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Wang P, Xiang J, Niu Y, Wei J, Lan C, Li X, Xu L, Yin Y, Wang H, Zhang T, Yang L, Xing H, Fan S, Niu Q, Kang H, Liang Y. Study of a precise treatment protocol for patients with consciousness disorders based on the brain network analysis of functional magnetic resonance imaging. Front Neurosci 2024; 18:1443478. [PMID: 39351395 PMCID: PMC11439825 DOI: 10.3389/fnins.2024.1443478] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2024] [Accepted: 08/19/2024] [Indexed: 10/04/2024] Open
Abstract
Objective How to conduct objective and accurate individualized assessments of patients with disorders of consciousness (DOC) and carry out precision rehabilitation treatment technology is a major rehabilitation problem that needs to be solved urgently. Methods In this study, a multi-layer brain network was constructed based on functional magnetic resonance imaging (fMRI) to analyze the structural and functional brain networks of patients with DOC at different levels and to find regulatory targets (imaging markers) with recovery potential for DOC. Then repeated transcranial magnetic stimulation (rTMS) was performed in DOC patients to clinically validate. Results The brain network connectivity of DOC patients with different consciousness states is different, and the most obvious brain regions appeared in the olfactory cortex and precuneus. rTMS stimulation could effectively improve the consciousness level of DOC patients and stimulate the occipital lobe (specific regions found in this study) and the dorsolateral prefrontal cortex (DLPFC), and both parts had a good consciousness recovery effect. Conclusion In clinical work, personalized stimulation regimen treatment combined with the brain network characteristics of DOC patients can improve the treatment effect.
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Affiliation(s)
- Pingzhi Wang
- Third Hospital of Shanxi Medical University, Shanxi Bethune Hospital, Tongji Shanxi Hospital, Shanxi Academy of Medical Sciences, Taiyuan, China
| | - Jie Xiang
- College of Computer Science and Technology (College of Data Science), Taiyuan University of Technology, Taiyuan, China
| | - Yan Niu
- College of Computer Science and Technology (College of Data Science), Taiyuan University of Technology, Taiyuan, China
| | - Jing Wei
- College of Computer Science and Technology (College of Data Science), Taiyuan University of Technology, Taiyuan, China
| | - Caiqin Lan
- Third Hospital of Shanxi Medical University, Shanxi Bethune Hospital, Tongji Shanxi Hospital, Shanxi Academy of Medical Sciences, Taiyuan, China
| | - Xiangping Li
- Third Hospital of Shanxi Medical University, Shanxi Bethune Hospital, Tongji Shanxi Hospital, Shanxi Academy of Medical Sciences, Taiyuan, China
| | - Liying Xu
- Third Hospital of Shanxi Medical University, Shanxi Bethune Hospital, Tongji Shanxi Hospital, Shanxi Academy of Medical Sciences, Taiyuan, China
| | - Yajie Yin
- Third Hospital of Shanxi Medical University, Shanxi Bethune Hospital, Tongji Shanxi Hospital, Shanxi Academy of Medical Sciences, Taiyuan, China
| | - Hongxiong Wang
- Third Hospital of Shanxi Medical University, Shanxi Bethune Hospital, Tongji Shanxi Hospital, Shanxi Academy of Medical Sciences, Taiyuan, China
| | - Tao Zhang
- Third Hospital of Shanxi Medical University, Shanxi Bethune Hospital, Tongji Shanxi Hospital, Shanxi Academy of Medical Sciences, Taiyuan, China
| | - Lei Yang
- Third Hospital of Shanxi Medical University, Shanxi Bethune Hospital, Tongji Shanxi Hospital, Shanxi Academy of Medical Sciences, Taiyuan, China
| | - Hao Xing
- Third Hospital of Shanxi Medical University, Shanxi Bethune Hospital, Tongji Shanxi Hospital, Shanxi Academy of Medical Sciences, Taiyuan, China
| | - Shasha Fan
- Third Hospital of Shanxi Medical University, Shanxi Bethune Hospital, Tongji Shanxi Hospital, Shanxi Academy of Medical Sciences, Taiyuan, China
| | - Qing Niu
- Third Hospital of Shanxi Medical University, Shanxi Bethune Hospital, Tongji Shanxi Hospital, Shanxi Academy of Medical Sciences, Taiyuan, China
| | - Huicong Kang
- Third Hospital of Shanxi Medical University, Shanxi Bethune Hospital, Tongji Shanxi Hospital, Shanxi Academy of Medical Sciences, Taiyuan, China
- Tongji Medical College, Tongji Hospital, Huazhong University of Science and Technology, Wuhan, China
| | - Ying Liang
- Third Hospital of Shanxi Medical University, Shanxi Bethune Hospital, Tongji Shanxi Hospital, Shanxi Academy of Medical Sciences, Taiyuan, China
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Jung JY, Yoo YJ, Yoon MJ, Hong BY, Kim TW, Park GY, Lee JI, Lee SH, Im S, Lim SH. The integrity of thalamo-dorsolateral prefrontal cortex tract: a key factor in residual consciousness in disorders of consciousness patients. Front Neurol 2024; 15:1373750. [PMID: 39206298 PMCID: PMC11349516 DOI: 10.3389/fneur.2024.1373750] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2024] [Accepted: 07/30/2024] [Indexed: 09/04/2024] Open
Abstract
Background The mesocircuit model describes a complex network that includes the prefrontal cortical-striatopallidal-thalamo-cortical loop systems and is involved in the mechanism underlying consciousness in patients with disorders of consciousness (DoC). Inhibitory signals to the thalamus become hyperactive in DoC patients, leading to a loss of consciousness. Reactivating this mesocircuit system is important for recovering consciousness in these patients. We investigated how the residual integrity of the thalamo-dorsolateral prefrontal cortex tract (TDLPFCT) influences consciousness in patients with DoC. Methods This retrospective case-control study included three groups: prolonged DoC (n = 20), stroke without DoC (n = 20), and healthy controls (n = 20). Diffusion tensor imaging (DTI) was performed at least 4 weeks after the onset. Thalamo-DLPFC tracts were reconstructed using diffusion tensor tractography, and fractional anisotropy (FA) and tract volume (TV) were measured for each hemisphere. Consciousness was assessed using the revised coma recovery scale (CRS-R) within a week of brain imaging. Results Significant differences in DLPFCT TV were observed across all three groups, in both affected and less-affected lobes, with the DoC group showing the greatest reduction. A significant correlation was found between the TV of the less-affected TDLPFCT and CRS-R score. Conclusion The integrity of the TDLPFCT, particularly in the less affected hemisphere, is associated with consciousness levels in patients with prolonged DoC. This finding suggests its potential importance in assessing prognosis and further developing therapeutic strategies for patients with DoC.
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Affiliation(s)
- Ji Yoon Jung
- Department of Rehabilitation Medicine, St. Vincent’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Yeun Jie Yoo
- Department of Rehabilitation Medicine, St. Vincent’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Mi-Jeong Yoon
- Department of Rehabilitation Medicine, St. Vincent’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Bo Young Hong
- Department of Rehabilitation Medicine, St. Vincent’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Tae-Woo Kim
- Department of Rehabilitation Medicine, National Traffic Injury Rehabilitation Hospital, Gyeonggi-do, Republic of Korea
| | - Geun-Young Park
- Department of Rehabilitation Medicine, Bucheon St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Jong In Lee
- Department of Rehabilitation Medicine, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Soo-Hwan Lee
- Department of Rehabilitation Medicine, Bucheon St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Sun Im
- Department of Rehabilitation Medicine, Bucheon St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Seong Hoon Lim
- Department of Rehabilitation Medicine, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
- Institute for Basic Medical Science, Catholic Medical Center, The Catholic University of Korea, Seoul, Republic of Korea
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Wan X, Zhang Y, Li Y, Song W. Effects of parietal repetitive transcranial magnetic stimulation in prolonged disorders of consciousness: A pilot study. Heliyon 2024; 10:e30192. [PMID: 38707352 PMCID: PMC11066627 DOI: 10.1016/j.heliyon.2024.e30192] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2023] [Revised: 04/21/2024] [Accepted: 04/22/2024] [Indexed: 05/07/2024] Open
Abstract
Objective Although the parietal cortex is related to consciousness, the dorsolateral prefrontal and primary motor cortices are the usual targets for repetitive transcranial magnetic stimulation (rTMS) for prolonged disorders of consciousness (pDoC). Herein, we applied parietal rTMS to patients with pDoC, to verify its neurobehavioral effects and explore a new potential rTMS target. Materials and methods Twenty-six patients with pDoC were assigned to a rTMS or sham group. The rTMS group received 10 sessions of parietal rTMS; the sham group received 10 sessions of sham stimulation. The Coma Recovery Scale-Revised (CRS-R) and event-related potential (ERP) were collected before and after the 10 sessions or sham sessions. Results After the 10 sessions, the rTMS group showed: a significant CRS-R score increase; ERP appearance of a P300 waveform and significantly increased Fz amplitudes; increased potentials on topographic mapping, especially in the left prefrontal cortex; and an increase in delta and theta band powers at Fz, Cz, and Pz. The sham group did not show such changes in CRS-R score or ERP results statistically. Conclusion Parietal rTMS shows promise as a novel intervention in the recovery of consciousness in pDoC. It showed neurobehavioral enhancement of residual brain function and may promote frontal activity by enhancing frontal-parietal connections. The parietal cortex may thus be an alternative for rTMS therapy protocols.
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Affiliation(s)
- Xiaoping Wan
- Department of Rehabilitation Medicine, Xuan Wu Hospital, Capital Medical University, No. 45 Chang Chun Street, Beijing, 100053, China
| | - Ye Zhang
- Department of Rehabilitation Medicine, Xuan Wu Hospital, Capital Medical University, No. 45 Chang Chun Street, Beijing, 100053, China
| | - Yanhua Li
- Department of Rehabilitation Medicine, Xuan Wu Hospital, Capital Medical University, No. 45 Chang Chun Street, Beijing, 100053, China
| | - Weiqun Song
- Department of Rehabilitation Medicine, Xuan Wu Hospital, Capital Medical University, No. 45 Chang Chun Street, Beijing, 100053, China
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Gallucci A, Varoli E, Del Mauro L, Hassan G, Rovida M, Comanducci A, Casarotto S, Lo Re V, Romero Lauro LJ. Multimodal approaches supporting the diagnosis, prognosis and investigation of neural correlates of disorders of consciousness: A systematic review. Eur J Neurosci 2024; 59:874-933. [PMID: 38140883 DOI: 10.1111/ejn.16149] [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: 12/12/2022] [Revised: 08/30/2023] [Accepted: 09/11/2023] [Indexed: 12/24/2023]
Abstract
The limits of the standard, behaviour-based clinical assessment of patients with disorders of consciousness (DoC) prompted the employment of functional neuroimaging, neurometabolic, neurophysiological and neurostimulation techniques, to detect brain-based covert markers of awareness. However, uni-modal approaches, consisting in employing just one of those techniques, are usually not sufficient to provide an exhaustive exploration of the neural underpinnings of residual awareness. This systematic review aimed at collecting the evidence from studies employing a multimodal approach, that is, combining more instruments to complement DoC diagnosis, prognosis and better investigating their neural correlates. Following the PRISMA guidelines, records from PubMed, EMBASE and Scopus were screened to select peer-review original articles in which a multi-modal approach was used for the assessment of adult patients with a diagnosis of DoC. Ninety-two observational studies and 32 case reports or case series met the inclusion criteria. Results highlighted a diagnostic and prognostic advantage of multi-modal approaches that involve electroencephalography-based (EEG-based) measurements together with neuroimaging or neurometabolic data or with neurostimulation. Multimodal assessment deepened the knowledge on the neural networks underlying consciousness, by showing correlations between the integrity of the default mode network and the different clinical diagnosis of DoC. However, except for studies using transcranial magnetic stimulation combined with electroencephalography, the integration of more than one technique in most of the cases occurs without an a priori-designed multi-modal diagnostic approach. Our review supports the feasibility and underlines the advantages of a multimodal approach for the diagnosis, prognosis and for the investigation of neural correlates of DoCs.
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Affiliation(s)
- Alessia Gallucci
- Ph.D. Program in Neuroscience, School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
- NeuroMi (Neuroscience Center), University of Milano-Bicocca, Milan, Italy
| | - Erica Varoli
- Neurology Service, Department of Diagnostic and Therapeutic Services, Istituto di Ricovero e Cura a Carattere Scientifico-Istituto Mediterraneo per i Trapianti e Terapie ad Alta Specializzazione (IRCCS ISMETT), Palermo, Italy
| | - Lilia Del Mauro
- Department of Psychology, University of Milano-Bicocca, Milan, Italy
| | - Gabriel Hassan
- Department of Biomedical and Clinical Sciences, University of Milan, Italy
| | - Margherita Rovida
- Department of Psychology, University of Milano-Bicocca, Milan, Italy
| | - Angela Comanducci
- IRCSS Fondazione Don Carlo Gnocchi ONLUS, Milan, Italy
- Università Campus Bio-Medico di Roma, Rome, Italy
| | - Silvia Casarotto
- Department of Biomedical and Clinical Sciences, University of Milan, Italy
- IRCCS Fondazione Don Carlo Gnocchi, Milan, Italy
| | - Vincenzina Lo Re
- Neurology Service, Department of Diagnostic and Therapeutic Services, Istituto di Ricovero e Cura a Carattere Scientifico-Istituto Mediterraneo per i Trapianti e Terapie ad Alta Specializzazione (IRCCS ISMETT), Palermo, Italy
| | - Leonor J Romero Lauro
- NeuroMi (Neuroscience Center), University of Milano-Bicocca, Milan, Italy
- Department of Psychology, University of Milano-Bicocca, Milan, Italy
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Vitello MM, Rosenfelder MJ, Cardone P, Niimi M, Willacker L, Thibaut A, Lejeune N, Laureys S, Bender A, Gosseries O. A protocol for a multicenter randomized and personalized controlled trial using rTMS in patients with disorders of consciousness. Front Neurol 2023; 14:1216468. [PMID: 37545735 PMCID: PMC10401598 DOI: 10.3389/fneur.2023.1216468] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2023] [Accepted: 07/06/2023] [Indexed: 08/08/2023] Open
Abstract
Background Improving the functional recovery of patients with DoC remains one of the greatest challenges of the field. Different theories exist about the role of the anterior (prefrontal areas) versus posterior (parietal areas) parts of the brain as hotspots for the recovery of consciousness. Repetitive transcranial magnetic stimulation (rTMS) is a powerful non-invasive brain stimulation technique for the treatment of DoC. However, a direct comparison of the effect of TMS treatment on the front versus the back of the brain has yet to be performed. In this study, we aim to assess the short- and long-term effects of frontal and parietal rTMS on DoC recovery and characterize responders phenotypically. Methods/design Ninety patients with subacute and prolonged DoC will be included in a two-part multicenter prospective study. In the first phase (randomized controlled trial, RCT), patients will undergo four rTMS sessions in a crossover design over 10 days, targeting (i) the left dorsolateral prefrontal cortex (DLPFC) and (ii) the left angular gyrus (AG), as well as (iii & iv) their sham alternatives. In the second phase (longitudinal personalized trial), patients will receive personalized stimulations for 20 working days targeting the brain area that showed the best results in the RCT and will be randomly assigned to either active or sham intervention. The effects of rTMS on neurobehavioral and neurophysiological functioning in patients with DoC will be evaluated using clinical biomarkers of responsiveness (i.e., the Coma Recovery Scale-Revised; CRS-R), and electrophysiological biomarkers (e.g., power spectra, functional and effective connectivity, perturbational complexity index before and after intervention). Functional long-term outcomes will be assessed at 3 and 6 months post-intervention. Adverse events will be recorded during the treatment phase. Discussion This study seeks to identify which brain region (front or back) is best to stimulate for the treatment of patients with DoC using rTMS, and to characterize the neural correlates of its action regarding recovery of consciousness and functional outcome. In addition, we will define the responders' profile based on patients' characteristics and functional impairments; and develop biomarkers of responsiveness using EEG analysis according to the clinical responsiveness to the treatment. Clinical Trial Registration https://clinicaltrials.gov/ct2/show/NCT04401319, Clinicaltrials.gov, n° NCT04401319.
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Affiliation(s)
- Marie M. Vitello
- Coma Science Group, GIGA Consciousness, University of Liège, Liège, Belgium
- Centre du Cerveau, University Hospital of Liège, Liège, Belgium
| | - Martin J. Rosenfelder
- Department of Neurology, Therapiezentrum Burgau, Burgau, Germany
- Clinical and Biological Psychology, Institute of Psychology and Education, Ulm University, Ulm, Germany
| | - Paolo Cardone
- Coma Science Group, GIGA Consciousness, University of Liège, Liège, Belgium
- Centre du Cerveau, University Hospital of Liège, Liège, Belgium
| | - Masachika Niimi
- Coma Science Group, GIGA Consciousness, University of Liège, Liège, Belgium
- Centre du Cerveau, University Hospital of Liège, Liège, Belgium
- Department of Rehabilitation Medicine, Nihon University School of Medicine, Tokyo, Japan
| | - Lina Willacker
- Department of Neurology, Ludwig-Maximilians University Hospital of Munich, University of Munich, Munich, Germany
| | - Aurore Thibaut
- Coma Science Group, GIGA Consciousness, University of Liège, Liège, Belgium
- Centre du Cerveau, University Hospital of Liège, Liège, Belgium
| | - Nicolas Lejeune
- Coma Science Group, GIGA Consciousness, University of Liège, Liège, Belgium
- Centre du Cerveau, University Hospital of Liège, Liège, Belgium
- William Lennox Neurological Hospital, Ottignies-Louvain-la-Neuve, Belgium
| | - Steven Laureys
- Coma Science Group, GIGA Consciousness, University of Liège, Liège, Belgium
- Centre du Cerveau, University Hospital of Liège, Liège, Belgium
- CERVO Research Center, Laval University, Québec, QC, Canada
| | - Andreas Bender
- Department of Neurology, Therapiezentrum Burgau, Burgau, Germany
- Department of Neurology, Ludwig-Maximilians University Hospital of Munich, University of Munich, Munich, Germany
| | - Olivia Gosseries
- Coma Science Group, GIGA Consciousness, University of Liège, Liège, Belgium
- Centre du Cerveau, University Hospital of Liège, Liège, Belgium
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Zheng RZ, Qi ZX, Wang Z, Xu ZY, Wu XH, Mao Y. Clinical Decision on Disorders of Consciousness After Acquired Brain Injury: Stepping Forward. Neurosci Bull 2023; 39:138-162. [PMID: 35804219 PMCID: PMC9849546 DOI: 10.1007/s12264-022-00909-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Accepted: 04/10/2022] [Indexed: 01/22/2023] Open
Abstract
Major advances have been made over the past few decades in identifying and managing disorders of consciousness (DOC) in patients with acquired brain injury (ABI), bringing the transformation from a conceptualized definition to a complex clinical scenario worthy of scientific exploration. Given the continuously-evolving framework of precision medicine that integrates valuable behavioral assessment tools, sophisticated neuroimaging, and electrophysiological techniques, a considerably higher diagnostic accuracy rate of DOC may now be reached. During the treatment of patients with DOC, a variety of intervention methods are available, including amantadine and transcranial direct current stimulation, which have both provided class II evidence, zolpidem, which is also of high quality, and non-invasive stimulation, which appears to be more encouraging than pharmacological therapy. However, heterogeneity is profoundly ingrained in study designs, and only rare schemes have been recommended by authoritative institutions. There is still a lack of an effective clinical protocol for managing patients with DOC following ABI. To advance future clinical studies on DOC, we present a comprehensive review of the progress in clinical identification and management as well as some challenges in the pathophysiology of DOC. We propose a preliminary clinical decision protocol, which could serve as an ideal reference tool for many medical institutions.
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Affiliation(s)
- Rui-Zhe Zheng
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, 200040, China
- National Center for Neurological Disorders, Shanghai, 200040, China
- Shanghai Key Laboratory of Brain Function and Restoration and Neural Regeneration, Shanghai, 200040, China
- Neurosurgical Institute of Fudan University, Shanghai, 200040, China
- Shanghai Clinical Medical Center of Neurosurgery, Shanghai, 200040, China
- State Key Laboratory of Medical Neurobiology, MOE Frontiers Center for Brain Science, School of Basic Medical Sciences and Institutes of Brain Science, Fudan University, Shanghai, 200032, China
| | - Zeng-Xin Qi
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, 200040, China
- National Center for Neurological Disorders, Shanghai, 200040, China
- Shanghai Key Laboratory of Brain Function and Restoration and Neural Regeneration, Shanghai, 200040, China
- Neurosurgical Institute of Fudan University, Shanghai, 200040, China
- Shanghai Clinical Medical Center of Neurosurgery, Shanghai, 200040, China
- State Key Laboratory of Medical Neurobiology, MOE Frontiers Center for Brain Science, School of Basic Medical Sciences and Institutes of Brain Science, Fudan University, Shanghai, 200032, China
| | - Zhe Wang
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, 200040, China
- National Center for Neurological Disorders, Shanghai, 200040, China
- Shanghai Key Laboratory of Brain Function and Restoration and Neural Regeneration, Shanghai, 200040, China
- Neurosurgical Institute of Fudan University, Shanghai, 200040, China
- Shanghai Clinical Medical Center of Neurosurgery, Shanghai, 200040, China
- State Key Laboratory of Medical Neurobiology, MOE Frontiers Center for Brain Science, School of Basic Medical Sciences and Institutes of Brain Science, Fudan University, Shanghai, 200032, China
| | - Ze-Yu Xu
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, 200040, China
- National Center for Neurological Disorders, Shanghai, 200040, China
- Shanghai Key Laboratory of Brain Function and Restoration and Neural Regeneration, Shanghai, 200040, China
- Neurosurgical Institute of Fudan University, Shanghai, 200040, China
- Shanghai Clinical Medical Center of Neurosurgery, Shanghai, 200040, China
- State Key Laboratory of Medical Neurobiology, MOE Frontiers Center for Brain Science, School of Basic Medical Sciences and Institutes of Brain Science, Fudan University, Shanghai, 200032, China
| | - Xue-Hai Wu
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, 200040, China.
- National Center for Neurological Disorders, Shanghai, 200040, China.
- Shanghai Key Laboratory of Brain Function and Restoration and Neural Regeneration, Shanghai, 200040, China.
- Neurosurgical Institute of Fudan University, Shanghai, 200040, China.
- Shanghai Clinical Medical Center of Neurosurgery, Shanghai, 200040, China.
- State Key Laboratory of Medical Neurobiology, MOE Frontiers Center for Brain Science, School of Basic Medical Sciences and Institutes of Brain Science, Fudan University, Shanghai, 200032, China.
| | - Ying Mao
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, 200040, China.
- National Center for Neurological Disorders, Shanghai, 200040, China.
- Shanghai Key Laboratory of Brain Function and Restoration and Neural Regeneration, Shanghai, 200040, China.
- Neurosurgical Institute of Fudan University, Shanghai, 200040, China.
- Shanghai Clinical Medical Center of Neurosurgery, Shanghai, 200040, China.
- State Key Laboratory of Medical Neurobiology, MOE Frontiers Center for Brain Science, School of Basic Medical Sciences and Institutes of Brain Science, Fudan University, Shanghai, 200032, China.
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Influence of High-Frequency Repetitive Transcranial Magnetic Stimulation on Neurobehavioral and Electrophysiology in Patients with Disorders of Consciousness. Neural Plast 2022; 2022:7195699. [PMID: 36437902 PMCID: PMC9699789 DOI: 10.1155/2022/7195699] [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: 08/27/2022] [Revised: 10/21/2022] [Accepted: 10/28/2022] [Indexed: 11/17/2022] Open
Abstract
Objective High-frequency repetitive transcranial magnetic stimulation (HF-rTMS) has been proposed as a promising therapeutic intervention for patients with disorders of consciousness (DOC). However, its therapeutic effects in the literature are inconsistently documented. The primary aim of this study was to explore the alterations in neural connectivity and neurobehavioral reactivity during rTMS modulation in patients with DOC. In addition, safety was investigated as a secondary aim. Methods The presence of bilateral N20 components in DOC patients was determined by somatosensory-evoked potential (SEP) before enrollment in the study. A total of 64 patients were enrolled and randomly placed into the active and sham groups. Ultimately, 50 patients completed the study. Twenty-five patients in the active group underwent real HF-rTMS, and 25 patients in the sham group underwent sham HF-rTMS, which was delivered over the left dorsolateral prefrontal cortex (DLPFC). The outcome measures of performed pre- and postintervention included the latencies of the N20 and N20-P25 amplitudes of SEP, brainstem auditory-evoked potential (BAEP) grade, JFK Coma Recovery Scale-Revised (CRS-R) score, and Glasgow Coma Scale (GCS) score; any adverse events were recorded at any time during the intervention. Result Following six weeks of treatment, a significant increase was observed in the total CRS-R and GCS scores, and the N20-P25 amplitudes of patients in the two groups were compared with that obtained from preintervention (all p values < 0.05). The waves of BAEP in the two groups also showed a trend toward normalized activity compared with preintervention grades (p values < 0.05). A significant decrease in the latencies of N20 (p values < 0.001) was observed in the active group compared with measurements obtained from preintervention, whereas no significant decrease was observed in the sham group (p values = 0.013). The improvement in total CRS-R scores (p values = 0.002), total GCS scores (p values = 0.023), and N20-P25 amplitudes (p values = 0.011) as well as the decrease in latencies of N20 (p values = 0.018) and change in BAEP grades (p values = 0.013) were significantly different between the two groups. The parameters in neural connectivity (N20-P25 amplitudes, N20 latencies, and BAEP grades) were significantly correlated with the total CRS-R and GCS scores at postintervention, and the changes of CRS-R before and after interventions have a positive relationship with N20-P25 amplitudes. No adverse events related to the rTMS protocol were recorded. Conclusion Neural connectivity levels are affected by HF-rTMS and are significantly related to clinical responses in DOC patients with the presence of bilateral N20. The elevation of neural connectivity levels may lay a foundation for successful HF-rTMS treatment for DOC patients.
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Understanding, detecting, and stimulating consciousness recovery in the ICU. Acta Neurochir (Wien) 2022; 165:809-828. [PMID: 36242637 DOI: 10.1007/s00701-022-05378-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Accepted: 08/07/2022] [Indexed: 11/01/2022]
Abstract
Coma is a medical and socioeconomic emergency. Although underfunded, research on coma and disorders of consciousness has made impressive progress. Lesion-network-mapping studies have delineated the precise brainstem regions that consistently produce coma when damaged. Functional neuroimaging has revealed how mechanisms like "communication through coherence" and "inhibition by gating" work in synergy to enable cortico-cortical processing and how this information transfer is disrupted in brain injury. On the cellular level, break-down of intracellular communication between the layer 5 pyramidal cell soma and the apical dendritic part impairs dendritic information integration, with up-stream effects on microcircuits in local neuronal populations and on large-scale fronto-parietal networks, which correlates with loss of consciousness. A breakthrough in clinical concepts occurred when fMRI, and later EEG, studies revealed that 15% of clinically unresponsive patients in acute and chronic settings are in fact awake and aware, as shown by their command following abilities revealed by brain activation during motor and locomotion imagery tasks. This condition is now termed "cognitive motor dissociation." Furthermore, epidemiological data on coma were literally non-existent until recently because of difficulties related to case ascertainment with traditional methods, but crowdsourcing of family observations enabled the first estimates of how frequent coma is in the general population (pooled annual incidence of 201 coma cases per 100,000 population in the UK and the USA). Diagnostic guidelines on coma and disorders of consciousness by the American Academy of Neurology and the European Academy of Neurology provide ambitious clinical frameworks to accommodate these achievements. As for therapy, a broad range of medical and non-medical treatment options is now being tested in increasingly larger trials; in particular, amantadine and transcranial direct current stimulation appear promising in this regard. Major international initiatives like the Curing Coma Campaign aim to raise awareness for coma and disorders of consciousness in the public, with the ultimate goal to make more brain-injured patients recover consciousness after a coma. To highlight all these accomplishments, this paper provides a comprehensive overview of recent progress and future challenges related to understanding, detecting, and stimulating consciousness recovery in the ICU.
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Zhong Y, Fan J, Wang H, He R. Simultaneously stimulating both brain hemispheres by rTMS in patients with unilateral brain lesions decreases interhemispheric asymmetry. Restor Neurol Neurosci 2021; 39:409-418. [PMID: 34334435 DOI: 10.3233/rnn-211172] [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] [Indexed: 11/15/2022]
Abstract
BACKGROUND Interhemispheric asymmetry caused by brain lesions is an adverse factor in the recovery of patients with neurological deficits. Repetitive transcranial magnetic stimulation (rTMS) has been shown to modulate cortical oscillation and proposed as an approach to rebalance the symmetry, which has not been documented well. OBJECTIVE In this study, we investigated the influence of repetitive transcranial magnetic stimulation (rTMS) on EEG power in patients with unilateral brain lesions by simultaneously stimulating both brain hemispheres and to elucidate asymmetrical changes in rTMS-induced neurophysiological activity. METHODS Fourteen patients with unilateral brain lesions were treated with one active and one sham session of 10 Hz rTMS over the vertex (Cz position). Resting-state EEGs were recorded before and immediately after rTMS. The brain symmetry index (BSI), calculated from a fast Fourier transform, was employed to quantify the power asymmetry in both hemispheres and paired channels over the entire range and five frequency bands (delta, theta, alpha, beta and gamma bands). RESULTS Comparison between active and sham sessions demonstrated rTMS-induced EEG after-effects. rTMS in the active session significantly reduced the BSI in patients with unilateral brain lesions over the entire frequency range (t = 2.767, P = 0.016). Among the five frequency bands, rTMS only induced a noticeable decrease in the BSI in the delta band (t = 2.254, P = 0.042). Furthermore, analysis of different brain regions showed that significant changes in the BSI of the alpha band were only demonstrated in the posterior parietal lobe. In addition, EEG topographic mapping showed a decreased power of delta oscillations in the ipsilesional hemisphere, whereas distinct cortical oscillations were observed in the alpha band around the parietal-occipital lobe in the contralesional hemisphere. CONCLUSIONS When both brain hemispheres were simultaneously activated, rTMS decreased interhemispheric asymmetry primarily via reducing the delta band in the lesioned hemisphere.
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Affiliation(s)
- Yuhua Zhong
- Department of Rehabilitation Medicine, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Jianzhong Fan
- Department of Rehabilitation Medicine, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Huijuan Wang
- Department of Rehabilitation Medicine, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Renhong He
- Department of Rehabilitation Medicine, Nanfang Hospital, Southern Medical University, Guangzhou, China
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10
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Claassen J, Akbari Y, Alexander S, Bader MK, Bell K, Bleck TP, Boly M, Brown J, Chou SHY, Diringer MN, Edlow BL, Foreman B, Giacino JT, Gosseries O, Green T, Greer DM, Hanley DF, Hartings JA, Helbok R, Hemphill JC, Hinson HE, Hirsch K, Human T, James ML, Ko N, Kondziella D, Livesay S, Madden LK, Mainali S, Mayer SA, McCredie V, McNett MM, Meyfroidt G, Monti MM, Muehlschlegel S, Murthy S, Nyquist P, Olson DM, Provencio JJ, Rosenthal E, Sampaio Silva G, Sarasso S, Schiff ND, Sharshar T, Shutter L, Stevens RD, Vespa P, Videtta W, Wagner A, Ziai W, Whyte J, Zink E, Suarez JI. Proceedings of the First Curing Coma Campaign NIH Symposium: Challenging the Future of Research for Coma and Disorders of Consciousness. Neurocrit Care 2021; 35:4-23. [PMID: 34236619 PMCID: PMC8264966 DOI: 10.1007/s12028-021-01260-x] [Citation(s) in RCA: 41] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2021] [Accepted: 04/15/2021] [Indexed: 01/04/2023]
Abstract
Coma and disorders of consciousness (DoC) are highly prevalent and constitute a burden for patients, families, and society worldwide. As part of the Curing Coma Campaign, the Neurocritical Care Society partnered with the National Institutes of Health to organize a symposium bringing together experts from all over the world to develop research targets for DoC. The conference was structured along six domains: (1) defining endotype/phenotypes, (2) biomarkers, (3) proof-of-concept clinical trials, (4) neuroprognostication, (5) long-term recovery, and (6) large datasets. This proceedings paper presents actionable research targets based on the presentations and discussions that occurred at the conference. We summarize the background, main research gaps, overall goals, the panel discussion of the approach, limitations and challenges, and deliverables that were identified.
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Affiliation(s)
- Jan Claassen
- Department of Neurology, Columbia University and New York-Presbyterian Hospital, 177 Fort Washington Avenue, MHB 8 Center, Room 300, New York City, NY, 10032, USA.
| | - Yama Akbari
- Departments of Neurology, Neurological Surgery, and Anatomy & Neurobiology and Beckman Laser Institute and Medical Clinic, University of California, Irvine, Irvine, CA, USA
| | - Sheila Alexander
- Acute and Tertiary Care, School of Nursing and Critical Care Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | | | - Kathleen Bell
- Department of Physical Medicine and Rehabilitation, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Thomas P Bleck
- Davee Department of Neurology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Melanie Boly
- Department of Neurology, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, WI, USA
| | - Jeremy Brown
- Office of Emergency Care Research, Division of Clinical Research, National Institute of Neurological Disorders and Stroke, Bethesda, MD, USA
| | - Sherry H-Y Chou
- Departments of Critical Care Medicine, Neurology, and Neurosurgery, School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Michael N Diringer
- Department of Neurology, Washington University in St. Louis, St. Louis, MO, USA
| | - Brian L Edlow
- Department of Neurology, Center for Neurotechnology and Neurorecovery, Massachusetts General Hospital and Harvard Medical School, Harvard University, Boston, MA, USA
| | - Brandon Foreman
- Departments of Neurology and Rehabilitation Medicine, College of Medicine, University of Cincinnati, Cincinnati, OH, USA
| | - Joseph T Giacino
- Department of Physical Medicine and Rehabilitation, Harvard Medical School, Harvard University, Boston, MA, USA
| | - Olivia Gosseries
- GIGA Consciousness After Coma Science Group, University of Liege, Liege, Belgium
| | - Theresa Green
- School of Nursing, Queensland University of Technology, Kelvin Grove, QLD, Australia
| | - David M Greer
- Department of Neurology, School of Medicine, Boston University, Boston, MA, USA
| | - Daniel F Hanley
- Division of Brain Injury Outcomes, Department of Neurology, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Jed A Hartings
- Department of Neurosurgery, College of Medicine, University of Cincinnati, Cincinnati, OH, USA
| | - Raimund Helbok
- Neurocritical Care Unit, Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - J Claude Hemphill
- Department of Neurology, Weill Institute for Neurosciences, School of Medicine, University of California, San Francisco, San Francisco, CA, USA
| | - H E Hinson
- Department of Neurology, School of Medicine, Oregon Health & Science University, Portland, OR, USA
| | - Karen Hirsch
- Department of Neurology, Stanford University, Palo Alto, CA, USA
| | - Theresa Human
- Department of Pharmacy, Barnes Jewish Hospital, St. Louis, MO, USA
| | - Michael L James
- Departments of Anesthesiology and Neurology, Duke University, Durham, NC, USA
| | - Nerissa Ko
- Department of Neurology, Weill Institute for Neurosciences, School of Medicine, University of California, San Francisco, San Francisco, CA, USA
| | - Daniel Kondziella
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
- Department of Neurology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Sarah Livesay
- College of Nursing, Rush University, Chicago, IL, USA
| | - Lori K Madden
- Center for Nursing Science, University of California, Davis, Sacramento, CA, USA
| | - Shraddha Mainali
- Department of Neurology, The Ohio State University, Columbus, OH, USA
| | - Stephan A Mayer
- Department of Neurology, New York Medical College, Valhalla, NY, USA
| | - Victoria McCredie
- Interdepartmental Division of Critical Care, Department of Respirology, University of Toronto, Toronto, ON, Canada
| | - Molly M McNett
- College of Nursing, The Ohio State University, Columbus, OH, USA
| | - Geert Meyfroidt
- Department of Intensive Care Medicine, University Hospitals Leuven and University of Leuven, Leuven, Belgium
| | - Martin M Monti
- Departments of Neurosurgery and Psychology, Brain Injury Research Center, University of California, Los Angeles, Los Angeles, CA, USA
| | - Susanne Muehlschlegel
- Departments of Neurology, Anesthesiology/Critical Care, and Surgery, Medical School, University of Massachusetts, Worcester, MA, USA
| | - Santosh Murthy
- Department of Neurology, Weill Cornell Medical College, New York City, NY, USA
| | - Paul Nyquist
- Division of Neurosciences Critical Care, Departments of Anesthesiology and Critical Care Medicine, Neurology, and Neurosurgery, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - DaiWai M Olson
- Departments of Neurology and Neurosurgery, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - J Javier Provencio
- Departments of Neurology and Neuroscience, School of Medicine, University of Virginia, Charlottesville, VA, USA
| | - Eric Rosenthal
- Department of Neurology, Harvard Medical School, Harvard University, Boston, MA, USA
| | - Gisele Sampaio Silva
- Department of Neurology, Albert Einstein Israelite Hospital and Universidade Federal de São Paulo, São Paulo, Brazil
| | - Simone Sarasso
- Department of Biomedical and Clinical Sciences "L. Sacco", Università degli Studi di Milano, Milan, Italy
| | - Nicholas D Schiff
- Department of Neurology and Brain Mind Research Institute, Weill Cornell Medicine, Cornell University, New York City, NY, USA
| | - Tarek Sharshar
- Department of Intensive Care, Paris Descartes University, Paris, France
| | - Lori Shutter
- Departments of Critical Care Medicine, Neurology, and Neurosurgery, School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Robert D Stevens
- Division of Neurosciences Critical Care, Departments of Anesthesiology and Critical Care Medicine, Neurology, and Neurosurgery, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Paul Vespa
- Departments of Neurosurgery and Neurology, University of California, Los Angeles, Los Angeles, CA, USA
| | - Walter Videtta
- National Hospital Alejandro Posadas, Buenos Aires, Argentina
| | - Amy Wagner
- Department of Physical Medicine and Rehabilitation, School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Wendy Ziai
- Division of Neurosciences Critical Care, Departments of Anesthesiology and Critical Care Medicine, Neurology, and Neurosurgery, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - John Whyte
- Moss Rehabilitation Research Institute, Elkins Park, PA, USA
| | - Elizabeth Zink
- Division of Neurosciences Critical Care, Department of Neurology, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Jose I Suarez
- Division of Neurosciences Critical Care, Departments of Anesthesiology and Critical Care Medicine, Neurology, and Neurosurgery, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
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11
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Formica C, De Salvo S, Corallo F, Alagna A, Logiudice AL, Todaro A, Bramanti P, Marino S. Role of neurorehabilitative treatment using transcranial magnetic stimulation in disorders of consciousness. J Int Med Res 2021; 49:300060520976472. [PMID: 33535855 PMCID: PMC7869152 DOI: 10.1177/0300060520976472] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Accepted: 11/04/2020] [Indexed: 11/16/2022] Open
Abstract
Disorders of consciousness (DOC) result from brain injuries that cause functional changes in vigilance, awareness and behaviour. It is important to correctly diagnose DOC so that the most appropriate rehabilitation treatments can be initiated. Several studies in DOC patients have demonstrated that repetitive transcranial magnetic stimulation (rTMS) has an important role to play in the recovery of consciousness as highlighted by monitoring clinical scale scores. Although studies indicate that rTMS can be used to aid recovery, it is not combined with other rehabilitative cognitive treatments. As of December 2018, there have been no studies published that combined DOC cognitive rehabilitation with TMS. This current review describes the use of rTMS as a form of non-invasive brain stimulation, as distinct from its use as a tool to investigate residual cortical activity, in terms of its possible therapeutic effects including cognitive rehabilitation. Literature searches were undertaken to identify all relevant studies. The available evidence suggests that rTMS may have an important role to play in in monitoring brain function during recovery and making other intensive rehabilitation treatments more effective, such as sensorial stimulations and cognitive training in patients after a severe acquired brain injury. Further research is required to establish the usefulness of rTMS treatment in DOC rehabilitation.
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Affiliation(s)
- Caterina Formica
- IRCCS Centro Neurolesi “Bonino Pulejo”, Messina, Italy
- Biomedical Department of Internal Medicine and Medical
Specialties, University of Palermo, Palermo, Italy
| | | | | | | | | | | | | | - Silvia Marino
- IRCCS Centro Neurolesi “Bonino Pulejo”, Messina, Italy
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12
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He R, Fan J, Wang H, Zhong Y, Ma J. Differentiating Responders and Non-responders to rTMS Treatment for Disorder of Consciousness Using EEG After-Effects. Front Neurol 2020; 11:583268. [PMID: 33329325 PMCID: PMC7714935 DOI: 10.3389/fneur.2020.583268] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Accepted: 10/26/2020] [Indexed: 12/17/2022] Open
Abstract
Background: It is controversial whether repetitive transcranial magnetic stimulation (rTMS) has potential benefits in improving the awareness of patients with disorder of consciousness (DOC). We hypothesized that rTMS could improve consciousness only in DOC patients who have measurable brain responses to rTMS. Objective: In this study, we aimed to investigate the EEG after-effects induced by rTMS in DOC patients and attempted to propose a prediction algorithm to discriminate between DOC patients who would respond to rTMS treatment from those who would not. Methods: Twenty-five DOC patients were enrolled in this study. Over 4 weeks, each patient received 20 sessions of 20 Hz rTMS that was applied over the left dorsolateral prefrontal cortex (DLPFC). For each patient, resting-state EEG was recorded before and immediately after one session of rTMS to assess the neurophysiologic modification induced by rTMS. The coma recovery scale revised (CRS-R) was used to define responders with improved consciousness. Results: Of the 25 DOC patients, 10 patients regained improved consciousness and were classified as responders. The responders were characterized by more preserved alpha power and a significant reduction of delta power induced by rTMS. The analysis of receiver operating characteristic (ROC) curves showed that the algorithm calculated from the relative alpha power and the relative delta power had a high accuracy in identifying DOC patients who were responders. Conclusions: DOC patients who had more preserved alpha power and a significant reduction in the delta band that was induced by rTMS are likely to regain improved consciousness, which provides a tool to identify DOC patients who may benefit in terms of therapeutic consciousness.
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Affiliation(s)
- Renhong He
- School of Biomedical Engineering, Southern Medical University, Guangzhou, China.,Department of Rehabilitation Medicine, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Jianzhong Fan
- Department of Rehabilitation Medicine, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Huijuan Wang
- Department of Rehabilitation Medicine, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Yuhua Zhong
- Department of Rehabilitation Medicine, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Jianhua Ma
- School of Biomedical Engineering, Southern Medical University, Guangzhou, China
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13
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Feng Y, Zhang J, Zhou Y, Bai Z, Yin Y. Noninvasive brain stimulation for patients with a disorder of consciousness: a systematic review and meta-analysis. Rev Neurosci 2020; 31:/j/revneuro.ahead-of-print/revneuro-2020-0033/revneuro-2020-0033.xml. [PMID: 32845870 DOI: 10.1515/revneuro-2020-0033] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Accepted: 06/11/2020] [Indexed: 01/08/2023]
Abstract
Noninvasive brain stimulation (NIBS) techniques have been used to facilitate the recovery from prolonged unconsciousness as a result of brain injury. The aim of this study is to systematically assess the effects of NIBS in patients with a disorder of consciousness (DOC). We searched four databases for any randomized controlled trials on the effect of NIBS in patients with a DOC, which used the JFK Coma Recovery Scale-Revised (CRS-R) as the primary outcome measure. A random-effects meta-analysis was conducted to pool effect sizes. Fourteen studies with 273 participants were included in this review, of which 12 studies with sufficient data were included in the meta-analysis. Our meta-analysis showed a significant effect on increasing CRS-R scores in favor of real stimulation as compared to sham (Hedges' g = 0.522; 95% confidence interval [CI], 0.318-0.726; P < 0.0001, I2 = 0.00%). Subgroup analysis demonstrated that only anodal transcranial direct current stimulation (tDCS) of the left dorsolateral prefrontal cortex (DLPFC) significantly enhances the CRS-R scores in patients with a DOC, as compared to sham (Hedges' g = 0.703; 95% CI, 0.419-0.986; P < 0.001), and this effect was predominant in patients in a minimally conscious state (MCS) (Hedges' g = 0.815; 95% CI, 0.429-1.200; P < 0.001). Anodal tDCS of the left DLPFC appears to be an effective approach for patients with MCS.
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Affiliation(s)
- Yali Feng
- Department of Rehabilitation Medicine, The Second Affiliated Hospital of Chongqing Medical University, Linjiang Road 74, Chongqing 400010, China
| | - Jiaqi Zhang
- Department of Rehabilitation Sciences, The Hong Kong Polytechnic University, Hong Kong SAR, China
| | - Yi Zhou
- Department of Rehabilitation Medicine, The Second Affiliated Hospital of Chongqing Medical University, Linjiang Road 74, Chongqing 400010, China
| | - Zhongfei Bai
- Department of Rehabilitation Sciences, The Hong Kong Polytechnic University, Hong Kong SAR, China
- Department of Occupational Therapy, Shanghai YangZhi Rehabilitation Hospital (Shanghai Sunshine Rehabilitation Center), Shanghai, China
| | - Ying Yin
- Department of Rehabilitation Medicine, The Second Affiliated Hospital of Chongqing Medical University, Linjiang Road 74, Chongqing 400010, China
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14
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Briand MM, Gosseries O, Staumont B, Laureys S, Thibaut A. Transcutaneous Auricular Vagal Nerve Stimulation and Disorders of Consciousness: A Hypothesis for Mechanisms of Action. Front Neurol 2020; 11:933. [PMID: 32982941 PMCID: PMC7477388 DOI: 10.3389/fneur.2020.00933] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2020] [Accepted: 07/20/2020] [Indexed: 01/12/2023] Open
Abstract
Disorders of consciousness (DoC) are the hallmark of severe acquired brain injuries characterized by abnormal activity in important brain areas and disruption within and between brain networks. As DoC's therapeutic arsenal is limited, new potential therapies such as transcutaneous auricular vagal nerve stimulation (taVNS) have recently been explored. The potential of taVNS in the process of consciousness recovery has been highlighted in recent studies with DoC patients. However, it is not clear how taVNS plays a role in the recovery of consciousness. In this article, we first describe the neural correlates of consciousness, the vagus nerve anatomy and functions, along with the results of functional magnetic resonance imaging studies using taVNS. Based on consciousness recovery and taVNS mechanisms, we propose the Vagal Cortical Pathways model. This model highlights four consecutive pathways (A. Lower brainstem activation, B. Upper brainstem activation, C. Norepinephrine pathway, and D. Serotonin pathway) likely to have an impact on patients with a brain injury and DoC. Additionally, we suggest six different mechanisms of action: (1) Activation of the ascending reticular activating system; (2) Activation of the thalamus; (3) Re-establishment of the cortico-striatal-thalamic-cortical loop; (4) Promotion of negative connectivity between external and default mode networks by the activation of the salience network; (5) Increase in activity and connectivity within the external network through the norepinephrine pathway; and (6) Increase in activity within the default mode network through the serotonin pathway. This model aims to explain the potential therapeutic effects that taVNS has on brain activity in the process of consciousness recovery.
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Affiliation(s)
- Marie-Michele Briand
- Coma Science Group, GIGA Consciousness, University of Liège, Liège, Belgium
- Centre du Cerveau, University Hospital of Liège, Liège, Belgium
- Physical Medicine and Rehabilitation Department, Institut de Réadaptation en Déficience Physique de Québec, Quebec City, QC, Canada
| | - Olivia Gosseries
- Coma Science Group, GIGA Consciousness, University of Liège, Liège, Belgium
- Centre du Cerveau, University Hospital of Liège, Liège, Belgium
| | - Bernard Staumont
- Coma Science Group, GIGA Consciousness, University of Liège, Liège, Belgium
- Centre du Cerveau, University Hospital of Liège, Liège, Belgium
| | - Steven Laureys
- Coma Science Group, GIGA Consciousness, University of Liège, Liège, Belgium
- Centre du Cerveau, University Hospital of Liège, Liège, Belgium
| | - Aurore Thibaut
- Coma Science Group, GIGA Consciousness, University of Liège, Liège, Belgium
- Centre du Cerveau, University Hospital of Liège, Liège, Belgium
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15
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Transcranial magnetic stimulation-evoked connectivity reveals modulation effects of repetitive transcranial magnetic stimulation on patients with disorders of consciousness. Neuroreport 2020; 30:1307-1315. [PMID: 31714484 DOI: 10.1097/wnr.0000000000001362] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Several studies have investigated possible role of repetitive transcranial magnetic stimulation (rTMS) in patients with disorder of consciousness (DOC). But the details of patients' brain responses to the rTMS are yet to be disclosed. The aim of the study is to explore the neural electrical responses of DOC patients to rTMS modulation. DOC Patients [14 vegetative state, seven minimally conscious state (MCS)] and healthy subjects were enrolled and received one session of rTMS. The TMS-electroencephalogram was recorded at before and immediately after rTMS stimulation. TMS-evoked potentials as well as TMS-evoked connectivity were proposed to capture the effective connectivity alteration induced by rTMS. Significant changes of TMS-evoked potential were found in the healthy group but not in DOC patients. TMS-evoked connectivity was significantly enhanced by the rTMS in healthy and MCS groups. In addition, the enhancement was positively correlated with patients' Coma Recovery Scale-Revised scores. Global synchrony of the TMS-evoked connectivity matrix significantly enhanced by rTMS in the control and MCS groups but not in vegetative state patients. Furthermore, after rTMS stimulation, the similarity of TMS-evoked connectivity patterns between pairwise patients was significantly raised in MCS patients. But no significant changes were found in vegetative state patients. TMS-evoked connectivity reveals that rTMS can effectively modulate effective connectivity of MCS patients, but no evidence of changes in vegetative state patients.
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16
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Billeri L, Filoni S, Russo EF, Portaro S, Militi D, Calabrò RS, Naro A. Toward Improving Diagnostic Strategies in Chronic Disorders of Consciousness: An Overview on the (Re-)Emergent Role of Neurophysiology. Brain Sci 2020; 10:brainsci10010042. [PMID: 31936844 PMCID: PMC7016627 DOI: 10.3390/brainsci10010042] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2019] [Revised: 01/03/2020] [Accepted: 01/08/2020] [Indexed: 12/13/2022] Open
Abstract
The differential diagnosis of patients with Disorder of Consciousness (DoC), in particular in the chronic phase, is significantly difficult. Actually, about 40% of patients with unresponsive wakefulness syndrome (UWS) and the minimally conscious state (MCS) are misdiagnosed. Indeed, only advanced paraclinical approaches, including advanced EEG analyses, can allow achieving a more reliable diagnosis, that is, discovering residual traces of awareness in patients with UWS (namely, functional Locked-In Syndrome (fLIS)). These approaches aim at capturing the residual brain network models, at rest or that may be activated in response to relevant stimuli, which may be appropriate for awareness to emerge (despite their insufficiency to generate purposeful motor behaviors). For this, different brain network models have been studied in patients with DoC by using sensory stimuli (i.e., passive tasks), probing response to commands (i.e., active tasks), and during resting-state. Since it can be difficult for patients with DoC to perform even simple active tasks, this scoping review aims at summarizing the current, innovative neurophysiological examination methods in resting state/passive modality to differentiate and prognosticate patients with DoC. We conclude that the electrophysiologically-based diagnostic procedures represent an important resource for diagnosis, prognosis, and, therefore, management of patients with DoC, using advance passive and resting state paradigm analyses for the patients who lie in the “greyzones” between MCS, UWS, and fLIS.
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Affiliation(s)
- Luana Billeri
- IRCCS Centro Neurolesi Bonino Pulejo, 98124 Messina, Italy; (L.B.); (S.P.); (A.N.)
| | - Serena Filoni
- Padre Pio Foundation and Rehabilitation Centers, San Giovanni Rotondo, 71013 Foggia, Italy;
- Correspondence: (S.F.); (R.S.C.); Tel.: +39-090-6012-8166 (R.S.C.)
| | | | - Simona Portaro
- IRCCS Centro Neurolesi Bonino Pulejo, 98124 Messina, Italy; (L.B.); (S.P.); (A.N.)
| | | | - Rocco Salvatore Calabrò
- IRCCS Centro Neurolesi Bonino Pulejo, 98124 Messina, Italy; (L.B.); (S.P.); (A.N.)
- Correspondence: (S.F.); (R.S.C.); Tel.: +39-090-6012-8166 (R.S.C.)
| | - Antonino Naro
- IRCCS Centro Neurolesi Bonino Pulejo, 98124 Messina, Italy; (L.B.); (S.P.); (A.N.)
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17
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Wang Y, Bai Y, Xia X, Yang Y, He J, Li X. Spinal cord stimulation modulates complexity of neural activities in patients with disorders of consciousness. Int J Neurosci 2019; 130:662-670. [PMID: 31847650 DOI: 10.1080/00207454.2019.1702543] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Affiliation(s)
- Yong Wang
- Institute of Electrical Engineering, Yanshan University, Qinhuangdao, China
| | - Yang Bai
- Department of Basic Medical Science, School of Medicine, Hangzhou Normal University, Hangzhou, China
| | - Xiaoyu Xia
- Department of Neurosurgery, The Seventh Medical Center of Chinese, PLA General Hospital, Beijing, China
| | - Yi Yang
- Department of Neurosurgery, The Seventh Medical Center of Chinese, PLA General Hospital, Beijing, China
| | - Jianghong He
- Department of Neurosurgery, The Seventh Medical Center of Chinese, PLA General Hospital, Beijing, China
| | - Xiaoli Li
- State Key Laboratory of Cognitive Neuroscience and Learning & IDG/McGovern Institute for Brain Research, Beijing, Normal University, Beijing, China
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18
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Thibaut A, Schiff N, Giacino J, Laureys S, Gosseries O. Therapeutic interventions in patients with prolonged disorders of consciousness. Lancet Neurol 2019; 18:600-614. [DOI: 10.1016/s1474-4422(19)30031-6] [Citation(s) in RCA: 78] [Impact Index Per Article: 15.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2018] [Revised: 01/10/2019] [Accepted: 01/10/2019] [Indexed: 12/21/2022]
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19
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Effects of 20 Hz Repetitive Transcranial Magnetic Stimulation on Disorders of Consciousness: A Resting-State Electroencephalography Study. Neural Plast 2018; 2018:5036184. [PMID: 29770146 PMCID: PMC5889874 DOI: 10.1155/2018/5036184] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2017] [Accepted: 12/14/2017] [Indexed: 12/28/2022] Open
Abstract
Repetitive transcranial magnetic stimulation (rTMS) has been proposed as an experimental approach for the treatment of disorders of consciousness (DOC). To date, there has been little research into the use of rTMS in DOC and the therapeutic effects have been variously documented. This study aimed to examine the effects of 20 Hz rTMS on the electroencephalography (EEG) reactivity and clinical response in patients with DOC and to explore the neuromodulatory effects of high-frequency rTMS. In this randomized, sham-controlled, crossover study, real or sham 20 Hz rTMS was applied to the left primary motor cortex (M1) of patients with DOC for 5 consecutive days. Evaluations were blindly performed at the baseline (T0), immediately after the end of the 5 days of treatment (T1) and 1 week after the treatment (T2) using the JFK coma recovery scale-revised (CRS-R) and resting-state EEG. Only one patient, with a history of 2 months of traumatic brain injury, showed long-lasting (T1, T2) behavioral and neurophysiological modifications after the real rTMS stimulation. The 5 remaining patients presented brain reactivity localized at several electrodes, and the EEG modification was not significant. rTMS stimulation may improve awareness and arousal of DOC. Additionally, EEG represents a potential biomarker for the therapeutic efficacy of rTMS. This trial is registered with (NCT03385278).
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Bai Y, Xia X, Li X. A Review of Resting-State Electroencephalography Analysis in Disorders of Consciousness. Front Neurol 2017; 8:471. [PMID: 28955295 PMCID: PMC5601979 DOI: 10.3389/fneur.2017.00471] [Citation(s) in RCA: 46] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2017] [Accepted: 08/25/2017] [Indexed: 01/01/2023] Open
Abstract
Recently, neuroimaging technologies have been developed as important methods for assessing the brain condition of patients with disorders of consciousness (DOC). Among these technologies, resting-state electroencephalography (EEG) recording and analysis has been widely applied by clinicians due to its relatively low cost and convenience. EEG reflects the electrical activity of the underlying neurons, and it contains information regarding neuronal population oscillations, the information flow pathway, and neural activity networks. Some features derived from EEG signal processing methods have been proposed to describe the electrical features of the brain with DOC. The computation of these features is challenging for clinicians working to comprehend the corresponding physiological meanings and then to put them into clinical applications. This paper reviews studies that analyze spontaneous EEG of DOC, with the purpose of diagnosis, prognosis, and evaluation of brain interventions. It is expected that this review will promote our understanding of the EEG characteristics in DOC.
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Affiliation(s)
- Yang Bai
- Institute of Electrical Engineering, Yanshan University, Qinhuangdao, China
| | - Xiaoyu Xia
- Department of Neurosurgery, PLA Army General Hospital, Beijing, China
| | - Xiaoli Li
- State Key Laboratory of Cognitive Neuroscience and Learning, IDG/McGovern Institute for Brain Research, Beijing Normal University, Beijing, China
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