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Cao T, He S, Wang L, Chai X, He Q, Liu D, Wang D, Wang N, He J, Wang S, Yang Y, Zhao J, Tan H. Clinical neuromodulatory effects of deep brain stimulation in disorder of consciousness: A literature review. CNS Neurosci Ther 2024; 30:e14559. [PMID: 38115730 PMCID: PMC11163193 DOI: 10.1111/cns.14559] [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: 08/26/2023] [Revised: 10/11/2023] [Accepted: 11/25/2023] [Indexed: 12/21/2023] Open
Abstract
BACKGROUND The management of patients with disorders of consciousness (DOC) presents substantial challenges in clinical practice. Deep brain stimulation (DBS) has emerged as a potential therapeutic approach, but the lack of standardized regulatory parameters for DBS in DOC hinders definitive conclusions. OBJECTIVE This comprehensive review aims to provide a detailed summary of the current issues concerning patient selection, target setting, and modulation parameters in clinical studies investigating the application of DBS for DOC patients. METHODS A meticulous systematic analysis of the literatures was conducted, encompassing articles published from 1968 to April 2023, retrieved from reputable databases (PubMed, Embase, Medline, and Web of Science). RESULTS The systematic analysis of 21 eligible articles, involving 146 patients with DOC resulting from acquired brain injury or other disorders, revealed significant insights. The most frequently targeted regions were the Centromedian-parafascicular complex (CM-pf) nuclei and central thalamus (CT), both recognized for their role in regulating consciousness. However, other targets have also been explored in different studies. The stimulation frequency was predominantly set at 25 or 100 Hz, with pulse width of 120 μs, and voltages ranged from 0 to 4 V. These parameters were customized based on individual patient responses and evaluations. The overall clinical efficacy rate in all included studies was 39.7%, indicating a positive effect of DBS in a subset of DOC patients. Nonetheless, the assessment methods, follow-up durations, and outcome measures varied across studies, potentially contributing to the variability in reported efficacy rates. CONCLUSION Despite the challenges arising from the lack of standardized parameters, DBS shows promising potential as a therapeutic option for patients with DOC. However, there still remains the need for standardized protocols and assessment methods, which are crucial to deepen the understanding and optimizing the therapeutic potential of DBS in this specific patient population.
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Affiliation(s)
- Tianqing Cao
- Department of Neurosurgery, Beijing Tiantan HospitalCapital Medical UniversityBeijingChina
- China National Clinical Research Center for Neurological DiseasesBeijingChina
| | - Shenghong He
- Medical Research Council Brain Network Dynamics Unit, Nuffield Department of Clinical NeurosciencesUniversity of OxfordOxfordUK
| | - Luchen Wang
- School of Information Science and TechnologyFudan UniversityShanghaiChina
| | - Xiaoke Chai
- Department of Neurosurgery, Beijing Tiantan HospitalCapital Medical UniversityBeijingChina
- China National Clinical Research Center for Neurological DiseasesBeijingChina
| | - Qiheng He
- Department of Neurosurgery, Beijing Tiantan HospitalCapital Medical UniversityBeijingChina
- China National Clinical Research Center for Neurological DiseasesBeijingChina
| | - Dongsheng Liu
- Department of NeurosurgeryAviation General HospitalBeijingChina
| | - Dong Wang
- Department of NeurosurgeryGanzhou People's HospitalGanzhouJiangxi ProvinceChina
| | - Nan Wang
- Department of Neurosurgery, Beijing Tiantan HospitalCapital Medical UniversityBeijingChina
- China National Clinical Research Center for Neurological DiseasesBeijingChina
| | - Jianghong He
- Department of Neurosurgery, Beijing Tiantan HospitalCapital Medical UniversityBeijingChina
| | - Shouyang Wang
- School of Information Science and TechnologyFudan UniversityShanghaiChina
| | - Yi Yang
- Department of Neurosurgery, Beijing Tiantan HospitalCapital Medical UniversityBeijingChina
- China National Clinical Research Center for Neurological DiseasesBeijingChina
- Medical Research Council Brain Network Dynamics Unit, Nuffield Department of Clinical NeurosciencesUniversity of OxfordOxfordUK
- Chinese Institute for Brain ResearchBeijingChina
- Beijing Institute of Brain DisordersBeijingChina
| | - Jizong Zhao
- Department of Neurosurgery, Beijing Tiantan HospitalCapital Medical UniversityBeijingChina
- China National Clinical Research Center for Neurological DiseasesBeijingChina
| | - Huiling Tan
- Medical Research Council Brain Network Dynamics Unit, Nuffield Department of Clinical NeurosciencesUniversity of OxfordOxfordUK
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Schiff ND. Toward an interventional science of recovery after coma. Neuron 2024; 112:1595-1610. [PMID: 38754372 DOI: 10.1016/j.neuron.2024.04.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2024] [Revised: 04/04/2024] [Accepted: 04/24/2024] [Indexed: 05/18/2024]
Abstract
Recovery of consciousness after coma remains one of the most challenging areas for accurate diagnosis and effective therapeutic engagement in the clinical neurosciences. Recovery depends on preservation of neuronal integrity and evolving changes in network function that re-establish environmental responsiveness. It typically occurs in defined steps: it begins with eye opening and unresponsiveness in a vegetative state, then limited recovery of responsiveness characterizes the minimally conscious state, and this is followed by recovery of reliable communication. This review considers several points for novel interventions, for example, in persons with cognitive motor dissociation in whom a hidden cognitive reserve is revealed. Circuit mechanisms underlying restoration of behavioral responsiveness and communication are discussed. An emerging theme is the possibility to rescue latent capacities in partially damaged human networks across time. These opportunities should be exploited for therapeutic engagement to achieve individualized solutions for restoration of communication and environmental interaction across varying levels of recovery.
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Affiliation(s)
- Nicholas D Schiff
- Jerold B. Katz Professor of Neurology and Neuroscience, Weill Cornell Medicine, New York, NY, USA.
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Yang Y, He Q, Dang Y, Xia X, Xu X, Chen X, Zhao J, He J. Long-term functional outcomes improved with deep brain stimulation in patients with disorders of consciousness. Stroke Vasc Neurol 2023; 8:368-378. [PMID: 36882201 PMCID: PMC10647871 DOI: 10.1136/svn-2022-001998] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2022] [Accepted: 01/26/2023] [Indexed: 03/09/2023] Open
Abstract
BACKGROUND Deep brain stimulation (DBS) has been preliminarily applied to treat patients with disorders of consciousness (DoCs). The study aimed to determine whether DBS was effective for treating patients with DoC and identify factors related to patients' outcomes. METHODS Data from 365 patients with DoCs who were consecutively admitted from 15 July 2011 to 31 December 2021 were retrospectively analysed. Multivariate regression and subgroup analysis were performed to adjust for potential confounders. The primary outcome was improvement in consciousness at 1 year. RESULTS An overall improvement in consciousness at 1 year was achieved in 32.4% (12/37) of the DBS group compared with 4.3% (14/328) of the conservative group. After full adjustment, DBS significantly improved consciousness at 1 year (adjusted OR 11.90, 95% CI 3.65-38.46, p<0.001). There was a significant treatment×follow up interaction (H=14.99, p<0.001). DBS had significantly better effects in patients with minimally conscious state (MCS) compared with patients with vegetative state/unresponsive wakefulness syndrome (p for interaction <0.001). A nomogram based on age, state of consciousness, pathogeny and duration of DoCs indicated excellent predictive performance (c-index=0.882). CONCLUSIONS DBS was associated with better outcomes in patients with DoC, and the effect was likely to be significantly greater in patients with MCS. DBS should be cautiously evaluated by nomogram preoperatively, and randomised controlled trials are still needed.
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Affiliation(s)
- Yi Yang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- Translational Medicine Center, Chinese Institute for Brain Research, Beijing, China
- Beijing Institute of Brain Disorders, Capital Medical University, Beijing, China
| | - Qiheng He
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yuanyuan Dang
- Department of Neurosurgery, PLA General Hospital, Beijing, China
| | - Xiaoyu Xia
- Department of Neurosurgery, PLA General Hospital, Beijing, China
| | - Xin Xu
- Department of Neurosurgery, PLA General Hospital, Beijing, China
| | - Xueling Chen
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Jizong Zhao
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- Academician Office, China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Jianghong He
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
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4
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Wu Y, Xu YY, Deng H, Zhang W, Zhang SX, Li JM, Xiong BT, Xiao LL, Li DH, Ren ZY, Qin YF, Yang RQ, Wang W. Spinal cord stimulation and deep brain stimulation for disorders of consciousness: a systematic review and individual patient data analysis of 608 cases. Neurosurg Rev 2023; 46:200. [PMID: 37578633 DOI: 10.1007/s10143-023-02105-1] [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: 06/04/2023] [Revised: 07/10/2023] [Accepted: 08/01/2023] [Indexed: 08/15/2023]
Abstract
The application of spinal cord stimulation (SCS) and deep brain stimulation (DBS) for disorders of consciousness (DoC) has been increasingly reported. However, there is no sufficient evidence to determine how effective and safe SCS and DBS are for DoC owing to various methodological limitations. We conducted a systematic review to elucidate the safety and efficacy of SCS and DBS for DoC by systematically reviewing related literature by searching PubMed, EMBASE, Medline, and Cochrane Library. Twenty eligible studies with 608 patients were included in this study. Ten studies with 508 patients reported the efficacy of SCS for DoC, and the estimated overall effectiveness rate was 37%. Five studies with 343 patients reported the efficacy of SCS for VS, and the estimated effectiveness rate was 30%. Three studies with 53 patients reported the efficacy of SCS for MCS, and the estimated effectiveness rate was 63%. Five studies with 92 patients reported the efficacy of DBS for DoC, and the estimated overall effectiveness rate was 40%. Four studies with 63 patients reported the efficacy of DBS for VS, and the estimated effectiveness rate was 26%. Three studies with 19 patients reported the efficacy of DBS for MCS, and the estimated effectiveness rate was 74%. The adverse event rate of DoC was 8.1% and 18.2% after SCS and DBS, respectively. These results suggest that SCS and DBS can be considered reasonable treatments for DoC with considerable efficacy and safety.
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Affiliation(s)
- Yang Wu
- Department of Neurosurgery, West China Hospital, Sichuan University, 37 Guoxue Alley, Chengdu, Sichuan Province, China
| | - Yang-Yang Xu
- Department of Neurosurgery, West China Hospital, Sichuan University, 37 Guoxue Alley, Chengdu, Sichuan Province, China
| | - Hao Deng
- Department of Neurosurgery, West China Hospital, Sichuan University, 37 Guoxue Alley, Chengdu, Sichuan Province, China
| | - Wei Zhang
- Department of Neurosurgery, West China Hospital, Sichuan University, 37 Guoxue Alley, Chengdu, Sichuan Province, China
| | - Shu-Xin Zhang
- Department of Histoembryology and Neurobiology, West China College of Basic Medicine and Forensic Medicine, Sichuan University, Chengdu, Sichuan Province, China
| | - Jia-Ming Li
- Department of Neurosurgery, West China Hospital, Sichuan University, 37 Guoxue Alley, Chengdu, Sichuan Province, China
| | - Bo-Tao Xiong
- Department of Neurosurgery, West China Hospital, Sichuan University, 37 Guoxue Alley, Chengdu, Sichuan Province, China
| | - Ling-Long Xiao
- Department of Neurosurgery, West China Hospital, Sichuan University, 37 Guoxue Alley, Chengdu, Sichuan Province, China
| | - Deng-Hui Li
- Department of Neurosurgery, West China Hospital, Sichuan University, 37 Guoxue Alley, Chengdu, Sichuan Province, China
| | - Zhi-Yi Ren
- Department of Histoembryology and Neurobiology, West China College of Basic Medicine and Forensic Medicine, Sichuan University, Chengdu, Sichuan Province, China
| | - Yi-Fan Qin
- Department of Histoembryology and Neurobiology, West China College of Basic Medicine and Forensic Medicine, Sichuan University, Chengdu, Sichuan Province, China
| | - Rui-Qing Yang
- Department of Neurosurgery, West China Hospital, Sichuan University, 37 Guoxue Alley, Chengdu, Sichuan Province, China
| | - Wei Wang
- Department of Neurosurgery, West China Hospital, Sichuan University, 37 Guoxue Alley, Chengdu, Sichuan Province, China.
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Schiff ND. Mesocircuit mechanisms in the diagnosis and treatment of disorders of consciousness. Presse Med 2023; 52:104161. [PMID: 36563999 DOI: 10.1016/j.lpm.2022.104161] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2022] [Revised: 11/14/2022] [Accepted: 12/13/2022] [Indexed: 12/24/2022] Open
Abstract
The 'mesocircuit hypothesis' proposes mechanisms underlying the recovery of consciousness following severe brain injuries. The model builds up from a single premise that multifocal brain injuries resulting in coma and subsequent disorders of consciousness produce widespread neuronal death and dysfunction. Considering the general properties of cortical, thalamic, and striatal neurons, a lawful and specific circuit-level mechanism is constructed based on these known anatomical and physiological specializations of neuronal subtypes. The mesocircuit model generates many testable predictions at the mesocircuit, local circuit, and cellular level across multiple cerebral structures to correlate diagnostic measurements and interpret therapeutic interventions. The anterior forebrain mesocircuit is integrally related to the frontal-parietal network, another network demonstrated to show strong correlation with levels of recovery in disorders of consciousness. A further extension known as the "ABCD" model has been used to examine interaction of these models in recovery of consciousness using electrophysiological data types. Many studies have examined predictions of the mesocircuit model; here we first present the model and review the accumulated evidence for several predictions of model across multiple stages of recovery function in human subjects. Recent studies linking the mesocircuit model, the ABCD model, and interactions with the frontoparietal network are reviewed. Finally, theoretical implications of the mesocircuit model at the neuronal level are considered to interpret recent studies of deep brain stimulation in the central lateral thalamus in patients recovering from coma and in new experimental models in the context of emerging understanding of neuronal and local circuit mechanisms underlying conscious brain states.
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Affiliation(s)
- Nicholas D Schiff
- Jerold B. Katz Professor of Neurology and Neuroscience, Feil Family Brain and Mind Research Institute, Weill Cornell Medical College, United States.
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6
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Baker JL, Toth R, Deli A, Zamora M, Fleming JE, Benjaber M, Goerzen D, Ryou JW, Purpura KP, Schiff ND, Denison T. Regulation of arousal and performance of a healthy non-human primate using closed-loop central thalamic deep brain stimulation. INTERNATIONAL IEEE/EMBS CONFERENCE ON NEURAL ENGINEERING : [PROCEEDINGS]. INTERNATIONAL IEEE EMBS CONFERENCE ON NEURAL ENGINEERING 2023; 2023:10123754. [PMID: 37228786 PMCID: PMC7614571 DOI: 10.1109/ner52421.2023.10123754] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Abstract
Application of closed-loop approaches in systems neuroscience and brain-computer interfaces holds great promise for revolutionizing our understanding of the brain and for developing novel neuromodulation strategies to restore lost function. The anterior forebrain mesocircuit (AFM) of the mammalian brain is hypothesized to underlie arousal regulation of the cortex and striatum, and support cognitive functions during wakefulness. Dysfunction of arousal regulation is hypothesized to contribute to cognitive dysfunctions in various neurological disorders, and most prominently in patients following traumatic brain injury (TBI). Several clinical studies have explored the use of daily central thalamic deep brain stimulation (CT-DBS) within the AFM to restore consciousness and executive attention in TBI patients. In this study, we explored the use of closed-loop CT-DBS in order to episodically regulate arousal of the AFM of a healthy non-human primate (NHP) with the goal of restoring behavioral performance. We used pupillometry and near real-time analysis of ECoG signals to episodically initiate closed-loop CT-DBS and here we report on our ability to enhance arousal and restore the animal's performance. The initial computer based approach was then experimentally validated using a customized clinical-grade DBS device, the DyNeuMo-X, a bi-directional research platform used for rapidly testing closed-loop DBS. The successful implementation of the DyNeuMo-X in a healthy NHP supports ongoing clinical trials employing the internal DyNeuMo system (NCT05437393, NCT05197816) and our goal of developing and accelerating the deployment of novel neuromodulation approaches to treat cognitive dysfunction in patients with structural brain injuries and other etiologies.
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Affiliation(s)
- Jonathan L. Baker
- Feil Family Brain and Mind Research Institute, Weill Cornell Medicine, New York, NY 10065, USA
| | - Robert Toth
- MRC Brain Network Dynamics Unit, Nuffield Department of Clinical Neurosciences, University of Oxford, OX1 3TH, UK
| | - Alceste Deli
- Department of Neurosurgery, John Radcliffe Hospital, University of Oxford, Oxford OX3 9DU, UK
| | - Mayela Zamora
- Institute of Biomedical Engineering, Department of Engineering Science, University of Oxford, Oxford OX3 7DQ, UK
| | - John E. Fleming
- Institute of Biomedical Engineering, Department of Engineering Science, University of Oxford, Oxford OX3 7DQ, UK
| | - Moaad Benjaber
- Institute of Biomedical Engineering, Department of Engineering Science, University of Oxford, Oxford OX3 7DQ, UK
| | - Dana Goerzen
- Feil Family Brain and Mind Research Institute, Weill Cornell Medicine, New York, NY 10065, USA
| | - Jae-Wook Ryou
- Feil Family Brain and Mind Research Institute, Weill Cornell Medicine, New York, NY 10065, USA
| | - Keith P. Purpura
- Feil Family Brain and Mind Research Institute, Weill Cornell Medicine, New York, NY 10065, USA
| | - Nicholas D. Schiff
- Feil Family Brain and Mind Research Institute, Weill Cornell Medicine, New York, NY 10065, USA
| | - Timothy Denison
- MRC Brain Network Dynamics Unit, Nuffield Department of Clinical Neurosciences, University of Oxford, OX1 3TH, UK
- Institute of Biomedical Engineering, Department of Engineering Science, University of Oxford, Oxford OX3 7DQ, UK
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Raciti L, Raciti G, Militi D, Tonin P, Quartarone A, Calabrò RS. Sleep in Disorders of Consciousness: A Brief Overview on a Still under Investigated Issue. Brain Sci 2023; 13:brainsci13020275. [PMID: 36831818 PMCID: PMC9954700 DOI: 10.3390/brainsci13020275] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2022] [Revised: 01/29/2023] [Accepted: 02/06/2023] [Indexed: 02/09/2023] Open
Abstract
Consciousness is a multifaceted concept, involving both wakefulness, i.e., a condition of being alert that is regulated by the brainstem, and awareness, a subjective experience of any thoughts or perception or emotion. Recently, the European Academy of Neurology has published international guidelines for a better diagnosis of coma and other disorders of consciousness (DOC) through the investigation of sleep patterns, such as slow-wave and REM, and the study of the EEG using machine learning methods and artificial intelligence. The management of sleep disorders in DOC patients is an increasingly hot topic and deserves careful diagnosis, to allow for the most accurate prognosis and the best medical treatment possible. The aim of this review was to investigate the anatomo-physiological basis of the sleep/wake cycle, as well as the main sleep patterns and sleep disorders in patients with DOC. We found that the sleep characteristics in DOC patients are still controversial. DOC patients often present a theta/delta pattern, while epileptiform activity, as well as other sleep elements, have been reported as correlating with outcomes in patients with coma and DOC. The absence of spindles, as well as REM and K-complexes of NREM sleep, have been used as poor predictors for early awakening in DOC patients, especially in UWS patients. Therefore, sleep could be considered a marker of DOC recovery, and effective treatments for sleep disorders may either indirectly or directly favor recovery of consciousness.
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Affiliation(s)
| | | | - David Militi
- IRCCS Centro Neurolesi Bonino Pulejo, 98121 Messina, Italy
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Yelden K, James LM, Duport S, Kempny A, Farmer SF, Leff AP, Playford ED. A simple intervention for disorders of consciousness- is there a light at the end of the tunnel? Front Neurol 2022; 13:824880. [PMID: 35937075 PMCID: PMC9355643 DOI: 10.3389/fneur.2022.824880] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Accepted: 06/27/2022] [Indexed: 12/02/2022] Open
Abstract
Sleep is a physiological state necessary for memory processing, learning and brain plasticity. Patients with disorders of consciousness (DOC) show none or minimal sign of awareness of themselves or their environment but appear to have sleep-wake cycles. The aim of our study was to assess baseline circadian rhythms and sleep in patients with DOC; to optimize circadian rhythm using an intervention combining blue light, melatonin and caffeine, and to identify the impact of this intervention on brain function using event related potentials. We evaluated baseline circadian rhythms and sleep in 17 patients with DOC with 24-h polysomnography (PSG) and 4-hourly saliva melatonin measurements for 48 h. Ten of the 17 patients (5 female, age 30–71) were then treated for 5 weeks with melatonin each night and blue light and caffeine treatment in the mornings. Behavioral assessment of arousal and awareness [Coma recovery scale-revised (CRS-R)], 24-h polysomnography and 4-hourly saliva melatonin measurements, oddball mismatch negativity (MMN) and subject's own name (SON) experiments were performed twice at baseline and following intervention. Baseline sleep was abnormal in all patients. Cosinor analysis of saliva melatonin results revealed that averaged baseline % rhythmicity was low (M: 31%, Range: 13–66.4%, SD: 18.4). However, increase in % Melatonin Rhythm following intervention was statistically significant (p = 0.012). 7 patients showed improvement of CRS-R scores with intervention and this was statistically significant (p = 0.034). All the patients who had improvement of clinical scores also had statistically significant improvement of neurophysiological responses on MMN and SON experiments at group level (p = 0.001). Our study shows that sleep and circadian rhythms are severely deranged in DOC but optimization is possible with melatonin, caffeine and blue light treatment. Clinical and physiological parameters improved with this simple and inexpensive intervention. Optimization of sleep and circadian rhythms should be integrated into rehabilitation programs for people with DOC.
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Affiliation(s)
- Kudret Yelden
- Neurological Rehabilitation, Royal Hospital for Neuro-Disability, London, United Kingdom
- Department of Neuroscience, King's College Hospital, London, United Kingdom
- UCL Queen Square Institute of Neurology, University College London, London, United Kingdom
- *Correspondence: Kudret Yelden
| | - Leon M. James
- Neurophysiology Department, Bupa Cromwell Hospital, London, United Kingdom
| | - Sophie Duport
- Research Department, Royal Hospital for Neuro-Disability, London, United Kingdom
| | - Agnieszka Kempny
- Research Department, Royal Hospital for Neuro-Disability, London, United Kingdom
| | - Simon F. Farmer
- UCL Queen Square Institute of Neurology, University College London, London, United Kingdom
- National Hospital for Neurology and Neurosurgery, University College London Hospital, London, United Kingdom
| | - Alex P. Leff
- UCL Queen Square Institute of Neurology, University College London, London, United Kingdom
- National Hospital for Neurology and Neurosurgery, University College London Hospital, London, United Kingdom
| | - E. Diane Playford
- UCL Queen Square Institute of Neurology, University College London, London, United Kingdom
- Warwick Medical School, University of Warwick, Coventry, United Kingdom
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Cacciatore M, Magnani FG, Leonardi M, Rossi Sebastiano D, Sattin D. Sleep Treatments in Disorders of Consciousness: A Systematic Review. Diagnostics (Basel) 2021; 12:diagnostics12010088. [PMID: 35054255 PMCID: PMC8775271 DOI: 10.3390/diagnostics12010088] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Revised: 12/24/2021] [Accepted: 12/30/2021] [Indexed: 12/23/2022] Open
Abstract
Sleep disorders are among the main comorbidities in patients with a Disorder of Consciousness (DOC). Given the key role of sleep in neural and cognitive functioning, detecting and treating sleep disorders in DOCs might be an effective therapeutic strategy to boost consciousness recovery and levels of awareness. To date, no systematic reviews have been conducted that explore the effect of sleep treatments in DOCs; thus, we systematically reviewed the existing studies on both pharmacological and non-pharmacological treatments for sleep disorders in DOCs. Among 2267 assessed articles, only 7 were included in the systematic review. The studies focused on two sleep disorder categories (sleep-related breathing disorders and circadian rhythm dysregulation) treated with both pharmacological (Modafinil and Intrathecal Baclofen) and non-pharmacological (positive airway pressure, bright light stimulation, and central thalamic deep brain stimulation) interventions. Although the limited number of studies and their heterogeneity do not allow generalized conclusions, all the studies highlighted the effectiveness of treatments on both sleep disorders and levels of awareness. For this reason, clinical and diagnostic evaluations able to detect sleep disorders in DOC patients should be adopted in the clinical routine for the purpose of intervening promptly with the most appropriate treatment.
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Affiliation(s)
- Martina Cacciatore
- UOC Neurologia, Salute Pubblica, Disabilità, Fondazione IRCCS Istituto Neurologico Carlo Besta, 20133 Milan, Italy; (M.C.); (M.L.)
| | - Francesca G. Magnani
- UOC Neurologia, Salute Pubblica, Disabilità, Fondazione IRCCS Istituto Neurologico Carlo Besta, 20133 Milan, Italy; (M.C.); (M.L.)
- Correspondence: ; Tel.: +39-02-23942188
| | - Matilde Leonardi
- UOC Neurologia, Salute Pubblica, Disabilità, Fondazione IRCCS Istituto Neurologico Carlo Besta, 20133 Milan, Italy; (M.C.); (M.L.)
| | - Davide Rossi Sebastiano
- Unità di Neurofisiopatologia, Fondazione IRCCS Istituto Neurologico Carlo Besta, 20133 Milan, Italy;
| | - Davide Sattin
- IRCCS Istituti Clinici Scientifici Maugeri di Milano, 20138 Milan, Italy;
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10
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Sleep in disorders of consciousness: diagnostic, prognostic, and therapeutic considerations. Curr Opin Neurol 2021; 33:684-690. [PMID: 33177374 DOI: 10.1097/wco.0000000000000870] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
PURPOSE OF REVIEW Sleep is important in the evaluation of patients with disorders of consciousness (DOC). However, it remains unclear whether reconstitution of sleep could enable consciousness or vice versa. Here we synthesize recent evidence on natural recovery of sleep in DOC, and sleep-promoting therapeutic interventions for recovery of consciousness. RECENT FINDINGS In subacute DOC, physiological sleep--wake cycles and complex sleep patterns are related to better outcomes. Moreover, structured rapid-eye-movement (REM), non-REM (NREM) stages, and presence of sleep spindles correlate with full or partial recovery. In chronic DOC, sleep organization may reflect both integrity of consciousness-supporting brain networks and engagement of those networks during wakefulness. Therapeutic strategies have integrated improvement of sleep and sleep--wake cycles in DOC patients; use of bright light stimulation or drugs enhancing sleep and/or vigilance, treatment of sleep apneas, and neuromodulatory stimulations are promising tools to promote healthy sleep architecture and wakeful recovery. SUMMARY Sleep features and sleep--wake cycles are important prognostic markers in subacute DOC and can provide insight into covert recovery in chronic DOC. Although large-scale studies are needed, preliminary studies in limited patients suggest that therapeutic options restoring sleep and/or sleep--wake cycles may improve cognitive function and outcomes in DOC.
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Abstract
Background: Reviving patients with prolonged disorders of consciousness (DOCs) has always been focused and challenging in medical research. Owing to the limited effectiveness of available medicine, recent research has increasingly turned towards neuromodulatory therapies, involving the stimulation of neural circuits. We summarised the progression of research regarding neuromodulatory therapies in the field of DOCs, compared the differences among different studies, in an attempt to explore optimal stimulation patterns and parameters, and analyzed the major limitations of the relevant studies to facilitate future research. Methods: We performed a search in the PubMed database, using the concepts of DOCs and neuromodulation. Inclusion criteria were: articles in English, published after 2002, and reporting clinical trials of neuromodulatory therapies in human patients with DOCs. Results: Overall, 187 published articles met the search criteria, and 60 articles met the inclusion criteria. There are differences among these studies regarding the clinical efficacies of neurostimulation techniques for patients with DOCs, and large-sample studies are still lacking. Conclusions: Neuromodulatory techniques were used as trial therapies for DOCs wherein their curative effects were controversial. The difficulties in detecting residual consciousness, the confounding effect between the natural course of the disease and therapeutic effect, and the heterogeneity across patients are the major limitations. Large-sample, well-designed studies, and innovations for both treatment and assessment are anticipated in future research.
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Li SJ, Lo YC, Lai HY, Lin SH, Lin HC, Lin TC, Chang CW, Chen TC, Chin-Jung Hsieh C, Yang SH, Chiu FM, Kuo CH, Chen YY. Uncovering the Modulatory Interactions of Brain Networks in Cognition with Central Thalamic Deep Brain Stimulation Using Functional Magnetic Resonance Imaging. Neuroscience 2020; 440:65-84. [DOI: 10.1016/j.neuroscience.2020.05.022] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2019] [Revised: 05/05/2020] [Accepted: 05/12/2020] [Indexed: 01/04/2023]
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Bourdillon P, Hermann B, Sitt JD, Naccache L. Electromagnetic Brain Stimulation in Patients With Disorders of Consciousness. Front Neurosci 2019; 13:223. [PMID: 30936822 PMCID: PMC6432925 DOI: 10.3389/fnins.2019.00223] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2018] [Accepted: 02/26/2019] [Indexed: 12/27/2022] Open
Abstract
Severe brain injury is a common cause of coma. In some cases, despite vigilance improvement, disorders of consciousness (DoC) persist. Several states of impaired consciousness have been defined, according to whether the patient exhibits only reflexive behaviors as in the vegetative state/unresponsive wakefulness syndrome (VS/UWS) or purposeful behaviors distinct from reflexes as in the minimally conscious state (MCS). Recently, this clinical distinction has been enriched by electrophysiological and neuroimaging data resulting from a better understanding of the physiopathology of DoC. However, therapeutic options, especially pharmacological ones, remain very limited. In this context, electroceuticals, a new category of therapeutic agents which act by targeting the neural circuits with electromagnetic stimulations, started to develop in the field of DoC. We performed a systematic review of the studies evaluating therapeutics relying on the direct or indirect electro-magnetic stimulation of the brain in DoC patients. Current evidence seems to support the efficacy of deep brain stimulation (DBS) and non-invasive brain stimulation (NIBS) on consciousness in some of these patients. However, while the latter is non-invasive and well tolerated, the former is associated with potential major side effects. We propose that all chronic DoC patients should be given the possibility to benefit from NIBS, and that transcranial direct current stimulation (tDCS) should be preferred over repetitive transcranial magnetic stimulation (rTMS), based on the literature and its simple use. Surgical techniques less invasive than DBS, such as vagus nerve stimulation (VNS) might represent a good compromise between efficacy and invasiveness but still need to be further investigated.
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Affiliation(s)
- Pierre Bourdillon
- Department of Neurosurgery, Adolphe de Rothschild Foundation, Paris, France
- Sorbonne Université, Faculté de Médecine Pitié-Salpêtrière, Paris, France
- Institut du Cerveau et de la Moelle Épinière, ICM, PICNIC Lab, Paris, France
- Inserm U 1127, Paris, France
- CNRS, UMR 7225, Paris, France
| | - Bertrand Hermann
- Sorbonne Université, Faculté de Médecine Pitié-Salpêtrière, Paris, France
- Institut du Cerveau et de la Moelle Épinière, ICM, PICNIC Lab, Paris, France
- Inserm U 1127, Paris, France
- CNRS, UMR 7225, Paris, France
- 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, Paris, France
- Inserm U 1127, Paris, France
- CNRS, UMR 7225, Paris, France
| | - Lionel Naccache
- Sorbonne Université, Faculté de Médecine Pitié-Salpêtrière, Paris, France
- Institut du Cerveau et de la Moelle Épinière, ICM, PICNIC Lab, Paris, France
- Inserm U 1127, Paris, France
- CNRS, UMR 7225, Paris, France
- Department of Neurophysiology, Groupe Hospitalier Pitié-Salpêtrière, AP-HP, Paris, France
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Rezaei Haddad A, Lythe V, Green AL. Deep Brain Stimulation for Recovery of Consciousness in Minimally Conscious Patients After Traumatic Brain Injury: A Systematic Review. Neuromodulation 2019; 22:373-379. [DOI: 10.1111/ner.12944] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2018] [Revised: 01/05/2019] [Accepted: 02/06/2019] [Indexed: 10/27/2022]
Affiliation(s)
- Ali Rezaei Haddad
- Medical Sciences Divisional Office University of Oxford, John Radcliffe Hospital Oxford UK
- Neurosurgical Department Oxford University Hospitals Oxford UK
| | - Vanessa Lythe
- Green Templeton College, University of Oxford Oxford UK
| | - Alexander L. Green
- Neurosurgical Department Oxford University Hospitals Oxford UK
- Nuffield Department of Surgical Sciences University of Oxford Oxford UK
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Gottshall JL, Adams ZM, Forgacs PB, Schiff ND. Daytime Central Thalamic Deep Brain Stimulation Modulates Sleep Dynamics in the Severely Injured Brain: Mechanistic Insights and a Novel Framework for Alpha-Delta Sleep Generation. Front Neurol 2019; 10:20. [PMID: 30778326 PMCID: PMC6369150 DOI: 10.3389/fneur.2019.00020] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2018] [Accepted: 01/08/2019] [Indexed: 12/17/2022] Open
Abstract
Loss of organized sleep electrophysiology is a characteristic finding following severe brain injury. The return of structured elements of sleep architecture has been associated with positive prognosis across injury etiologies, suggesting a role for sleep dynamics as biomarkers of wakeful neuronal circuit function. In a continuing study of one minimally conscious state patient studied over the course of ~8½ years, we sought to investigate whether changes in daytime brain activation induced by central thalamic deep brain stimulation (CT-DBS) influenced sleep electrophysiology. In this patient subject, we previously reported significant improvements in sleep electrophysiology during 5½ years of CT-DBS treatment, including increased sleep spindle frequency and SWS delta power. We now present novel findings that many of these improvements in sleep electrophysiology regress following CT-DBS discontinuation; these regressions in sleep features correlate with a significant decrease in behavioral responsiveness. We also observe the re-emergence of alpha-delta sleep, which had been previously suppressed by daytime CT-DBS in this patient subject. Importantly, CT-DBS was only active during the daytime and has been proposed to mediate recovery of consciousness by driving synaptic activity across frontostriatal systems through the enhancement of thalamocortical output. Accordingly, the improvement of sleep dynamics during daytime CT-DBS and their subsequent regression following CT-DBS discontinuation implicates wakeful synaptic activity as a robust modulator of sleep electrophysiology. We interpret these findings in the context of the “synaptic homeostasis hypothesis,” whereby we propose that daytime upregulation of thalamocortical output in the severely injured brain may facilitate organized frontocortical circuit activation and yield net synaptic potentiation during wakefulness, providing a homeostatic drive that reconstitutes sleep dynamics over time. Furthermore, we consider common large-scale network dynamics across several neuropsychiatric disorders in which alpha-delta sleep has been documented, allowing us to formulate a novel mechanistic framework for alpha-delta sleep generation. We conclude that the bi-directional modulation of sleep electrophysiology by daytime thalamocortical activity in the severely injured brain: (1) emphasizes the cyclical carry-over effects of state-dependent circuit activation on large-scale brain dynamics, and (2) further implicates sleep electrophysiology as a sensitive indicator of wakeful brain activation and covert functional recovery in the severely injured brain.
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Affiliation(s)
- Jackie L Gottshall
- Feil Family Brain and Mind Research Institute, Weill Cornell Medicine, New York, NY, United States
| | - Zoe M Adams
- Department of Neurology, Weill Cornell Medicine, New York, NY, United States
| | - Peter B Forgacs
- Feil Family Brain and Mind Research Institute, Weill Cornell Medicine, New York, NY, United States.,Department of Neurology, Weill Cornell Medicine, New York, NY, United States.,Rockefeller University Hospital, New York, NY, United States
| | - Nicholas D Schiff
- Feil Family Brain and Mind Research Institute, Weill Cornell Medicine, New York, NY, United States.,Department of Neurology, Weill Cornell Medicine, New York, NY, United States.,Rockefeller University Hospital, New York, NY, United States
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16
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Xia X, Yang Y, Guo Y, Bai Y, Dang Y, Xu R, He J. Current Status of Neuromodulatory Therapies for Disorders of Consciousness. Neurosci Bull 2018; 34:615-625. [PMID: 29916112 DOI: 10.1007/s12264-018-0244-4] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2018] [Accepted: 04/25/2018] [Indexed: 11/26/2022] Open
Abstract
Treatment for disorders of consciousness (DOCs) is still a Gordian knot. Evidence-based guidelines on the treatment of DOC patients are not currently available, while neuromodulation techniques are seen as a potential treatment. Multiple neuromodulation therapies have been applied. This article reviews the most relevant studies in the literature in order to describe a clear picture of the current state of neuromodulation therapies that could be used to treat DOC patients. Both invasive and non-invasive brain stimulation is discussed. Significant behavioral improvements in prolonged DOCs under neuromodulation therapies are rare. The efficacy of various such therapies remains a matter of debate. Further clinical investigations of existing techniques in larger samples properly controlling for spontaneous recovery are needed, and new approaches are awaited.
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Affiliation(s)
- Xiaoyu Xia
- Department of Neurosurgery, PLA Army General Hospital, Beijing, 100700, China
| | - Yi Yang
- Department of Neurosurgery, PLA Army General Hospital, Beijing, 100700, China
| | - Yongkun Guo
- Department of Neurosurgery, Zhengzhou Central Hospital Affiliated to Zhengzhou University, Zhengzhou, 450007, China
| | - Yang Bai
- International Vegetative State and Consciousness Science Institute, Hangzhou Normal University, Hangzhou, 311121, China
| | - Yuanyuan Dang
- Department of Neurosurgery, PLA Army General Hospital, Beijing, 100700, China
| | - Ruxiang Xu
- Department of Neurosurgery, PLA Army General Hospital, Beijing, 100700, China
| | - Jianghong He
- Department of Neurosurgery, PLA Army General Hospital, Beijing, 100700, China.
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Illuminating Neural Circuits: From Molecules to MRI. J Neurosci 2017; 37:10817-10825. [PMID: 29118210 DOI: 10.1523/jneurosci.2569-17.2017] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2017] [Revised: 09/22/2017] [Accepted: 09/26/2017] [Indexed: 11/21/2022] Open
Abstract
Neurological disease drives symptoms through pathological changes to circuit functions. Therefore, understanding circuit mechanisms that drive behavioral dysfunction is of critical importance for quantitative diagnosis and systematic treatment of neurological disease. Here, we describe key technologies that enable measurement and manipulation of neural activity and neural circuits. Applying these approaches led to the discovery of circuit mechanisms underlying pathological motor behavior, arousal regulation, and protein accumulation. Finally, we discuss how optogenetic functional magnetic resonance imaging reveals global scale circuit mechanisms, and how circuit manipulations could lead to new treatments of neurological diseases.
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Vanhoecke J, Hariz M. Deep brain stimulation for disorders of consciousness: Systematic review of cases and ethics. Brain Stimul 2017; 10:1013-1023. [PMID: 28966051 DOI: 10.1016/j.brs.2017.08.006] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2017] [Revised: 07/24/2017] [Accepted: 08/21/2017] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND A treatment for patients suffering from prolonged severely altered consciousness is not available. The success of Deep Brain Stimulation (DBS) in diseases such as Parkinson's, dystonia and essential tremor provided a renewed impetus for its application in Disorders of Consciousness (DoC). OBJECTIVE To evaluate the rationale for DBS in patients with DoC, through systematic review of literature containing clinical data and ethical considerations. METHODS Articles from PubMed, Embase, Medline and Web of Science were systematically reviewed. RESULTS The outcomes of 78 individual patients reported in 19 articles from 1968 onwards were pooled and elements of ethical discussions were compared. There is no clear clinical evidence that DBS is a treatment for DoC that can restore both consciousness and the ability to communicate. In patients who benefitted, the outcome of DBS is often confounded by the time frame of spontaneous recovery from DoC. Difficult ethical considerations remain, such as the risk of increasing self-awareness of own limitations, without improving overall wellbeing, and the issues of proxy consent. CONCLUSION DBS is far from being evident as a possible future therapeutic avenue for patients with DoC. Double-blind studies are lacking, and many clinical and ethical issues have to be addressed. In the rare cases when DBS for patients with DoC is considered, this needs to be evaluated meticulously on a case by case basis, with comprehensive overall outcome measures including psychological and quality-of-life assessments, and with the guidance of an ethical and interdisciplinary panel, especially in relation to proxy consent.
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Affiliation(s)
- Jonathan Vanhoecke
- Unit of Functional Neurosurgery, Institute of Neurology, University College London, Queen Square, WC1N 3BG, London, UK.
| | - Marwan Hariz
- Unit of Functional Neurosurgery, Institute of Neurology, University College London, Queen Square, WC1N 3BG, London, UK; Department of Clinical Neuroscience, Umeå University, SE-901 87, Umeå, Sweden.
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