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Vatrano M, Nemirovsky IE, Tonin P, Riganello F. Assessing Consciousness through Neurofeedback and Neuromodulation: Possibilities and Challenges. Life (Basel) 2023; 13:1675. [PMID: 37629532 PMCID: PMC10455583 DOI: 10.3390/life13081675] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2023] [Revised: 07/27/2023] [Accepted: 07/30/2023] [Indexed: 08/27/2023] Open
Abstract
Neurofeedback is a non-invasive therapeutic approach that has gained traction in recent years, showing promising results for various neurological and psychiatric conditions. It involves real-time monitoring of brain activity, allowing individuals to gain control over their own brainwaves and improve cognitive performance or alleviate symptoms. The use of electroencephalography (EEG), such as brain-computer interface (BCI), transcranial direct current stimulation (tDCS), and transcranial magnetic stimulation (TMS), has been instrumental in developing neurofeedback techniques. However, the application of these tools in patients with disorders of consciousness (DoC) presents unique challenges. In this narrative review, we explore the use of neurofeedback in treating patients with DoC. More specifically, we discuss the advantages and challenges of using tools such as EEG neurofeedback, tDCS, TMS, and BCI for these conditions. Ultimately, we hope to provide the neuroscientific community with a comprehensive overview of neurofeedback and emphasize its potential therapeutic applications in severe cases of impaired consciousness levels.
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Affiliation(s)
- Martina Vatrano
- S. Anna Institute, Research in Advanced Neurorehabilitation, Via Siris, 11, 88900 Crotone, Italy;
| | - Idan Efim Nemirovsky
- Department of Physics and Astronomy, Brain and Mind Institute, University of Western Ontario, London, ON N6A 3K7, Canada;
| | - Paolo Tonin
- S. Anna Institute, Research in Advanced Neurorehabilitation, Via Siris, 11, 88900 Crotone, Italy;
| | - Francesco Riganello
- S. Anna Institute, Research in Advanced Neurorehabilitation, Via Siris, 11, 88900 Crotone, Italy;
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2
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Bagnato S. The role of plasticity in the recovery of consciousness. HANDBOOK OF CLINICAL NEUROLOGY 2022; 184:375-395. [PMID: 35034750 DOI: 10.1016/b978-0-12-819410-2.00020-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Disorders of consciousness (DOCs), i.e., coma, vegetative state, and minimally conscious state are the consequences of a severe brain injury that disrupts the brain ability to generate consciousness. Recovery from DOCs requires functional and structural changes in the brain. The sites where these plastic changes take place vary according to the pathophysiology of the DOC. The ascending reticular activating system of the brainstem and its complex connections with the thalamus and cortex are involved in the pathophysiology of coma. Subcortical structures, such as the striatum and globus pallidus, together with thalamocortical and corticothalamic projections, the basal forebrain, and several networks among different cortical areas are probably involved in vegetative and minimally conscious states. Some mechanisms of plasticity that allegedly operate in each of these sites to promote recovery of consciousness will be discussed in this chapter. While some mechanisms of plasticity work at a local level, others produce functional changes in complex neuronal networks, for example by entraining neuronal oscillations. The specific mechanisms of brain plasticity represent potential targets for future treatments aiming to restore consciousness in patients with severe DOCs.
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Affiliation(s)
- Sergio Bagnato
- Unit of Neurophysiology and Unit for Severe Acquired Brain Injuries, Rehabilitation Department, Giuseppe Giglio Foundation, Cefalù (PA), Italy.
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3
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FIERAIN A, GASPARD N, LEJEUNE N, EL TAHRY R, SPEYBROECK N, DERMAUW V, FERRAO SANTOS S. Beware of nonconvulsive seizures in prolonged disorders of consciousness: long-term EEG monitoring is the key. Clin Neurophysiol 2022; 136:228-234. [DOI: 10.1016/j.clinph.2021.12.020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Revised: 11/22/2021] [Accepted: 12/14/2021] [Indexed: 11/24/2022]
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4
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Shou Z, Li Z, Wang X, Chen M, Bai Y, Di H. Non-invasive brain intervention techniques used in patients with disorders of consciousness. Int J Neurosci 2020; 131:390-404. [PMID: 32238043 DOI: 10.1080/00207454.2020.1744598] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Aim of the study: With the development of emergency medicine and intensive care technology, the number of people who survive with disorders of consciousness (DOC) has dramatically increased. The diagnosis and treatment of such patients have attracted much attention from the medical community. From the latest evidence-based guidelines, non-invasive brain intervention (NIBI) techniques may be valuable and promising in the diagnosis and conscious rehabilitation of DOC patients.Methods: This work reviews the studies on NIBI techniques for the assessment and intervention of DOC patients.Results: A large number of studies have explored the application of NIBI techniques in DOC patients. The NIBI techniques include transcranial magnetic stimulation, transcranial electric stimulation, music stimulation, near-infrared laser stimulation, focused shock wave therapy, low-intensity focused ultrasound pulsation and transcutaneous auricular vagus nerve stimulation.Conclusions: NIBI techniques present numerous advantages such as being painless, safe and inexpensive; having adjustable parameters and targets; and having broad development prospects in treating DOC patients.
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Affiliation(s)
- Zeyu Shou
- International Vegetative State and Consciousness Science Institute, Hangzhou Normal University, Hangzhou, China.,Key Laboratory of Aging and Cancer Biology of Zhejiang Province, Hangzhou Normal University, Hangzhou, China
| | - Zhilong Li
- International Vegetative State and Consciousness Science Institute, Hangzhou Normal University, Hangzhou, China.,Key Laboratory of Aging and Cancer Biology of Zhejiang Province, Hangzhou Normal University, Hangzhou, China
| | - Xueying Wang
- International Vegetative State and Consciousness Science Institute, Hangzhou Normal University, Hangzhou, China.,Key Laboratory of Aging and Cancer Biology of Zhejiang Province, Hangzhou Normal University, Hangzhou, China
| | - Miaoyang Chen
- International Vegetative State and Consciousness Science Institute, Hangzhou Normal University, Hangzhou, China.,Key Laboratory of Aging and Cancer Biology of Zhejiang Province, Hangzhou Normal University, Hangzhou, China
| | - Yang Bai
- International Vegetative State and Consciousness Science Institute, Hangzhou Normal University, Hangzhou, China.,Key Laboratory of Aging and Cancer Biology of Zhejiang Province, Hangzhou Normal University, Hangzhou, China
| | - Haibo Di
- International Vegetative State and Consciousness Science Institute, Hangzhou Normal University, Hangzhou, China.,Key Laboratory of Aging and Cancer Biology of Zhejiang Province, Hangzhou Normal University, Hangzhou, China
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Calabrò RS, Chillura A, Billeri L, Cannavò A, Buda A, Molonia F, Manuli A, Bramanti P, Naro A. Peri-Personal Space Tracing by Hand-Blink Reflex Modulation in Patients with Chronic Disorders of Consciousness. Sci Rep 2020; 10:1712. [PMID: 32015445 PMCID: PMC6997168 DOI: 10.1038/s41598-020-58625-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2019] [Accepted: 01/17/2020] [Indexed: 12/14/2022] Open
Abstract
The assessment of awareness in patients with chronic Disorders of Consciousness (DoC), including Unresponsive Wakefulness Syndrome (UWS) and Minimally Conscious State (MCS), is challenging. The level of awareness impairment may depend on the degree of deterioration of the large-scale cortical-thalamo-cortical networks induced by brain injury. Electrophysiological approaches may shed light on awareness presence in patients with DoC by estimating cortical functions related to the cortical-thalamo-cortical networks including, for example, the cortico-subcortical processes generating motor responses to the perturbation of the peri-personal space (PPS). We measured the amplitude, latency, and duration of the hand-blink reflex (HBR) responses by recording electromyography (EMG) signals from both the orbicularis oculi muscles while electrically stimulating the median nerve at the wrist. Such a BR is thought to be mediated by a neural circuit at the brainstem level. Despite its defensive-response nature, HBR can be modulated by the distance between the stimulated hand and the face. This suggests a functional top-down control of HBR as reflected by HBR features changes (latency, amplitude, and magnitude). We therefore estimated HBR responses in a sample of patients with DoC (8 MCS and 12 UWS, compared to 15 healthy controls -HC) while performing a motor task targeting the PPS. This consisted of passive movements in which the hand of the subject was positioned at different distances from the participant's face. We aimed at demonstrating a residual top-down modulation of HBR properties, which could be useful to differentiate patients with DoC and, potentially, demonstrate awareness preservation. We found a decrease in latency, and an increase in duration and magnitude of HBR responses, which were all inversely related to the hand-to-face distance in HC and patients with MCS, but not in individuals with UWS. Our data suggest that only patients with MCS have preserved, residual, top-down modulation of the processes related to the PPS from higher-order cortical areas to sensory-motor integration network. Although the sample size was relatively small, being thus our data preliminary, HBR assessment seems a rapid, easy, and first-level tool to differentiate patients with MCS from those with UWS. We may also hypothesize that such a HBR modulation suggests awareness preservation.
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Affiliation(s)
| | | | - Luana Billeri
- IRCCS Centro Neurolesi Bonino Pulejo, Messina, Italy
| | | | - Antonio Buda
- IRCCS Centro Neurolesi Bonino Pulejo, Messina, Italy
| | | | | | | | - Antonino Naro
- IRCCS Centro Neurolesi Bonino Pulejo, Messina, Italy
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6
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Pink AE, Williams C, Alderman N, Stoffels M. The use of repetitive transcranial magnetic stimulation (rTMS) following traumatic brain injury (TBI): A scoping review. Neuropsychol Rehabil 2019; 31:479-505. [PMID: 31880207 DOI: 10.1080/09602011.2019.1706585] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
There is continued interest in developing effective and innovative treatment approaches to manage and improve outcomes after traumatic brain injury (TBI). Included in this, is the potential use of repetitive transcranial magnetic stimulation (rTMS), a neuromodulatory tool currently recommended by the National Institute for Health and Care Excellence as a treatment for depression. This review considers the application of rTMS after TBI, focussing on its therapeutic efficacy for a broad range of sequalae, whether an optimal and safe rTMS protocol can be determined, and recommendations for future clinical and research work. Five research databases (MEDLINE, CINAHL, PsychINFO, SCOPUS, and Web of Science) were electronically searched, identifying 30 empirical studies (single and multiple subject case reports; randomized controlled trials) for the full review. Evidence suggests that rTMS has the potential to be an efficacious therapeutic intervention for multiple symptoms after TBI, including depression, dizziness, central pain, and visual neglect. However, the picture is less encouraging for prolonged disorders of consciousness and mixed for cognitive outcomes. Overall, rTMS was well-tolerated by patients, although some incidents of side effects and seizures have been reported. Recommendations are made for more comprehensive guidelines and sufficient reporting of rTMS parameters and procedures.
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Affiliation(s)
- Aimee E Pink
- Department of Psychology, Swansea University, Swansea, UK.,Independent Neurorehabilitation Providers Alliance, Newcastle upon Tyne, UK
| | | | - Nick Alderman
- Department of Psychology, Swansea University, Swansea, UK.,Elysium Neurological Services, Elysium Healthcare, Daventry, UK
| | - Martine Stoffels
- Priory Neurobehavioural Brain Injury Services, Burton Park Brain Injury Hospital, Priory Group, Melton Mowbray, UK
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Khanmohammadi S, Laurido-Soto O, Eisenman LN, Kummer TT, Ching S. Intrinsic network reactivity differentiates levels of consciousness in comatose patients. Clin Neurophysiol 2018; 129:2296-2305. [PMID: 30240976 PMCID: PMC6202231 DOI: 10.1016/j.clinph.2018.08.004] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2018] [Revised: 08/13/2018] [Accepted: 08/23/2018] [Indexed: 12/14/2022]
Abstract
OBJECTIVE We devise a data-driven framework to assess the level of consciousness in etiologically heterogeneous comatose patients using intrinsic dynamical changes of resting-state Electroencephalogram (EEG) signals. METHODS EEG signals were collected from 54 comatose patients (GCS ⩽ 8) and 20 control patients (GCS > 8). We analyzed the EEG signals using a new technique, termed Intrinsic Network Reactivity Index (INRI), that aims to assess the overall lability of brain dynamics without the use of extrinsic stimulation. The proposed technique uses three sigma EEG events as a trigger for ensuing changes to the directional derivative of signals across the EEG montage. RESULTS The INRI had a positive relationship with GCS and was significantly different between various levels of consciousness. In comparison, classical band-limited power analysis did not show any specific patterns correlated to GCS. CONCLUSIONS These findings suggest that reaching low variance EEG activation patterns becomes progressively harder as the level of consciousness of patients deteriorate, and provide a quantitative index based on passive measurements that characterize this change. SIGNIFICANCE Our results emphasize the role of intrinsic brain dynamics in assessing the level of consciousness in coma patients and the possibility of employing simple electrophysiological measures to recognize the severity of disorders of consciousness (DOC).
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Affiliation(s)
- Sina Khanmohammadi
- Department of Electrical & Systems Engineering, Washington University in St. Louis, St. Louis, MO 63130, USA; Department of Neurology, Washington University School of Medicine, St. Louis, MO 63110, USA.
| | - Osvaldo Laurido-Soto
- Department of Neurology, Washington University School of Medicine, St. Louis, MO 63110, USA.
| | - Lawrence N Eisenman
- Department of Neurology, Washington University School of Medicine, St. Louis, MO 63110, USA.
| | - Terrance T Kummer
- Department of Neurology, Washington University School of Medicine, St. Louis, MO 63110, USA.
| | - ShiNung Ching
- Department of Electrical & Systems Engineering, Washington University in St. Louis, St. Louis, MO 63130, USA; Department of Biomedical Engineering, Washington University in St. Louis, St. Louis, MO 63130, USA; Division of Biology and Biomedical Science, Washington University in St. Louis, St. Louis, MO 63130, USA.
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8
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Shin SS, Krishnan V, Stokes W, Robertson C, Celnik P, Chen Y, Song X, Lu H, Liu P, Pelled G. Transcranial magnetic stimulation and environmental enrichment enhances cortical excitability and functional outcomes after traumatic brain injury. Brain Stimul 2018; 11:1306-1313. [PMID: 30082198 DOI: 10.1016/j.brs.2018.07.050] [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: 11/20/2017] [Revised: 07/18/2018] [Accepted: 07/23/2018] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND Therapeutic strategies for traumatic brain injury (TBI) in the last three decades have failed to show significant benefit in large scale studies. Given the multitude of pathological mechanisms involved in TBI, strategies focusing on multimodality regimen have gained interest as promising future interventions. HYPOTHESIS We hypothesized that combining noninvasive transcranial magnetic stimulation (TMS) with rehabilitative training in an environmental enrichment (EE) can facilitate post-TBI recovery in rats via cortical excitability and reorganization. METHODS We subjected rats to controlled cortical impact, and then assigned them to one of four groups: 1. No treatments (TBI), 2. EE after injury (TBI + EE), 3. TMS for one week (TBI + TMS), and 4. TMS for one week combined with EE (TBI + TMS/EE). For TMS, a 10 Hz repetitive TMS protocol was used. RESULTS At 7 days, TBI + TMS and TBI + TMS/EE groups had significantly increased primary somatosensory cortex local field potential (LFP) compared to TBI and TBI + EE groups (P < 0.05). Also, TBI + TMS/EE group had significantly improved performance on beam walk test compared to TBI group (P < 0.005). At 6 weeks, there was significantly higher response in TBI + TMS/EE group compared to TBI + TMS for somatosensory cortex LFP (P < 0.05), bicep motor evoked potentials (MEP) (P < 0.05), challenge ladder test performance (P < 0.01), and fMRI responses to tactile forepaw stimulation. CONCLUSIONS We demonstrate here for the first time the mechanism by which combined therapy using TMS and EE after TBI leads to functional improvement, possibly via cortical excitability and reorganization.
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Affiliation(s)
- Samuel S Shin
- Department of Neurology, The Johns Hopkins University School of Medicine, Baltimore, MD, USA; F.M. Kirby Research Center for Functional Brain Imaging, Kennedy Krieger Institute, Baltimore, MD, USA; Russell H. Morgan Department of Radiology, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Vijai Krishnan
- F.M. Kirby Research Center for Functional Brain Imaging, Kennedy Krieger Institute, Baltimore, MD, USA; Russell H. Morgan Department of Radiology, The Johns Hopkins University School of Medicine, Baltimore, MD, USA; Department of Biomedical Engineering, Michigan State University, East Lansing, MI, USA; The Institute of Quantitative Health Science and Engineering, Michigan State University, East Lansing, MI, USA
| | - William Stokes
- F.M. Kirby Research Center for Functional Brain Imaging, Kennedy Krieger Institute, Baltimore, MD, USA; Russell H. Morgan Department of Radiology, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Courtney Robertson
- Department of Anesthesiology/Critical Care Medicine and Pediatrics, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Pablo Celnik
- Department of Neurology, The Johns Hopkins University School of Medicine, Baltimore, MD, USA; Department of Physical Medicine and Rehabilitation, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Yanrong Chen
- F.M. Kirby Research Center for Functional Brain Imaging, Kennedy Krieger Institute, Baltimore, MD, USA; Russell H. Morgan Department of Radiology, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Xiaolei Song
- F.M. Kirby Research Center for Functional Brain Imaging, Kennedy Krieger Institute, Baltimore, MD, USA; Russell H. Morgan Department of Radiology, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Hanzhang Lu
- F.M. Kirby Research Center for Functional Brain Imaging, Kennedy Krieger Institute, Baltimore, MD, USA; Russell H. Morgan Department of Radiology, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Peiying Liu
- F.M. Kirby Research Center for Functional Brain Imaging, Kennedy Krieger Institute, Baltimore, MD, USA; Russell H. Morgan Department of Radiology, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Galit Pelled
- F.M. Kirby Research Center for Functional Brain Imaging, Kennedy Krieger Institute, Baltimore, MD, USA; Russell H. Morgan Department of Radiology, The Johns Hopkins University School of Medicine, Baltimore, MD, USA; Department of Biomedical Engineering, Michigan State University, East Lansing, MI, USA; The Institute of Quantitative Health Science and Engineering, Michigan State University, East Lansing, MI, USA; Department of Radiology, Michigan State University, East Lansing, MI, USA.
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Naro A, Chillura A, Portaro S, Bramanti A, De Luca R, Bramanti P, Calabrò RS. Novel Approaches to the Diagnosis of Chronic Disorders of Consciousness: Detecting Peripersonal Space by Using Ultrasonics. Front Neurol 2018; 9:47. [PMID: 29459847 PMCID: PMC5807342 DOI: 10.3389/fneur.2018.00047] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2017] [Accepted: 01/18/2018] [Indexed: 01/17/2023] Open
Abstract
The assessment of behavioral responsiveness in patients suffering from chronic disorders of consciousness (DoC), including Unresponsive Wakefulness Syndrome (UWS) and Minimally Conscious State (MCS), is challenging. Even if a patient is unresponsive, he/she may be covertly aware in reason of a cognitive-motor dissociation, i.e., a preservation of cognitive functions despite a solely reflexive behavioral responsiveness. The approach of an external stimulus to the peripersonal space (PPS) modifies some biological measures (e.g., hand-blink reflex amplitude) to the purpose of defensive responses from threats. Such modulation depends on a top-down control of subcortical neural circuits, which can be explored through changes in cerebral blood flow velocity (CBFV), using functional transcranial Doppler (fTCD) and, thus, gaining useful, indirect information on brain connectivity. These data may be used for the DoC differential diagnosis. We evaluated the changes in CBFV by measuring the pulsatility index (PI) in 21 patients with DoC (10 patients with MCS and 11 with UWS) and 25 healthy controls (HC) during a passive movement and motor imagery (MI) task in which the hand of the subject approached and, then, moved away from the subject’s face. In the passive movement task, the PI increased progressively in the HCs when the hand was moved toward the face and, then, it decreased when the hand was removed from the face. The PI increased when the hand was moved toward the face in patients with DoC, but then, it remained high when the hand was removed from the face and up to 30 s after the end of the movement in the patients with MCS (both MCS+ and MCS−) and 1 min in those with UWS, thus differentiating between patients with MCS and UWS. In the MI task, all the HCs, three out of four patients with MCS+, and one out of six patients with MCS− showed an increase–decrease PI change, whereas the remaining patients with MCS and all the patients with UWS showed no PI changes. Even though there is the possibility that our findings will not be replicated in all patients with DoC, we propose fTCD as a rapid and very easy tool to differentiate between patients with MCS and UWS, by identifying residual top-down modulation processes from higher-order cortical areas to sensory-motor integration networks related to the PPS, when using passive movement tasks.
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Affiliation(s)
- Antonino Naro
- IRCCS centro Neurolesi Bonino-Pulejo, Messina, Italy
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10
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Naro A, Bruno R, Leo A, Russo M, Salviera C, Bramanti A, Bramanti P, Calabrò RS. Twist and turn into chronic disorders of consciousness: Potential role of the auditory stapedial reflex. Restor Neurol Neurosci 2018; 35:77-85. [PMID: 28059800 DOI: 10.3233/rnn-160655] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
BACKGROUND Patients suffering from chronic disorders of consciousness (DOC), including minimally conscious state (MCS) and unresponsive wakefulness syndrome (UWS), typically show an awareness impairment paralleled by a significant reflex hyper-excitability, which depend on the cortical deafferentation following brain-damage-induced thalamocortical system deterioration. Nonetheless, recent studies have shown a residual preservation of cortico-subcortical pathways that may sustain residual fragments of awareness in some DOC patients. OBJECTIVE The aim of our study was to assess whether the cortical modulation of auditory stapedial reflex (ASR) could be a marker of a higher degree of brain network connectivity, which is a fundamental prerequisite for awareness generation and maintenance. METHODS We applied a repetitive transcranial magnetic stimulation (rTMS) protocol over the primary auditory area and measured the neuromodulation effects on ASR threshold (ASRt) in a DOC sample and a healthy control group (HC). RESULTS We observed an ASRt reduction in all the HC and MCS individuals, in parallel to a better sound-induced motor responsiveness in MCS sample, while all the UWS patients, but two, did not show any significant ASRt modulation. CONCLUSION We hypothesize that our conditioning protocol may have entrained and potentiated some spared cortico-subcortical networks that sustained the clinical and electrophysiological amelioration we found. Our data electrophysiologically demonstrate for the first time that primary the auditory area can influence ASR elicitation, and such finding may support the DOC differential diagnosis.
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Affiliation(s)
- Antonino Naro
- IRCCS Centro Neurolesi "Bonino-Pulejo", Contrada Casazza, Messina, Italy
| | - Rocco Bruno
- Otorhinolaryngoiatry Unit, University of Messina, Messina, Italy
| | - Antonino Leo
- IRCCS Centro Neurolesi "Bonino-Pulejo", Contrada Casazza, Messina, Italy
| | - Margherita Russo
- IRCCS Centro Neurolesi "Bonino-Pulejo", Contrada Casazza, Messina, Italy
| | - Carlo Salviera
- Otorhinolaryngoiatry Unit, University of Messina, Messina, Italy
| | - Alessia Bramanti
- IRCCS Centro Neurolesi "Bonino-Pulejo", Contrada Casazza, Messina, Italy
| | - Placido Bramanti
- IRCCS Centro Neurolesi "Bonino-Pulejo", Contrada Casazza, Messina, Italy
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Naro A, Bramanti A, Leo A, Bramanti P, Calabrò RS. Metaplasticity: A Promising Tool to Disentangle Chronic Disorders of Consciousness Differential Diagnosis. Int J Neural Syst 2017; 28:1750059. [PMID: 29370729 DOI: 10.1142/s0129065717500599] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
The extent of cortical reorganization after brain injury in patients with Vegetative State/Unresponsive Wakefulness Syndrome (UWS) and Minimally Conscious State (MCS) depends on the residual capability of modulating synaptic plasticity. Neuroplasticity is largely abnormal in patients with UWS, although the fragments of cortical activity may exist, while patients MCS show a better cortical organization. The aim of this study was to evaluate cortical excitability in patients with disorders of consciousness (DoC) using a transcranial direct current stimulation (TDCS) metaplasticity protocol. To this end, we tested motor-evoked potential (MEP) amplitude, short intracortical inhibition (SICI), and intracortical facilitation (ICF). These measures were correlated with the level of consciousness (by the Coma Recovery Scale-Revised, CRS-R). MEP amplitude, SICI, and ICF strength were significantly modulated following different metaplasticity TDCS protocols only in the patients with MCS. SICI modulations showed a significant correlation with the CRS-R score. Our findings demonstrate, for the first time, a partial preservation of metaplasticity properties in some patients with DoC, which correlates with the level of awareness. Thus, metaplasticity assessment may help the clinician in differentiating the patients with DoC, besides the clinical evaluation. Moreover, the responsiveness to metaplasticity protocols may identify the subjects who could benefit from neuromodulation protocols.
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Affiliation(s)
- Antonino Naro
- IRCCS Centro Neurolesi “Bonino-Pulejo”, Messina, Italy
| | | | - Antonino Leo
- IRCCS Centro Neurolesi “Bonino-Pulejo”, Messina, Italy
| | | | - Rocco Salvatore Calabrò
- IRCCS Centro Neurolesi “Bonino-Pulejo”, Messina, Italy
- S.S. 113, Contrada Casazza, 98124 Messina, Italy
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12
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Kotchoubey B. Evoked and event-related potentials in disorders of consciousness: A quantitative review. Conscious Cogn 2017; 54:155-167. [DOI: 10.1016/j.concog.2017.05.002] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2016] [Revised: 04/18/2017] [Accepted: 05/10/2017] [Indexed: 11/25/2022]
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13
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Ragazzoni A, Cincotta M, Giovannelli F, Cruse D, Young GB, Miniussi C, Rossi S. Clinical neurophysiology of prolonged disorders of consciousness: From diagnostic stimulation to therapeutic neuromodulation. Clin Neurophysiol 2017; 128:1629-1646. [DOI: 10.1016/j.clinph.2017.06.037] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2017] [Revised: 05/17/2017] [Accepted: 06/15/2017] [Indexed: 10/19/2022]
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14
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Shin SS, Pelled G. Novel Neuromodulation Techniques to Assess Interhemispheric Communication in Neural Injury and Neurodegenerative Diseases. Front Neural Circuits 2017; 11:15. [PMID: 28337129 PMCID: PMC5343068 DOI: 10.3389/fncir.2017.00015] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2016] [Accepted: 02/20/2017] [Indexed: 12/23/2022] Open
Abstract
Interhemispheric interaction has a major role in various neurobehavioral functions. Its disruption is a major contributor to the pathological changes in the setting of brain injury such as traumatic brain injury, peripheral nerve injury, and stroke, as well as neurodegenerative diseases. Because interhemispheric interaction has a crucial role in functional consequence in these neuropathological states, a review of noninvasive and state-of-the-art molecular based neuromodulation methods that focus on or have the potential to elucidate interhemispheric interaction have been performed. This yielded approximately 170 relevant articles on human subjects or animal models. There has been a recent surge of reports on noninvasive methods such as transcranial magnetic stimulation and transcranial direct current stimulation. Since these are noninvasive techniques with little to no side effects, their widespread use in clinical studies can be easily justified. The overview of novel neuromodulation methods and how they can be applied to study the role of interhemispheric communication in neural injury and neurodegenerative disease is provided. Additionally, the potential of each method in therapeutic use as well as investigating the pathophysiology of interhemispheric interaction in neurodegenerative diseases and brain injury is discussed. New technologies such as transcranial magnetic stimulation or transcranial direct current stimulation could have a great impact in understanding interhemispheric pathophysiology associated with acquired injury and neurodegenerative diseases, as well as designing improved rehabilitation therapies. Also, advances in molecular based neuromodulation techniques such as optogenetics and other chemical, thermal, and magnetic based methods provide new capabilities to stimulate or inhibit a specific brain location and a specific neuronal population.
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Affiliation(s)
- Samuel S Shin
- F.M. Kirby Research Center for Functional Brain Imaging, Kennedy Krieger InstituteBaltimore, MD, USA; Department of Radiology, Johns Hopkins University School of MedicineBaltimore, MD, USA
| | - Galit Pelled
- F.M. Kirby Research Center for Functional Brain Imaging, Kennedy Krieger InstituteBaltimore, MD, USA; Department of Radiology, Johns Hopkins University School of MedicineBaltimore, MD, USA
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Naro A, Leo A, Buda A, Manuli A, Bramanti A, Bramanti P, Calabrò RS. Do you see me? The role of visual fixation in chronic disorders of consciousness differential diagnosis. Brain Res 2016; 1653:59-66. [PMID: 27773729 DOI: 10.1016/j.brainres.2016.10.015] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2016] [Revised: 09/20/2016] [Accepted: 10/17/2016] [Indexed: 01/09/2023]
Abstract
Visual fixation (VF) of a target is a possible, although atypical, feature of the Unresponsive Wakefulness Syndrome (UWS). Whether VF may indicate residual awareness in these patients is debatable, since it may simply subtend a series of reflex processes. Objective tools should therefore be used to identify aware VF, which depends on the integrity of visuomotor networks encompassing frontal-parietal-occipital areas. The aim of our study was to detect residual visuomotor network functionality potentially sustaining aware VF. To this end, we evaluated the visuomotor integration (VMI) and visual P300 patterns in a chronic Disorder of Consciousness (DOC) sample and a control group of healthy individuals (HC), using an associative stimulation protocol combining transcranial magnetic stimulation (TMS) with visual stimulation through transorbital alternating current stimulation. The Minimally Conscious State (MCS) patients showed preserved patterns of VMI and P300, whereas nearly all the UWS patients showed no significant VMI. Notably, the electrophysiological findings were correlated with the visual domain of the Coma Recovery Scale-Revised. Nonetheless, two fixating UWS individuals had a VMI similar to MCS patients. Our data suggest that some UWS patients showing VF could be aware, but unable to manifest it clearly, probably because of a severe motor output impairment, which is a condition compatible with the Functional Locked-In Syndrome.
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Affiliation(s)
- Antonino Naro
- IRCCS Centro Neurolesi "Bonino-Pulejo" Messina, Italy
| | - Antonino Leo
- IRCCS Centro Neurolesi "Bonino-Pulejo" Messina, Italy
| | - Antonio Buda
- IRCCS Centro Neurolesi "Bonino-Pulejo" Messina, Italy
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Naro A, Leo A, Buda A, Manuli A, Bramanti A, Bramanti P, Calabrò RS. Unravelling motor networks in patients with chronic disorders of consciousness: A promising minimally invasive approach. Brain Res 2016; 1646:262-268. [PMID: 27288702 DOI: 10.1016/j.brainres.2016.06.012] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2016] [Revised: 06/01/2016] [Accepted: 06/07/2016] [Indexed: 12/12/2022]
Abstract
Behavioral responsiveness and awareness levels correlate with the degree of functional connectivity within cortical-thalamocortical networks, whose breakdown accounts for chronic disorders of consciousness (DOC). Our study was aimed at assessing the role of the primary motor area (M1) and premotor-M1 circuitry dysfunction in motor output deterioration in minimally conscious state (MCS) and unresponsive wakefulness syndrome (UWS) patients. As a control group, we included a healthy subject (HC) sample in the study. We evaluated the effects of different types of transcranial magnetic stimuli over M1 by recording post-stimulus time histogram (PSTH), which includes a series of peaks of unit firing activity that match with D and I-waves, characterizing the descending corticospinal volleys evoked by transcranial magnetic stimuli. As compared to HC, DOC patients showed a dysfunction of intra-M1 and premotor-M1 circuits, which correlated with the Coma Recovery Scale-Revised scorings. Nonetheless, one UWS patient showed a partially preserved premotor-M1 circuitry, paralleled by a severe intra-M1 circuitry dysfunction. Our data suggest that motor unresponsiveness in some DOC patients may be due to a pure motor output failure, as in the functional locked-in syndrome (fLIS), rather than to a premotor-motor connectivity impairment, which instead characterizes MCS and UWS.
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Affiliation(s)
- Antonino Naro
- IRCCS Centro Neurolesi "Bonino-Pulejo", Messina, Italy
| | - Antonino Leo
- IRCCS Centro Neurolesi "Bonino-Pulejo", Messina, Italy
| | - Antonio Buda
- IRCCS Centro Neurolesi "Bonino-Pulejo", Messina, Italy
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17
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Naro A, Bramanti P, Leo A, Russo M, Calabrò RS. Transcranial Alternating Current Stimulation in Patients with Chronic Disorder of Consciousness: A Possible Way to Cut the Diagnostic Gordian Knot? Brain Topogr 2016; 29:623-44. [PMID: 27062669 DOI: 10.1007/s10548-016-0489-z] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2015] [Accepted: 04/04/2016] [Indexed: 01/10/2023]
Abstract
Unresponsive wakefulness syndrome (UWS) is a chronic disorder of consciousness (DOC) characterized by a lack of awareness and purposeful motor behaviors, owing to an extensive brain connectivity impairment. Nevertheless, some UWS patients may retain residual brain connectivity patterns, which may sustain a covert awareness, namely functional locked-in syndrome (fLIS). We evaluated the possibility of bringing to light such residual neural networks using a non-invasive neurostimulation protocol. To this end, we enrolled 15 healthy individuals and 26 DOC patients (minimally conscious state-MCS- and UWS), who underwent a γ-band transcranial alternating current stimulation (tACS) over the right dorsolateral prefrontal cortex. We measured the effects of tACS on power and partial-directed coherence within local and long-range cortical networks, before and after the protocol application. tACS was able to specifically modulate large-scale cortical effective connectivity and excitability in all the MCS participants and some UWS patients, who could be, therefore, considered as suffering from fLIS. Hence, tACS could be a useful approach in supporting a DOC differential diagnosis, depending on the level of preservation of the cortical large-scale effective connectivity.
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Affiliation(s)
- Antonino Naro
- IRCCS Centro Neurolesi "Bonino-Pulejo" Messina, S.S.113, Contrada Casazza, 98124, Messina, Italy
| | - Placido Bramanti
- IRCCS Centro Neurolesi "Bonino-Pulejo" Messina, S.S.113, Contrada Casazza, 98124, Messina, Italy
| | - Antonino Leo
- IRCCS Centro Neurolesi "Bonino-Pulejo" Messina, S.S.113, Contrada Casazza, 98124, Messina, Italy
| | - Margherita Russo
- IRCCS Centro Neurolesi "Bonino-Pulejo" Messina, S.S.113, Contrada Casazza, 98124, Messina, Italy
| | - Rocco Salvatore Calabrò
- IRCCS Centro Neurolesi "Bonino-Pulejo" Messina, S.S.113, Contrada Casazza, 98124, Messina, Italy.
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Lord V, Opacka-Juffry J. Electroencephalography (EEG) Measures of Neural Connectivity in the Assessment of Brain Responses to Salient Auditory Stimuli in Patients with Disorders of Consciousness. Front Psychol 2016; 7:397. [PMID: 27047424 PMCID: PMC4801887 DOI: 10.3389/fpsyg.2016.00397] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2016] [Accepted: 03/04/2016] [Indexed: 12/19/2022] Open
Affiliation(s)
- Victoria Lord
- Department of Life Sciences, University of Roehampton London, UK
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Naro A, Leo A, Cannavò A, Buda A, Bramanti P, Calabrò RS. Do unresponsive wakefulness syndrome patients feel pain? Role of laser-evoked potential-induced gamma-band oscillations in detecting cortical pain processing. Neuroscience 2016; 317:141-8. [PMID: 26791527 DOI: 10.1016/j.neuroscience.2016.01.009] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2015] [Revised: 01/04/2016] [Accepted: 01/07/2016] [Indexed: 01/18/2023]
Affiliation(s)
- A Naro
- IRCCS Centro Neurolesi Bonino-Pulejo, Messina, Italy
| | - A Leo
- IRCCS Centro Neurolesi Bonino-Pulejo, Messina, Italy
| | - A Cannavò
- IRCCS Centro Neurolesi Bonino-Pulejo, Messina, Italy
| | - A Buda
- IRCCS Centro Neurolesi Bonino-Pulejo, Messina, Italy
| | - P Bramanti
- IRCCS Centro Neurolesi Bonino-Pulejo, Messina, Italy
| | - R S Calabrò
- IRCCS Centro Neurolesi Bonino-Pulejo, Messina, Italy.
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20
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Bagnato S, Boccagni C, Sant'Angelo A, Prestandrea C, Virgilio V, Galardi G. EEG epileptiform abnormalities at admission to a rehabilitation department predict the risk of seizures in disorders of consciousness following a coma. Epilepsy Behav 2016; 56:83-7. [PMID: 26851645 DOI: 10.1016/j.yebeh.2015.12.012] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2015] [Revised: 12/06/2015] [Accepted: 12/09/2015] [Indexed: 11/18/2022]
Abstract
BACKGROUND Seizures affect about a quarter of patients with disorders of consciousness (DOC) after a coma. AIMS We investigated whether the presence of epileptiform abnormalities (EAs) in the electroencephalogram (EEG) of patients with DOC may predict the occurrence of seizures. Moreover, we evaluated whether EAs have a prognostic role in these patients. METHODS This was a retrospective single-center cohort study of patients hospitalized between January 2005 and December 2014 in a rehabilitation department (mean time from acute brain injury: 46.1 days). We analyzed 30-minute EEGs at admittance for 112 patients with unresponsive wakefulness syndrome (UWS) or in a minimally conscious state (MCS), then compared occurrence of seizures over the following three months across patients with absent, unilateral, and bilateral EAs (generalized or bilateral independent). Outcomes at three months were assessed in the same groups using the Coma Recovery Scale Revised. RESULTS Epileptiform abnormalities were observed in 38 patients (33.9%). Of these, 25 were unilateral, and 13 were bilateral. Seizures occurred in 84.6% of patients with bilateral EAs, which was significantly higher than in patients without EAs (10.8%, p<0.001) or with unilateral EAs (24%, p=0.001). The presence of EAs was not related to etiology or different DOC and did not significantly affect outcomes at three months. CONCLUSIONS Patients with EAs at admission to a rehabilitation department have an increased risk of seizures. Specifically, most patients with bilateral EAs had seizures within the following 3 months. Evaluation of EAs in EEGs of patients with DOC may give valuable information in the management of antiepileptic drug treatment.
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Affiliation(s)
- Sergio Bagnato
- Unit of Neurophysiology and Unit for Severe Acquired Brain Injuries, Rehabilitation Department, Fondazione Istituto San Raffaele G. Giglio, Cefalù (PA), Italy.
| | - Cristina Boccagni
- Unit of Neurophysiology and Unit for Severe Acquired Brain Injuries, Rehabilitation Department, Fondazione Istituto San Raffaele G. Giglio, Cefalù (PA), Italy
| | - Antonino Sant'Angelo
- Unit of Neurophysiology and Unit for Severe Acquired Brain Injuries, Rehabilitation Department, Fondazione Istituto San Raffaele G. Giglio, Cefalù (PA), Italy
| | - Caterina Prestandrea
- Unit of Neurophysiology and Unit for Severe Acquired Brain Injuries, Rehabilitation Department, Fondazione Istituto San Raffaele G. Giglio, Cefalù (PA), Italy
| | - Vittorio Virgilio
- Unit of Neurophysiology and Unit for Severe Acquired Brain Injuries, Rehabilitation Department, Fondazione Istituto San Raffaele G. Giglio, Cefalù (PA), Italy
| | - Giuseppe Galardi
- Unit of Neurophysiology and Unit for Severe Acquired Brain Injuries, Rehabilitation Department, Fondazione Istituto San Raffaele G. Giglio, Cefalù (PA), Italy
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21
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Pisani LR, Naro A, Leo A, Aricò I, Pisani F, Silvestri R, Bramanti P, Calabrò RS. Repetitive transcranial magnetic stimulation induced slow wave activity modification: A possible role in disorder of consciousness differential diagnosis? Conscious Cogn 2015; 38:1-8. [PMID: 26496476 DOI: 10.1016/j.concog.2015.09.012] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2015] [Revised: 09/07/2015] [Accepted: 09/29/2015] [Indexed: 10/22/2022]
Abstract
Slow wave activity (SWA) generation depends on cortico-thalamo-cortical loops that are disrupted in patients with chronic Disorders of Consciousness (DOC), including the Unresponsive Wakefulness Syndrome (UWS) and the Minimally Conscious State (MCS). We hypothesized that the modulation of SWA by means of a repetitive transcranial magnetic stimulation (rTMS) could reveal residual patterns of connectivity, thus supporting the DOC clinical differential diagnosis. We enrolled 10 DOC individuals who underwent a 24hh polysomnography followed by a real or sham 5Hz-rTMS over left primary motor area, and a second polysomnographic recording. A preserved sleep-wake cycle, a standard temporal progression of sleep stages, and a SWA perturbation were found in all of the MCS patients and in none of the UWS individuals, only following the real-rTMS. In conclusion, our combined approach may improve the differential diagnosis between MCS patients, who show a partial preservation of cortical plasticity, and UWS individuals, who lack such properties.
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Affiliation(s)
| | - Antonino Naro
- IRCCS Centro Neurolesi Bonino-Pulejo, Messina, Italy
| | - Antonino Leo
- IRCCS Centro Neurolesi Bonino-Pulejo, Messina, Italy
| | - Irene Aricò
- Department of Neuroscience, University of Messina, Messina, Italy
| | - Francesco Pisani
- Department of Neuroscience, University of Messina, Messina, Italy
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22
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Reti IM, Schwarz N, Bower A, Tibbs M, Rao V. Transcranial magnetic stimulation: A potential new treatment for depression associated with traumatic brain injury. Brain Inj 2015; 29:789-97. [PMID: 25950260 DOI: 10.3109/02699052.2015.1009168] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
BACKGROUND Each year, more than 1.7 million Americans suffer a traumatic brain injury (TBI) and the lifetime prevalence of major depressive disorder following TBI is between 25-50%. There are no validated established strategies to treat TBI depression. Repetitive transcranial magnetic stimulation (rTMS) is a novel putative treatment option for post-TBI depression, which, compared with standard pharmacological agents, may provide a more targeted treatment with fewer side-effects. However, TBI is associated with an increased risk of both early and late spontaneous seizures, a significant consideration in evaluating rTMS as a potential treatment for TBI depression. Whilst the risk of seizure from rTMS is low, underlying neuropathology may somewhat increase that risk. REVIEW This review focuses on the safety aspects of rTMS in TBI patients. The authors review why low frequency rTMS might be less likely to trigger a seizure than high frequency rTMS and propose low frequency rTMS as a safer option in TBI patients. Because there is little data on the safety of rTMS in TBI, the authors also review the safety of rTMS in patients with other brain pathology. CONCLUSION It is concluded that pilot safety and tolerability studies should be first conducted in persons with TBI and neuropsychiatric comorbidities. These results could be used to help design larger randomized controlled trials.
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Affiliation(s)
- Irving M Reti
- Department of Psychiatry and Behavioral Sciences, The Johns Hopkins University , Baltimore, MD , USA
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23
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Moisset X, Goudeau S, Poindessous-Jazat F, Baudic S, Clavelou P, Bouhassira D. Prolonged Continuous Theta-burst Stimulation is More Analgesic Than ‘Classical’ High Frequency Repetitive Transcranial Magnetic Stimulation. Brain Stimul 2015; 8:135-41. [DOI: 10.1016/j.brs.2014.10.006] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2014] [Revised: 09/30/2014] [Accepted: 10/11/2014] [Indexed: 01/24/2023] Open
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Naro A, Leo A, Russo M, Quartarone A, Bramanti P, Calabrò RS. Shaping Thalamo-cortical Plasticity: A Marker of Cortical Pain Integration in Patients With Post-anoxic Unresponsive Wakefulness Syndrome? Brain Stimul 2015; 8:97-104. [PMID: 25260422 DOI: 10.1016/j.brs.2014.09.001] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2014] [Revised: 09/01/2014] [Accepted: 09/01/2014] [Indexed: 01/18/2023] Open
Affiliation(s)
- Antonino Naro
- IRCCS Centro Neurolesi "Bonino-Pulejo", Messina, Italy
| | - Antonino Leo
- IRCCS Centro Neurolesi "Bonino-Pulejo", Messina, Italy
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25
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Naro A, Russo M, Leo A, Bramanti P, Quartarone A, Calabrò RS. A Single Session of Repetitive Transcranial Magnetic Stimulation Over the Dorsolateral Prefrontal Cortex in Patients With Unresponsive Wakefulness Syndrome. Neurorehabil Neural Repair 2014; 29:603-13. [PMID: 25539781 DOI: 10.1177/1545968314562114] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background. The level of consciousness is regulated by the activation of the frontal parietal network since a disruption within this interregional cortical connectivity is associated with a consciousness breakdown. Objective. The primary aim of the present study was to examine the feasibility and the safety of a single session of repetitive transcranial magnetic stimulation (rTMS), delivered over the dorsolateral prefrontal cortex (DLPFC), in patients with unresponsive wakefulness syndrome (UWS). As a secondary aim, we investigated the efficacy of rTMS over DLPFC on cortico-cortical connectivity as tested with paired-pulse and dual-coil TMS techniques. Methods. We enrolled 10 healthy and 10 postanoxic UWS subjects. After clinical assessment, subjects underwent a single/paired pulse TMS paradigm evaluating the inhibitory and facilitatory intracortical circuits. In addition, several interregional interactions between primary motor, dorsal and ventral premotor, supplementary motor, and posterior parietal cortex areas were investigated by means of dual-coil TMS technique. These parameters were evaluated at baseline, immediately after, and 60 minutes after a protocol of 10-Hz rTMS delivered at the level of the DLPFC. Results. rTMS over DLPFC did not cause any adverse events. We showed that rTMS over DLPFC did not induce, at group level, any clinical improvement or intra-/intercortical connectivity changes. Interestingly, in 3 patients rTMS induced a significant, although transient, clinical improvement associated with a short-lasting reshaping of brain connectivity. Conclusions. We demonstrated that a single session of 10-Hz rTMS over the right DLPFC may transiently improve consciousness and partially restore the connectivity within several cortical areas in some patients with UWS.
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Affiliation(s)
- Antonino Naro
- IRCCS Centro Neurolesi “Bonino-Pulejo,” Messina, Italy
| | | | - Antonino Leo
- IRCCS Centro Neurolesi “Bonino-Pulejo,” Messina, Italy
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Castel-Lacanal E, Tarri M, Loubinoux I, Gasq D, de Boissezon X, Marque P, Simonetta-Moreau M. Transcranial magnetic stimulation in brain injury. ACTA ACUST UNITED AC 2013; 33:83-7. [PMID: 24378049 DOI: 10.1016/j.annfar.2013.11.006] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVES Transcranial magnetic stimulations (TMS) have been used for many years as a diagnostic tool to explore changes in cortical excitability, and more recently as a tool for therapeutic neuromodulation. We are interested in their applications following brain injury: stroke, traumatic and anoxic brain injury. DATA SYNTHESIS Following brain injury, there is decreased cortical excitability and changes in interhemispheric interactions depending on the type, the severity, and the time-lapse between the injury and the treatment implemented. rTMS (repetitive TMS) is a therapeutic neuromodulation tool which restores the interhemispheric interactions following stroke by inhibiting the healthy cortex with frequencies ≤1Hz, or by exciting the lesioned cortex with frequencies between 3 and 50Hz. Results in motor recovery are promising and those in improving aphasia or visuospatial neglect are also encouraging. Finally, the use of TMS is mainly limited by the risk of seizure, and is therefore contraindicated for many patients. CONCLUSION TMS is a useful non-invasive brain stimulation tool to diagnose the effects of brain injury, to study the mechanisms of recovery and a non-invasive neuromodulation promising tool to influence the post-lesional recovery.
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Affiliation(s)
- E Castel-Lacanal
- Service de médecine physique et réadaptation, CHU Rangueil, 1, avenue Jean-Poulhès, TSA 50032, 31059 Toulouse cedex 9, France; Inserm U 825, CHU Purpan, pavillon Baudot, place du Dr-Baylac, 31024 Toulouse cedex 3, France.
| | - M Tarri
- Inserm U 825, CHU Purpan, pavillon Baudot, place du Dr-Baylac, 31024 Toulouse cedex 3, France
| | - I Loubinoux
- Inserm U 825, CHU Purpan, pavillon Baudot, place du Dr-Baylac, 31024 Toulouse cedex 3, France
| | - D Gasq
- Service de médecine physique et réadaptation, CHU Rangueil, 1, avenue Jean-Poulhès, TSA 50032, 31059 Toulouse cedex 9, France; Inserm U 825, CHU Purpan, pavillon Baudot, place du Dr-Baylac, 31024 Toulouse cedex 3, France
| | - X de Boissezon
- Service de médecine physique et réadaptation, CHU Rangueil, 1, avenue Jean-Poulhès, TSA 50032, 31059 Toulouse cedex 9, France; Inserm U 825, CHU Purpan, pavillon Baudot, place du Dr-Baylac, 31024 Toulouse cedex 3, France
| | - P Marque
- Service de médecine physique et réadaptation, CHU Rangueil, 1, avenue Jean-Poulhès, TSA 50032, 31059 Toulouse cedex 9, France; Inserm U 825, CHU Purpan, pavillon Baudot, place du Dr-Baylac, 31024 Toulouse cedex 3, France
| | - M Simonetta-Moreau
- Inserm U 825, CHU Purpan, pavillon Baudot, place du Dr-Baylac, 31024 Toulouse cedex 3, France; Service de neurologie, CHU Purpan, pavillon Riser, place du Dr-Baylac, 31024 Toulouse cedex 3, France
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Bagnato S, Boccagni C, Sant'angelo A, Fingelkurts AA, Fingelkurts AA, Galardi G. Emerging from an unresponsive wakefulness syndrome: Brain plasticity has to cross a threshold level. Neurosci Biobehav Rev 2013; 37:2721-36. [PMID: 24060531 DOI: 10.1016/j.neubiorev.2013.09.007] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2013] [Revised: 08/29/2013] [Accepted: 09/12/2013] [Indexed: 12/27/2022]
Affiliation(s)
- Sergio Bagnato
- Unit of Neurophysiology and Unit for Severe Acquired Brain Injury, Rehabilitation Department, Fondazione Istituto San Raffaele G. Giglio, Cefalù, PA, Italy.
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28
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Bagnato S, Boccagni C, Sant'angelo A, Galardi G. A range of antiepileptic drugs do not affect the recovery of consciousness in vegetative and minimally conscious states. Epilepsy Behav 2013; 27:365-70. [PMID: 23542540 DOI: 10.1016/j.yebeh.2013.02.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2013] [Revised: 02/01/2013] [Accepted: 02/02/2013] [Indexed: 11/30/2022]
Abstract
Since most antiepileptic drugs (AEDs) have cognitive effects, the aim of this study was to evaluate the influence of AED therapy on the recovery of consciousness in 103 consecutive patients in a vegetative or minimally conscious state (VS, MCS). The levels of cognitive functioning (LCF) score was retrospectively compared after a three-month period of rehabilitation between patients who were medicated (n=54) and patients who were not medicated (n=49) with AEDs. Mean LCF scores in AED-medicated and nonmedicated patients were 2.2±0.7 and 2.3±0.8 at admission and 3.8±2.2 and 3.7±2.1 after three months, respectively (p values>0.05). These results did not change when we compared patients with the same etiology separately, with the same disorder of consciousness only, or patients treated with only one or more than one AED. In conclusion, AEDs did not affect the recovery of consciousness in a large cohort of patients in a VS or MCS following an acute brain injury.
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Affiliation(s)
- Sergio Bagnato
- Unit of Neurophysiology, Rehabilitation Department, Fondazione Istituto San Raffaele-G. Giglio, Cefalù (PA), Italy.
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Pistoia F, Sacco S, Carolei A, Sarà M. Corticomotor facilitation in vegetative state: results of a pilot study. Arch Phys Med Rehabil 2013; 94:1599-606. [PMID: 23385107 DOI: 10.1016/j.apmr.2013.01.019] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2012] [Revised: 01/08/2013] [Accepted: 01/21/2013] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To investigate whether corticomotor facilitation induced by transcranial magnetic stimulation (TMS-CF) could evoke a simple purposeful motor behavior in patients with a diagnosis of vegetative state. DESIGN Cross-sectional survey. SETTING Post-coma and rehabilitation care unit. PARTICIPANTS Patients (N=6) with a diagnosis of vegetative state. INTERVENTIONS A cascade of consecutive motor-evoked potentials (MEPs) was elicited under 3 different conditions: in the first condition, patients were at rest (Rest); in the second, they were asked to open and close the right hand (Execution); in the third, the examiner modeled a movement of abduction of the thumb in front of the patient who was encouraged in advance to imitate the action (Observation to Imitate). MAIN OUTCOME MEASURES Changes in MEP values from the abductor pollicis brevis muscle and improvement in scores on the Coma Recovery Scale-Revised. RESULTS TMS-CF alone or combined with verbal instructions did not yield any change; only the combination with imitation caused changes in MEPs (shorter latency and increased amplitude) associated with behavioral improvement in 4 patients. CONCLUSIONS Encouraging observation to imitate may favor the transformation of some perceived actions into motor images and performances, probably depending on the activation of mirror motor neurons. In our opinion, combining visual input with TMS-CF might have reinforced the coupling between movement planning and execution, promoting the recovery of elementary motor activities in some patients. The proposed protocol may contribute to unmasking signs of preserved consciousness in patients with latent capacities for recovery.
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Lapitskaya N, Gosseries O, De Pasqua V, Pedersen AR, Nielsen JF, de Noordhout AM, Laureys S. Abnormal corticospinal excitability in patients with disorders of consciousness. Brain Stimul 2013; 6:590-7. [PMID: 23403267 DOI: 10.1016/j.brs.2013.01.002] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2012] [Revised: 01/04/2013] [Accepted: 01/05/2013] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Transcranial magnetic stimulation (TMS) has been frequently used to explore changes in the human motor cortex in different conditions, while the extent of motor cortex reorganization in patients in vegetative state (VS) (now known as unresponsive wakefulness syndrome, UWS) and minimally conscious (MCS) states due to severe brain damage remains largely unknown. OBJECTIVE/HYPOTHESIS It was hypothesized that cortical motor excitability would be decreased and would correlate to the level of consciousness in patients with disorders of consciousness. METHODS Corticospinal excitability was assessed in 47 patients (24 VS/UWS and 23 MCS) and 14 healthy controls. The test parameters included maximal peak-to-peak M-wave (Mmax), F-wave persistence, peripheral and central motor conduction times, sensory (SEP) and motor evoked (MEP) potential latencies and amplitudes, resting motor threshold (RMT), stimulus/response curves, and short latency afferent inhibition (SAI). TMS measurements were correlated to the level of consciousness (assessed using the Coma Recovery Scale-Revised). RESULTS On average, the patient group had lower Mmax, lower MEP and SEP amplitudes, higher RMTs, narrower stimulus/response curves, and reduced SAI compared to the healthy controls (P < 0.05). The SAI alterations were correlated to the level of consciousness (P < 0.05). CONCLUSIONS The findings demonstrated the impairment of the cortical inhibitory circuits in patients with disorders of consciousness. Moreover, the significant relationship was found between cortical inhibition and clinical consciousness dysfunction.
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Affiliation(s)
- Natallia Lapitskaya
- Research Department, Hammel Neurorehabilitation and Research Centre, Voldbyvej 15, 8450 Hammel, Denmark.
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Structural epilepsy occurrence in vegetative and minimally conscious states. Epilepsy Res 2013; 103:106-9. [DOI: 10.1016/j.eplepsyres.2012.09.008] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2012] [Revised: 09/08/2012] [Accepted: 09/22/2012] [Indexed: 11/22/2022]
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