were conducted with the Coma Recovery Scale-Revised (CRS-R) until emergence from MCS, discharge, or death. RESULTS Twenty-one children, nine admitted with a UWS and 12 admitted in an MCS, were included in the study. Four children with a UWS transitioned to an MCS with a CRS-R of 10 (9.2 to 12.2) by showing visual pursuit, visual fixation, or localization to noxious stimulation. Twelve children emerged from the MCS with a CRS-R of 20.5 (19 to 21.7). Children who emerged from the MCS had had a shorter time postinjury and higher CRS-R at admission, compared with those who did not emerge. CONCLUSIONS Almost half of the children who were admitted with a UWS transitioned to an MCS, and almost all who were admitted in an MCS emerged from this state. Children who emerged had shorter times since injury and higher scores on the CRS-R at admission, compared with those who did not emerge.
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Affiliation(s)
- Carolina Colomer
- IRENEA, Instituto de Rehabilitación Neurológica, Fundación Hospitales Vithas, València, Spain.
| | - Roberto Llorens
- IRENEA, Instituto de Rehabilitación Neurológica, Fundación Hospitales Vithas, València, Spain; Neurorehabilitation and Brain Research Group, Institute for Human-Centered Technology Research, Universitat Politècnica de València, València, Spain
| | - María Dolores Navarro
- IRENEA, Instituto de Rehabilitación Neurológica, Fundación Hospitales Vithas, València, Spain
| | - Enrique Noé
- IRENEA, Instituto de Rehabilitación Neurológica, Fundación Hospitales Vithas, València, Spain
| | - Joan Ferri
- IRENEA, Instituto de Rehabilitación Neurológica, Fundación Hospitales Vithas, València, Spain
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Campagnini S, Llorens R, Navarro MD, Colomer C, Mannini A, Estraneo A, Ferri J, Noé E. Which information derived from the Coma Recovery Scale-Revised provides the most reliable prediction of clinical diagnosis and recovery of consciousness? A comparative study using machine learning techniques. Eur J Phys Rehabil Med 2024; 60:190-197. [PMID: 38193722 PMCID: PMC11114154 DOI: 10.23736/s1973-9087.23.08093-0] [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: 06/15/2023] [Revised: 11/09/2023] [Accepted: 11/29/2023] [Indexed: 01/10/2024]
Abstract
BACKGROUND The Coma Recovery Scale-Revised (CRS-R) is the most recommended clinical tool to examine the neurobehavioral condition of individuals with disorders of consciousness (DOCs). Different studies have investigated the prognostic value of the information provided by the conventional administration of the scale, while other measures derived from the scale have been proposed to improve the prognosis of DOCs. However, the heterogeneity of the data used in the different studies prevents a reliable comparison of the identified predictors and measures. AIM This study investigates which information derived from the CRS-R provides the most reliable prediction of both the clinical diagnosis and recovery of consciousness at the discharge of a long-term neurorehabilitation program. DESIGN Retrospective observational multisite study. SETTING The enrollment was performed in three neurorehabilitation facilities of the same hospital network. POPULATION A total of 171 individuals with DOCs admitted to an inpatient neurorehabilitation program for a minimum of 3 months were enrolled. METHODS Machine learning classifiers were trained to predict the clinical diagnosis and recovery of consciousness at discharge using clinical confounders and different metrics extracted from the CRS-R scale. RESULTS Results showed that the neurobehavioral state at discharge was predicted with acceptable and comparable predictive value with all the indices and measures derived from the CRS-R, but for the clinical diagnosis and the Consciousness Domain Index, and the recovery of consciousness was predicted with higher accuracy and similarly by all the investigated measures, with the exception of initial clinical diagnosis. CONCLUSIONS Interestingly, the total score in the CRS-R and, especially, the total score in its subscales provided the best overall results, in contrast to the clinical diagnosis, which could indicate that a comprehensive measure of the clinical diagnosis rather than the condition of the individuals could provide a more reliable prediction of the neurobehavioral progress of individuals with prolonged DOC. CLINICAL REHABILITATION IMPACT The results of this work have important implications in clinical practice, offering a more accurate prognosis of patients and thus giving the possibility to personalize and optimize the rehabilitation plan of patients with DoC using low-cost and easily collectable information.
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Affiliation(s)
| | - Roberto Llorens
- Neurorehabilitation and Brain Research Group, Institute for Human-Centered Technology Research, Polytechnic University of Valencia, Valencia, Spain -
| | - M Dolores Navarro
- IRENEA Instituto de Rehabilitación Neurológica, Vithas Foundation, Valencia, Spain
| | - Carolina Colomer
- IRENEA Instituto de Rehabilitación Neurológica, Vithas Foundation, Valencia, Spain
| | - Andrea Mannini
- IRCCS Fondazione Don Carlo Gnocchi onlus, Florence, Italy
| | - Anna Estraneo
- IRCCS Fondazione Don Carlo Gnocchi onlus, Florence, Italy
| | - Joan Ferri
- IRENEA Instituto de Rehabilitación Neurológica, Vithas Foundation, Valencia, Spain
| | - Enrique Noé
- IRENEA Instituto de Rehabilitación Neurológica, Vithas Foundation, Valencia, Spain
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Llorens R, Ippoliti C, Navarro MD, Colomer C, Maza A, Goizueta S, Olaya J, Moliner B, Ferri J, Noé E. Minimally conscious state plus versus minus: Likelihood of emergence and long-term functional independence. Ann Clin Transl Neurol 2024; 11:719-728. [PMID: 38366789 DOI: 10.1002/acn3.51993] [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] [Received: 07/31/2023] [Revised: 12/07/2023] [Accepted: 01/01/2024] [Indexed: 02/18/2024] Open
Abstract
OBJECTIVE Severe brain injuries can result in disorders of consciousness, such as the Minimally Conscious State (MCS), where individuals display intermittent yet discernible signs of conscious awareness. The varied levels of responsiveness and awareness observed in this state have spurred the progressive delineation of two subgroups within MCS, termed "plus" (MCS+) and "minus" (MCS-). However, the clinical validity of these classifications remains uncertain. This study aimed to investigate and compare the likelihood of emergence from MCS, as well as the functional independence after emergence, in individuals categorized as in MCS+ and MCS-. METHODS Demographic and behavioral data of 80 participants, admitted as either in MCS+ (n = 30) or MCS- (n = 50) to a long-term neurorehabilitation unit, were retrospectively analyzed. The neurobehavioral condition of each participant was evaluated weekly until discharge, demise, or emergence from MCS. The functional independence of those participants who emerged from MCS was assessed 6 months after emergence. RESULTS While only about half of the individuals classified as in MCS- (n = 24) emerged from the MCS, all those admitted as in MCS+ did, and in a shorter postinjury period. Despite these differences, all individuals who emerged from the MCS demonstrated similar high disability and low functional independence 6 months after emergence, regardless of their state at admission. INTERPRETATION Individuals classified as MCS+ exhibited a higher likelihood of emergence and a shorter time to emergence compared to those in MCS-. However, the level of functional independence 6 months after emergence was found to be unrelated to the initial state at admission.
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Affiliation(s)
- Roberto Llorens
- Neurorehabilitation and Brain Research Group, Universitat Politècnica de València, València, Spain
| | - Camilla Ippoliti
- SC Neurologia, Salute Pubblica, Disabilità - Fondazione IRCCS Istituto Neurologico Carlo Besta, Milano, Italy
| | | | - Carolina Colomer
- IRENEA, Instituto de Rehabilitación Neurológica, Fundación Vithas, València, Spain
| | - Anny Maza
- Neurorehabilitation and Brain Research Group, Universitat Politècnica de València, València, Spain
| | - Sandra Goizueta
- Neurorehabilitation and Brain Research Group, Universitat Politècnica de València, València, Spain
| | - José Olaya
- IRENEA, Instituto de Rehabilitación Neurológica, Fundación Vithas, València, Spain
| | - Belén Moliner
- IRENEA, Instituto de Rehabilitación Neurológica, Fundación Vithas, València, Spain
| | - Joan Ferri
- IRENEA, Instituto de Rehabilitación Neurológica, Fundación Vithas, València, Spain
| | - Enrique Noé
- IRENEA, Instituto de Rehabilitación Neurológica, Fundación Vithas, València, Spain
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Riganello F, Vatrano M, Cortese MD, Tonin P, Soddu A. Central autonomic network and early prognosis in patients with disorders of consciousness. Sci Rep 2024; 14:1610. [PMID: 38238457 PMCID: PMC10796939 DOI: 10.1038/s41598-024-51457-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2023] [Accepted: 01/05/2024] [Indexed: 01/22/2024] Open
Abstract
The central autonomic network (CAN) plays a crucial role in modulating the autonomic nervous system. Heart rate variability (HRV) is a valuable marker for assessing CAN function in disorders of consciousness (DOC) patients. We used HRV analysis for early prognosis in 58 DOC patients enrolled within ten days of hospitalization. They underwent a five-minute electrocardiogram during baseline and acoustic/visual stimulation. The coma recovery scale-revised (CRS-R) was used to define the patient's consciousness level and categorize the good/bad outcome at three months. The high-frequency Power Spectrum Density and the standard deviation of normal-to-normal peaks in baseline, the sample entropy during the stimulation, and the time from injury features were used in the support vector machine analysis (SVM) for outcome prediction. The SVM predicted the patients' outcome with an accuracy of 96% in the training test and 100% in the validation test, underscoring its potential to provide crucial clinical information about prognosis.
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Affiliation(s)
- Francesco Riganello
- Reseach in Advanced Neurorehabilitation, S. Anna Institute, 88900, Crotone, Italy.
| | - Martina Vatrano
- Reseach in Advanced Neurorehabilitation, S. Anna Institute, 88900, Crotone, Italy
| | | | - Paolo Tonin
- Reseach in Advanced Neurorehabilitation, S. Anna Institute, 88900, Crotone, Italy
| | - Andrea Soddu
- Physics & Astronomy Department and Western Institute for Neuroscience, University of Western Ontario, London, ON, Canada
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Snider SB, Temkin NR, Barber J, Edlow BL, Giacino JT, Hammond FM, Izzy S, Kowalski RG, Markowitz AJ, Rovito CA, Shih SL, Zafonte RD, Manley GT, Bodien YG. Predicting Functional Dependency in Patients with Disorders of Consciousness: A TBI-Model Systems and TRACK-TBI Study. Ann Neurol 2023; 94:1008-1023. [PMID: 37470289 PMCID: PMC10799195 DOI: 10.1002/ana.26741] [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: 03/28/2023] [Revised: 06/27/2023] [Accepted: 06/29/2023] [Indexed: 07/21/2023]
Abstract
OBJECTIVE It is not currently possible to predict long-term functional dependency in patients with disorders of consciousness (DoC) after traumatic brain injury (TBI). Our objective was to fit and externally validate a prediction model for 1-year dependency in patients with DoC ≥ 2 weeks after TBI. METHODS We included adults with TBI enrolled in TBI Model Systems (TBI-MS) or Transforming Research and Clinical Knowledge in TBI (TRACK-TBI) studies who were not following commands at rehabilitation admission or 2 weeks post-injury, respectively. We fit a logistic regression model in TBI-MS and validated it in TRACK-TBI. The primary outcome was death or dependency at 1 year post-injury, defined using the Disability Rating Scale. RESULTS In the TBI-MS Discovery Sample, 1,960 participants (mean age 40 [18] years, 76% male, 68% white) met inclusion criteria, and 406 (27%) were dependent 1 year post-injury. In a TBI-MS held out cohort, the dependency prediction model's area under the receiver operating characteristic curve was 0.79 (95% CI 0.74-0.85), positive predictive value was 53% and negative predictive value was 86%. In the TRACK-TBI external validation (n = 124, age 40 [16] years, 77% male, 81% white), the area under the receiver operating characteristic curve was 0.66 (0.53, 0.79), equivalent to the standard IMPACTcore + CT score (p = 0.8). INTERPRETATION We developed a 1-year dependency prediction model using the largest existing cohort of patients with DoC after TBI. The sensitivity and negative predictive values were greater than specificity and positive predictive values. Accuracy was diminished in an external sample, but equivalent to the IMPACT model. Further research is needed to improve dependency prediction in patients with DoC after TBI. ANN NEUROL 2023;94:1008-1023.
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Affiliation(s)
- Samuel B. Snider
- Division of Neurocritical Care, Department of Neurology, Brigham and Women’s Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Nancy R. Temkin
- Department of Neurological Surgery, University of Washington, Seattle, Washington, USA
- Department of Biostatistics, University of Washington, Seattle, Washington, USA
| | - Jason Barber
- Department of Neurological Surgery, University of Washington, Seattle, Washington, USA
| | - Brian L. Edlow
- Harvard Medical School, Boston, MA, USA
- Center for Neurotechnology and Neurorecovery and Department of Neurology, Massachusetts General Hospital, Boston, MA, USA
- Athinoula A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital, Charlestown, MA, USA
| | - Joseph T. Giacino
- Harvard Medical School, Boston, MA, USA
- Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Boston, MA USA
| | - Flora M. Hammond
- Department of Physical Medicine and Rehabilitation, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Saef Izzy
- Division of Neurocritical Care, Department of Neurology, Brigham and Women’s Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Robert G. Kowalski
- Departments of Neurosurgery and Neurology, University of Colorado School of Medicine, Aurora CO, USA
| | | | - Craig A. Rovito
- Harvard Medical School, Boston, MA, USA
- Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Boston, MA USA
| | - Shirley L. Shih
- Harvard Medical School, Boston, MA, USA
- Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Boston, MA USA
| | - Ross D. Zafonte
- Harvard Medical School, Boston, MA, USA
- Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Boston, MA USA
| | - Geoffrey T. Manley
- Department of Neurological Surgery, UCSF, San Francisco, CA USA
- Brain and Spinal Cord Injury Center, Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, CA USA
| | - Yelena G. Bodien
- Harvard Medical School, Boston, MA, USA
- Center for Neurotechnology and Neurorecovery and Department of Neurology, Massachusetts General Hospital, Boston, MA, USA
- Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Boston, MA USA
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Carlson JM, Lin DJ. Prognostication in Prolonged and Chronic Disorders of Consciousness. Semin Neurol 2023; 43:744-757. [PMID: 37758177 DOI: 10.1055/s-0043-1775792] [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: 10/03/2023]
Abstract
Patients with prolonged disorders of consciousness (DOCs) longer than 28 days may continue to make significant gains and achieve functional recovery. Occasionally, this recovery trajectory may extend past 3 (for nontraumatic etiologies) and 12 months (for traumatic etiologies) into the chronic period. Prognosis is influenced by several factors including state of DOC, etiology, and demographics. There are several testing modalities that may aid prognostication under active investigation including electroencephalography, functional and anatomic magnetic resonance imaging, and event-related potentials. At this time, only one treatment (amantadine) has been routinely recommended to improve functional recovery in prolonged DOC. Given that some patients with prolonged or chronic DOC have the potential to recover both consciousness and functional status, it is important for neurologists experienced in prognostication to remain involved in their care.
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Affiliation(s)
- Julia M Carlson
- Division of Neurocritical Care, Department of Neurology, University of North Carolina Hospital, University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - David J Lin
- Center for Neurotechnology and Neurorecovery, Division of Neurocritical Care and Stroke Service, Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
- Center for Neurorestoration and Neurotechnology, Rehabilitation Research and Development Service, Department of Veterans Affairs, Providence, Rhode Island
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Onami S, Tran D, Koh-Pham C, Shih W, Chi B, Peng J, Shavlik D, Singh P, Giacino J. Coma Recovery Scale-Revised Predicts Disability Rating Scale in Acute Rehabilitation of Severe Traumatic Brain Injury. Arch Phys Med Rehabil 2023; 104:1054-1061. [PMID: 36736600 PMCID: PMC10404472 DOI: 10.1016/j.apmr.2023.01.007] [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: 05/26/2022] [Revised: 12/19/2022] [Accepted: 01/04/2023] [Indexed: 02/03/2023]
Abstract
OBJECTIVE To explore the prognostic value of the Coma Recovery Scale-Revised (CRS-R) in predicting disability outcomes in patients with severe traumatic brain injury using the Disability Rating Scale (DRS). DESIGN Secondary analysis including linear and logistic regressions were performed. SETTING Data were collected in a previous clinical trial. PARTICIPANTS One hundred eighty-four participants across 3 countries (N=184). MAIN OUTCOME MEASURES Disability Rating Scales. RESULTS Analyses showed an inverse relation between CRS-R scores obtained at baseline and change in DRS scores at 6 weeks. Similarly, changes in CRS-R scores between baseline and 4 weeks were also found to have an inverse relation to change in DRS scores at 6 weeks. CONCLUSIONS This study generates a tool that can be used to predict the probability that a patient with severe traumatic brain injury lands in 1 of 3 disability categories. The CRS-R may be useful in prognostication of disability in patients with severe traumatic brain injury.
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Affiliation(s)
- Susan Onami
- Physical Medicine & Rehabilitation, Loma Linda University, Loma Linda, CA
| | - Duc Tran
- Physical Medicine & Rehabilitation, Loma Linda University, Loma Linda, CA
| | - Christine Koh-Pham
- Physical Medicine & Rehabilitation, Loma Linda University, Loma Linda, CA.
| | - Wendy Shih
- Research Consulting Group, Loma Linda University School of Public Health, Loma Linda, CA
| | - Bradley Chi
- Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY
| | - Jiahao Peng
- Research Consulting Group, Loma Linda University School of Public Health, Loma Linda, CA
| | - David Shavlik
- Research Consulting Group, Loma Linda University School of Public Health, Loma Linda, CA
| | - Pramil Singh
- Research Consulting Group, Loma Linda University School of Public Health, Loma Linda, CA
| | - Joseph Giacino
- Physical Medicine & Rehabilitation, Spaulding Rehabilitation Hospital, Charleston, MA
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Snider SB, Temkin NR, Barber J, Edlow BL, Giacino JT, Hammond FM, Izzy S, Kowalski RG, Markowitz AJ, Rovito CA, Shih SL, Zafonte RD, Manley GT, Bodien YG. Predicting Functional Dependency in Patients with Disorders of Consciousness: A TBI-Model Systems and TRACK-TBI Study. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2023:2023.03.14.23287249. [PMID: 36993195 PMCID: PMC10055467 DOI: 10.1101/2023.03.14.23287249] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/19/2023]
Abstract
Importance There are currently no models that predict long-term functional dependency in patients with disorders of consciousness (DoC) after traumatic brain injury (TBI). Objective Fit, test, and externally validate a prediction model for 1-year dependency in patients with DoC 2 or more weeks after TBI. Design Secondary analysis of patients enrolled in TBI Model Systems (TBI-MS, 1988-2020, Discovery Sample) or Transforming Research and Clinical Knowledge in TBI (TRACK-TBI, 2013-2018, Validation Sample) and followed 1-year post-injury. Setting Multi-center study at USA rehabilitation hospitals (TBI-MS) and acute care hospitals (TRACK-TBI). Participants Adults with TBI who were not following commands at rehabilitation admission (TBI-MS; days post-injury vary) or 2-weeks post-injury (TRACK-TBI). Exposures In the TBI-MS database (model fitting and testing), we screened demographic, radiological, clinical variables, and Disability Rating Scale (DRS) item scores for association with the primary outcome. Main Outcome The primary outcome was death or complete functional dependency at 1-year post-injury, defined using a DRS-based binary measure (DRS Depend ), indicating need for assistance with all activities and concomitant cognitive impairment. Results In the TBI-MS Discovery Sample, 1,960 subjects (mean age 40 [18] years, 76% male, 68% white) met inclusion criteria and 406 (27%) were dependent at 1-year post-injury. A dependency prediction model had an area under the receiver operating characteristic curve (AUROC) of 0.79 [0.74, 0.85], positive predictive value of 53%, and negative predictive value of 86% for dependency in a held-out TBI-MS Testing cohort. Within the TRACK-TBI external validation sample (N=124, age 40 [16], 77% male, 81% white), a model modified to remove variables not collected in TRACK-TBI, had an AUROC of 0.66 [0.53, 0.79], equivalent to the gold-standard IMPACT core+CT score (0.68; 95% AUROC difference CI: -0.2 to 0.2, p=0.8). Conclusions and Relevance We used the largest existing cohort of patients with DoC after TBI to develop, test and externally validate a prediction model of 1-year dependency. The model’s sensitivity and negative predictive value were greater than specificity and positive predictive value. Accuracy was diminished in an external sample, but equivalent to the best-available models. Further research is needed to improve dependency prediction in patients with DoC after TBI.
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Mélotte E, Maudoux A, Panda R, Kaux JF, Lagier A, Herr R, Belorgeot M, Laureys S, Gosseries O. Links Between Swallowing and Consciousness: A Narrative Review. Dysphagia 2023; 38:42-64. [PMID: 35773497 DOI: 10.1007/s00455-022-10452-2] [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: 03/30/2021] [Accepted: 12/06/2021] [Indexed: 01/27/2023]
Abstract
This literature review explores a wide range of themes addressing the links between swallowing and consciousness. Signs of consciousness are historically based on the principle of differentiating reflexive from volitional behaviors. We show that the sequencing of the components of swallowing falls on a continuum of voluntary to reflex behaviors and we describe several types of volitional and non-volitional swallowing tasks. The frequency, speed of initiation of the swallowing reflex, efficacy of the pharyngeal phase of swallowing and coordination between respiration and swallowing are influenced by the level of consciousness during non-pathological modifications of consciousness such as sleep and general anesthesia. In patients with severe brain injury, the level of consciousness is associated with several components related to swallowing, such as the possibility of extubation, risk of pneumonia, type of feeding or components directly related to swallowing such as oral or pharyngeal abnormalities. Based on our theoretical and empirical analysis, the efficacy of the oral phase and the ability to receive exclusive oral feeding seem to be the most robust signs of consciousness related to swallowing in patients with disorders of consciousness. Components of the pharyngeal phase (in terms of abilities of saliva management) and evoked cough may be influenced by consciousness, but further studies are necessary to determine if they constitute signs of consciousness as such or only cortically mediated behaviors. This review also highlights the critical lack of tools and techniques to assess and treat dysphagia in patients with disorders of consciousness.
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Affiliation(s)
- Evelyne Mélotte
- Coma Science Group, GIGA-Consciousness, University of Liège, Liège, Belgium.
- Physical and Rehabilitation Medicine Department, University and University Hospital of Liège, Avenue de l'Hopital 1, 4000, Liège, Belgium.
- Centre du Cerveau², University Hospital of Liège, Liège, Belgium.
| | - Audrey Maudoux
- Sensation and Perception Research Group, GIGA, University and University Hospital of Liège, Liège, Belgium
- Otorhinolaryngology Head and Neck Surgery Department, Robert Debré University Hospital, APHP, Paris, France
| | - Rajanikant Panda
- Coma Science Group, GIGA-Consciousness, University of Liège, Liège, Belgium
| | - Jean-François Kaux
- Physical and Rehabilitation Medicine Department, University and University Hospital of Liège, Avenue de l'Hopital 1, 4000, Liège, Belgium
| | - Aude Lagier
- Otorhinolaryngology Head and Neck Surgery Department, University Hospital of Liège, Liège, Belgium
| | - Roxanne Herr
- Department of Speech and Language Pathology, Faculty of Medicine, University of Strasbourg, Strasbourg, France
| | - Marion Belorgeot
- Physical and Rehabilitation Medicine Department, University Hospital of Nîmes, Nîmes, France
| | - Steven Laureys
- Coma Science Group, GIGA-Consciousness, University of Liège, Liège, Belgium
- Centre du Cerveau², University Hospital of Liège, Liège, Belgium
| | - Olivia Gosseries
- Coma Science Group, GIGA-Consciousness, University of Liège, Liège, Belgium
- Centre du Cerveau², University Hospital of Liège, Liège, Belgium
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Crumlish L, Wallace SJ, Copley A, Rose TA. Exploring the measurement of pediatric cognitive-communication disorders in traumatic brain injury research: A scoping review. Brain Inj 2022; 36:1207-1227. [PMID: 36303459 DOI: 10.1080/02699052.2022.2111026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
OBJECTIVE To synthesize information about the constructs measured, measurement instruments used, and the timing of assessment of cognitive-communication disorders (CCDs) in pediatric traumatic brain injury (TBI) research. METHODS AND PROCEDURES Scoping review conducted in alignment with Arksey and O'Malley's five-stage methodological framework and reported per the PRISMA extension for Scoping Reviews. Inclusion criteria: (a) cohort description, case-control, and treatment studies; (b) participants with TBI aged 5-18 years; (c) communication or psychosocial outcomes; and (d) English full-text journal articles. The first author reviewed all titles, abstracts, and full-text articles; 10% were independently reviewed. OUTCOMES AND RESULTS Following screening, a total of 687 articles were included and 919 measurement instruments, measuring 2134 unique constructs, were extracted. The Child Behavior Checklist was the most used measurement instrument and 'Global Outcomes/Recovery' was the construct most frequently measured. The length of longitudinal monitoring ranged between ≤3 months and 16 years. CONCLUSIONS AND IMPLICATIONS We found considerable heterogeneity in the constructs measured, the measurement instruments used, and the timing of CCD assessment in pediatric TBI research. A consistent approach to measurement may support clinical decision-making and the efficient use of data beyond individual studies in systematic reviews and meta-analyses.
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Affiliation(s)
- Lauren Crumlish
- School of Health and Rehabilitation Sciences, The University of Queensland, Brisbane, Australia
| | - Sarah J Wallace
- School of Health and Rehabilitation Sciences, The University of Queensland, Brisbane, Australia.,Queensland Aphasia Research Centre, Australia
| | - Anna Copley
- School of Health and Rehabilitation Sciences, The University of Queensland, Brisbane, Australia
| | - Tanya A Rose
- School of Health and Rehabilitation Sciences, The University of Queensland, Brisbane, Australia.,Queensland Aphasia Research Centre, Australia
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Boltzmann M, Schmidt SB, Gutenbrunner C, Krauss JK, Höglinger GU, Weimar C, Rollnik JD. Validity of the Early Functional Ability scale (EFA) among critically ill patients undergoing early neurological rehabilitation. BMC Neurol 2022; 22:333. [PMID: 36068496 PMCID: PMC9446867 DOI: 10.1186/s12883-022-02855-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Accepted: 08/24/2022] [Indexed: 11/17/2022] Open
Abstract
Background A reliable assessment of the functional abilities of patients after severe brain damage is crucial for valid prognostication and treatment decisions, but most clinical scales are of limited use among this specific group of patients. Aim The present study investigates the usefulness of the Early Functional Ability (EFA) scale, which determines the functional abilities of severely impaired patients. Methods Critically ill patients consecutively admitted to early neurological rehabilitation were screened for eligibility. We assessed the correlation between the EFA scale and (i) the Early Rehabilitation Barthel Index (ERBI), and (ii) the Coma Recovery Scale-Revised (CRS-R). The 1-year outcome on the Glasgow Outcome Scale-extended (GOSE) was used to examine the predictive validity. Demographical and medical variables were entered into univariate and multivariate binary regression models to identify independent predictors of 1-year outcome. Results Two hundred fifty-seven patients (168 men) with a median age of 62 years (IQR = 51–75) were enrolled. The correlation of the EFA scale with the CRS-R was high but low with the ERBI upon admission. Multivariate regression analysis yielded the vegetative subscale of the EFA scale as the only independent predictor for the 1-year outcome of patients admitted to early neurological rehabilitation. Conclusions This study shows a high correlation of the EFA scale with the CRS-R but a weak correlation with the ERBI in patients with low functional abilities. With improving patient abilities, these correlations were partly reversed. Thus, the EFA scale is a useful tool to assess the functional abilities and the prognosis of critically ill patients adequately and may be more feasible than other scales.
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Affiliation(s)
- Melanie Boltzmann
- BDH-Clinic Hessisch Oldendorf, Institute for Neurorehabilitation Research, Associated Institute of Hannover Medical School, Hessisch Oldendorf, Germany.
| | - Simone B Schmidt
- BDH-Clinic Hessisch Oldendorf, Institute for Neurorehabilitation Research, Associated Institute of Hannover Medical School, Hessisch Oldendorf, Germany
| | | | - Joachim K Krauss
- Department of Neurosurgery, Hannover Medical School, Hannover, Germany
| | | | - Christian Weimar
- Institute for Medical Informatics, Biometry and Epidemiology, University of Duisburg-Essen, Essen, Germany.,BDH-Clinic Elzach, Elzach, Germany
| | - Jens D Rollnik
- BDH-Clinic Hessisch Oldendorf, Institute for Neurorehabilitation Research, Associated Institute of Hannover Medical School, Hessisch Oldendorf, Germany
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12
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Boltzmann M, Schmidt SB, Gutenbrunner C, Krauss JK, Höglinger GU, Rollnik JD. One-year outcome of brain injured patients undergoing early neurological rehabilitation: a prospective observational study. BMC Neurol 2022; 22:30. [PMID: 35039012 PMCID: PMC8762846 DOI: 10.1186/s12883-022-02549-w] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Accepted: 12/28/2021] [Indexed: 11/10/2022] Open
Abstract
Background The present study intended to analyze the outcome of patients with severe brain injury one-year after discharge from early rehabilitation. Methods Early neurological rehabilitation patients admitted to intensive or intermediate care units and discharged between June 2018 and May 2020 were screened for eligibility. The level of consciousness was evaluated using the Coma Recovery Scale-Revised (CRS-R) upon admission and at discharge. At one-year follow-up, the outcome was assessed with the Glasgow Outcome Scale-extended (GOSE). Demographical and clinical data collected during inpatient rehabilitation were used to predict the outcome 1 year after discharge. Results Two hundred sixty-four patients (174 males, 90 females) with a median age of 62 years (IQR = 51–75) and a median duration of their disease of 18 days (IQR = 12–28) were included in the study. At follow-up, the mortality rate was 27% (n = 71). Age and discharge CRS-R total score were independent predictors in a Cox proportional hazards model with death (yes/no) as the dependent variable. According to the GOSE interviews, most patients were either dead (n = 71; 27%), in a vegetative state (n = 28; 11%) or had a severe disability (n = 124; 47%), whereas only a few patients showed a moderate disability (n = 18; 7%) or a good recovery (n = 23; 9%) 1 year after discharge. Age, non-traumatic etiology, discharge CRS-R total score and length of stay independently predicted whether the outcome was good or poor at follow-up. Conclusion Age was an important predictor for outcome at one-year follow-up, which might be due to altered brain plasticity and more comorbidities in elderly subjects. In addition, the present study demonstrated that the CRS-R total score at discharge might be more important for the prediction of one-year outcome than the initial assessment upon admission.
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Affiliation(s)
- Melanie Boltzmann
- BDH-Clinic Hessisch Oldendorf, Institute for Neurorehabilitation Research, Associated Institute of Hannover Medical School, Hessisch Oldendorf, Germany.
| | - Simone B Schmidt
- BDH-Clinic Hessisch Oldendorf, Institute for Neurorehabilitation Research, Associated Institute of Hannover Medical School, Hessisch Oldendorf, Germany
| | | | - Joachim K Krauss
- Department of Neurosurgery, Hannover Medical School, Hannover, Germany
| | | | - Jens D Rollnik
- BDH-Clinic Hessisch Oldendorf, Institute for Neurorehabilitation Research, Associated Institute of Hannover Medical School, Hessisch Oldendorf, Germany
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13
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Overbeek BUH, Lavrijsen JCM, van Gaal S, Kondziella D, Eilander HJ, Koopmans RTCM. Towards consensus on visual pursuit and visual fixation in patients with disorders of consciousness. A Delphi study. J Neurol 2022; 269:3204-3215. [PMID: 35001197 DOI: 10.1007/s00415-021-10905-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2021] [Revised: 11/10/2021] [Accepted: 11/11/2021] [Indexed: 10/19/2022]
Abstract
BACKGROUND The aim of this Delphi study was to reach consensus about definition, operationalization and assessment of visual pursuit (VP) and visual fixation (VF). METHODS In a three-round international Delphi study, clinical and research experts on disorders of consciousness indicated their level of agreement on 87 statements using a 5-point Likert scale. Consensus for agreement was defined by a median of 5, an interquartile range (IQR) ≤ 1, and ≥ 80% indicating moderate or strong agreement. RESULTS Forty-three experts from three continents participated, 32 completed all three rounds. For VP, the consensus statements with the highest levels of agreement were on the term 'pursuit of a visual stimulus', the description 'ability to follow visually in horizontal and/or vertical plane', a duration > 2 s, tracking in horizontal and vertical planes, and a frequency of more than 2 times per assessment. For VF, consensus statements with the highest levels of agreement were on the term 'sustained VF', the description 'sustained fixation in response to a salient stimulus', a duration of > 2 s and a frequency of 2 or more times per assessment. The assessment factors with the highest levels of agreement were personalized stimuli, the use of eye tracking technology, a patient dependent time of assessment, sufficient environmental light, upright posture, and the necessity to exclude ocular/oculomotor problems. CONCLUSION This first international Delphi study on VP and VF in patients with disorders of consciousness provides provisional operational definitions and an overview of the most relevant assessment factors.
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Affiliation(s)
- Berno U H Overbeek
- Department of Primary and Community Care, Radboud Institute of Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands. .,Kalorama, Beek Ubbergen, The Netherlands. .,Azora, Terborg, The Netherlands.
| | - Jan C M Lavrijsen
- Department of Primary and Community Care, Radboud Institute of Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Simon van Gaal
- Faculty of Social and Behavioural Sciences, Department of Psychology, University of Amsterdam, Amsterdam, The Netherlands
| | - Daniel Kondziella
- Department of Neurology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark.,Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Henk J Eilander
- Department of Primary and Community Care, Radboud Institute of Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Raymond T C M Koopmans
- Department of Primary and Community Care, Radboud Institute of Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands.,Center for Specialized Geriatric Care, Joachim en Anna, Nijmegen, The Netherlands
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14
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Sattin D, Rossi Sebastiano D, Magnani FG, D'Incerti L, Marotta G, Benti R, Tirelli S, Bersano A, Duran D, Visani E, Ferraro S, Minati L, Nigri A, Rosazza C, Bianchi Marzoli S, Ciasca P, Carcagni A, Bruzzone MG, Franceschetti S, Leonardi M, Guido D. Visual fixation in disorders of consciousness: Development of predictive models to support differential diagnosis. Physiol Behav 2021; 230:113310. [PMID: 33412191 DOI: 10.1016/j.physbeh.2021.113310] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2020] [Revised: 12/29/2020] [Accepted: 12/30/2020] [Indexed: 12/13/2022]
Abstract
The visual fixation represents a doubtful behavioral sign to discriminate Vegetative from Minimally Conscious State (MCS). To disentangle its meaning, we fitted univariate and multivariable logistic regression models matching different neurophysiological and neuroimaging data of 54 patients with Disorders of Consciousness to select the best model predicting which visual performance (visual blink or pursuit) was shown by patients and the best predictors set. The best models found highlighted the importance of the structural MRI and the visual evoked potentials data in predicting visual pursuit. Then, a qualitative pilot test was made on four patients showing visual fixation revealing that the obtained models correctly predict whether the patients' visual performance could support/correlate to a cognitively mediated behavior. The present pilot models could help clinicians to evaluate if the visual fixation response can support the MCS diagnosis.
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Affiliation(s)
- Davide Sattin
- Neurology, Public Health, Disability Unit - Coma Research Centre; Scientific Directorate, Fondazione IRCCS Istituto Neurologico Carlo Besta, Via Celoria 11, Milan, 20133, Italy.
| | - Davide Rossi Sebastiano
- Neurophysiology and Diagnostic Epileptology Unit - Fondazione IRCCS Istituto Neurologico Carlo Besta n, Via Celoria 11, Milan, 20133, Italy.
| | - Francesca Giulia Magnani
- Neurology, Public Health, Disability Unit - Coma Research Centre; Scientific Directorate, Fondazione IRCCS Istituto Neurologico Carlo Besta, Via Celoria 11, Milan, 20133, Italy.
| | - Ludovico D'Incerti
- Neuroradiology Unit, Fondazione IRCCS Istituto Neurologico Carlo Besta, Via Celoria 11, Milan, 20133, Italy.
| | - Giorgio Marotta
- Department of Nuclear Medicine, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via Francesco Sforza 35, Milan, 20122, Italy; Dipartimento di Studi Umanistici (DISTUM), Università degli Studi di Urbino Carlo Bo, Via Bramante, 17, 61029 Urbino PU.
| | - Riccardo Benti
- Department of Nuclear Medicine, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via Francesco Sforza 35, Milan, 20122, Italy.
| | - Simone Tirelli
- Neurology, Public Health, Disability Unit - Coma Research Centre; Scientific Directorate, Fondazione IRCCS Istituto Neurologico Carlo Besta, Via Celoria 11, Milan, 20133, Italy
| | - Anna Bersano
- Neurology Unit, UCV, Fondazione IRCCS Istituto Neurologico Carlo Besta, Via Celoria 11, Milan, 20133, Italy.
| | - Dunja Duran
- Neurophysiology and Diagnostic Epileptology Unit - Fondazione IRCCS Istituto Neurologico Carlo Besta n, Via Celoria 11, Milan, 20133, Italy.
| | - Elisa Visani
- Neurophysiology and Diagnostic Epileptology Unit - Fondazione IRCCS Istituto Neurologico Carlo Besta n, Via Celoria 11, Milan, 20133, Italy.
| | - Stefania Ferraro
- Neuroradiology Unit, Fondazione IRCCS Istituto Neurologico Carlo Besta, Via Celoria 11, Milan, 20133, Italy.
| | - Ludovico Minati
- Direzione Scientifica, Fondazione IRCCS Istituto Neurologico Carlo Besta, Via Celoria 11, Milan, 20133, Italy.
| | - Anna Nigri
- Neuroradiology Unit, Fondazione IRCCS Istituto Neurologico Carlo Besta, Via Celoria 11, Milan, 20133, Italy.
| | - Cristina Rosazza
- Neuroradiology Unit, Fondazione IRCCS Istituto Neurologico Carlo Besta, Via Celoria 11, Milan, 20133, Italy; Dipartimento di Studi Umanistici (DISTUM), Università degli Studi di Urbino Carlo Bo, Via Bramante, 17, 61029 Urbino PU.
| | - Stefania Bianchi Marzoli
- Neuro-Ophthalmology Center, IRCCS Istituto Auxologico Italiano, Scientific Institute Capitanio Hospital, via Mercalli, 28, Milan 20122, Italy.
| | - Paola Ciasca
- Neuro-Ophthalmology Center, IRCCS Istituto Auxologico Italiano, Scientific Institute Capitanio Hospital, via Mercalli, 28, Milan 20122, Italy.
| | - Antonella Carcagni
- Data Methods and Systems Statistical Laboratory, Department of Economics and Management, University of Brescia, Contrada Santa Chiara, 50, Brescia, 25122, Italy.
| | - Maria Grazia Bruzzone
- Neuroradiology Unit, Fondazione IRCCS Istituto Neurologico Carlo Besta, Via Celoria 11, Milan, 20133, Italy.
| | - Silvana Franceschetti
- Neurophysiology and Diagnostic Epileptology Unit - Fondazione IRCCS Istituto Neurologico Carlo Besta n, Via Celoria 11, Milan, 20133, Italy.
| | - Matilde Leonardi
- Neurology, Public Health, Disability Unit - Coma Research Centre; Scientific Directorate, Fondazione IRCCS Istituto Neurologico Carlo Besta, Via Celoria 11, Milan, 20133, Italy.
| | - Davide Guido
- Neurology, Public Health, Disability Unit - Coma Research Centre; Scientific Directorate, Fondazione IRCCS Istituto Neurologico Carlo Besta, Via Celoria 11, Milan, 20133, Italy.
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15
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When, How, and to What Extent Are Individuals with Unresponsive Wakefulness Syndrome Able to Progress? Neurobehavioral Progress. Brain Sci 2021; 11:brainsci11010126. [PMID: 33478033 PMCID: PMC7835897 DOI: 10.3390/brainsci11010126] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2020] [Revised: 01/09/2021] [Accepted: 01/15/2021] [Indexed: 01/21/2023] Open
Abstract
Accurate estimation of the neurobehavioral progress of patients with unresponsive wakefulness syndrome (UWS) is essential to anticipate their most likely clinical course and guide clinical decision making. Although different studies have described this progress and possible predictors of neurobehavioral improvement in these patients, they have methodological limitations that could restrict the validity and generalization of the results. This study investigates the neurobehavioral progress of 100 patients with UWS consecutively admitted to a neurorehabilitation center using systematic weekly assessments based on standardized measures, and the prognostic factors of changes in their neurobehavioral condition. Our results showed that, during the analyzed period, 34% of the patients were able to progress from UWS to minimally conscious state (MCS), 12% of the total sample (near one third from those who progressed to MCS) were able to emerge from MCS, and 10% of the patients died. Transition to MCS was mostly denoted by visual signs, which appeared either alone or in combination with motor signs, and was predicted by etiology and the score on the Coma Recovery Scale-Revised at admission with an accuracy of 75%. Emergence from MCS was denoted in the same proportion by functional communication and object use. Predictive models of emergence from MCS and mortality were not valid and the identified predictors could not be accounted for.
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16
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Perez P, Valente M, Hermann B, Sitt J, Faugeras F, Demeret S, Rohaut B, Naccache L. Auditory Event-Related "Global Effect" Predicts Recovery of Overt Consciousness. Front Neurol 2021; 11:588233. [PMID: 33488494 PMCID: PMC7819971 DOI: 10.3389/fneur.2020.588233] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Accepted: 12/03/2020] [Indexed: 01/23/2023] Open
Abstract
Objective: To explore whether the presence of an event-related potential (ERP) "global effect" (GE+)-that corresponds to a correlate of conscious processing in the local-global auditory task-predicts behaviorally overt consciousness recovery in a large cohort of patients suffering from disorders of consciousness (DOC). Methods: We conducted a prospective study on all DOC patients evaluated during the 2009-2018 period. Behavioral examination included Coma Recovery Scale-Revised (CRS-R) scores and bedside high-density EEG recordings. Consciousness recovery was evaluated at 6 months by a structured phone interview. The predictive value of a GE+ was calculated both on survivors and on all patients. Results: A total of 236 patients with a documented outcome and technically valid EEG recordings could be included. Among them, 66 patients had a GE+ status (28%). Presence of GE+ predicted behaviorally overt consciousness recovery in survivors with high specificity (Sp = 84%) and high positive predictive value (PPV = 80%) but with low sensitivity (Se = 35%) and low negative predictive value (NPV = 42%). Positive likelihood ratio (LR+) of GE+ was superior to LR+ of initial clinical status and of ERP effect indexing unconscious auditory processing [local effect (LE)]. Interpretation: Our results demonstrate that the presence of a bedside ERP GE+ is highly predictive of behaviorally overt consciousness recovery in DOC patients, regardless of the delay, of behavioral status, and of the etiology of brain dysfunction. However, the absence of this effect is not a reliable predictor of negative outcome. This study provides Class III evidence that the presence of an ERP "global effect" predicts consciousness recovery in DOC patients.
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Affiliation(s)
- Pauline Perez
- PICNIC Lab Team, INSERM, U 1127, CNRS UMR 7225, Faculté de Médecine de Sorbonne Université, UMR S 1127, Institut du Cerveau et de la Moelle épinière, ICM, Hôpital Pitié-Salpêtrière, Paris, France
| | - Mélanie Valente
- PICNIC Lab Team, INSERM, U 1127, CNRS UMR 7225, Faculté de Médecine de Sorbonne Université, UMR S 1127, Institut du Cerveau et de la Moelle épinière, ICM, Hôpital Pitié-Salpêtrière, Paris, France.,Assistance Publique Hôpitaux de Paris (APHP), Hôpital Pitié-Salpêtrière, Department of Clinical Neurophysiology, Paris, France
| | - Bertrand Hermann
- PICNIC Lab Team, INSERM, U 1127, CNRS UMR 7225, Faculté de Médecine de Sorbonne Université, UMR S 1127, Institut du Cerveau et de la Moelle épinière, ICM, Hôpital Pitié-Salpêtrière, Paris, France
| | - Jacobo Sitt
- PICNIC Lab Team, INSERM, U 1127, CNRS UMR 7225, Faculté de Médecine de Sorbonne Université, UMR S 1127, Institut du Cerveau et de la Moelle épinière, ICM, Hôpital Pitié-Salpêtrière, Paris, France
| | - Frédéric Faugeras
- Assistance Publique Hôpitaux de Paris (APHP), Hôpital Henri-Mondor, Department of Neurology, Créteil, France
| | - Sophie Demeret
- Assistance Publique Hôpitaux de Paris (APHP), Hôpital Pitié-Salpêtrière, Department of Neurology, Paris, France
| | - Benjamin Rohaut
- PICNIC Lab Team, INSERM, U 1127, CNRS UMR 7225, Faculté de Médecine de Sorbonne Université, UMR S 1127, Institut du Cerveau et de la Moelle épinière, ICM, Hôpital Pitié-Salpêtrière, Paris, France.,Assistance Publique Hôpitaux de Paris (APHP), Hôpital Pitié-Salpêtrière, Department of Neurology, Paris, France.,Faculté de Médecine Pitié-Salpêtrière, Sorbonne Université, Paris, France
| | - Lionel Naccache
- PICNIC Lab Team, INSERM, U 1127, CNRS UMR 7225, Faculté de Médecine de Sorbonne Université, UMR S 1127, Institut du Cerveau et de la Moelle épinière, ICM, Hôpital Pitié-Salpêtrière, Paris, France.,Assistance Publique Hôpitaux de Paris (APHP), Hôpital Pitié-Salpêtrière, Department of Neurology, Paris, France.,Faculté de Médecine Pitié-Salpêtrière, Sorbonne Université, Paris, France
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17
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Olaya J, Noé E, Navarro MD, O’Valle M, Colomer C, Moliner B, Ippoliti C, Ferri J, Maza A, Llorens R. When, How, and to What Extent Are Individuals with Unresponsive Wakefulness Syndrome Able to Progress? Functional Independence. Brain Sci 2020; 10:brainsci10120990. [PMID: 33339138 PMCID: PMC7765669 DOI: 10.3390/brainsci10120990] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2020] [Revised: 12/03/2020] [Accepted: 12/07/2020] [Indexed: 12/04/2022] Open
Abstract
Accurate estimation of the functional independence of patients with unresponsive wakefulness syndrome (UWS) is essential to adjust family and clinical expectations and plan long-term necessary resources. Although different studies have described the clinical course of these patients, they have methodological limitations that could restrict generalization of the results. This study investigates the neurobehavioral progress of 100 patients with UWS consecutively admitted to a neurorehabilitation center using systematic weekly assessments based on standardized measures, and the functional independence staging of those patients who emerged from a minimally conscious state (MCS) during the first year post-emergence. Our results showed that one year after emergence, most patients were severely dependent, although some of them showed extreme or moderate severity. Clinically meaningful functional improvement was less likely to occur in cognitively-demanding activities, such as activities of daily living and executive function. Consequently, the use of specific and staging functional independence measures, with domain-specific evaluations, are recommended to detect the functional changes that might be expected in these patients. The information provided by these instruments, together with that obtained from repeated assessments of the preserved consciousness with standardized instruments, could help clinicians to adjust expectations and plan necessary resources for this population.
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Affiliation(s)
- José Olaya
- NEURORHB, Servicio de Neurorrehabilitación de Hospitales Vithas, Fundación Vithas, Callosa d’En Sarrià 12, 46007 València, Spain; (J.O.); (M.D.N.); (M.O.); (C.C.); (B.M.); (C.I.); (J.F.); or (R.L.)
| | - Enrique Noé
- NEURORHB, Servicio de Neurorrehabilitación de Hospitales Vithas, Fundación Vithas, Callosa d’En Sarrià 12, 46007 València, Spain; (J.O.); (M.D.N.); (M.O.); (C.C.); (B.M.); (C.I.); (J.F.); or (R.L.)
- Correspondence: ; Tel.: +34-96-335-2506
| | - María Dolores Navarro
- NEURORHB, Servicio de Neurorrehabilitación de Hospitales Vithas, Fundación Vithas, Callosa d’En Sarrià 12, 46007 València, Spain; (J.O.); (M.D.N.); (M.O.); (C.C.); (B.M.); (C.I.); (J.F.); or (R.L.)
| | - Myrtha O’Valle
- NEURORHB, Servicio de Neurorrehabilitación de Hospitales Vithas, Fundación Vithas, Callosa d’En Sarrià 12, 46007 València, Spain; (J.O.); (M.D.N.); (M.O.); (C.C.); (B.M.); (C.I.); (J.F.); or (R.L.)
| | - Carolina Colomer
- NEURORHB, Servicio de Neurorrehabilitación de Hospitales Vithas, Fundación Vithas, Callosa d’En Sarrià 12, 46007 València, Spain; (J.O.); (M.D.N.); (M.O.); (C.C.); (B.M.); (C.I.); (J.F.); or (R.L.)
| | - Belén Moliner
- NEURORHB, Servicio de Neurorrehabilitación de Hospitales Vithas, Fundación Vithas, Callosa d’En Sarrià 12, 46007 València, Spain; (J.O.); (M.D.N.); (M.O.); (C.C.); (B.M.); (C.I.); (J.F.); or (R.L.)
| | - Camilla Ippoliti
- NEURORHB, Servicio de Neurorrehabilitación de Hospitales Vithas, Fundación Vithas, Callosa d’En Sarrià 12, 46007 València, Spain; (J.O.); (M.D.N.); (M.O.); (C.C.); (B.M.); (C.I.); (J.F.); or (R.L.)
| | - Joan Ferri
- NEURORHB, Servicio de Neurorrehabilitación de Hospitales Vithas, Fundación Vithas, Callosa d’En Sarrià 12, 46007 València, Spain; (J.O.); (M.D.N.); (M.O.); (C.C.); (B.M.); (C.I.); (J.F.); or (R.L.)
| | - Anny Maza
- Neurorehabilitation and Brain Research Group, Instituto de Investigación e Innovación en Bioingeniería, Universitat Politècnica de València, Camino de Vera s/n, 46011 València, Spain;
| | - Roberto Llorens
- NEURORHB, Servicio de Neurorrehabilitación de Hospitales Vithas, Fundación Vithas, Callosa d’En Sarrià 12, 46007 València, Spain; (J.O.); (M.D.N.); (M.O.); (C.C.); (B.M.); (C.I.); (J.F.); or (R.L.)
- Neurorehabilitation and Brain Research Group, Instituto de Investigación e Innovación en Bioingeniería, Universitat Politècnica de València, Camino de Vera s/n, 46011 València, Spain;
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18
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Hermann B, Salah AB, Perlbarg V, Valente M, Pyatigorskaya N, Habert MO, Raimondo F, Stender J, Galanaud D, Kas A, Puybasset L, Perez P, Sitt JD, Rohaut B, Naccache L. Habituation of auditory startle reflex is a new sign of minimally conscious state. Brain 2020; 143:2154-2172. [PMID: 32582938 PMCID: PMC7364741 DOI: 10.1093/brain/awaa159] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2019] [Revised: 03/05/2020] [Accepted: 03/30/2020] [Indexed: 02/07/2023] Open
Abstract
Neurological examination of non-communicating patients relies on a few decisive items that enable the crucial distinction between vegetative state (VS)-also coined unresponsive wakefulness syndrome (UWS)-and minimally conscious state. Over the past 10 years, this distinction has proven its diagnostic value as well as its important prognostic value on consciousness recovery. However, clinicians are currently limited by three factors: (i) the current behavioural repertoire of minimally conscious state items is limited and restricted to a few cognitive domains in the goldstandard revised version of the Coma Recovery Scale; (ii) a proportion of ∼15-20% clinically VS/UWS patients are actually in a richer state than VS/UWS as evidenced by functional brain imaging; and (iii) the neurophysiological and cognitive interpretation of each minimally conscious state item is still unclear and debated. In the current study we demonstrate that habituation of the auditory startle reflex (hASR) tested at bedside constitutes a novel, simple and powerful behavioural sign that can accurately distinguish minimally conscious state from VS/UWS. In addition to enlarging the minimally conscious state items repertoire, and therefore decreasing the low sensitivity of current behavioural measures, we also provide an original and rigorous description of the neurophysiological basis of hASR through a combination of functional (high density EEG and 18F-fluorodeoxyglucose PET imaging) and structural (diffusion tensor imaging MRI) measures. We show that preservation of hASR is associated with the functional and structural integrity of a brain-scale fronto-parietal network, including prefrontal regions related to control of action and inhibition, and meso-parietal areas associated with minimally conscious and conscious states. Lastly, we show that hASR predicts 6-month improvement of consciousness. Taken together, our results show that hASR is a cortically-mediated behaviour, and suggest that it could be a new clinical item to clearly and accurately identify non-communicating patients who are in the minimally conscious state.
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Affiliation(s)
- Bertrand Hermann
- Institut du Cerveau et de la Moelle épinière - ICM, Inserm U1127, CNRS UMR 7225, F-75013, Paris, France
- Department of Neurology, Groupe hospitalier Pitié-Salpêtrière, AP-HP, F-75013, Paris, France
- Faculté de Médecine Pitié-Salpêtrière, Sorbonne Universités, UPMC Université Paris 06, Paris, France
| | - Amina Ben Salah
- Institut du Cerveau et de la Moelle épinière - ICM, Inserm U1127, CNRS UMR 7225, F-75013, Paris, France
| | - Vincent Perlbarg
- Sorbonne Université, CNRS, INSERM, Laboratoire d’Imagerie Biomédicale, LIB, F-75006, Paris, France
- BrainTale SAS, F-75013, Paris, France
| | - Mélanie Valente
- Institut du Cerveau et de la Moelle épinière - ICM, Inserm U1127, CNRS UMR 7225, F-75013, Paris, France
- Department of Clinical Neurophysiology, Groupe hospitalier Pitié-Salpêtrière, AP-HP, F-75013, Paris, France
| | - Nadya Pyatigorskaya
- Institut du Cerveau et de la Moelle épinière - ICM, Inserm U1127, CNRS UMR 7225, F-75013, Paris, France
- Faculté de Médecine Pitié-Salpêtrière, Sorbonne Universités, UPMC Université Paris 06, Paris, France
- Department of Neuroradiology, Groupe hospitalier Pitié-Salpêtrière, AP-HP, F-75013, Paris, France
| | - Marie-Odile Habert
- Sorbonne Université, CNRS, INSERM, Laboratoire d’Imagerie Biomédicale, LIB, F-75006, Paris, France
- Department of Nuclear Medicine, Groupe hospitalier Pitié-Salpêtrière, AP-HP, F-75013, Paris, France
| | - Federico Raimondo
- Institut du Cerveau et de la Moelle épinière - ICM, Inserm U1127, CNRS UMR 7225, F-75013, Paris, France
- Coma Science Group, GIGA Consciousness, University of Liège, Belgium
- Centre du Cerveau, University Hospital of Liège, Belgium
| | - Johan Stender
- Institut du Cerveau et de la Moelle épinière - ICM, Inserm U1127, CNRS UMR 7225, F-75013, Paris, France
| | - Damien Galanaud
- Institut du Cerveau et de la Moelle épinière - ICM, Inserm U1127, CNRS UMR 7225, F-75013, Paris, France
- Faculté de Médecine Pitié-Salpêtrière, Sorbonne Universités, UPMC Université Paris 06, Paris, France
- Department of Neuroradiology, Groupe hospitalier Pitié-Salpêtrière, AP-HP, F-75013, Paris, France
| | - Aurélie Kas
- Sorbonne Université, CNRS, INSERM, Laboratoire d’Imagerie Biomédicale, LIB, F-75006, Paris, France
- Department of Nuclear Medicine, Groupe hospitalier Pitié-Salpêtrière, AP-HP, F-75013, Paris, France
| | - Louis Puybasset
- Faculté de Médecine Pitié-Salpêtrière, Sorbonne Universités, UPMC Université Paris 06, Paris, France
- Sorbonne Université, CNRS, INSERM, Laboratoire d’Imagerie Biomédicale, LIB, F-75006, Paris, France
- Department of Anesthesia and Critical Care, Multidisciplinary Intensive Care Unit, Groupe hospitalier Pitié-Salpêtrière, AP-HP, F-75013, Paris, France
| | - Pauline Perez
- Institut du Cerveau et de la Moelle épinière - ICM, Inserm U1127, CNRS UMR 7225, F-75013, Paris, France
| | - Jacobo D Sitt
- Institut du Cerveau et de la Moelle épinière - ICM, Inserm U1127, CNRS UMR 7225, F-75013, Paris, France
| | - Benjamin Rohaut
- Institut du Cerveau et de la Moelle épinière - ICM, Inserm U1127, CNRS UMR 7225, F-75013, Paris, France
- Department of Neurology, Groupe hospitalier Pitié-Salpêtrière, AP-HP, F-75013, Paris, France
- Faculté de Médecine Pitié-Salpêtrière, Sorbonne Universités, UPMC Université Paris 06, Paris, France
- Department of Neurology, Columbia University, New York, NY 10027, USA
| | - Lionel Naccache
- Institut du Cerveau et de la Moelle épinière - ICM, Inserm U1127, CNRS UMR 7225, F-75013, Paris, France
- Department of Neurology, Groupe hospitalier Pitié-Salpêtrière, AP-HP, F-75013, Paris, France
- Faculté de Médecine Pitié-Salpêtrière, Sorbonne Universités, UPMC Université Paris 06, Paris, France
- Department of Clinical Neurophysiology, Groupe hospitalier Pitié-Salpêtrière, AP-HP, F-75013, Paris, France
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19
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Martens G, Bodien Y, Thomas A, Giacino J. Temporal Profile of Recovery of Communication in Patients With Disorders of Consciousness After Severe Brain Injury. Arch Phys Med Rehabil 2020; 101:1260-1264. [PMID: 32113971 DOI: 10.1016/j.apmr.2020.01.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2019] [Revised: 12/27/2019] [Accepted: 01/29/2020] [Indexed: 11/19/2022]
Abstract
OBJECTIVE Characterize the temporal profile of recovery of communication after severe brain injury. DESIGN Retrospective cohort study. SETTING Inpatient rehabilitation hospital. PARTICIPANTS Patients with severe acquired brain injury and no evidence of communication on the Coma Recovery Scale-Revised (CRS-R) (N=175). MAIN OUTCOME MEASURES Time from injury to recovery of intentional communication (IC, inconsistent yes/no responses) and functional communication (FC, consistent and accurate yes/no responses) on the CRS-R Communication subscale. RESULTS Patients (N=175) were included in the primary observation period of the first 8 weeks of inpatient rehabilitation (median [interquartile range, IQR]: 48 [27-61] years old, 105 men, 28 [21-38] days postinjury, 100 traumatic etiology). Fifty-four patients (31%) did not recover IC or FC. Thirty patients (17%) recovered IC only (median [IQR] days from injury to IC= 40 [34-54]), 72 patients (41%) recovered IC followed by FC (days from injury to FC=50 [42-61]), and 19 patients (11%) recovered FC without first recovering IC (43 [32-63]). The patients who recovered neither IC nor FC within 8 weeks of admission were admitted to rehabilitation later than those who recovered IC and/or FC (P<.01). Sixteen patients who did not recover communication within 8 weeks of admission to rehabilitation subsequently recovered FC prior to discharge. CONCLUSIONS In patients with severe brain injury receiving inpatient rehabilitation, discernible yes-no responses emerged approximately 6 weeks postinjury and became reliable 1 week later. Approximately 1 in 3 patients did not demonstrate IC or FC within 8 weeks of admission to rehabilitation, although 33% of these individuals recovered communication prior to discharge. In total, 61% of patients recovered FC prior to discharge from rehabilitation.
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Affiliation(s)
- Géraldine Martens
- Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Harvard Medical School, Boston, MA; Coma Science Group, GIGA Research, GIGA-Consciousness, University of Liège, Liège, Belgium; Centre du Cerveau(2), Centre intégré pluridisciplinaire de l'étude du cerveau, de la cognition et de la conscience, University Hospital of Liège, Liège, Belgium.
| | - Yelena Bodien
- Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Harvard Medical School, Boston, MA; Laboratory for Neuroimaging in Coma and Consciousness, Massachusetts General Hospital, Boston, MA
| | - Amber Thomas
- Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Harvard Medical School, Boston, MA
| | - Joseph Giacino
- Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Harvard Medical School, Boston, MA
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20
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Giacino JT, Sherer M, Christoforou A, Maurer-Karattup P, Hammond FM, Long D, Bagiella E. Behavioral Recovery and Early Decision Making in Patients with Prolonged Disturbance in Consciousness after Traumatic Brain Injury. J Neurotrauma 2020; 37:357-365. [PMID: 31502498 PMCID: PMC6964809 DOI: 10.1089/neu.2019.6429] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
The extent of behavioral recovery that occurs in patients with traumatic disorders of consciousness (DoC) following discharge from the acute care setting has been under-studied and increases the risk of overly pessimistic outcome prediction. The aim of this observational cohort study was to systematically track behavioral and functional recovery in patients with prolonged traumatic DoC following discharge from the acute care setting. Standardized behavioral data were acquired from 95 patients in a minimally conscious (MCS) or vegetative state (VS) recruited from 11 clinic sites and randomly assigned to the placebo arm of a previously completed prospective clinical trial. Patients were followed for 6 weeks by blinded observers to determine frequency of recovery of six target behaviors associated with functional status. The Coma Recovery Scale-Revised and Disability Rating Scale were used to track reemergence of target behaviors and assess degree of functional disability, respectively. Twenty percent (95% confidence interval [CI]: 13-30%) of participants (mean age 37.2; median 47 days post-injury; 69 men) recovered all six target behaviors within the 6 week observation period. The odds of recovering a specific target behavior were 3.2 (95% CI: 1.2-8.1) to 7.8 (95% CI: 2.7-23.0) times higher for patients in MCS than for those in VS. Patients with preserved language function ("MCS+") recovered the most behaviors (p ≤ 0.002) and had the least disability (p ≤ 0.002) at follow-up. These findings suggest that recovery of high-level behaviors underpinning functional independence is common in patients with prolonged traumatic DoC. Clinicians involved in early prognostic counseling should recognize that failure to emerge from traumatic DoC before 28 days does not necessarily portend unfavorable outcome.
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Affiliation(s)
- Joseph T. Giacino
- Spaulding Rehabilitation Hospital, Charlestown, Massachusetts
- Department of Physical Medicine and Rehabilitation, Harvard Medical School, Boston, Massachusetts
- JFK Johnson Rehabilitation Institute, Edison, New Jersey
| | - Mark Sherer
- Methodist Rehabilitation Center, Jackson, Mississippi
- TIRR Memorial Hermann, Houston, Texas
| | - Andrea Christoforou
- Spaulding Rehabilitation Hospital, Charlestown, Massachusetts
- Department of Physical Medicine and Rehabilitation, Harvard Medical School, Boston, Massachusetts
| | | | - Flora M. Hammond
- Department of Physical Medicine and Rehabilitation, Carolinas Rehabilitation, Charlotte, North Carolina
- Department of Physical Medicine and Rehabilitation, Indiana University School of Medicine, Indianapolis, Indiana
| | - David Long
- Brain Injury Program, Bryn Mawr Rehab Hospital, Malvern, Pennsylvania
| | - Emilia Bagiella
- Center for Biostatistics, Icahn School of Medicine at Mount Sinai, New York, New York
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21
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Martens G, Bodien Y, Sheau K, Christoforou A, Giacino JT. Which behaviours are first to emerge during recovery of consciousness after severe brain injury? Ann Phys Rehabil Med 2019; 63:263-269. [PMID: 31783144 DOI: 10.1016/j.rehab.2019.10.004] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2019] [Revised: 10/26/2019] [Accepted: 10/29/2019] [Indexed: 10/25/2022]
Abstract
BACKGROUND Early detection of consciousness after severe brain injury is critical for establishing an accurate prognosis and planning appropriate treatment. OBJECTIVES To determine which behavioural signs of consciousness emerge first and to estimate the time course to recovery of consciousness in patients with severe acquired brain injury. METHODS Retrospective observational study using the Coma Recovery Scale-Revised and days to recovery of consciousness in 79 patients (51 males; 34 with traumatic brain injury; median [IQR] age 48 [26-61] years; median time since injury 26 [20-36] days) who transitioned from coma or unresponsive wakefulness syndrome (UWS)/vegetative state (VS) to the minimally conscious state (MCS) or emerged from MCS during inpatient rehabilitation. RESULTS Visual pursuit was the most common initial sign of MCS (41% of patients; 95% CI [30-52]), followed by reproducible command-following (25% [16-35]) and automatic movements (24% [15-33]). Ten other behaviours emerged first in less than 16% of cases. Median [IQR] time to recovery of consciousness was 44 [33-59] days. Etiology did not significantly affect time to recovered consciousness. CONCLUSION Recovery of consciousness after severe brain injury is most often signalled by reemergence of visual pursuit, reproducible command-following and automatic movements. Clinicians should use assessment measures that are sensitive to these behaviours because early detection of consciousness is critical for accurate prognostication and treatment planning.
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Affiliation(s)
- Geraldine Martens
- Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Charlestown, MA, United States of America; Department of Physical Medicine and Rehabilitation, Harvard Medical School, Boston, MA, United States of America; Coma Science Group, GIGA Research, GIGA-Consciousness, University of Liege, 11, avenue de l'Hôpital, 4000 Liège (Sart Tilman), Belgium; Centre du Cerveau(2) - Centre intégré pluridisciplinaire de l'étude du cerveau, de la cognition et de la conscience, University Hospital of Liège, Liège, Belgium.
| | - Yelena Bodien
- Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Charlestown, MA, United States of America; Department of Physical Medicine and Rehabilitation, Harvard Medical School, Boston, MA, United States of America; Laboratory for Neuroimaging in Coma and Consciousness, Massachusetts General Hospital, Boston, MA, United States of America
| | - Kristen Sheau
- Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Charlestown, MA, United States of America; Massachusetts General Hospital Institute of Health Professions, Boston, MA, United States of America
| | - Andrea Christoforou
- Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Charlestown, MA, United States of America; Department of Physical Medicine and Rehabilitation, Harvard Medical School, Boston, MA, United States of America
| | - Joseph T Giacino
- Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Charlestown, MA, United States of America; Department of Physical Medicine and Rehabilitation, Harvard Medical School, Boston, MA, United States of America
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22
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Current validity of diagnosis of permanent vegetative state: a longitudinal study in a sample of patients with altered states of consciousness. NEUROLOGÍA (ENGLISH EDITION) 2019. [DOI: 10.1016/j.nrleng.2017.04.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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23
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Estraneo A, De Bellis F, Masotta O, Loreto V, Fiorenza S, Lo Sapio M, Trojano L. Demographical and clinical indices for long-term evolution of patients in vegetative or in minimally conscious state. Brain Inj 2019; 33:1633-1639. [DOI: 10.1080/02699052.2019.1658220] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Affiliation(s)
- A Estraneo
- Disorders of Consciousness Laboratory, Institute of Telese Terme, Maugeri Scientific and Clinical Institutes, IRCCS, Telese Terme (BN), Italy
- Department of Neurology, Santa Maria della Pietà General Hospital, Nola, Italy
| | - F De Bellis
- Disorders of Consciousness Laboratory, Institute of Telese Terme, Maugeri Scientific and Clinical Institutes, IRCCS, Telese Terme (BN), Italy
| | - O Masotta
- Disorders of Consciousness Laboratory, Institute of Telese Terme, Maugeri Scientific and Clinical Institutes, IRCCS, Telese Terme (BN), Italy
| | - V Loreto
- Disorders of Consciousness Laboratory, Institute of Telese Terme, Maugeri Scientific and Clinical Institutes, IRCCS, Telese Terme (BN), Italy
- Department of Neurology, Santa Maria della Pietà General Hospital, Nola, Italy
| | - S Fiorenza
- Disorders of Consciousness Laboratory, Institute of Telese Terme, Maugeri Scientific and Clinical Institutes, IRCCS, Telese Terme (BN), Italy
| | - M Lo Sapio
- Disorders of Consciousness Laboratory, Institute of Telese Terme, Maugeri Scientific and Clinical Institutes, IRCCS, Telese Terme (BN), Italy
| | - L Trojano
- Neuropsychology Lab., Department of Psychology, University of Campania 'Luigi Vanvitelli', Caserta, Italy
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24
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Wutzl B, Leibnitz K, Rattay F, Kronbichler M, Murata M, Golaszewski SM. Genetic algorithms for feature selection when classifying severe chronic disorders of consciousness. PLoS One 2019; 14:e0219683. [PMID: 31295332 PMCID: PMC6622536 DOI: 10.1371/journal.pone.0219683] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2018] [Accepted: 06/30/2019] [Indexed: 11/18/2022] Open
Abstract
The diagnosis and prognosis of patients with severe chronic disorders of consciousness are still challenging issues and a high rate of misdiagnosis is evident. Hence, new tools are needed for an accurate diagnosis, which will also have an impact on the prognosis. In recent years, functional Magnetic Resonance Imaging (fMRI) has been gaining more and more importance when diagnosing this patient group. Especially resting state scans, i.e., an examination when the patient does not perform any task in particular, seems to be promising for these patient groups. After preprocessing the resting state fMRI data with a standard pipeline, we extracted the correlation matrices of 132 regions of interest. The aim was to find the regions of interest which contributed most to the distinction between the different patient groups and healthy controls. We performed feature selection using a genetic algorithm and a support vector machine. Moreover, we show by using only those regions of interest for classification that are most often selected by our algorithm, we get a much better performance of the classifier.
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Affiliation(s)
- Betty Wutzl
- Graduate School of Information Science and Technology, Osaka University, Osaka, Japan
- Center for Information and Neural Networks, National Institute of Information and Communications Technology and Osaka University, Osaka, Japan
- Institute for Analysis and Scientific Computing, TU Wien, Vienna, Austria
- Department of Neurology, Paracelsus Medical University, Salzburg, Austria
- * E-mail:
| | - Kenji Leibnitz
- Graduate School of Information Science and Technology, Osaka University, Osaka, Japan
- Center for Information and Neural Networks, National Institute of Information and Communications Technology and Osaka University, Osaka, Japan
| | - Frank Rattay
- Institute for Analysis and Scientific Computing, TU Wien, Vienna, Austria
| | - Martin Kronbichler
- Neuroscience Institute, Christian-Doppler Medical Centre, Paracelsus Medical University, Salzburg, Austria
- Centre for Cognitive Neuroscience and Department of Psychology, University of Salzburg, Salzburg, Austria
| | - Masayuki Murata
- Graduate School of Information Science and Technology, Osaka University, Osaka, Japan
- Center for Information and Neural Networks, National Institute of Information and Communications Technology and Osaka University, Osaka, Japan
| | - Stefan Martin Golaszewski
- Department of Neurology, Paracelsus Medical University, Salzburg, Austria
- Neuroscience Institute, Christian-Doppler Medical Centre, Paracelsus Medical University, Salzburg, Austria
- Karl Landsteiner Institute for Neurorehabilitation and Space Neurology, Vienna, Austria
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25
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Hermann B, Goudard G, Courcoux K, Valente M, Labat S, Despois L, Bourmaleau J, Richard-Gilis L, Faugeras F, Demeret S, Sitt JD, Naccache L, Rohaut B. Wisdom of the caregivers: pooling individual subjective reports to diagnose states of consciousness in brain-injured patients, a monocentric prospective study. BMJ Open 2019; 9:e026211. [PMID: 30792234 PMCID: PMC6410088 DOI: 10.1136/bmjopen-2018-026211] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
OBJECTIVES The clinical distinction between vegetative state/unresponsive wakefulness syndrome (UWS) and minimally conscious state (MCS) is a key step to elaborate a prognosis and formulate an appropriate medical plan for any patient suffering from disorders of consciousness (DoC). However, this assessment is often challenging and may require specialised expertise. In this study, we hypothesised that pooling subjective reports of the level of consciousness of a given patient across several nursing staff members can be used to clinically detect MCS. SETTING AND PARTICIPANTS Patients referred to consciousness assessment were prospectively screened. MCS (target condition) was defined according to the best Coma Recovery Scale-Revised score (CRS-R) obtained from expert physicians (reference standard). 'DoC-feeling' score was defined as the median of individual subjective reports pooled from multiple staff members during a week of hospitalisation (index test). Individual ratings were collected at the end of each shift using a 100 mm Visual Analogue Scale, blinded from the reference standard. Diagnostic accuracy was evaluated using area under the receiver operating characteristic curve (AUC), sensitivity and specificity metrics. RESULTS 692 ratings performed by 83 nursing staff members were collected from 47 patients. Twenty patients were diagnosed with UWS and 27 with MCS. DoC-feeling scores obtained by pooling all individual ratings obtained for a given patient were significantly greater in patients with MCS than with UWS (59.2 mm (IQR: 27.3-77.3) vs 7.2 mm (IQR: 2.4-11.4); p<0.001) yielding an AUC of 0.92 (95% CI 0.84 to 0.99). CONCLUSIONS DoC-feeling capitalises on the expertise of nursing staff to evaluate patients' consciousness. Together with the CRS-R as well as with brain imaging, DoC-feeling might improve diagnostic and prognostic accuracy of patients with DoC.
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Affiliation(s)
- Bertrand Hermann
- Department of Neurology, Neuro ICU, Groupe Hospitalier Pitié-Salpêtrière, AP-HP, Paris, France
- Institut du Cerveau et de la Moelle épinière, ICM, PICNIC lab, F-75013, Paris, France
- Inserm U 1127, F-75013, Paris, France
- CNRS, UMR 7225, F-75013, Paris, France
| | - Gwen Goudard
- Department of Neurology, Neuro ICU, Groupe Hospitalier Pitié-Salpêtrière, AP-HP, Paris, France
| | - Karine Courcoux
- Department of Neurology, Neuro ICU, Groupe Hospitalier Pitié-Salpêtrière, AP-HP, Paris, France
| | - Mélanie Valente
- Institut du Cerveau et de la Moelle épinière, ICM, PICNIC lab, F-75013, Paris, France
- Inserm U 1127, F-75013, Paris, France
- CNRS, UMR 7225, F-75013, Paris, France
- Department of Neurophysiology, Groupe Hospitalier Pitié-Salpêtrière, AP-HP, Paris, France
| | - Sébastien Labat
- Department of Neurology, Neuro ICU, Groupe Hospitalier Pitié-Salpêtrière, AP-HP, Paris, France
| | - Lucienne Despois
- Department of Neurology, Neuro ICU, Groupe Hospitalier Pitié-Salpêtrière, AP-HP, Paris, France
| | - Julie Bourmaleau
- Department of Neurology, Neuro ICU, Groupe Hospitalier Pitié-Salpêtrière, AP-HP, Paris, France
| | - Louise Richard-Gilis
- Department of Neurology, Neuro ICU, Groupe Hospitalier Pitié-Salpêtrière, AP-HP, Paris, France
- Institut du Cerveau et de la Moelle épinière, ICM, PICNIC lab, F-75013, Paris, France
- Inserm U 1127, F-75013, Paris, France
- CNRS, UMR 7225, F-75013, Paris, France
| | - Frédéric Faugeras
- Institut du Cerveau et de la Moelle épinière, ICM, PICNIC lab, F-75013, Paris, France
- Inserm U 1127, F-75013, Paris, France
- CNRS, UMR 7225, F-75013, Paris, France
| | - Sophie Demeret
- Department of Neurology, Neuro ICU, Groupe Hospitalier Pitié-Salpêtrière, AP-HP, Paris, France
| | - Jacobo D Sitt
- Institut du Cerveau et de la Moelle épinière, ICM, PICNIC lab, F-75013, Paris, France
- Inserm U 1127, F-75013, Paris, France
- CNRS, UMR 7225, F-75013, Paris, France
| | - Lionel Naccache
- Department of Neurology, Neuro ICU, Groupe Hospitalier Pitié-Salpêtrière, AP-HP, Paris, France
- Institut du Cerveau et de la Moelle épinière, ICM, PICNIC lab, F-75013, Paris, France
- Inserm U 1127, F-75013, Paris, France
- CNRS, UMR 7225, F-75013, Paris, France
- Department of Neurophysiology, Groupe Hospitalier Pitié-Salpêtrière, AP-HP, Paris, France
- Sorbonne Universités, Faculté de Médecine Pitié-Salpêtrière, Paris, France
| | - Benjamin Rohaut
- Department of Neurology, Neuro ICU, Groupe Hospitalier Pitié-Salpêtrière, AP-HP, Paris, France
- Institut du Cerveau et de la Moelle épinière, ICM, PICNIC lab, F-75013, Paris, France
- Inserm U 1127, F-75013, Paris, France
- CNRS, UMR 7225, F-75013, Paris, France
- Division of Critical Care and Hospitalist Neurology, Columbia University, New York City, New York
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26
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Xu Y, Li P, Zhang S, Wang Y, Zhao X, Wang X, Wang W. Cervical Spinal Cord Stimulation for the Vegetative State: A Preliminary Result of 12 Cases. Neuromodulation 2018; 22:347-354. [PMID: 30548939 DOI: 10.1111/ner.12903] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2018] [Revised: 10/24/2018] [Accepted: 10/29/2018] [Indexed: 02/05/2023]
Abstract
OBJECTIVES Data on the treatment of the vegetative state (VS) with cervical spinal cord stimulation (cSCS) are limited and prognostic factors are inconclusive. In this study, we present our experience of treating 12 VS patients with cSCS and discuss the prognostic factors. METHODS Twelve VS patients were enrolled. Preoperative assessments included CT/MRI, PET, brainstem auditory evoked potentials (BAEPs), somatosensory evoked potentials (SEPs), and electroencephalogram (EEG). cSCS surgeries were performed at West China Hospital. The electrode was implanted in the epidural space of the C2-4 vertebrae. Levels of consciousness were evaluated based on the Coma Recovery Scale-Revised (CRS-R) at baseline and during follow-up. RESULTS The average follow-up was 11.1 months. The average CRS-R score at the last evaluation was 10.8, which was significantly improved compared with the baseline score (6.25). Five patients achieved responsive outcomes (three recovered and two evolved to a minimally conscious state) and seven achieved unresponsive outcomes (six remained in VS and one died). Age, preoperative CRS-R score, the interval between acute comatose injury and cSCS, and the Vth wave of BAEPs did not differ significantly between the responsive group and the unresponsive group. Appearance of the N20 of SEPs and multifocal abnormalities on CT/MRI and PET were significantly associated with a better outcome, while the etiology of ischemia and anoxia (IAA) was significantly associated with a poor outcome. CONCLUSIONS cSCS should be a glimmer of hope for VS patients. Patients whose N20 is elicited or whose CT/MRI or PET demonstrates multifocal abnormalities are more likely to benefit from cSCS, whereas those with an IAA etiology have a lower likelihood of recovery after cSCS.
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Affiliation(s)
- Yangyang Xu
- Department of Neurosurgery, West China Hospital of Sichuan University, Chengdu, China
| | - Peng Li
- Department of Neurosurgery, West China Hospital of Sichuan University, Chengdu, China
| | - Shizhen Zhang
- Department of Neurosurgery, The Second Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Yi Wang
- Department of Neurosurgery, West China Hospital of Sichuan University, Chengdu, China
| | - Xiaoyan Zhao
- Department of Neurosurgery, West China Hospital of Sichuan University, Chengdu, China
| | - Xin Wang
- Department of Neurosurgery, West China Hospital of Sichuan University, Chengdu, China
| | - Wei Wang
- Department of Neurosurgery, West China Hospital of Sichuan University, Chengdu, China
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Rivera-Lillo G, Rojas-Líbano D, Burgos P, Egaña JI, Chennu S, Maldonado PE. Reduced delta-band modulation underlies the loss of P300 responses in disorders of consciousness. Clin Neurophysiol 2018; 129:2613-2622. [PMID: 30458356 DOI: 10.1016/j.clinph.2018.09.104] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2018] [Revised: 08/16/2018] [Accepted: 09/19/2018] [Indexed: 10/27/2022]
Abstract
OBJECTIVE The P300 component of a sensory event-related potential is one of the major electrophysiological markers used to explore remnants of cognitive function in patients with disorders of consciousness (DoC). However, measuring the P300 in patients is complicated by significant inter-trial variability commonly observed in levels of arousal and awareness. To overcome this limitation, we analyzed single-trial modulation of power in the delta and theta frequency bands, which underlie the P300. METHODS In a preliminary cross-sectional study using a 24-channel EEG and a passive own-name oddball paradigm, we analyzed event-related synchronization (ERS) across trials in the delta and theta bands in a sample of 10 control and 12 DoC subjects. RESULTS In comparison to controls, DoC subjects presented a low percentage of trials where delta ERS was observed. In particular, coordinated modulation between delta and theta in response to the stimulus was absent, with a high percentage of trials where only theta ERS was observed. Further, we found a positive correlation between the percentage of epochs with delta ERS and the strength of the P300. CONCLUSIONS Reduced modulation of spectral activity in the delta band in response to stimuli indicates a dissociation in the activity of the neural networks that oscillate in delta and theta ranges and contribute to the generation of the P300. SIGNIFICANCE The reduction in spectral modulation observed in DoC provides a deeper understanding of neurophysiological dysfunction and the means to develop a more fine-grained marker of residual cognitive function in individual patients.
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Affiliation(s)
- Gonzalo Rivera-Lillo
- Physical Therapy Department, Faculty of Medicine, Universidad de Chile, Chile; Neuroscience Department, Faculty of Medicine, Universidad de Chile, Chile; Center of Integrated Studies in Neurorehabilitation, Clínica Los Coihues, Santiago, Chile
| | - Daniel Rojas-Líbano
- Laboratorio de Neurociencia Cognitiva y Social, Facultad de Psicología, Universidad Diego Portales, Santiago, Chile
| | - Pablo Burgos
- Physical Therapy Department, Faculty of Medicine, Universidad de Chile, Chile; Neuroscience Department, Faculty of Medicine, Universidad de Chile, Chile; Research and Development, Universidad Tecnológica de Chile, Inacap, Chile
| | - Jose I Egaña
- Anesthesia Department, Faculty of Medicine, Universidad de Chile, Chile; Biomedical Neuroscience Institute, Universidad de Chile, Chile
| | - Srivas Chennu
- School of Computing, University of Kent, UK; Department of Clinical Neurosciences, University of Cambridge, UK
| | - Pedro E Maldonado
- Neuroscience Department, Faculty of Medicine, Universidad de Chile, Chile; Biomedical Neuroscience Institute, Universidad de Chile, Chile.
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Naccache L. Minimally conscious state or cortically mediated state? Brain 2018; 141:949-960. [PMID: 29206895 PMCID: PMC5888986 DOI: 10.1093/brain/awx324] [Citation(s) in RCA: 91] [Impact Index Per Article: 15.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2017] [Revised: 09/07/2017] [Accepted: 09/27/2017] [Indexed: 01/04/2023] Open
Abstract
Durable impairments of consciousness are currently classified in three main neurological categories: comatose state, vegetative state (also recently coined unresponsive wakefulness syndrome) and minimally conscious state. While the introduction of minimally conscious state, in 2002, was a major progress to help clinicians recognize complex non-reflexive behaviours in the absence of functional communication, it raises several problems. The most important issue related to minimally conscious state lies in its criteria: while behavioural definition of minimally conscious state lacks any direct evidence of patient's conscious content or conscious state, it includes the adjective 'conscious'. I discuss this major problem in this review and propose a novel interpretation of minimally conscious state: its criteria do not inform us about the potential residual consciousness of patients, but they do inform us with certainty about the presence of a cortically mediated state. Based on this constructive criticism review, I suggest three proposals aiming at improving the way we describe the subjective and cognitive state of non-communicating patients. In particular, I present a tentative new classification of impairments of consciousness that combines behavioural evidence with functional brain imaging data, in order to probe directly and univocally residual conscious processes.
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Affiliation(s)
- Lionel Naccache
- AP-HP, Groupe hospitalier Pitié-Salpêtrière, Department of Neurology, 75013, Paris, France
- AP-HP, Groupe hospitalier Pitié-Salpêtrière, Department of Neurophysiology, 75013, Paris, France
- INSERM, U 1127, F-75013, Paris, France
- Institut du Cerveau et de la Moelle épinière, ICM, PICNIC Lab, F-75013, Paris, France
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Portaccio E, Morrocchesi A, Romoli AM, Hakiki B, Taglioli MP, Lippi E, Di Renzone M, Grippo A, Macchi C. Score on Coma Recovery Scale-Revised at admission predicts outcome at discharge in intensive rehabilitation after severe brain injury. Brain Inj 2018; 32:730-734. [DOI: 10.1080/02699052.2018.1440420] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Affiliation(s)
- Emilio Portaccio
- Intensive Rehabilitation Unit, IRCCS Don Gnocchi Foundation, Florence, Italy
- Intensive Rehabilitation Unit Study Group of the IRCCS Don Gnocchi Foundation, Italy
| | - Azzurra Morrocchesi
- Intensive Rehabilitation Unit, IRCCS Don Gnocchi Foundation, Florence, Italy
- Intensive Rehabilitation Unit Study Group of the IRCCS Don Gnocchi Foundation, Italy
| | - Anna Maria Romoli
- Intensive Rehabilitation Unit, IRCCS Don Gnocchi Foundation, Florence, Italy
- Intensive Rehabilitation Unit Study Group of the IRCCS Don Gnocchi Foundation, Italy
| | - Bahia Hakiki
- Intensive Rehabilitation Unit, IRCCS Don Gnocchi Foundation, Florence, Italy
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
- Intensive Rehabilitation Unit Study Group of the IRCCS Don Gnocchi Foundation, Italy
| | - Maria Pia Taglioli
- Intensive Rehabilitation Unit, IRCCS Don Gnocchi Foundation, Florence, Italy
- Intensive Rehabilitation Unit Study Group of the IRCCS Don Gnocchi Foundation, Italy
| | - Elena Lippi
- Intensive Rehabilitation Unit, IRCCS Don Gnocchi Foundation, Florence, Italy
- Intensive Rehabilitation Unit Study Group of the IRCCS Don Gnocchi Foundation, Italy
| | - Martina Di Renzone
- Intensive Rehabilitation Unit, IRCCS Don Gnocchi Foundation, Florence, Italy
- Intensive Rehabilitation Unit Study Group of the IRCCS Don Gnocchi Foundation, Italy
| | - Antonello Grippo
- Intensive Rehabilitation Unit, IRCCS Don Gnocchi Foundation, Florence, Italy
- Intensive Rehabilitation Unit Study Group of the IRCCS Don Gnocchi Foundation, Italy
| | - Claudio Macchi
- Intensive Rehabilitation Unit, IRCCS Don Gnocchi Foundation, Florence, Italy
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
- Intensive Rehabilitation Unit Study Group of the IRCCS Don Gnocchi Foundation, Italy
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Portaccio E, Morrocchesi A, Romoli AM, Hakiki B, Taglioli MP, Lippi E, Di Renzone M, Grippo A, Macchi C. Improvement on the Coma Recovery Scale-Revised During the First Four Weeks of Hospital Stay Predicts Outcome at Discharge in Intensive Rehabilitation After Severe Brain Injury. Arch Phys Med Rehabil 2018; 99:914-919. [PMID: 29428346 DOI: 10.1016/j.apmr.2018.01.015] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2017] [Revised: 01/11/2018] [Accepted: 01/13/2018] [Indexed: 12/01/2022]
Abstract
OBJECTIVES To evaluate the prognostic utility of serial assessment on the Coma Recovery Scale-Revised (CRS-R) during the first 4 weeks of intensive rehabilitation in patients surviving a severe brain injury. DESIGN Prospective cohort study. SETTING An intensive rehabilitation unit. PARTICIPANTS Patients (N=110) consecutively admitted to the intensive rehabilitation unit. Inclusion criteria were (1) a diagnosis of unresponsive wakefulness syndrome (UWS) or minimally conscious state (MCS) caused by an acquired brain injury, and (2) aged >18 years. INTERVENTIONS All patients underwent clinical evaluations using the Italian version of the CRS-R during the first month of hospital stay. MAIN OUTCOME MEASURES Behavioral classification on the CRS-R and the score on the Glasgow Outcome Scale (GOS) at final discharge. Patients transitioning from UWS to MCS or emergence from MCS (E-MCS), and from MCS to E-MCS were classified as patients with improved responsiveness (IR). RESULTS After a mean ± SD hospital stay of 5.3±2.7 months, 59 of 110 patients (53.6%) achieved IR. In the multivariable analysis, a higher CRS-R score change at week 4 (odds ratio =1.99; 95% confidence interval [CI], 1.49-2.66; P<.001) was the only significant predictor of IR at discharge. Fifty-three patients (48.2%) were classified as severely impaired at discharge (GOS=3). In the multivariable analysis, higher GOS scores were related to a higher CRS-R score at admission (B=.051; 95% CI, .027-.074; P<.001), a higher CRS-R score change at week 4 (B=.087; 95% CI, .064-.110; P<.001), and an absence of severe infections (B=-.477; 95% CI, -.778 to -.176; P=.002). CONCLUSIONS An improvement on the total CRS-R score and on different subscales across the first 4 weeks of inpatient rehabilitation discriminates patients who will have a better outcome at discharge, providing information for rehabilitation planning and for communication with patients and their caregivers.
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Affiliation(s)
| | | | | | - Bahia Hakiki
- IRCCS Don Gnocchi Foundation, Florence, Italy; University of Florence, Florence, Italy
| | | | - Elena Lippi
- IRCCS Don Gnocchi Foundation, Florence, Italy
| | | | | | - Claudio Macchi
- IRCCS Don Gnocchi Foundation, Florence, Italy; University of Florence, Florence, Italy
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Faugeras F, Rohaut B, Valente M, Sitt J, Demeret S, Bolgert F, Weiss N, Grinea A, Marois C, Quirins M, Demertzi A, Raimondo F, Galanaud D, Habert MO, Engemann D, Puybasset L, Naccache L. Survival and consciousness recovery are better in the minimally conscious state than in the vegetative state. Brain Inj 2017; 32:72-77. [PMID: 29156989 DOI: 10.1080/02699052.2017.1364421] [Citation(s) in RCA: 59] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
BACKGROUND The prognosis value of early clinical diagnosis of consciousness impairment is documented by an extremely limited number of studies, whereas it may convey important information to guide medical decisions. OBJECTIVE We aimed at determining if patients diagnosed at an early stage (<90 days after brain injury) as being in the minimally conscious state (MCS) have a better prognosis than patients in the vegetative state/Unresponsive Wakefulness syndrome (VS/UWS), independent of care limitations or withdrawal decisions. METHODS Patients hospitalized in ICUs of the Pitié-Salpêtrière Hospital (Paris, France) from November 2008 to January 2011 were included and evaluated behaviourally with standardized assessment and with the Coma Recovery Scale-Revised as being either in the VS/UWS or in the MCS. They were then prospectively followed until 1July 2011 to evaluate their outcome with the GOSE. We compared survival function and outcomes of these two groups. RESULTS Both survival function and outcomes, including consciousness recovery, were significantly better in the MCS group. This difference of outcome still holds when considering only patients still alive at the end of the study. CONCLUSIONS Early accurate clinical diagnosis of VS/UWS or MCS conveys a strong prognostic value of survival and of consciousness recovery.
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Affiliation(s)
- Frédéric Faugeras
- a AP-HP, Groupe hospitalier Pitié-Salpêtrière , Department of Neurology , Paris , France.,b AP-HP, Groupe hospitalier Pitié-Salpêtrière , Department of Neurophysiology , Paris , France.,c INSERM, U 1127 , Paris , France.,d Institut du Cerveau et de la Moelle épinière, ICM , PICNIC Lab , Paris , France
| | - Benjamin Rohaut
- a AP-HP, Groupe hospitalier Pitié-Salpêtrière , Department of Neurology , Paris , France.,b AP-HP, Groupe hospitalier Pitié-Salpêtrière , Department of Neurophysiology , Paris , France.,c INSERM, U 1127 , Paris , France.,d Institut du Cerveau et de la Moelle épinière, ICM , PICNIC Lab , Paris , France
| | - Mélanie Valente
- c INSERM, U 1127 , Paris , France.,d Institut du Cerveau et de la Moelle épinière, ICM , PICNIC Lab , Paris , France
| | - Jacobo Sitt
- c INSERM, U 1127 , Paris , France.,d Institut du Cerveau et de la Moelle épinière, ICM , PICNIC Lab , Paris , France
| | - Sophie Demeret
- a AP-HP, Groupe hospitalier Pitié-Salpêtrière , Department of Neurology , Paris , France
| | - Francis Bolgert
- a AP-HP, Groupe hospitalier Pitié-Salpêtrière , Department of Neurology , Paris , France
| | - Nicolas Weiss
- a AP-HP, Groupe hospitalier Pitié-Salpêtrière , Department of Neurology , Paris , France
| | - Alexandra Grinea
- a AP-HP, Groupe hospitalier Pitié-Salpêtrière , Department of Neurology , Paris , France
| | - Clémence Marois
- a AP-HP, Groupe hospitalier Pitié-Salpêtrière , Department of Neurology , Paris , France.,c INSERM, U 1127 , Paris , France.,d Institut du Cerveau et de la Moelle épinière, ICM , PICNIC Lab , Paris , France
| | - Marion Quirins
- c INSERM, U 1127 , Paris , France.,d Institut du Cerveau et de la Moelle épinière, ICM , PICNIC Lab , Paris , France
| | - Athena Demertzi
- c INSERM, U 1127 , Paris , France.,d Institut du Cerveau et de la Moelle épinière, ICM , PICNIC Lab , Paris , France
| | - Federico Raimondo
- c INSERM, U 1127 , Paris , France.,d Institut du Cerveau et de la Moelle épinière, ICM , PICNIC Lab , Paris , France
| | - Damien Galanaud
- e AP-HP, Groupe hospitalier Pitié-Salpêtrière , Department of Neuroradiology , Paris , France.,f Sorbonne Universités, UPMC Univ Paris 06 , Faculté de Médecine Pitié-Salpêtrière , Paris , France
| | - Marie-Odile Habert
- f Sorbonne Universités, UPMC Univ Paris 06 , Faculté de Médecine Pitié-Salpêtrière , Paris , France.,g AP-HP, Groupe hospitalier Pitié-Salpêtrière , Department of Nuclear Medicine , Paris , France.,h Sorbonne Universités, UPMC Univ Paris 06 , CNRS, INSERM, Laboratoire d'Imagerie Biomédicale , Paris , France
| | - Denis Engemann
- c INSERM, U 1127 , Paris , France.,d Institut du Cerveau et de la Moelle épinière, ICM , PICNIC Lab , Paris , France
| | - Louis Puybasset
- f Sorbonne Universités, UPMC Univ Paris 06 , Faculté de Médecine Pitié-Salpêtrière , Paris , France.,i AP-HP, Groupe hospitalier Pitié-Salpêtrière , Department of Anesthesiology , Paris , France
| | - Lionel Naccache
- a AP-HP, Groupe hospitalier Pitié-Salpêtrière , Department of Neurology , Paris , France.,b AP-HP, Groupe hospitalier Pitié-Salpêtrière , Department of Neurophysiology , Paris , France.,c INSERM, U 1127 , Paris , France.,d Institut du Cerveau et de la Moelle épinière, ICM , PICNIC Lab , Paris , France.,f Sorbonne Universités, UPMC Univ Paris 06 , Faculté de Médecine Pitié-Salpêtrière , Paris , France
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Noé E, Olaya J, Colomer C, Moliner B, Ugart P, Rodriguez C, Llorens R, Ferri J. Current validity of diagnosis of permanent vegetative state: A longitudinal study in a sample of patients with altered states of consciousness. Neurologia 2017; 34:589-595. [PMID: 28712840 DOI: 10.1016/j.nrl.2017.04.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2016] [Revised: 04/05/2017] [Accepted: 04/28/2017] [Indexed: 10/19/2022] Open
Abstract
INTRODUCTION Altered states of consciousness have traditionally been associated with poor prognosis. At present, clinical differences between these entities are beginning to be established. METHOD Our study included 37 patients diagnosed with vegetative state/unresponsive wakefulness syndrome (UWS) and 43 in a minimally conscious state (MCS) according to the Coma Recovery Scale-Revised (CRS-R). All patients were followed up each month for at least 6 months using the CRS-R. We recorded the time points when vegetative state progressed from 'persistent' to 'permanent' based on the cut-off points established by the Multi-Society-Task-Force: 12 months in patients with traumatic injury and 3 months in those with non-traumatic injury. A logistic regression model was used to determine the factors potentially predicting which patients will emerge from MCS. RESULTS In the UWS group, 23 patients emerged from UWS but only 9 emerged from MCS. Of the 43 patients in the MCS group, 26 patients emerged from that state during follow-up. Eight of the 23 patients (34.7%) who emerged from UWS and 17 of the 35 (48.6%) who emerged from MCS recovered after the time points proposed by the Multi-Society-Task-Force. According to the multivariate regression analysis, aetiology (P<.01), chronicity (P=.01), and CRS-R scores at admission (P<.001) correctly predicted emergence from MCS in 77.5% of the cases. CONCLUSIONS UWS and MCS are different clinical entities in terms of diagnosis and outcomes. Some of the factors traditionally associated with poor prognosis, such as time from injury and likelihood of recovery, should be revaluated.
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Affiliation(s)
- E Noé
- Servicio de Neurorrehabilitación y Daño Cerebral, Hospitales Vithas-NISA, Fundación Hospitales Vithas-NISA, Valencia, España.
| | - J Olaya
- Servicio de Neurorrehabilitación y Daño Cerebral, Hospitales Vithas-NISA, Fundación Hospitales Vithas-NISA, Valencia, España
| | - C Colomer
- Servicio de Neurorrehabilitación y Daño Cerebral, Hospitales Vithas-NISA, Fundación Hospitales Vithas-NISA, Valencia, España
| | - B Moliner
- Servicio de Neurorrehabilitación y Daño Cerebral, Hospitales Vithas-NISA, Fundación Hospitales Vithas-NISA, Valencia, España
| | - P Ugart
- Servicio de Neurorrehabilitación y Daño Cerebral, Hospitales Vithas-NISA, Fundación Hospitales Vithas-NISA, Valencia, España
| | - C Rodriguez
- Servicio de Neurorrehabilitación y Daño Cerebral, Hospitales Vithas-NISA, Fundación Hospitales Vithas-NISA, Valencia, España
| | - R Llorens
- Servicio de Neurorrehabilitación y Daño Cerebral, Hospitales Vithas-NISA, Fundación Hospitales Vithas-NISA, Valencia, España; Neurorehabilitation and Brain Research Group, Instituto de Investigación e Innovación en Bioingeniería, Universitat Politècnica de València, Valencia, España
| | - J Ferri
- Servicio de Neurorrehabilitación y Daño Cerebral, Hospitales Vithas-NISA, Fundación Hospitales Vithas-NISA, Valencia, España
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Rohaut B, Naccache L. Disentangling conscious from unconscious cognitive processing with event-related EEG potentials. Rev Neurol (Paris) 2017; 173:521-528. [DOI: 10.1016/j.neurol.2017.08.001] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2017] [Revised: 08/06/2017] [Accepted: 08/07/2017] [Indexed: 01/23/2023]
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Wannez S, Gosseries O, Azzolini D, Martial C, Cassol H, Aubinet C, Annen J, Martens G, Bodart O, Heine L, Charland-Verville V, Thibaut A, Chatelle C, Vanhaudenhuyse A, Demertzi A, Schnakers C, Donneau AF, Laureys S. Prevalence of coma-recovery scale-revised signs of consciousness in patients in minimally conscious state. Neuropsychol Rehabil 2017; 28:1350-1359. [DOI: 10.1080/09602011.2017.1310656] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Affiliation(s)
- Sarah Wannez
- Coma Science Group, GIGA-Consciousness and Neurology Department, University of Liège, Liège, Belgium
| | - Olivia Gosseries
- Coma Science Group, GIGA-Consciousness and Neurology Department, University of Liège, Liège, Belgium
| | - Deborah Azzolini
- Coma Science Group, GIGA-Consciousness and Neurology Department, University of Liège, Liège, Belgium
| | - Charlotte Martial
- Coma Science Group, GIGA-Consciousness and Neurology Department, University of Liège, Liège, Belgium
| | - Helena Cassol
- Coma Science Group, GIGA-Consciousness and Neurology Department, University of Liège, Liège, Belgium
| | - Charlène Aubinet
- Coma Science Group, GIGA-Consciousness and Neurology Department, University of Liège, Liège, Belgium
| | - Jitka Annen
- Coma Science Group, GIGA-Consciousness and Neurology Department, University of Liège, Liège, Belgium
| | - Géraldine Martens
- Coma Science Group, GIGA-Consciousness and Neurology Department, University of Liège, Liège, Belgium
| | - Olivier Bodart
- Coma Science Group, GIGA-Consciousness and Neurology Department, University of Liège, Liège, Belgium
| | - Lizette Heine
- Coma Science Group, GIGA-Consciousness and Neurology Department, University of Liège, Liège, Belgium
| | - Vanessa Charland-Verville
- Coma Science Group, GIGA-Consciousness and Neurology Department, University of Liège, Liège, Belgium
| | - Aurore Thibaut
- Coma Science Group, GIGA-Consciousness and Neurology Department, University of Liège, Liège, Belgium
| | - Camille Chatelle
- Coma Science Group, GIGA-Consciousness and Neurology Department, University of Liège, Liège, Belgium
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, USA
| | - Audrey Vanhaudenhuyse
- Coma Science Group, GIGA-Consciousness and Neurology Department, University of Liège, Liège, Belgium
- Department of Algology, University Hospital of Liège, Liège, Belgium
| | - Athena Demertzi
- Coma Science Group, GIGA-Consciousness and Neurology Department, University of Liège, Liège, Belgium
| | - Caroline Schnakers
- Department of Neurosurgery, University of California, Los Angeles, USA
- Research Department, Casa Colina Hospital and Centers for Healthcare, Pomona, USA
| | | | - Steven Laureys
- Coma Science Group, GIGA-Consciousness and Neurology Department, University of Liège, Liège, Belgium
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Gosseries O, Pistoia F, Charland-Verville V, Carolei A, Sacco S, Laureys S. The Role of Neuroimaging Techniques in Establishing Diagnosis, Prognosis and Therapy in Disorders of Consciousness. Open Neuroimag J 2016; 10:52-68. [PMID: 27347265 PMCID: PMC4894918 DOI: 10.2174/1874440001610010052] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2016] [Revised: 04/06/2016] [Accepted: 04/11/2016] [Indexed: 12/30/2022] Open
Abstract
Non-communicative brain damaged patients raise important clinical and scientific issues. Here, we review three major pathological disorders of consciousness: coma, the unresponsive wakefulness syndrome and the minimally conscious state. A number of clinical studies highlight the difficulty in making a correct diagnosis in patients with disorders of consciousness based only on behavioral examinations. The increasing use of neuroimaging techniques allows improving clinical characterization of these patients. Recent neuroimaging studies using positron emission tomography, functional magnetic resonance imaging, electroencephalography and transcranial magnetic stimulation can help assess diagnosis, prognosis, and therapeutic treatment. These techniques, using resting state, passive and active paradigms, also highlight possible dissociations between consciousness and responsiveness, and are facilitating a more accurate understanding of brain function in this challenging population.
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Affiliation(s)
- Olivia Gosseries
- Coma Science Group, GIGA, University of Liege, Liege, Belgium; Department of Psychology and Psychiatry, University of Wisconsin, Madison, WI, United-States
| | - Francesca Pistoia
- Department of Biotechnological and Applied Clinical Sciences, Neurological Institute, University of L'Aquila, L'Aquila, Italy
| | | | - Antonio Carolei
- Department of Biotechnological and Applied Clinical Sciences, Neurological Institute, University of L'Aquila, L'Aquila, Italy
| | - Simona Sacco
- Department of Biotechnological and Applied Clinical Sciences, Neurological Institute, University of L'Aquila, L'Aquila, Italy
| | - Steven Laureys
- Coma Science Group, GIGA, University of Liege, Liege, Belgium
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van Erp WS, Lavrijsen JCM, Vos PE, Bor H, Laureys S, Koopmans RTCM. The vegetative state: prevalence, misdiagnosis, and treatment limitations. J Am Med Dir Assoc 2016; 16:85.e9-85.e14. [PMID: 25528282 DOI: 10.1016/j.jamda.2014.10.014] [Citation(s) in RCA: 79] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2014] [Accepted: 10/20/2014] [Indexed: 12/21/2022]
Abstract
INTRODUCTION Patients in a vegetative state/unresponsive wakefulness syndrome (VS/UWS) open their eyes spontaneously, but show only reflexive behavior. Although VS/UWS is one of the worst possible outcomes of acquired brain injury, its prevalence is largely unknown. This study's objective was to map the total population of hospitalized and institutionalized patients in VS/UWS in the Netherlands: prevalence, clinical characteristics, and treatment limitations. METHODS Nationwide point prevalence study on patients in VS/UWS at least 1 month after acute brain injury in hospitals, rehabilitation centers, nursing homes, institutions for people with intellectual disability, and hospices; diagnosis verification by a researcher using the Coma Recovery Scale-revised (CRS-r); gathering of demographics, clinical characteristics, and treatment limitations. RESULTS We identified 33 patients in VS/UWS, 24 of whose diagnoses could be verified. Patients were on average 51 years old with a mean duration of VS/UWS of 5 years. The main etiology was hypoxia sustained during cardiac arrest and resuscitation. More than 50% of patients had not received rehabilitation services. Most were given life-sustaining treatment beyond internationally accepted prognostic boundaries regarding recovery of consciousness. Seventeen (39%) of 41 patients presumed to be in VS/UWS were found to be at least minimally conscious. CONCLUSIONS Results translate to a prevalence of 0.1 to 0.2 hospitalized and institutionalized VS/UWS patients per 100,000 members of the general population. This small figure may be related to the legal option to withhold or withdraw life-sustaining treatment, including artificial nutrition and hydration. On the other hand, this study shows that in certain cases, physicians continue life-prolonging treatment for up to 25 years. Patients have poor access to rehabilitation and are at substantial risk for misdiagnosis.
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Affiliation(s)
- Willemijn S van Erp
- Department of Primary and Community Care, Centre for Family Medicine, Geriatric Care and Public Health, Radboud University Medical Centre, Nijmegen, The Netherlands; Coma Science Group, Cyclotron Research Center and Neurology Department, University of Liège, Liège, Belgium.
| | - Jan C M Lavrijsen
- Department of Primary and Community Care, Centre for Family Medicine, Geriatric Care and Public Health, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Pieter E Vos
- Department of Neurology, Singeland Ziekenhuis, Doetinchem, The Netherlands
| | - Hans Bor
- Department of Primary and Community Care, Centre for Family Medicine, Geriatric Care and Public Health, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Steven Laureys
- Coma Science Group, Cyclotron Research Center and Neurology Department, University of Liège, Liège, Belgium; University Hospital of Liège, Liège, Belgium; Belgian Funds for Scientific Research, Belgium
| | - Raymond T C M Koopmans
- Department of Primary and Community Care, Centre for Family Medicine, Geriatric Care and Public Health, Radboud University Medical Centre, Nijmegen, The Netherlands; Waalboog Foundation, Joachim and Anna, Centre for Specialised Geriatric Care, Nijmegen, The Netherlands
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Padilla R, Domina A. Effectiveness of Sensory Stimulation to Improve Arousal and Alertness of People in a Coma or Persistent Vegetative State After Traumatic Brain Injury: A Systematic Review. Am J Occup Ther 2016; 70:7003180030p1-8. [DOI: 10.5014/ajot.2016.021022] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Abstract
OBJECTIVE. This systematic review evaluates the effectiveness of sensory stimulation to improve arousal and alertness of people in a coma or persistent vegetative state after traumatic brain injury (TBI).
METHOD. Databases searched included Medline, PsycINFO, CINAHL, OTseeker, and the Cochrane Database of Systematic Reviews. The search was limited to outcomes studies published in English in peer-reviewed journals between 2008 and 2013.
RESULTS. Included studies provide strong evidence that multimodal sensory stimulation improves arousal and enhances clinical outcomes for people in a coma or persistent vegetative state after TBI. Moderate evidence was also provided for auditory stimulation, limited evidence was provided for complex stimuli, and insufficient evidence was provided for median nerve stimulation.
CONCLUSION. Interventions should be tailored to client tolerance and premorbid preferences. Bimodal or multimodal stimulation should begin early, be frequent, and be sustained until more complex activity is possible.
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Affiliation(s)
- René Padilla
- René Padilla, PhD, OT/L, FAOTA, LMHP, is Executive Director of Global Engagement and Associate Professor of Occupational Therapy, Creighton University, Omaha, NE;
| | - Anna Domina
- Anna Domina, OTD, OTR/L, is Assistant Professor of Occupational Therapy and Academic Clinical Education Coordinator, Creighton University, Omaha, NE
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Ferri J, Noé E, Lloréns R. The Spanish version of the Coma Recovery Scale-revised: Events on a correct timeline. Brain Inj 2015; 29:1002-3. [PMID: 25996470 DOI: 10.3109/02699052.2015.1022884] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Lancioni GE, Singh NN, O'Reilly MF, Sigafoos J, Olivetti Belardinelli M, Buonocunto F, D'Amico F, Navarro J, Lanzilotti C, Ferlisi G, Denitto F. Technology-aided programs for post-coma patients emerged from or in a minimally conscious state. Front Hum Neurosci 2014; 8:931. [PMID: 25538593 PMCID: PMC4257021 DOI: 10.3389/fnhum.2014.00931] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2014] [Accepted: 10/31/2014] [Indexed: 11/17/2022] Open
Abstract
Post-coma persons in a minimally conscious state (MCS) or emerged/emerging from such state (E-MCS), who are affected by extensive motor impairment and lack of speech, may develop an active role and interact with their environment with the help of technology-aided intervention programs. Although a number of studies have been conducted in this area during the last few years, new evidence about the efficacy of those programs is warranted. These three studies were an effort in that direction. Study I assessed a technology-aided program to enable six MCS participants to access preferred environmental stimulation independently. Studies II and III assessed technology-aided programs to enable six E-MCS participants to make choices. In Study II, three of those participants were led to choose among leisure and social stimuli, and caregiver interventions automatically presented to them. In Study III, the remaining three participants were led to choose (a) among general stimulus/intervention options (e.g., songs, video-recordings of family members, and caregiver interventions); and then (b) among variants of those options. The results of all three studies were largely positive with substantial increases of independent stimulation access for the participants of Study I and independent choice behavior for the participants of Studies II and III. The results were analyzed in relation to previous data and in terms of their implications for daily contexts working with MCS and E-MCS persons affected by multiple disabilities.
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Affiliation(s)
- Giulio E Lancioni
- Department of Neuroscience and Sense Organs, University of Bari Bari, Italy
| | - Nirbhay N Singh
- Medical College of Georgia, Georgia Regents University Augusta, GA, USA
| | - Mark F O'Reilly
- Department of Special Education, University of Texas at Austin Austin, TX, USA
| | - Jeff Sigafoos
- Department of Educational Psychology, Victoria University of Wellington Wellington, New Zealand
| | | | | | - Fiora D'Amico
- S. Raffaele Rehabilitation and Care Centers Ceglie and Alberobello, Italy
| | - Jorge Navarro
- S. Raffaele Rehabilitation and Care Centers Ceglie and Alberobello, Italy
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Gerrard P, Zafonte R, Giacino JT. Coma Recovery Scale–Revised: Evidentiary Support for Hierarchical Grading of Level of Consciousness. Arch Phys Med Rehabil 2014; 95:2335-41. [PMID: 25010536 DOI: 10.1016/j.apmr.2014.06.018] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2013] [Revised: 05/19/2014] [Accepted: 06/20/2014] [Indexed: 11/26/2022]
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Gosseries O, Zasler ND, Laureys S. Recent advances in disorders of consciousness: Focus on the diagnosis. Brain Inj 2014; 28:1141-50. [PMID: 25099018 DOI: 10.3109/02699052.2014.920522] [Citation(s) in RCA: 89] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Affiliation(s)
- Olivia Gosseries
- Coma Science Group, Cyclotron Research Centre and Neurology Department, University and University Hospital of Liege , Liege , Belgium
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Abstract
Significant advances have been made in the behavioral assessment and clinical management of disorders of consciousness (DOC). In addition, functional neuroimaging paradigms are now available to help assess consciousness levels in this challenging patient population. The success of these neuroimaging approaches as diagnostic markers is, however, intrinsically linked to understanding the relationships between consciousness and the brain. In this context, a combined theoretical approach to neuroimaging studies is needed. The promise of such theoretically based markers is illustrated by recent findings that used a perturbational approach to assess the levels of consciousness. Further research on the contents of consciousness in DOC is also needed.
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Affiliation(s)
- Olivia Gosseries
- Coma Science Group, Cyclotron Research Center and Neurology Department, University of Liege, and University Hospital of Liege, 4000 Liege, Belgium; , , ,
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Lancioni GE, Singh NN, O'Reilly MF, Sigafoos J, Buonocunto F, D'Amico F, Navarro J, Lanzilotti C, Megna M. Occupation and communication programs for post-coma persons with or without consciousness disorders who show extensive motor impairment and lack of speech. RESEARCH IN DEVELOPMENTAL DISABILITIES 2014; 35:1110-1118. [PMID: 24582854 DOI: 10.1016/j.ridd.2014.01.029] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/15/2014] [Accepted: 01/28/2014] [Indexed: 06/03/2023]
Abstract
These two studies were aimed at extending the assessment of technology-aided programs for post-coma persons with extensive motor impairment and lack of speech. Specifically, Study I assessed a new program arrangement, in which stimulation access and caregiver attention could be obtained with variations of the same response (i.e., single- versus double-hand closure) by three participants who were diagnosed at the upper level of the minimally conscious state at the start of the study. Study II was aimed at enabling two persons who had emerged from a minimally conscious state to engage in leisure activities, listen to audio-recordings of family members, and send and receive messages. The responses selected for these participants were hand pressure and eyelid closure, respectively. The results of both studies were positive. The participants of Study I increased their responding to increase their stimulation input and caregiver interaction. The participants of Study II managed to successfully select all the options the program included (i.e., the leisure options, as well as the family and communication options). General implications of the programs and the related technology packages for intervention with post-coma persons with multiple disabilities are discussed.
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Affiliation(s)
| | - Nirbhay N Singh
- Medical College of Georgia, Georgia Regents University, Augusta, USA
| | | | | | | | - Fiora D'Amico
- S. Raffaele Rehabilitation Center, Ceglie Messapica, Italy
| | - Jorge Navarro
- S. Raffaele Rehabilitation Center, Ceglie Messapica, Italy
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Lancioni GE, Singh NN, O'Reilly MF, Sigafoos J, Oliva D, Campodonico F, D'Amico F, Buonocunto F, Sacco V, Didden R. Post-coma persons emerging from a minimally conscious state with multiple disabilities make technology-aided phone contacts with relevant partners. RESEARCH IN DEVELOPMENTAL DISABILITIES 2013; 34:3190-3196. [PMID: 23891723 DOI: 10.1016/j.ridd.2013.06.021] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/14/2013] [Accepted: 06/14/2013] [Indexed: 06/02/2023]
Abstract
Post-coma individuals emerging from a minimally conscious state with multiple disabilities may enjoy contact with relevant partners (e.g., family members and friends), but may not have easy access to them. These two single-case studies assessed whether those individuals could make contact with partners through computer-aided telephone technology and enjoy such contact. The technology involved a computer system with special software, a global system for mobile communication modem (GSM), and microswitch devices. In Study I, the computer system presented a 23-year-old man the names of the partners that he could contact, one at a time, automatically. Together with each partner's name, the system also presented the voice of the partner asking the man whether he wanted to call him or her. The man could (a) place a call to that partner by activating a camera-based microswitch through mouth movements or (b) bypass that partner and wait for the next one to be presented. In Study II, the system presented a 36-year-old man the partners' names only after he had activated his wobble microswitch with a hand movement. The man could place a call or bypass a partner as in Study I. The results showed that both men (a) were able to contact relevant partners through the technology, (b) seemed to enjoy their telephone-mediated communication contacts with the partners, and (c) showed preferences among the partners. Implications of the findings are discussed.
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Lancioni GE, Singh NN, O'Reilly MF, Sigafoos J, Buonocunto F, Sacco V, Navarro J, Lanzilotti C, D'Amico F, Sasanelli G, De Tommaso M, Megna M. Technology-aided recreation and communication opportunities for post-coma persons affected by lack of speech and extensive motor impairment. RESEARCH IN DEVELOPMENTAL DISABILITIES 2013; 34:2959-2966. [PMID: 23816631 DOI: 10.1016/j.ridd.2013.06.006] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/30/2013] [Accepted: 06/05/2013] [Indexed: 06/02/2023]
Abstract
This study assessed technology-aided intervention programs for two post-coma men who had re-acquired consciousness, but were unable to engage in personally or socially relevant occupations, given their lack of functional speech and their extensive motor disabilities. The microswitches used for accessing the program contents consisted of (a) a pressure sensor fixed in the palm of the first man's hand that could be activated with a small hand closure movement, and (b) an optic sensor fixed under the chin of the second man that could be activated by mouth opening movements. The programs' content consisted of recreation and communication options, which involved activating music, videos, and basic requests, sending and receiving (listening to) text messages, and placing phone calls. The results showed that the men (a) used the technology-aided programs successfully to manage the recreation and communication options available and (b) showed consistent preference for the sessions with the technology-aided program over other daily events. Family and staff members interviewed about the participants' programs (seven members for each participant) thought that the participants enjoyed the intervention sessions with the programs and that the programs had beneficial effects for them. Implications of the findings are discussed.
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Lancioni GE, O'Reilly MF, Singh NN, Sigafoos J, Buonocunto F, Sacco V, Navarro J, Lanzilotti C, De Tommaso M, Megna M, Oliva D. Technology-aided leisure and communication opportunities for two post-coma persons emerged from a minimally conscious state and affected by multiple disabilities. RESEARCH IN DEVELOPMENTAL DISABILITIES 2013; 34:809-816. [PMID: 23220057 DOI: 10.1016/j.ridd.2012.10.008] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/14/2012] [Accepted: 10/18/2012] [Indexed: 06/01/2023]
Abstract
This study assessed technology-aided programs for helping two post-coma persons, who had emerged from a minimally conscious state and were affected by multiple disabilities, to (a) engage with leisure stimuli and request caregiver's procedures, (b) send out and listen to text messages for communication with distant partners, and (c) combine leisure engagement and procedure requests with text messaging within the same sessions. The program for leisure engagement and procedure requests relied on the use of a portable computer with commercial software, and a microswitch for the participants' response. The program for text messaging communication involved the use of a portable computer, a GSM modem, a microswitch for the participants' response, and specifically developed software. Results indicated that the participants were successful at each of the three stages of the study, thus providing relevant evidence concerning performance achievements only minimally documented. The implications of the findings in terms of technology and practical opportunities for post-coma persons with multiple disabilities are discussed.
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Affiliation(s)
- Giulio E Lancioni
- Department of Neuroscience and Sense Organs, University of Bari, Italy.
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Abstract
Objectives: To summarise available evidence for responsiveness of six key assessments used with patients with disorders of consciousness: Coma Recovery Scale – Revised (CRS-R), Disorders Of Consciousness Scale (DOCS), Sensory Modality Assessment and Rehabilitation Technique (SMART), Sensory Stimulation Assessment Measure (SSAM), Wessex Head Injury Matrix (WHIM), and the Western Neuro Sensory Stimulation Profile (WNSSP).Method: A literature search of five electronic databases was conducted using a systematic search strategy. Relevant literature was evaluated and pertinent information extracted.Results: Database searches using key terms initially yielded 132 articles. Following review for inclusion identified 24 articles. No studies were specifically designed to investigate responsiveness of any of the measures and therefore responsiveness data were either based on statistical significance of change post-treatment or descriptive analysis of change scores. The majority of studies identified used the CRS-R (n= 11), WHIM (n= 5) and WNSSP (n= 6) and have established responsiveness to change. There is some preliminary evidence for the responsiveness of the other measures, based on very few available studies: DOCS (n= 2), SMART (n= 1) or SSAM (n= 1).Conclusion: Future studies should seek to include responsiveness analysis, particularly in relation to the DOCS, SMART and SSAM.
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Can we scientifically and reliably measure the level of consciousness in vegetative and minimally conscious States? Rasch analysis of the coma recovery scale-revised. Arch Phys Med Rehabil 2012; 94:527-535.e1. [PMID: 23127303 DOI: 10.1016/j.apmr.2012.09.035] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2012] [Revised: 09/27/2012] [Accepted: 09/27/2012] [Indexed: 11/20/2022]
Abstract
OBJECTIVES (1) To appraise, by the means of Rasch analysis, the internal validity and reliability of the Coma Recovery Scale-Revised (CRS-R) in a sample of patients with disorder of consciousness (DOC); and (2) to provide information about the comparability of CRS-R scores across persons with DOC across different settings and groups, including different etiologies. DESIGN Multicenter observational prospective study. SETTING Two rehabilitation wards, 1 intermediate care facility, and 2 nursing homes in Italy. PARTICIPANTS Consecutively admitted patients (N=129) for which assessments at 2 different time points were available, giving a total sample of 258 observations. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURE CRS-R. RESULTS After controlling for any possible dependency between persons' measures collected at different time points, and for uniform differential item functioning by etiology showed by the visual subscale, Rasch analysis demonstrated adequate satisfaction of all the model's requirements, including adequate ordering of scoring categories, unidimensionality, local independence, invariance (χ(2)21=27.798, P=.146), and absence of differential item functioning across patients' sex, age, time, and setting. The reliability (person separation index=.896) was adequate for individual person measurement. We devised a practical raw score to measure conversion tables based on the CRS-R calibrations. CONCLUSIONS The CRS-R is a psychometrically sound and robust measurement tool. The linear measures of ability derived from the CRS-R total scores do satisfy all the principles of scientific measurement and are sufficiently reliable for high stakes assessments, such as the diagnosis of the level of consciousness in individual patients. Future studies are needed to directly explore the capabilities of the CRS-R measures to reduce the risk of vegetative state misdiagnosis.
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Lancioni GE, Singh NN, O'Reilly MF, Sigafoos J, Belardinelli MO, Buonocunto F, Sacco V, Navarro J, Lanzilotti C, De Tommaso M, Megna M, Badagliacca F. Promoting adaptive behavior in persons with acquired brain injury, extensive motor and communication disabilities, and consciousness disorders. RESEARCH IN DEVELOPMENTAL DISABILITIES 2012; 33:1964-1974. [PMID: 22738766 DOI: 10.1016/j.ridd.2012.05.027] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/27/2012] [Accepted: 05/29/2012] [Indexed: 06/01/2023]
Abstract
These two studies extended the evidence on the use of technology-based intervention packages to promote adaptive behavior in persons with acquired brain injury and multiple disabilities. Study I involved five participants in a minimally conscious state who were provided with intervention packages based on specific arrangements of optic, tilt, or pressure microswitches (linked to preferred environmental stimuli) and eyelid, toe and finger responses. Study II involved three participants who were emerging from a minimally conscious state and were provided with intervention packages based on computer presentations of stimulus options (i.e., preferred stimuli, functional caregiver's procedures, and non-preferred stimuli) and pressure microswitches to choose among them. Intervention data of Study I showed that the participants acquired relatively high levels of microswitch responding (thus engaging widely with preferred environmental stimuli) and kept that responding consistent except for one case. Intervention data of Study II showed that the participants were active in choosing among preferred stimuli and positive caregivers' procedures, but generally abstained from non-preferred stimuli. The results were discussed in terms of the successful use of fairly new/infrequent microswitch-response arrangements (Study I) and the profitable inclusion of functional caregiver's procedures among the options available to choice (Study II).
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Affiliation(s)
- Giulio E Lancioni
- Department of Neuroscience and Sense Organs, University of Bari, Italy.
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