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Zhi N, Sun N, Huang P, Yang LY, Guo CX, Xiong J, Liu YW, Zhang H. Acupuncture-assisted therapy for prolonged disorders of consciousness: study protocol for a randomized, conventional-controlled, assessor-and-statistician-blinded trial. Front Neurol 2024; 15:1334483. [PMID: 39291097 PMCID: PMC11407111 DOI: 10.3389/fneur.2024.1334483] [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: 11/07/2023] [Accepted: 07/18/2024] [Indexed: 09/19/2024] Open
Abstract
Background Acupuncture is a promising non-pharmaceutical complementary therapy in treating prolonged Disorders of consciousness (pDOC), but solid evidence to support its effectiveness and safety is still lacking. Thus, the purpose of this study is to investigate the efficacy and safety of acupuncture-assisted therapy for pDOC patients. Methods A single-center, prospective, randomized, conventional-controlled, assessor-and-statistician-blinded trial has been designed and is being conducted at West China Hospital of Sichuan University. A total of 110 participants will be randomly assigned to the experimental group and the control group in a 1:1 allocation ratio and evaluated using Coma Recovery Scale-Revised (CRS-R) at 8 a.m., 12 p.m., and 4 p.m. on 2 consecutive days before enrollment to determine the consciousness level. The experimental group will receive acupuncture combined with conventional treatment, while the control group will receive only conventional treatment during the trial observation period. The treatment duration of both groups will be 20 days. Among them, the frequency of acupuncture-assisted therapy is once a day, with 10 consecutive sessions followed by a day's rest for a total of 24 days. Data will be collected separately during baseline and after the final treatment. For data analysis, both Full Analysis Set (FAS) and Per Protocol Set (PPS) principles will be performed together by applying SPSS 27.0 software. The primary outcome measures are the changes of CRS-R before and after treatment, while the secondary outcome measures are the changes of Full Outline of Unresponsiveness Scale (FOUR), the changes of Nociception Coma Scale-Revised (NCS-R), the changes of Disability Rating Scale (DRS), the changes of Mismatch Negativity (MMN) and P300 before and after treatment, respectively. Discussion This trial aims to rationally assess the consciousness level from multiple 2 perspectives through subjective evaluation and objective detection by selecting several standardized clinical scales combined with Event-Related Potential (ERP) detection technology. In this way, we will be able to reduce the subjectivity of consciousness assessment and objectively evaluate the clinical efficacy of acupuncture-assisted therapy for pDOC. The study, if proven to be effective and safe enough, will provide a favorable evidence to guide medical decision-making choices and future researches. Clinical trial registration https://www.chictr.org.cn/, identifier ChiCTR2300076180.
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Affiliation(s)
- Na Zhi
- Acupuncture and Tuina School, Chengdu University of Traditional Chinese Medicine, Chengdu, Sichuan, China
| | - Ning Sun
- Rehabilitation Medicine Center and Institute of Rehabilitation Medicine, West China Hospital, Sichuan University, Chengdu, China
| | - Pan Huang
- Acupuncture and Tuina School, Chengdu University of Traditional Chinese Medicine, Chengdu, Sichuan, China
| | - Li-Yuan Yang
- Acupuncture and Tuina School, Chengdu University of Traditional Chinese Medicine, Chengdu, Sichuan, China
| | - Cai-Xia Guo
- Acupuncture and Tuina School, Chengdu University of Traditional Chinese Medicine, Chengdu, Sichuan, China
| | - Jing Xiong
- Rehabilitation Medicine Department, West China Tianfu Hospital, Sichuan University, Chengdu, China
| | - Yi-Wei Liu
- Rehabilitation Medicine Center and Institute of Rehabilitation Medicine, West China Hospital, Sichuan University, Chengdu, China
| | - Hong Zhang
- Acupuncture and Tuina School, Chengdu University of Traditional Chinese Medicine, Chengdu, Sichuan, China
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Dhadwal N, Cunningham K, Pino W, Hampton S, Fischer D. Altered Mental Status at the Extreme: Behavioral Evaluation of Disorders of Consciousness. Semin Neurol 2024. [PMID: 39102862 DOI: 10.1055/s-0044-1788807] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/07/2024]
Abstract
Disorders of consciousness represent altered mental status at its most severe, comprising a continuum between coma, the vegetative state/unresponsive wakefulness syndrome, the minimally conscious state, and emergence from the minimally conscious state. Patients often transition between these levels throughout their recovery, and determining a patient's current level can be challenging, particularly in the acute care setting. Although healthcare providers have classically relied on a bedside neurological exam or the Glasgow Coma Scale to aid with assessment of consciousness, studies have identified multiple limitations of doing so. Neurobehavioral assessment measures, such as the Coma Recovery Scale-Revised, have been developed to address these shortcomings. Each behavioral metric has strengths as well as weaknesses when applied in the acute care setting. In this review, we appraise common assessment approaches, outline alternative measures for fine-tuning these assessments in the acute care setting, and highlight strategies for implementing these practices in an interdisciplinary manner.
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Affiliation(s)
- Neha Dhadwal
- Department of Physical Medicine and Rehabilitation, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Kyle Cunningham
- Good Shepherd Penn Partners at the Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - William Pino
- Good Shepherd Penn Partners at the Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Stephen Hampton
- Department of Physical Medicine and Rehabilitation, University of Pennsylvania, Philadelphia, Pennsylvania
| | - David Fischer
- Department of Neurology, University of Pennsylvania, Philadelphia, Pennsylvania
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Moretta P, Femiano C, Cavallo ND, Lanzillo A, Luciano F, Ferrante C, Maiorino A, Santangelo G, Marcuccio L. Family caregivers improve the diagnostic accuracy of disorders of consciousness: from remote to near-bed auditory stimulation. Eur J Phys Rehabil Med 2024; 60:198-206. [PMID: 38381451 PMCID: PMC11114155 DOI: 10.23736/s1973-9087.24.08179-6] [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: 08/07/2023] [Revised: 10/20/2023] [Accepted: 01/17/2024] [Indexed: 02/22/2024]
Abstract
BACKGROUND Family caregivers (FC) contribute to reducing the misdiagnosis rate in patients with disorders of consciousness (DOC). Unfortunately, the recent pandemic of COVID-19 imposed drastic restrictions that limited the access of FC to the sensory/cognitive stimulation protocols. Telemedicine approaches have been implemented to avoid discontinuity in care pathways and to ensure caregivers involvement in rehabilitation programs. AIM The aim was to investigate whether the presence of FC remotely connected might help clinicians in eliciting higher cortically mediated behavioral responses in patients with DOC. DESIGN Cross-sectional study. SETTING Post-acute Unit of Neurorehabilitation. POPULATION DOC due to severe brain injury. METHODS Consecutive patients with DOC were assessed by means of the Coma Recovery Scale-Revised (CRS-R) by two expert examiners. Each patient underwent to five assessments in two weeks in three different conditions: 1) by the examiner only (standard); 2) with the verbal stimulation given by the FC remotely connected by PC tablet (caregiver in remote); and 3) with the verbal stimulation given by the FC physically present (caregiver in presence). RESULTS Thirty patients with DOC (VS/UWS=10; MCS=20; mean age: 51, range: 21-79; vascular: 16; anoxic: 6; TBI=8) and their FC were enrolled. Higher total scores of CRS-R were recorded both in "caregiver in remote" and in "caregiver in presence" than in standard condition (standard vs. remote, Z=2.942, P=0.003; standard vs. presence, Z=3.736, P<0.001). Furthermore, the administration of the CRS-R with a FC, elicited higher levels of behavioral responses in MCS patients, than CRS-R performed in standard condition. In particular, 2 patients out of 30 (6.66%) showed higher scores and better diagnosis when the CRS-R was administered with FC in remote. Similarly, 5 out of 30 patients (16.66%) showed better diagnoses when the CRS-R was administered with FC in presence. Five patients changed diagnosis between standard and presence conditions (3 MCS- were diagnosed as MCS+; 2 MCS+ were diagnosed as conscious). CONCLUSIONS Our findings add new evidence regarding the beneficial role of family members in the diagnosis of DOC, even mediated by telemedicine approach. CLINICAL REHABILITATION IMPACT In future guidelines, FC should have an active and supporting role in the diagnostic and rehabilitative process of DOC.
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Affiliation(s)
- Pasquale Moretta
- Istituti Clinici Scientifici Maugeri IRCCS, Neurological Rehabilitation Unit of Telese Terme, Telese Terme, Benevento, Italy -
| | - Cinzia Femiano
- Istituti Clinici Scientifici Maugeri IRCCS, Neurological Rehabilitation Unit of Telese Terme, Telese Terme, Benevento, Italy
| | - Nicola D Cavallo
- Department of Psychology, Luigi Vanvitelli University of Campania, Caserta, Italy
| | - Anna Lanzillo
- Istituti Clinici Scientifici Maugeri IRCCS, Neurological Rehabilitation Unit of Telese Terme, Telese Terme, Benevento, Italy
| | - Fabrizio Luciano
- Istituti Clinici Scientifici Maugeri IRCCS, Neurological Rehabilitation Unit of Telese Terme, Telese Terme, Benevento, Italy
| | - Cesario Ferrante
- Istituti Clinici Scientifici Maugeri IRCCS, Neurological Rehabilitation Unit of Telese Terme, Telese Terme, Benevento, Italy
| | - Antonio Maiorino
- Istituti Clinici Scientifici Maugeri IRCCS, Neurological Rehabilitation Unit of Telese Terme, Telese Terme, Benevento, Italy
| | - Gabriella Santangelo
- Department of Psychology, Luigi Vanvitelli University of Campania, Caserta, Italy
| | - Laura Marcuccio
- Istituti Clinici Scientifici Maugeri IRCCS, Neurological Rehabilitation Unit of Telese Terme, Telese Terme, Benevento, Italy
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Campagnini S, Llorens R, Navarro MD, Colomer C, Mannini A, Estraneo A, Ferri J, Noé E. Which information derived from the Coma Recovery Scale-Revised provides the most reliable prediction of clinical diagnosis and recovery of consciousness? A comparative study using machine learning techniques. Eur J Phys Rehabil Med 2024; 60:190-197. [PMID: 38193722 PMCID: PMC11114154 DOI: 10.23736/s1973-9087.23.08093-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2023] [Revised: 11/09/2023] [Accepted: 11/29/2023] [Indexed: 01/10/2024]
Abstract
BACKGROUND The Coma Recovery Scale-Revised (CRS-R) is the most recommended clinical tool to examine the neurobehavioral condition of individuals with disorders of consciousness (DOCs). Different studies have investigated the prognostic value of the information provided by the conventional administration of the scale, while other measures derived from the scale have been proposed to improve the prognosis of DOCs. However, the heterogeneity of the data used in the different studies prevents a reliable comparison of the identified predictors and measures. AIM This study investigates which information derived from the CRS-R provides the most reliable prediction of both the clinical diagnosis and recovery of consciousness at the discharge of a long-term neurorehabilitation program. DESIGN Retrospective observational multisite study. SETTING The enrollment was performed in three neurorehabilitation facilities of the same hospital network. POPULATION A total of 171 individuals with DOCs admitted to an inpatient neurorehabilitation program for a minimum of 3 months were enrolled. METHODS Machine learning classifiers were trained to predict the clinical diagnosis and recovery of consciousness at discharge using clinical confounders and different metrics extracted from the CRS-R scale. RESULTS Results showed that the neurobehavioral state at discharge was predicted with acceptable and comparable predictive value with all the indices and measures derived from the CRS-R, but for the clinical diagnosis and the Consciousness Domain Index, and the recovery of consciousness was predicted with higher accuracy and similarly by all the investigated measures, with the exception of initial clinical diagnosis. CONCLUSIONS Interestingly, the total score in the CRS-R and, especially, the total score in its subscales provided the best overall results, in contrast to the clinical diagnosis, which could indicate that a comprehensive measure of the clinical diagnosis rather than the condition of the individuals could provide a more reliable prediction of the neurobehavioral progress of individuals with prolonged DOC. CLINICAL REHABILITATION IMPACT The results of this work have important implications in clinical practice, offering a more accurate prognosis of patients and thus giving the possibility to personalize and optimize the rehabilitation plan of patients with DoC using low-cost and easily collectable information.
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Affiliation(s)
| | - Roberto Llorens
- Neurorehabilitation and Brain Research Group, Institute for Human-Centered Technology Research, Polytechnic University of Valencia, Valencia, Spain -
| | - M Dolores Navarro
- IRENEA Instituto de Rehabilitación Neurológica, Vithas Foundation, Valencia, Spain
| | - Carolina Colomer
- IRENEA Instituto de Rehabilitación Neurológica, Vithas Foundation, Valencia, Spain
| | - Andrea Mannini
- IRCCS Fondazione Don Carlo Gnocchi onlus, Florence, Italy
| | - Anna Estraneo
- IRCCS Fondazione Don Carlo Gnocchi onlus, Florence, Italy
| | - Joan Ferri
- IRENEA Instituto de Rehabilitación Neurológica, Vithas Foundation, Valencia, Spain
| | - Enrique Noé
- IRENEA Instituto de Rehabilitación Neurológica, Vithas Foundation, Valencia, Spain
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Liuzzi P, Mannini A, Hakiki B, Campagnini S, Romoli AM, Draghi F, Burali R, Scarpino M, Cecchi F, Grippo A. Brain microstate spatio-temporal dynamics as a candidate endotype of consciousness. Neuroimage Clin 2023; 41:103540. [PMID: 38101096 PMCID: PMC10727951 DOI: 10.1016/j.nicl.2023.103540] [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: 05/18/2023] [Revised: 10/02/2023] [Accepted: 11/09/2023] [Indexed: 12/17/2023]
Abstract
Consciousness can be defined as a phenomenological experience continuously evolving. Current research showed how conscious mental activity can be subdivided into a series of atomic brain states converging to a discrete spatiotemporal pattern of global neuronal firing. Using the high temporal resolution of EEG recordings in patients with a severe Acquired Brain Injury (sABI) admitted to an Intensive Rehabilitation Unit (IRU), we detected a novel endotype of consciousness from the spatiotemporal brain dynamics identified via microstate analysis. Also, we investigated whether microstate features were associated with common neurophysiological alterations. Finally, the prognostic information comprised in such descriptors was analysed in a sub-cohort of patients with prolonged Disorder of Consciousness (pDoC). Occurrence of frontally-oriented microstates (C microstate), likelihood of maintaining such brain state or transitioning to the C topography and complexity were found to be indicators of consciousness presence and levels. Features of left-right asymmetric microstates and transitions toward them were found to be negatively correlated with antero-posterior brain reorganization and EEG symmetry. Substantial differences in microstates' sequence complexity and presence of C topography were found between groups of patients with alpha dominant background, cortical reactivity and antero-posterior gradient. Also, transitioning from left-right to antero-posterior microstates was found to be an independent predictor of consciousness recovery, stronger than consciousness levels at IRU's admission. In conclusions, global brain dynamics measured with scale-free estimators can be considered an indicator of consciousness presence and a candidate marker of short-term recovery in patients with a pDoC.
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Affiliation(s)
- Piergiuseppe Liuzzi
- IRCCS Don Carlo Gnocchi ONLUS, Firenze, Italy; Istituto di BioRobotica, Scuola Superiore Sant'Anna, Pontedera, Italy
| | | | | | | | | | | | | | | | - Francesca Cecchi
- IRCCS Don Carlo Gnocchi ONLUS, Firenze, Italy; Dipartimento di Medicina Sperimentale e Clinica, Università di Firenze, Firenze, Italy
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Wang J, Gao X, Xiang Z, Sun F, Yang Y. Evaluation of consciousness rehabilitation via neuroimaging methods. Front Hum Neurosci 2023; 17:1233499. [PMID: 37780959 PMCID: PMC10537959 DOI: 10.3389/fnhum.2023.1233499] [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: 06/02/2023] [Accepted: 08/30/2023] [Indexed: 10/03/2023] Open
Abstract
Accurate evaluation of patients with disorders of consciousness (DoC) is crucial for personalized treatment. However, misdiagnosis remains a serious issue. Neuroimaging methods could observe the conscious activity in patients who have no evidence of consciousness in behavior, and provide objective and quantitative indexes to assist doctors in their diagnosis. In the review, we discussed the current research based on the evaluation of consciousness rehabilitation after DoC using EEG, fMRI, PET, and fNIRS, as well as the advantages and limitations of each method. Nowadays single-modal neuroimaging can no longer meet the researchers` demand. Considering both spatial and temporal resolution, recent studies have attempted to focus on the multi-modal method which can enhance the capability of neuroimaging methods in the evaluation of DoC. As neuroimaging devices become wireless, integrated, and portable, multi-modal neuroimaging methods will drive new advancements in brain science research.
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Affiliation(s)
| | | | | | - Fangfang Sun
- College of Automation, Hangzhou Dianzi University, Hangzhou, China
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Lindenbaum L, Steppacher I, Mehlmann A, Kissler JM. The effect of neural pre-stimulus oscillations on post-stimulus somatosensory event-related potentials in disorders of consciousness. Front Neurosci 2023; 17:1179228. [PMID: 37360157 PMCID: PMC10287968 DOI: 10.3389/fnins.2023.1179228] [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: 03/03/2023] [Accepted: 05/22/2023] [Indexed: 06/28/2023] Open
Abstract
Brain activity of people in a disorder of consciousness (DoC) is diffuse and different from healthy people. In order to get a better understanding of their cognitive processes and functions, electroencephalographic activity has often been examined in patients with DoC, including detection of event-related potentials (ERPs) and spectral power analysis. However, the relationship between pre-stimulus oscillations and post-stimulus ERPs has rarely been explored in DoC, although it is known from healthy participants that pre-stimulus oscillations predispose subsequent stimulus detection. Here, we examine to what extent pre-stimulus electroencephalography band power in DoC relates to post-stimulus ERPs in a similar way as previously documented in healthy people. 14 DoC patients in an unresponsive wakefulness syndrome (UWS, N = 2) or a minimally conscious state (MCS, N = 12) participated in this study. In an active oddball paradigm patients received vibrotactile stimuli. Significant post-stimulus differences between brain responses to deviant and standard stimulation could be found in six MCS patients (42.86%). Regarding relative pre-stimulus frequency bands, delta oscillations predominated in most patients, followed by theta and alpha, although two patients showed a relatively normal power spectrum. The statistical analysis of the relationship between pre-stimulus power and post-stimulus event-related brain response showed multiple significant correlations in five out of the six patients. Individual results sometimes showed similar correlation patterns as in healthy subjects primarily between the relative pre-stimulus alpha power and post-stimulus variables in later time-intervals. However, opposite effects were also found, indicating high inter-individual variability in DoC patients´ functional brain activity. Future studies should determine on an individual level to what extent the relationship between pre- and post-stimulus brain activity could relate to the course of the disorder.
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Affiliation(s)
- Laura Lindenbaum
- Department of Psychology, Bielefeld University, Bielefeld, Germany
- Center for Cognitive Interaction Technology (CITEC), Bielefeld University, Bielefeld, Germany
| | - Inga Steppacher
- Department of Psychology, Bielefeld University, Bielefeld, Germany
| | | | - Johanna Maria Kissler
- Department of Psychology, Bielefeld University, Bielefeld, Germany
- Center for Cognitive Interaction Technology (CITEC), Bielefeld University, Bielefeld, Germany
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Liuzzi P, Campagnini S, Hakiki B, Burali R, Scarpino M, Macchi C, Cecchi F, Mannini A, Grippo A. Heart rate variability for the evaluation of patients with disorders of consciousness. Clin Neurophysiol 2023; 150:31-39. [PMID: 37002978 DOI: 10.1016/j.clinph.2023.03.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2022] [Revised: 12/12/2022] [Accepted: 03/03/2023] [Indexed: 04/03/2023]
Abstract
OBJECTIVE Clinical responsiveness of patients with a Disorder of Consciousness (DoC) correlates to sympathetic/parasympathetic homeostatic balance. Heart Rate Variability (HRV) metrics result in non-invasive proxies of modulation capabilities of visceral states. In this work, our aim was to evaluate whether HRV measures could improve the differential diagnosis between Unresponsive Wakefulness Syndrome (UWS) and Minimally Conscious State (MCS) with respect to multivariate models based on standard clinical electroencephalography (EEG) labeling only in a rehabilitation setting. METHODS A prospective observational study was performed consecutively enrolling 82 DoC patients. Polygraphic recordings were performed. HRV-metrics and EEG descriptors derived from the American Clinical Neurophysiology Society's Standardized Critical Care terminology were included. Descriptors entered univariate and then multivariate logistic regressions with the target set to the UWS/MCS diagnosis. RESULTS HRV measures resulted significantly different between UWS and MCS patients, with higher values being associated with better consciousness levels. Specifically, adding HRV-related metrics to ACNS EEG descriptors increased the Nagelkerke R2 from 0.350 (only EEG descriptors) to 0.565 (HRV-EEG combination) with the outcome set to the consciousness diagnosis. CONCLUSIONS HRV changes across the lowest states of consciousness. Rapid changes in heart rate, occurring in better consciousness levels, confirm the mutual correlation between visceral state functioning patterns and consciousness alterations. SIGNIFICANCE Quantitative analysis of heart rate in patients with a DoC paves the way for the implementation of low-cost pipelines supporting medical decisions within multimodal consciousness assessments.
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Affiliation(s)
- Piergiuseppe Liuzzi
- IRCCS Fondazione Don Carlo Gnocchi, Firenze, Via di Scandicci 269, Italy; Scuola Superiore Sant'Anna, Istituto di BioRobotica, Pontedera, Viale Rinaldo Piaggio 34, Italy
| | - Silvia Campagnini
- IRCCS Fondazione Don Carlo Gnocchi, Firenze, Via di Scandicci 269, Italy; Scuola Superiore Sant'Anna, Istituto di BioRobotica, Pontedera, Viale Rinaldo Piaggio 34, Italy
| | - Bahia Hakiki
- IRCCS Fondazione Don Carlo Gnocchi, Firenze, Via di Scandicci 269, Italy.
| | - Rachele Burali
- IRCCS Fondazione Don Carlo Gnocchi, Firenze, Via di Scandicci 269, Italy
| | - Maenia Scarpino
- IRCCS Fondazione Don Carlo Gnocchi, Firenze, Via di Scandicci 269, Italy
| | - Claudio Macchi
- IRCCS Fondazione Don Carlo Gnocchi, Firenze, Via di Scandicci 269, Italy; Università di Firenze, Dipartimento di Medicina Sperimentale e Clinica, Firenze, Largo Brambilla 3, Italy
| | - Francesca Cecchi
- IRCCS Fondazione Don Carlo Gnocchi, Firenze, Via di Scandicci 269, Italy; Università di Firenze, Dipartimento di Medicina Sperimentale e Clinica, Firenze, Largo Brambilla 3, Italy
| | - Andrea Mannini
- IRCCS Fondazione Don Carlo Gnocchi, Firenze, Via di Scandicci 269, Italy
| | - Antonello Grippo
- IRCCS Fondazione Don Carlo Gnocchi, Firenze, Via di Scandicci 269, Italy
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Chen H, Miao G, Wang S, Zheng J, Zhang X, Lin J, Hao C, Huang H, Jiang T, Gong Y, Liao W. Disturbed functional connectivity and topological properties of the frontal lobe in minimally conscious state based on resting-state fNIRS. Front Neurosci 2023; 17:1118395. [PMID: 36845431 PMCID: PMC9950516 DOI: 10.3389/fnins.2023.1118395] [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: 12/07/2022] [Accepted: 01/30/2023] [Indexed: 02/12/2023] Open
Abstract
Background Patients in minimally conscious state (MCS) exist measurable evidence of consciousness. The frontal lobe is a crucial part of the brain that encodes abstract information and is closely related to the conscious state. We hypothesized that the disturbance of the frontal functional network exists in MCS patients. Methods We collected the resting-state functional near-infrared spectroscopy (fNIRS) data of fifteen MCS patients and sixteen age- and gender-matched healthy controls (HC). The Coma Recovery Scale-Revised (CRS-R) scale of MCS patients was also composed. The topology of the frontal functional network was analyzed in two groups. Results Compared with HC, the MCS patients showed widely disrupted functional connectivity in the frontal lobe, especially in the frontopolar area and right dorsolateral prefrontal cortex. Moreover, the MCS patients displayed lower clustering coefficient, global efficiency, local efficiency, and higher characteristic path length. In addition, the nodal clustering coefficient and nodal local efficiency in the left frontopolar area and right dorsolateral prefrontal cortex were significantly reduced in MCS patients. Furthermore, the nodal clustering coefficient and nodal local efficiency in the right dorsolateral prefrontal cortex were positively correlated to auditory subscale scores. Conclusion This study reveals that MCS patients' frontal functional network is synergistically dysfunctional. And the balance between information separation and integration in the frontal lobe is broken, especially the local information transmission in the prefrontal cortex. These findings help us to understand the pathological mechanism of MCS patients better.
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Affiliation(s)
| | | | - Sirui Wang
- Department of Rehabilitation Medicine, Zhongnan Hospital of Wuhan University, Wuhan, Hubei, China
| | - Jun Zheng
- Department of Rehabilitation Medicine, Zhongnan Hospital of Wuhan University, Wuhan, Hubei, China
| | - Xin Zhang
- Department of Rehabilitation Medicine, Zhongnan Hospital of Wuhan University, Wuhan, Hubei, China
| | - Junbin Lin
- Department of Rehabilitation Medicine, Zhongnan Hospital of Wuhan University, Wuhan, Hubei, China
| | - Chizi Hao
- Department of Rehabilitation Medicine, Zhongnan Hospital of Wuhan University, Wuhan, Hubei, China
| | - Hailong Huang
- Department of Rehabilitation Medicine, Zhongnan Hospital of Wuhan University, Wuhan, Hubei, China
| | - Ting Jiang
- Department of Rehabilitation Medicine, Zhongnan Hospital of Wuhan University, Wuhan, Hubei, China
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Corsi L, Liuzzi P, Ballanti S, Scarpino M, Maiorelli A, Sterpu R, Macchi C, Cecchi F, Hakiki B, Grippo A, Lanatà A, Carrozza MC, Bocchi L, Mannini A. EEG asymmetry detection in patients with severe acquired brain injuries via machine learning methods. Biomed Signal Process Control 2023. [DOI: 10.1016/j.bspc.2022.104260] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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Zheng R, Qi Z, Thibaut A, Wang Z, Xu Z, Di H, Wu X, Mao Y, Laureys S. Clinical application of neuromodulation therapy in patients with disorder of consciousness: A pooled analysis of 544 participants. NeuroRehabilitation 2023; 53:491-503. [PMID: 37927281 DOI: 10.3233/nre-230103] [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: 11/07/2023]
Abstract
BACKGROUND The number of patients with disorders of consciousness (DoC) has increased dramatically with the advancement of intensive care and emergency medicine, which brings tremendous economic burdens and even ethical issues to families and society. OBJECTIVE To evaluate the effectiveness of neuromodulation therapy for patients with DoC. METHODS First, we conducted a literature review of individual patient data (IPD) on PubMed, EMBASE, and Cochrane-controlled trials following PRISMA guidelines. Then, we collected neuromodulation cases from our institution. Finally, we conducted a pooled analysis using the participants from the medical literature (n = 522) and our local institutions (n = 22). RESULTS In this pooled analysis of 544 patients with DoC with a mean age of 46.33 years, our results revealed that patients have improved CRS-R scores [1.0 points (95% CI, 0.57-1.42)] after neuromodulation. Among them, patients have better effectiveness in traumatic than non-traumatic etiology (P < 0.05). The effectiveness of consciousness improvement could be affected by the age, baseline consciousness state, and duration of stimulation. Compared with non-invasive intervention, an invasive intervention can bring more behavioral improvement (P < 0.0001) to MCS rather than UWS/VS patients. Importantly, neuromodulation is a valuable therapy even years after the onset of DoC. CONCLUSION This pooled analysis spotlights that the application of neuromodulation can improve the behavioral performance of patients with DoC. A preliminary trend is that age, etiology, baseline consciousness state, and stimulation duration could impact its effectiveness.
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Affiliation(s)
- Ruizhe Zheng
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China
- National Center for Neurological Disorders, Shanghai, China
- Shanghai Key Laboratory of Brain Function Restoration and Neural Regeneration, Shanghai, China
- Neurosurgical Institute of Fudan University, Shanghai, China
- Shanghai Clinical Medical Center of Neurosurgery, Shanghai, China
- School of Basic Medical Sciences, Institutes of Brain Science, State Key Laboratory of Medical Neurobiology and Ministry of Education's (MOE) Frontiers Center for Brain Science, Fudan University, Shanghai, China
| | - Zengxin Qi
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China
- National Center for Neurological Disorders, Shanghai, China
- Shanghai Key Laboratory of Brain Function Restoration and Neural Regeneration, Shanghai, China
- Neurosurgical Institute of Fudan University, Shanghai, China
- Shanghai Clinical Medical Center of Neurosurgery, Shanghai, China
- School of Basic Medical Sciences, Institutes of Brain Science, State Key Laboratory of Medical Neurobiology and Ministry of Education's (MOE) Frontiers Center for Brain Science, Fudan University, Shanghai, China
| | - Aurore Thibaut
- GIGA Consciousness Research Unit, Coma Science Group, Liège University, Liège, Belgium
- GIGA Consciousness, Centre du Cerveau, Liège University Hospital, Liège, Belgium
| | - Zhe Wang
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China
- National Center for Neurological Disorders, Shanghai, China
- Shanghai Key Laboratory of Brain Function Restoration and Neural Regeneration, Shanghai, China
- Neurosurgical Institute of Fudan University, Shanghai, China
- Shanghai Clinical Medical Center of Neurosurgery, Shanghai, China
- School of Basic Medical Sciences, Institutes of Brain Science, State Key Laboratory of Medical Neurobiology and Ministry of Education's (MOE) Frontiers Center for Brain Science, Fudan University, Shanghai, China
| | - Zeyu Xu
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China
- National Center for Neurological Disorders, Shanghai, China
- Shanghai Key Laboratory of Brain Function Restoration and Neural Regeneration, Shanghai, China
- Neurosurgical Institute of Fudan University, Shanghai, China
- Shanghai Clinical Medical Center of Neurosurgery, Shanghai, China
- School of Basic Medical Sciences, Institutes of Brain Science, State Key Laboratory of Medical Neurobiology and Ministry of Education's (MOE) Frontiers Center for Brain Science, Fudan University, Shanghai, China
| | - Haibo Di
- International Consciousness Science Institute, Hangzhou Normal University, Hangzhou, China
| | - Xuehai Wu
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China
- National Center for Neurological Disorders, Shanghai, China
- Shanghai Key Laboratory of Brain Function Restoration and Neural Regeneration, Shanghai, China
- Neurosurgical Institute of Fudan University, Shanghai, China
- Shanghai Clinical Medical Center of Neurosurgery, Shanghai, China
- School of Basic Medical Sciences, Institutes of Brain Science, State Key Laboratory of Medical Neurobiology and Ministry of Education's (MOE) Frontiers Center for Brain Science, Fudan University, Shanghai, China
| | - Ying Mao
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China
- National Center for Neurological Disorders, Shanghai, China
- Shanghai Key Laboratory of Brain Function Restoration and Neural Regeneration, Shanghai, China
- Neurosurgical Institute of Fudan University, Shanghai, China
- Shanghai Clinical Medical Center of Neurosurgery, Shanghai, China
- School of Basic Medical Sciences, Institutes of Brain Science, State Key Laboratory of Medical Neurobiology and Ministry of Education's (MOE) Frontiers Center for Brain Science, Fudan University, Shanghai, China
| | - Steven Laureys
- GIGA Consciousness Research Unit, Coma Science Group, Liège University, Liège, Belgium
- GIGA Consciousness, Centre du Cerveau, Liège University Hospital, Liège, Belgium
- International Consciousness Science Institute, Hangzhou Normal University, Hangzhou, China
- Joint International Research Unit on Consciousness, CERVO Brain Research Centre, Laval University, Quebec, QC, Canada
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12
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Hakiki B, Liuzzi P, Pansini G, Pancani S, Romoli A, Draghi F, Orlandini S, Mannini A, Della Puppa A, Macchi C, Cecchi F. Impact of decompressive craniectomy on functional outcome of severe acquired brain injuries patients, at discharge from intensive inpatient rehabilitation. Disabil Rehabil 2022; 44:8375-8381. [PMID: 34928755 DOI: 10.1080/09638288.2021.2015461] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
PURPOSE Decompressive craniectomy (DC) is a life-saving procedure conducted to treat refractory intracranial hypertension. Although DC reduces mortality of severe Acquired Brain Injury (sABI) survivors, it has been associated with severe long-term disability. This observational study compares functional outcomes at discharge from an Intensive Rehabilitative Unit (IRU) between sABI patients with and without DC. MATERIAL AND METHODS sABI patients undergoing DC before entering the Don Gnocchi Foundation IRU were compared with a group of sABI patients who did not undergo DC (No-DC group), after matching it by age, sex, aetiology, time post-onset, and clinical status. Inclusion criteria were: diagnosis of sABI, age 18+, time from the event <90 days. RESULTS A total of 87 (DC: 47) patients were included (median age: 60.5 [IQR = 17.47]). The two groups did not differ for admission clinical features except for the tracheostomy presence (more frequent in DC, p < 0.001). No significant differences were also found at discharge. DC group presented a significantly longer length-of-stay than No-DC group (p < 0.001) and a longer time to tracheostomy removal (p = 0.036). DC was not found to influence outcomes as consciousness improvement, tracheostomy removal, oral intake and functional independence. CONCLUSIONS sABI patients with DC improved after rehabilitation as much as No-DC patients did but they required a longer stay.Implications for RehabilitationDecompressive craniectomy (DC) is practiced during the acute phase after hemorrhagic, ischemic, traumatic severe brain injury as a life-saving procedure to treat refractory intracranial hypertensionDC has been associated with follow-up severe long-term disability, but no study yet addressed whether DC may affect intensive rehabilitation outcomes.Undergoing a DC is not a negative prognostic factor for achieving rehabilitation goals after a severe acquired brain injuryDC must be taken into account when customizing rehabilitation pathway especially because these patients required a longer time to reach the outcomes.
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Affiliation(s)
- Bahia Hakiki
- IRCCS Fondazione Don Carlo Gnocchi-ONLUS, Via di Scandicci 269, Florence (Fi), Italy
| | - Piergiuseppe Liuzzi
- IRCCS Fondazione Don Carlo Gnocchi-ONLUS, Via di Scandicci 269, Florence (Fi), Italy.,The BioRobotics Institute, Scuola Superiore Sant'Anna, Viale Rinaldo Piaggio 34, Pontedera (Pi), Italy
| | - Gastone Pansini
- Neurosurgery Unit, Azienda Ospedaliera Universitaria Careggi, Largo Giovanni Alessandro Brambilla 3, Firenze (Fi), Italy
| | - Silvia Pancani
- IRCCS Fondazione Don Carlo Gnocchi-ONLUS, Via di Scandicci 269, Florence (Fi), Italy
| | - Annamaria Romoli
- IRCCS Fondazione Don Carlo Gnocchi-ONLUS, Via di Scandicci 269, Florence (Fi), Italy
| | - Francesca Draghi
- IRCCS Fondazione Don Carlo Gnocchi-ONLUS, Via di Scandicci 269, Florence (Fi), Italy
| | - Simone Orlandini
- Neurosurgery Unit, Azienda Ospedaliera Universitaria Careggi, Largo Giovanni Alessandro Brambilla 3, Firenze (Fi), Italy
| | - Andrea Mannini
- IRCCS Fondazione Don Carlo Gnocchi-ONLUS, Via di Scandicci 269, Florence (Fi), Italy.,The BioRobotics Institute, Scuola Superiore Sant'Anna, Viale Rinaldo Piaggio 34, Pontedera (Pi), Italy
| | - Alessandro Della Puppa
- Neurosurgery Unit, Azienda Ospedaliera Universitaria Careggi, Largo Giovanni Alessandro Brambilla 3, Firenze (Fi), Italy
| | - Claudio Macchi
- IRCCS Fondazione Don Carlo Gnocchi-ONLUS, Via di Scandicci 269, Florence (Fi), Italy.,Department of Experimental and Clinical Medicine, Università di Firenze, Largo Giovanni Alessandro Brambilla 3, Firenze (Fi), Italy
| | - Francesca Cecchi
- IRCCS Fondazione Don Carlo Gnocchi-ONLUS, Via di Scandicci 269, Florence (Fi), Italy.,Department of Experimental and Clinical Medicine, Università di Firenze, Largo Giovanni Alessandro Brambilla 3, Firenze (Fi), Italy
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13
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Functional Connectivity Increases in Response to High-Definition Transcranial Direct Current Stimulation in Patients with Chronic Disorder of Consciousness. Brain Sci 2022; 12:brainsci12081095. [PMID: 36009158 PMCID: PMC9405975 DOI: 10.3390/brainsci12081095] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2022] [Revised: 08/10/2022] [Accepted: 08/16/2022] [Indexed: 11/17/2022] Open
Abstract
Highlights Functional connectivity induced by HD-tDCS in DLPFC has different trends in CRS-R score improvers and non-improvers. An increase in theta PLV in the left frontal–parietooccipital region was significantly associated with CRS-R changes. DOC patients with increased PLV of the alpha band in the intra-bifrontal region have a better prognosis than those without.
Abstract High-definition transcranial direct current stimulation (HD-tDCS) has been shown to play an important role in improving consciousness in patients with disorders of consciousness (DOCs), but its neuroelectrophysiological evidence is still lacking. To better explain the electrophysiological mechanisms of the effects of HD-tDCS on patients with DOCs, 22 DOC patients underwent 10 anodal HD-tDCS sessions of the left dorsolateral prefrontal cortex (DLPFC). This study used the Coma Recovery Scale-Revised (CRS-R) to assess the level of consciousness in DOC patients. According to whether the CRS-R score increased before and after stimulation, DOC patients were divided into a responsive group and a non-responsive group. By comparing the differences in resting-state EEG functional connectivity between different frequency bands and brain regions, as well as the relationship between functional connectivity values and clinical scores, the electrophysiological mechanism of the clinical effects of HD-tDCS was further explored. The change of the phase locking value (PLV) on the theta frequency band in the left frontal–parietooccipital region was positively correlated with the change in the CRS-R scores. As the number of interventions increased, we observed that in the responsive group, the change in PLV showed an upward trend, and the increase in the PLV appeared in the left frontal–parietooccipital region at 4–8 Hz and in the intra-bifrontal region at 8–13 Hz. In the non-responsive group, although the CRS-R scores did not change after stimulation, the PLV showed a downward trend, and the decrease in the PLV appeared in the intra-bifrontal region at 8–13 Hz. In addition, at the three-month follow-up, patients with increased PLV in the intra-bifrontal region at 8–13 Hz after repeated HD-tDCS stimulation had better outcomes than those without. Repeated anodal stimulation of the left DLPFC with HD-tDCS resulted in improved consciousness in some patients with DOCs. The increase in functional connectivity in the brain regions may be associated with the improvement of related awareness after HD-tDCS and may be a predictor of better long-term outcomes.
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14
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Magnani FG, Barbadoro F, Cacciatore M, Leonardi M. The importance of instrumental assessment in disorders of consciousness: a comparison between American, European, and UK International recommendations. Crit Care 2022; 26:245. [PMID: 35948933 PMCID: PMC9367125 DOI: 10.1186/s13054-022-04119-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2022] [Accepted: 08/03/2022] [Indexed: 11/23/2022] Open
Abstract
The use of instrumental tools for improving both the diagnostic accuracy and the prognostic soundness in patients with disorders of consciousness (DOC) plays an important role. However, the most recent international guidelines on DOC published by the American and the European Academies of Neurology and by the UK Royal College of Physicians contain heterogeneous recommendations on the implementation of these techniques in the clinical routine for both diagnosis and prognosis. With the present work, starting from the comparison of the DOC guidelines’ recommendations, we look for possible explanations behind such discrepancies considering the adopted methodologies and the reference health systems that could have affected the guidelines’ perspectives. We made a provocative argument about the need to find the most appropriate common methodology to retrieve and grade the evidence, increase the meta-analytic studies, and reduce the health policies that influence on the guidelines development that, in turn, should inform the health policies with the strongest scientific evidence.
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15
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Liuzzi P, Magliacano A, De Bellis F, Mannini A, Estraneo A. Predicting outcome of patients with prolonged disorders of consciousness using machine learning models based on medical complexity. Sci Rep 2022; 12:13471. [PMID: 35931703 PMCID: PMC9356130 DOI: 10.1038/s41598-022-17561-w] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2022] [Accepted: 07/27/2022] [Indexed: 12/25/2022] Open
Abstract
Patients with severe acquired brain injury and prolonged disorders of consciousness (pDoC) are characterized by high clinical complexity and high risk to develop medical complications. The present multi-center longitudinal study aimed at investigating the impact of medical complications on the prediction of clinical outcome by means of machine learning models. Patients with pDoC were consecutively enrolled at admission in 23 intensive neurorehabilitation units (IRU) and followed-up at 6 months from onset via the Glasgow Outcome Scale-Extended (GOSE). Demographic and clinical data at study entry and medical complications developed within 3 months from admission were collected. Machine learning models were developed, targeting neurological outcomes at 6 months from brain injury using data collected at admission. Then, after concatenating predictions of such models to the medical complications collected within 3 months, a cascade model was developed. One hundred seventy six patients with pDoC (M: 123, median age 60.2 years) were included in the analysis. At admission, the best performing solution (k-Nearest Neighbors regression, KNN) resulted in a median validation error of 0.59 points [IQR 0.14] and a classification accuracy of dichotomized GOS-E of 88.6%. Coherently, at 3 months, the best model resulted in a median validation error of 0.49 points [IQR 0.11] and a classification accuracy of 92.6%. Interpreting the admission KNN showed how the negative effect of older age is strengthened when patients' communication levels are high and ameliorated when no communication is present. The model trained at 3 months showed appropriate adaptation of the admission prediction according to the severity of the developed medical complexity in the first 3 months. In this work, we developed and cross-validated an interpretable decision support tool capable of distinguishing patients which will reach sufficient independence levels at 6 months (GOS-E > 4). Furthermore, we provide an updated prediction at 3 months, keeping in consideration the rehabilitative path and the risen medical complexity.
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Affiliation(s)
- Piergiuseppe Liuzzi
- IRCCS Fondazione Don Carlo Gnocchi ONLUS, Via di Scandicci 269, Florence, Italy.,Scuola Superiore Sant'Anna, Istituto di BioRobotica, Viale Rinaldo Piaggio 34, Pontedera, Italy
| | - Alfonso Magliacano
- Fondazione Don Carlo Gnocchi ONLUS, Scientific Institute for Research and Health Care, Via Quadrivio, Sant'Angelo dei Lombardi, Italy
| | - Francesco De Bellis
- Fondazione Don Carlo Gnocchi ONLUS, Scientific Institute for Research and Health Care, Via Quadrivio, Sant'Angelo dei Lombardi, Italy
| | - Andrea Mannini
- IRCCS Fondazione Don Carlo Gnocchi ONLUS, Via di Scandicci 269, Florence, Italy.
| | - Anna Estraneo
- Fondazione Don Carlo Gnocchi ONLUS, Scientific Institute for Research and Health Care, Via Quadrivio, Sant'Angelo dei Lombardi, Italy.,Unità di Neurologia, Santa Maria della Pietà General Hospital, Via della Repubblica 7, Nola, Italy
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16
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Effects of Acupuncture on Cortical Activation in Patients with Disorders of Consciousness: A Functional Near-Infrared Spectroscopy Study. EVIDENCE-BASED COMPLEMENTARY AND ALTERNATIVE MEDICINE 2022; 2022:5711961. [PMID: 35958938 PMCID: PMC9363174 DOI: 10.1155/2022/5711961] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/24/2022] [Revised: 06/12/2022] [Accepted: 06/28/2022] [Indexed: 11/17/2022]
Abstract
Background. Disorder of consciousness (DoC) is a clinical condition caused by severe brain damage. Some studies have reported that acupuncture, a traditional Chinese treatment, could facilitate the recovery of the patient’s consciousness. The therapeutic effects of acupuncture may be due to its modulation of facilitating cortex (PFC) activity, but it has not been greatly demonstrated. Objectives. We intended to observe the effects of acupuncture on prefrontal cortical activity, explore the potential correlation between cortical activation and the severity of DoC, and analyze the functional brain network connectivity to provide a theoretical basis for its application in clinical practice. Methods. Participants diagnosed with DoC were included in the study. Before the intervention, we assessed the patient’s state of consciousness using relevant scales, such as the Glasgow coma scale (GCS) and the coma recovery scale-revised (CRS-R). All patients received acupuncture manipulation with the functional near-infrared spectroscopy (fNIRS) system monitored. Result. A total of 16 subjects participated in our study. We observed that the concentration of oxygenated hemoglobin (HbO) in the PFC was increased during the acupuncture manipulation and declined during the resting state. Then, the connection strength of the left cerebral cortex was generally higher than that of the right. Finally, we observed only a weak difference in hemodynamic responses of PFC between the vegetative state (VS) and minimally conscious state (MCS) groups. However, the difference was not statistically significant. Conclusion. Our results indicated that acupuncture can increase the concentration of HbO in the PFC and strengthen the connection strength of the left cerebral cortex. However, our present study did not find a significant correlation between the cortical hemodynamic response and the severity of DoC.
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17
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Liuzzi P, De Bellis F, Magliacano A, Estraneo A, Mannini A. Consciousness-Domain Index: a data-driven clustering-based consciousness labeling. ANNUAL INTERNATIONAL CONFERENCE OF THE IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. ANNUAL INTERNATIONAL CONFERENCE 2022; 2022:1062-1065. [PMID: 36086422 DOI: 10.1109/embc48229.2022.9871151] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
Assessing consciousness results in one of the most complex neurological diagnosis. Even more complex and uncertain is prognosticating on consciousness recovery. Currently, consciousness is assessed by using a six-items scale, the Coma Recovery Scale-Revised. Namely, scores on the sub-items can individually assign or not a specific level of consciousness to a patient. In our work, by using solely the six sub-items of the CRS-R, we implemented a clustering algorithm labeling patients with the Consciousness-Domains Index (CDI) starting from a dataset of 190 patients with a Disorder of Consciousness (DoC). Then, the CDI is compared with the clinical state at admission and at six months via univariate analysis. The number of clusters best dividing the groups resulted equal to two and the most influencing sub-items resulted the visual and motor one. The CDI closely resembles the clinical state at admission (CSA) (Cohen's k=0.85). On the other hand, when comparing CDI and CSA, a net improvement was found in the prognostic power of the neurological outcome at six months, targeted as presence/absence of a DoC ( ). Data-driven techniques pave the way for automated and model-based search of prognostic factors, together with the use of such prognostic factors in multivariate prognostic models. Future works will address the external validation of the CDI, together with the inclusion of the CDI in a multivariate supervised model, in order to assess the true potential of such novel index. Clinical Relevance- A completely data-driven index was derived from a clustering of CRS-R sub-items. It correlates with the neurological outcome at six months better than the state of consciousness at admission.
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18
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Liuzzi P, Grippo A, Campagnini S, Scarpino M, Draghi F, Romoli A, Bahia H, Sterpu R, Maiorelli A, Macchi C, Cecchi F, Carrozza MC, Mannini A. Merging Clinical and EEG Biomarkers in an Elastic-Net Regression for Disorder of Consciousness Prognosis Prediction. IEEE Trans Neural Syst Rehabil Eng 2022; 30:1504-1513. [PMID: 35635833 DOI: 10.1109/tnsre.2022.3178801] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Patients with Disorder of Consciousness (DoC) entering Intensive Rehabilitation Units after a severe Acquired Brain Injury have a highly variable evolution of the state of consciousness which is a complex aspect to predict. Besides clinical factors, electroencephalography has clearly shown its potential into the identification of prognostic biomarkers of consciousness recovery. In this retrospective study, with a dataset of 271 patients with DoC, we proposed three different Elastic-Net regressors trained on different datasets to predict the Coma Recovery Scale-Revised value at discharge based on data collected at admission. One dataset was completely EEG-based, one solely clinical data-based and the last was composed by the union of the two. Each model was optimized, validated and tested with a robust nested cross-validation pipeline. The best models resulted in a median absolute test error of 4.54 [IQR = 4.56], 3.39 [IQR = 4.36], 3.16 [IQR = 4.13] for respectively the EEG, clinical and hybrid model. Furthermore, the hybrid model for what concerns overcoming an unresponsive wakefulness state and exiting a DoC results in an AUC of 0.91 and 0.88 respectively. Small but useful improvements are added by the EEG dataset to the clinical model for what concerns overcoming an unresponsive wakefulness state. Data-driven techniques and namely, machine learning models are hereby shown to be capable of supporting the complex decision-making process the practitioners must face.
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19
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Hakiki B, Donnini I, Romoli AM, Draghi F, Maccanti D, Grippo A, Scarpino M, Maiorelli A, Sterpu R, Atzori T, Mannini A, Campagnini S, Bagnoli S, Ingannato A, Nacmias B, De Bellis F, Estraneo A, Carli V, Pasqualone E, Comanducci A, Navarro J, Carrozza MC, Macchi C, Cecchi F. Clinical, Neurophysiological, and Genetic Predictors of Recovery in Patients With Severe Acquired Brain Injuries (PRABI): A Study Protocol for a Longitudinal Observational Study. Front Neurol 2022; 13:711312. [PMID: 35295839 PMCID: PMC8919857 DOI: 10.3389/fneur.2022.711312] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2021] [Accepted: 01/13/2022] [Indexed: 01/03/2023] Open
Abstract
Background Due to continuous advances in intensive care technology and neurosurgical procedures, the number of survivors from severe acquired brain injuries (sABIs) has increased considerably, raising several delicate ethical issues. The heterogeneity and complex nature of the neurological damage of sABIs make the detection of predictive factors of a better outcome very challenging. Identifying the profile of those patients with better prospects of recovery will facilitate clinical and family choices and allow to personalize rehabilitation. This paper describes a multicenter prospective study protocol, to investigate outcomes and baseline predictors or biomarkers of functional recovery, on a large Italian cohort of sABI survivors undergoing postacute rehabilitation. Methods All patients with a diagnosis of sABI admitted to four intensive rehabilitation units (IRUs) within 4 months from the acute event, aged above 18, and providing informed consent, will be enrolled. No additional exclusion criteria will be considered. Measures will be taken at admission (T0), at three (T1) and 6 months (T2) from T0, and follow-up at 12 and 24 months from onset, including clinical and functional data, neurophysiological results, and analysis of neurogenetic biomarkers. Statistics Advanced machine learning algorithms will be cross validated to achieve data-driven prediction models. To assess the clinical applicability of the solutions obtained, the prediction of recovery milestones will be compared to the evaluation of a multiprofessional, interdisciplinary rehabilitation team, performed within 2 weeks from admission. Discussion Identifying the profiles of patients with a favorable prognosis would allow customization of rehabilitation strategies, to provide accurate information to the caregivers and, possibly, to optimize rehabilitation outcomes. Conclusions The application and validation of machine learning algorithms on a comprehensive pool of clinical, genetic, and neurophysiological data can pave the way toward the implementation of tools in support of the clinical prognosis for the rehabilitation pathways of patients after sABI.
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Affiliation(s)
- Bahia Hakiki
- Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Fondazione Don Carlo Gnocchi, Firenze, Italy
| | - Ida Donnini
- Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Fondazione Don Carlo Gnocchi, Firenze, Italy
| | - Anna Maria Romoli
- Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Fondazione Don Carlo Gnocchi, Firenze, Italy
| | - Francesca Draghi
- Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Fondazione Don Carlo Gnocchi, Firenze, Italy
| | - Daniela Maccanti
- Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Fondazione Don Carlo Gnocchi, Firenze, Italy
| | - Antonello Grippo
- Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Fondazione Don Carlo Gnocchi, Firenze, Italy
| | - Maenia Scarpino
- Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Fondazione Don Carlo Gnocchi, Firenze, Italy
| | - Antonio Maiorelli
- Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Fondazione Don Carlo Gnocchi, Firenze, Italy
| | - Raisa Sterpu
- Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Fondazione Don Carlo Gnocchi, Firenze, Italy
| | - Tiziana Atzori
- Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Fondazione Don Carlo Gnocchi, Firenze, Italy
| | - Andrea Mannini
- Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Fondazione Don Carlo Gnocchi, Firenze, Italy.,The Biorobotics Institute, Scuola Superiore Sant'Anna, Pisa, Italy
| | - Silvia Campagnini
- Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Fondazione Don Carlo Gnocchi, Firenze, Italy.,The Biorobotics Institute, Scuola Superiore Sant'Anna, Pisa, Italy
| | - Silvia Bagnoli
- Neuroscience Section, Department of Neurofarba, University of Florence, Firenze, Italy
| | - Assunta Ingannato
- Neuroscience Section, Department of Neurofarba, University of Florence, Firenze, Italy
| | - Benedetta Nacmias
- Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Fondazione Don Carlo Gnocchi, Firenze, Italy.,Neuroscience Section, Department of Neurofarba, University of Florence, Firenze, Italy
| | - Francesco De Bellis
- Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Fondazione Don Carlo Gnocchi, Firenze, Italy
| | - Anna Estraneo
- Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Fondazione Don Carlo Gnocchi, Firenze, Italy
| | - Valentina Carli
- Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Fondazione Don Carlo Gnocchi, Firenze, Italy
| | - Eugenia Pasqualone
- Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Fondazione Don Carlo Gnocchi, Firenze, Italy
| | - Angela Comanducci
- Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Fondazione Don Carlo Gnocchi, Milano, Italy
| | - Jorghe Navarro
- Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Fondazione Don Carlo Gnocchi, Milano, Italy
| | | | - Claudio Macchi
- Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Fondazione Don Carlo Gnocchi, Firenze, Italy.,Department of Experimental and Clinical Medicine, University of Florence, Firenze, Italy
| | - Francesca Cecchi
- Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Fondazione Don Carlo Gnocchi, Firenze, Italy.,Department of Experimental and Clinical Medicine, University of Florence, Firenze, Italy
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20
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Hakiki B, Grippo A, Scarpino M, Liuzzi P, Mannini A, Macchi C, Cecchi F. Effects of COVID-19 pandemic on intensive rehabilitation after severe acquired brain injuries. Neurol Sci 2022; 43:791-798. [PMID: 34762195 PMCID: PMC8581285 DOI: 10.1007/s10072-021-05709-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2021] [Accepted: 10/29/2021] [Indexed: 02/08/2023]
Abstract
PURPOSE COVID-19 pandemic has affected most components of health systems including rehabilitation. The study aims to compare demographic and clinical data of patients admitted to an intensive rehabilitation unit (IRU) after severe acquired brain injuries (sABIs), before and during the pandemic. MATERIALS AND METHODS In this observational retrospective study, all patients admitted to the IRU between 2017 and 2020 were included. Demographics were collected, as well as data from the clinical and functional assessment at admission and discharge from the IRU. Patients were grouped in years starting from March 2017, and the 2020/21 cohort was compared to those admitted between March 2017/18, 2018/19, and 2019/20. Lastly, the pooled cohort March 2017 to March 2020 was compared with the COVID-19 year alone. RESULTS This study included 251 patients (F: 96 (38%): median age 68 years [IQR = 19.25], median time post-onset at admission: 42 days, [IQR = 23]). In comparison with the pre-pandemic years, a significant increase of hemorrhagic strokes (p < 0.001) and a decrease of traumatic brain injuries (p = 0.048), a reduction of the number of patients with a prolonged disorder of consciousness admitted to the IRU (p < 0.001) and a lower length of stay (p < 0.001) were observed in 2020/21. CONCLUSIONS These differences in the case mix of sABI patients admitted to IRU may be considered another side-effect of the pandemic. Facing this health emergency, rehabilitation specialists need to adapt readily to the changing clinical and functional needs of patients' addressing the IRUs.
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Affiliation(s)
- Bahia Hakiki
- IRCCS Fondazione Don Carlo Gnocchi-ONLUS, Via di Scandicci, 269 - 50143, Florence, Italy
| | - Antonello Grippo
- IRCCS Fondazione Don Carlo Gnocchi-ONLUS, Via di Scandicci, 269 - 50143, Florence, Italy
| | - Maenia Scarpino
- IRCCS Fondazione Don Carlo Gnocchi-ONLUS, Via di Scandicci, 269 - 50143, Florence, Italy.
| | - Piergiuseppe Liuzzi
- IRCCS Fondazione Don Carlo Gnocchi-ONLUS, Via di Scandicci, 269 - 50143, Florence, Italy
- Istituto Di Biorobotica, Scuola Superiore Sant'Anna, Viale Rinaldo Piaggio, 34, 56025, Pontedera (Pisa), Italy
| | - Andrea Mannini
- IRCCS Fondazione Don Carlo Gnocchi-ONLUS, Via di Scandicci, 269 - 50143, Florence, Italy
- Istituto Di Biorobotica, Scuola Superiore Sant'Anna, Viale Rinaldo Piaggio, 34, 56025, Pontedera (Pisa), Italy
| | - Claudio Macchi
- IRCCS Fondazione Don Carlo Gnocchi-ONLUS, Via di Scandicci, 269 - 50143, Florence, Italy
- Department of Experimental and Clinical Medicine, University of Florence, Largo Brambilla, Florence, Italy
| | - Francesca Cecchi
- IRCCS Fondazione Don Carlo Gnocchi-ONLUS, Via di Scandicci, 269 - 50143, Florence, Italy
- Department of Experimental and Clinical Medicine, University of Florence, Largo Brambilla, Florence, Italy
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21
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Qiu L, Zhong Y, Xie Q, He Z, Wang X, Chen Y, Zhan CA, Pan J. Multi-Modal Integration of EEG-fNIRS for Characterization of Brain Activity Evoked by Preferred Music. Front Neurorobot 2022; 16:823435. [PMID: 35173597 PMCID: PMC8841473 DOI: 10.3389/fnbot.2022.823435] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2021] [Accepted: 01/07/2022] [Indexed: 11/20/2022] Open
Abstract
Music can effectively improve people's emotions, and has now become an effective auxiliary treatment method in modern medicine. With the rapid development of neuroimaging, the relationship between music and brain function has attracted much attention. In this study, we proposed an integrated framework of multi-modal electroencephalogram (EEG) and functional near infrared spectroscopy (fNIRS) from data collection to data analysis to explore the effects of music (especially personal preferred music) on brain activity. During the experiment, each subject was listening to two different kinds of music, namely personal preferred music and neutral music. In analyzing the synchronization signals of EEG and fNIRS, we found that music promotes the activity of the brain (especially the prefrontal lobe), and the activation induced by preferred music is stronger than that of neutral music. For the multi-modal features of EEG and fNIRS, we proposed an improved Normalized-ReliefF method to fuse and optimize them and found that it can effectively improve the accuracy of distinguishing between the brain activity evoked by preferred music and neutral music (up to 98.38%). Our work provides an objective reference based on neuroimaging for the research and application of personalized music therapy.
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Affiliation(s)
- Lina Qiu
- School of Software, South China Normal University, Guangzhou, China
| | - Yongshi Zhong
- School of Software, South China Normal University, Guangzhou, China
| | - Qiuyou Xie
- Department of Rehabilitation Medicine, Zhujiang Hospital, Southern Medical University, Guangzhou, China
| | - Zhipeng He
- School of Software, South China Normal University, Guangzhou, China
| | - Xiaoyun Wang
- Guangdong Work Injury Rehabilitation Hospital, Guangzhou, China
| | - Yingyue Chen
- Guangdong Work Injury Rehabilitation Hospital, Guangzhou, China
| | - Chang'an A. Zhan
- School of Biomedical Engineering, Southern Medical University, Guangzhou, China
- Chang'an A. Zhan
| | - Jiahui Pan
- School of Software, South China Normal University, Guangzhou, China
- *Correspondence: Jiahui Pan
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22
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da Conceição Teixeira L, Blacker D, Campos C, Garrett C, Duport S, Rocha NB. Repeated Clinical Assessment Using Sensory Modality Assessment and Rehabilitation Technique for Diagnosis in Prolonged Disorders of Consciousness. Front Hum Neurosci 2021; 15:728637. [PMID: 34924975 PMCID: PMC8671934 DOI: 10.3389/fnhum.2021.728637] [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: 08/10/2021] [Accepted: 11/10/2021] [Indexed: 11/13/2022] Open
Abstract
Purpose: The recommended way to assess consciousness in prolonged disorders of consciousness is to observe the patient's responses to sensory stimulation. Multiple assessment sessions have to be completed in order to reach a correct diagnosis. There is, however, a lack of data on how many sessions are sufficient for validity and reliability. The aim of this study was to identify the number of Sensory Modality Assessment and Rehabilitation Technique (SMART) assessment sessions needed to reach a reliable diagnosis. A secondary objective was to identify which sensory stimulation modalities are more useful to reach a diagnosis. Materials and Methods: A retrospective analysis of all the adult patients (who received a SMART assessment) admitted to a specialist brain injury unit over the course of 4 years was conducted (n = 35). An independent rater analyzed the SMART levels for each modality and session and provided a suggestive diagnosis based on the highest SMART level per session. Results: For the vast majority of patients between 5 and 6 sessions was sufficient to reach the final clinical diagnosis. The visual, auditory, tactile, and motor function modalities were found to be more associated with the final diagnosis than the olfactory and gustatory modalities. Conclusion: These findings provide for the first time a rationale for optimizing the time spent on assessing patients using SMART.
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Affiliation(s)
- Liliana da Conceição Teixeira
- Center for Innovative Care and Health Technology, School of Health Sciences, Polytechnic of Leiria, Leiria, Portugal.,Center for Rehabilitation Research, School of Health, Polytechnic Institute of Porto, Porto, Portugal.,Faculty of Medicine, University of Porto, Porto, Portugal
| | - Danielle Blacker
- Occupational Therapy Department, Royal Hospital for Neuro-Disability, London, United Kingdom
| | - Carlos Campos
- Center for Rehabilitation Research, School of Health, Polytechnic Institute of Porto, Porto, Portugal.,Faculty of Medicine, University of Porto, Porto, Portugal.,Laboratory of Neuropsychophysiology, Faculty of Psychology and Educational Sciences, University of Porto, Porto, Portugal
| | | | - Sophie Duport
- Research Department, Royal Hospital for Neuro-Disability, London, United Kingdom
| | - Nuno Barbosa Rocha
- Center for Rehabilitation Research, School of Health, Polytechnic Institute of Porto, Porto, Portugal
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23
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Mannini A, Hakiki B, Liuzzi P, Campagnini S, Romoli A, Draghi F, Macchi C, Carrozza MC. Data-driven prediction of decannulation probability and timing in patients with severe acquired brain injury. COMPUTER METHODS AND PROGRAMS IN BIOMEDICINE 2021; 209:106345. [PMID: 34419756 DOI: 10.1016/j.cmpb.2021.106345] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/20/2021] [Accepted: 08/02/2021] [Indexed: 06/13/2023]
Abstract
BACKGROUND AND OBJECTIVES From a rehabilitation perspective, removal of tracheostomy in patients with severe acquired brain injuries (sABI) is a crucial step. Predictive parameters for a successful decannulation are currently still a focus of the research for sABI patients, especially for those presenting a disorder of consciousness. For this reason, we adopted a data-driven approach predicting decannulation probability and timing using ensemble learning models in patients in intensive rehabilitation units. METHODS 327 patients, 186 of which were successfully decannulated during their intensive rehabilitative stay, were recruited in a non-concurrent retrospective study. Decannulation probability and timing were predicted using data available within one week from admission at the rehabilitation unit. Two predictive models were trained and cross-validated independently, with the first being an ensemble of a Support Vector Machine and Random Forests and the second an Adaptive Boosting with a Support Vector Regression as weak learner. Confusion matrix, accuracy and AUC were considered as evaluation metrics for the classifier and median absolute error was considered for the regressor. To quantify the advantages in the clinical practice of using the latter prediction, we compared timing estimation with a timing guess (median) calculated on available data. The comparison was based on a Wilcoxon signed rank test. RESULTS Decannulation probability was successfully predicted with an accuracy of 84.8% (AUC = 0.85) and timing with a median absolute error of 25.7 days [IQR = 25.6]. This resulted in a significant improvement with respect to the weaning time guess (p<0.05) with an effect size of 71.7%. Furthermore, dichotomizing the regression prediction with a threshold (3 months from the event), resulted in a prediction accuracy of 77.5% (AUC = 0.82) on the test set. DISCUSSIONS A model capable of providing a prediction on decannulation probability and timing was developed and cross-validated, built on data taken at admission to the intensive rehabilitation unit. Translated in clinical practice, this information can support the clinical decision process and provide a mean to improve both in-hospital and domiciliary care organization.
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Affiliation(s)
- Andrea Mannini
- IRCCS Fondazione Don Carlo Gnocchi, via di Scandicci 269, Firenze 50134, FI, Italy; the BioRobotics Institute, Scuola Superiore Sant'Anna, Pontedera 56025, PI, Italy
| | - Bahia Hakiki
- IRCCS Fondazione Don Carlo Gnocchi, via di Scandicci 269, Firenze 50134, FI, Italy
| | - Piergiuseppe Liuzzi
- IRCCS Fondazione Don Carlo Gnocchi, via di Scandicci 269, Firenze 50134, FI, Italy; the BioRobotics Institute, Scuola Superiore Sant'Anna, Pontedera 56025, PI, Italy.
| | - Silvia Campagnini
- IRCCS Fondazione Don Carlo Gnocchi, via di Scandicci 269, Firenze 50134, FI, Italy; the BioRobotics Institute, Scuola Superiore Sant'Anna, Pontedera 56025, PI, Italy
| | - Annamaria Romoli
- IRCCS Fondazione Don Carlo Gnocchi, via di Scandicci 269, Firenze 50134, FI, Italy
| | - Francesca Draghi
- IRCCS Fondazione Don Carlo Gnocchi, via di Scandicci 269, Firenze 50134, FI, Italy
| | - Claudio Macchi
- IRCCS Fondazione Don Carlo Gnocchi, via di Scandicci 269, Firenze 50134, FI, Italy; Dep. of Experimental and Clinical Medicine, University of Florence, Piazza S. Marco 4, Firenze 50121, FI, Italy
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24
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Abdalmalak A, Milej D, Norton L, Debicki DB, Owen AM, Lawrence KS. The Potential Role of fNIRS in Evaluating Levels of Consciousness. Front Hum Neurosci 2021; 15:703405. [PMID: 34305558 PMCID: PMC8296905 DOI: 10.3389/fnhum.2021.703405] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Accepted: 05/31/2021] [Indexed: 12/13/2022] Open
Abstract
Over the last few decades, neuroimaging techniques have transformed our understanding of the brain and the effect of neurological conditions on brain function. More recently, light-based modalities such as functional near-infrared spectroscopy have gained popularity as tools to study brain function at the bedside. A recent application is to assess residual awareness in patients with disorders of consciousness, as some patients retain awareness albeit lacking all behavioural response to commands. Functional near-infrared spectroscopy can play a vital role in identifying these patients by assessing command-driven brain activity. The goal of this review is to summarise the studies reported on this topic, to discuss the technical and ethical challenges of working with patients with disorders of consciousness, and to outline promising future directions in this field.
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Affiliation(s)
- Androu Abdalmalak
- Department of Physiology and Pharmacology, Western University, London, ON, Canada.,Brain and Mind Institute, Western University, London, ON, Canada
| | - Daniel Milej
- Imaging Program, Lawson Health Research Institute, London, ON, Canada.,Department of Medical Biophysics, Western University, London, ON, Canada
| | - Loretta Norton
- Department of Psychology, King's College, Western University, London, ON, Canada
| | - Derek B Debicki
- Brain and Mind Institute, Western University, London, ON, Canada.,Clinical Neurological Sciences, Western University, London, ON, Canada
| | - Adrian M Owen
- Department of Physiology and Pharmacology, Western University, London, ON, Canada.,Brain and Mind Institute, Western University, London, ON, Canada.,Department of Psychology, Western University, London, ON, Canada
| | - Keith St Lawrence
- Imaging Program, Lawson Health Research Institute, London, ON, Canada.,Department of Medical Biophysics, Western University, London, ON, Canada
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25
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Quiñones-Ossa GA, Durango-Espinosa YA, Janjua T, Moscote-Salazar LR, Agrawal A. Persistent vegetative state: an overview. EGYPTIAN JOURNAL OF NEUROSURGERY 2021. [DOI: 10.1186/s41984-021-00111-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Disorder of consciousness diagnosis, especially when is classified as persistent vegetative state (without misestimating the other diagnosis classifications), in the intensive care is an important diagnosis to evaluate and treat. Persistent vegetative state diagnosis is a challenge in the daily clinical practice because the diagnosis is made mainly based upon the clinical history and the patient behavior observation. There are some specific criteria for this diagnosis, and this could be very tricky when the physician is not well trained.
Main body
We made a literature review regarding the persistent vegetative state diagnosis, clinical features, management, prognosis, and daily medical practice challenges while considering the bioethical issues and the family perspective about the patient status. The objective of this overview is to provide updated information regarding this clinical state’s features while considering the current medical literature available.
Conclusions
Regardless of the currently available guidelines and literature, there is still a lot of what we do not know about the persistent vegetative state. There is a lack of evidence regarding the optimal diagnosis and even more, about how to expect a natural history of this disorder of consciousness. It is important to recall that the patients (despite of their altered mental state diagnosis) should always be treated to avoid some of the intensive care unit long-stance complications.
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26
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Kowalski RG, Hammond FM, Weintraub AH, Nakase-Richardson R, Zafonte RD, Whyte J, Giacino JT. Recovery of Consciousness and Functional Outcome in Moderate and Severe Traumatic Brain Injury. JAMA Neurol 2021; 78:548-557. [PMID: 33646273 DOI: 10.1001/jamaneurol.2021.0084] [Citation(s) in RCA: 81] [Impact Index Per Article: 27.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Importance Traumatic brain injury (TBI) leads to 2.9 million visits to US emergency departments annually and frequently involves a disorder of consciousness (DOC). Early treatment, including withdrawal of life-sustaining therapies and rehabilitation, is often predicated on the assumed worse outcome of disrupted consciousness. Objective To quantify the loss of consciousness, factors associated with recovery, and return to functional independence in a 31-year sample of patients with moderate or severe brain trauma. Design, Setting, and Participants This cohort study analyzed patients with TBI who were enrolled in the Traumatic Brain Injury Model Systems National Database, a prospective, multiyear, longitudinal database. Patients were survivors of moderate or severe TBI who were discharged from acute hospitalization and admitted to inpatient rehabilitation from January 4, 1989, to June 19, 2019, at 1 of 23 inpatient rehabilitation centers that participated in the Traumatic Brain Injury Model Systems program. Follow-up for the study was through completion of inpatient rehabilitation. Exposures Traumatic brain injury. Main Outcomes and Measures Outcome measures were Glasgow Coma Scale in the emergency department, Disability Rating Scale, posttraumatic amnesia, and Functional Independence Measure. Patient-related data included demographic characteristics, injury cause, and brain computed tomography findings. Results The 17 470 patients with TBI analyzed in this study had a median (interquartile range [IQR]) age at injury of 39 (25-56) years and included 12 854 male individuals (74%). Of these patients, 7547 (57%) experienced initial loss of consciousness, which persisted to rehabilitation in 2058 patients (12%). Those with persisting DOC were younger; had more high-velocity injuries; had intracranial mass effect, intraventricular hemorrhage, and subcortical contusion; and had longer acute care than patients without DOC. Eighty-two percent (n = 1674) of comatose patients recovered consciousness during inpatient rehabilitation. In a multivariable analysis, the factors associated with consciousness recovery were absence of intraventricular hemorrhage (adjusted odds ratio [OR], 0.678; 95% CI, 0.532-0.863; P = .002) and intracranial mass effect (adjusted OR, 0.759; 95% CI, 0.595-0.968; P = .03). Functional improvement (change in total functional independence score from admission to discharge) was +43 for patients with DOC and +37 for those without DOC (P = .002), and 803 of 2013 patients with DOC (40%) became partially or fully independent. Younger age, male sex, and absence of intraventricular hemorrhage, intracranial mass effect, and subcortical contusion were associated with better functional outcome. Findings were consistent across the 3 decades of the database. Conclusions and Relevance This study found that DOC occurred initially in most patients with TBI and persisted in some patients after rehabilitation, but most patients with persisting DOC recovered consciousness during rehabilitation. This recovery trajectory may inform acute and rehabilitation treatment decisions and suggests caution is warranted in consideration of withdrawing or withholding care in patients with TBI and DOC.
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Affiliation(s)
- Robert G Kowalski
- Department of Neurology, University of Colorado School of Medicine, Aurora.,Research Department, Craig Hospital, Englewood, Colorado
| | - Flora M Hammond
- Department of Physical Medicine and Rehabilitation, Indiana University School of Medicine, Indianapolis
| | - Alan H Weintraub
- Research Department, Craig Hospital, Englewood, Colorado.,CNS Medical Group, Englewood, Colorado
| | - Risa Nakase-Richardson
- Mental Health and Behavioral Sciences, James A. Haley Veterans Hospital, Tampa, Florida.,Sleep Medicine Division, Department of Internal Medicine, University of South Florida, Tampa
| | - Ross D Zafonte
- Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Massachusetts General Hospital, Brigham and Women's Hospital and Harvard Medical School, Boston
| | - John Whyte
- Moss Rehabilitation Research Institute, Elkins Park, Pennsylvania
| | - Joseph T Giacino
- Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Massachusetts General Hospital, Brigham and Women's Hospital and Harvard Medical School, Boston
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27
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Hu Y, Yu F, Wang C, Yan X, Wang K. Can Music Influence Patients With Disorders of Consciousness? An Event-Related Potential Study. Front Neurosci 2021; 15:596636. [PMID: 33897341 PMCID: PMC8064410 DOI: 10.3389/fnins.2021.596636] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2020] [Accepted: 03/19/2021] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Long-term disorders of consciousness (DOC) are a huge burden on both patients and their families. Previously, music intervention has been attempted as a potential therapy in DOC, with results indicating an enhancement of arousal and awareness; yet, to date, there are limited studies on music interventions in DOC with electroencephalogram monitoring. Meanwhile, prediction of awareness recovery is a challenge facing clinicians. The predictive value mismatch negativity (MMN), as a classical cognitive component in event-related potential, is still controversial. In this study, we use auditory event-related potential to probe the effect of music in DOC, and investigate whether music may improve the predictive value of MMN in awareness recovery. METHODS Fourteen DOC patients were included in the prospective study. Auditory oddball electroencephalogram data were recorded twice with each patient, before and after 5 min of listening to a Chinese symphony that has joyful associations. The outcome was assessed 6 months later. RESULTS Significant differences of MMN amplitude were found between healthy controls and pre-music DOC patients (p < 0.001), but no significant differences were found between healthy controls and post-music DOC patients. The presence of MMN before music was not correlated with favorable outcome, and 50% of patients with MMN did not recover awareness. When MMN was absent, 50% of patients awoke. After listening to music, among the 11 patients who showed MMN, seven patients recovered awareness. When MMN was absent, no one recovered awareness. CONCLUSIONS Some DOC patients, even those in a minimal consciousness state and those with unresponsive wakefulness syndrome (UWS), were affected by music. The MMN amplitude was elevated by the music to some extent. A single test of MMN did not have a good prognostic value of our study; however, retesting of MMN after stimulation with familiar music that has joyful associations might be valuable for observation and detection of possible recovery. The musical processing in DOC patients and the effect of musical therapeutic practices need further investigations.
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Affiliation(s)
- Yajuan Hu
- Department of Neurology, The First Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Fengqiong Yu
- Department of Medical Psychology, Chaohu Clinical Medical College, Anhui Medical University, Hefei, China
- Collaborative Innovation Center of Neuropsychiatric Disorders and Mental Health, Hefei, China
- Anhui Province Key Laboratory of Cognition and Neuropsychiatric Disorders, Hefei, China
| | - Changqing Wang
- Department of Neurology, The First Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Xiaoxiang Yan
- Department of Neurology, The First Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Kai Wang
- Department of Neurology, The First Affiliated Hospital of Anhui Medical University, Hefei, China
- Collaborative Innovation Center of Neuropsychiatric Disorders and Mental Health, Hefei, China
- Anhui Province Key Laboratory of Cognition and Neuropsychiatric Disorders, Hefei, China
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28
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Khalili H, Rakhsha A, Ghaedian T, Niakan A, Masoudi N. Application of Brain Perfusion SPECT in the Evaluation of Response to Zolpidem Therapy in Consciousness Disorder Due to Traumatic Brain Injury. Indian J Nucl Med 2021; 35:315-320. [PMID: 33642756 PMCID: PMC7905279 DOI: 10.4103/ijnm.ijnm_97_20] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Revised: 05/18/2020] [Accepted: 05/22/2020] [Indexed: 12/01/2022] Open
Abstract
Background: Traumatic brain injury (TBI) is a critical health problem with various comorbidities and socioeconomic consequences. Tending to increase in recent decades, TBI results in more cases of consciousness disorders including vegetative state (VS)/minimally conscious state (MCS). However, no definite or effective treatment still exists for these conditions. The aim of this article is to study the effects of zolpidem in patients with VS caused by TBI by using brain perfusion single-photon emission computed tomography (SPECT). Materials and Methods: This was a prospective clinical trial on a cohort of patients with VS. We evaluated the TBI database to find VS/MCS patients, between the ages of 20 and 65 years. We received written consent from their family members prior to enrollment and compared their clinical status and brain perfusion SPECT prior and after 2 weeks of zolpidem therapy. Results: Among the 12 patients included in this study, six patients changed to MCS after 2 weeks. Comparison of their motor score, revealed a statistically significant difference (2.08 vs. 3.75, P = 0.007, respectively). None of the quantitative or qualitative brain perfusion parameters showed any differences after zolpidem therapy. However, the perfusion pattern, with focal or multifocal cortical defects, was significantly more prevalent in the responder group (five patients vs. one patient, P = 0.015). Conclusion: Zolpidem therapy may improve consciousness levels and motor function in a considerable portion of VS patients with TBI. This study showed that the presence of focal brain perfusion defect can predict response to zolpidem.
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Affiliation(s)
- Hosseinali Khalili
- Department of Neurosurgery, Trauma Research Center, Shahid Rajaee (Emtiaz) Trauma Hospital, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Abbas Rakhsha
- Department of Neurosurgery, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Tahereh Ghaedian
- Nuclear Medicine and Molecular Imaging Research Center, Namazi Teaching Hospital, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Amin Niakan
- Department of Neurosurgery, Trauma Research Center, Shahid Rajaee (Emtiaz) Trauma Hospital, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Nahid Masoudi
- Nuclear Medicine and Molecular Imaging Research Center, Namazi Teaching Hospital, Shiraz University of Medical Sciences, Shiraz, Iran
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29
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Bodine CE, Seu A, Roth EA, Wegener EE, Magee WL. Examining the Functionality of the MATADOC With the CRS-R: A Pilot Study. J Music Ther 2020; 57:432-454. [PMID: 32621608 DOI: 10.1093/jmt/thaa010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Prolonged disorders of consciousness (PDOC) following acquired brain injury affect a person's awareness of self and the environment. Motor, communication, sensory, and cognitive deficits challenge assessment. Rigorously tested behavioral assessments, sensitive to detecting awareness, are critical for discerning a prognosis for recovery and access to treatment. The Coma Recovery Scale-Revised (CRS-R) is considered the gold standard in PDOC diagnostic assessments. This study explored preliminary concurrent validity of the Music Therapy Assessment Tool for Awareness in Disorders of Consciousness (MATADOC) with the CRS-R. The MATADOC and CRS-R were administered concurrently to 8 participants utilizing a repeated measures design. Correlations for diagnosis and item functionality were explored between and within the 2 measures. There was an adequate level of agreement between the 2 measures for overall diagnosis. Significant positive correlations were found between measures for all domains utilizing the MATADOC repeated administrations design. Within-measure relationships were significant for each of the auditory and communication domains with diagnosis for both measures, and additionally for each of the visual and arousal domains with diagnosis on the MATADOC. Both measures yielded significant inter-item relationships for auditory-visual domains, communication-visual domains, arousal-auditory domains, and arousal-visual domains. The MATADOC yielded an additional significant correlation for the auditory-communication domains. The findings have positive implications for the MATADOC as a diagnostic measure and companion assessment in cases of questionable diagnosis. Research with a larger sample is warranted. Generally, higher arousal scores on the MATADOC support music as effective in eliciting arousal, giving patients the opportunity to perform at their optimal level of function.
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Affiliation(s)
| | - Alika Seu
- Western Michigan University, Kalamazoo, MI.,Spectrum Health, Grand Rapids, MI
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30
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Hakiki B, Pancani S, Draghi F, Portaccio E, Tofani A, Binazzi B, Anna Maria R, Scarpino M, Macchi C, Cecchi F. Decannulation and improvement of responsiveness in patients with disorders of consciousness. Neuropsychol Rehabil 2020; 32:520-536. [PMID: 33100115 DOI: 10.1080/09602011.2020.1833944] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Decannulation is a rehabilitation milestone in patients with Disorders of Consciousness (DoC). investigate the relationship between decannulation and improvement of responsiveness (IR) in DoC. 236 tracheostomized patients with severe Acquired Brain Injury and DoC admitted in the Intensive Rehabilitation Unit were retrospectively included. They received personalized interdisciplinary rehabilitation. At discharge, IR was evaluated. The association between IR and demographic/clinical data was investigated using a logistic regression analysis, both in the Unresponsive Wakefulness Syndrome (UWS) and Minimal Consciousness State (MCS) group, divided according to their Coma Recovery Scale-Revised score at admission. In the UWS group (N = 107), only decannulation was associated with IR at discharge (OR: 5.94, CI: 2.08-16.91, p = .001). In the MCS group (N = 129) time post-injury (OR: 0.983, CI: 0.97-0.99, p = .012) and decannulation were associated with IR at discharge (OR: 17.9, CI: 6.39-50.13, p < .001). Decannulation and IR were found to be strongly related, independently from the initial clinical state. While the retrospective nature of the study could not exclude that decannulation may be a consequence of a spontaneous recovery, the obtained results may disclose its potential influence on the clinical history of patients with DoC.
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Affiliation(s)
- Bahia Hakiki
- IRCCS Fondazione Don Carlo Gnocchi, Florence, Italy
| | | | | | - Emilio Portaccio
- SOC Neurologia, Ospedale San Giovanni di Dio, Firenze, AUSL Toscana Centro, Florence, Italy
| | | | | | | | - Maenia Scarpino
- IRCCS Fondazione Don Carlo Gnocchi, Florence, Italy.,Dipartimento Neuromuscolo-Scheletrico e degli Organi di Senso, SODc Neurofisiopatologia, AOU Careggi, Florence, Italy
| | - Claudio Macchi
- IRCCS Fondazione Don Carlo Gnocchi, Florence, Italy.,Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
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31
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Wang J, Hu X, Hu Z, Sun Z, Laureys S, Di H. The misdiagnosis of prolonged disorders of consciousness by a clinical consensus compared with repeated coma-recovery scale-revised assessment. BMC Neurol 2020; 20:343. [PMID: 32919461 PMCID: PMC7488705 DOI: 10.1186/s12883-020-01924-9] [Citation(s) in RCA: 46] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2019] [Accepted: 09/08/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Previous studies have shown that a single Coma-Recovery Scale-Revision (CRS-R) assessment can identify high rates of misdiagnosis by clinical consensus. The aim of this study was to investigate the proportion of misdiagnosis by clinical consensus compared to repeated behavior-scale assessments in patients with prolonged disorders of consciousness (DOC). METHODS Patients with prolonged DOC during hospitalization were screened by clinicians, and the clinicians formed a clinical-consensus diagnosis. Trained professionals used the CRS-R to evaluate the consciousness levels of the enrolled patients repeatedly (≥5 times) within a week. Based on the repeated evaluation results, the enrolled patients with prolonged DOC were divided into unresponsive wakefulness syndrome (UWS), minimally conscious state (MCS), and emergence from MCS (EMCS). Finally, the relationship between the results of the CRS-R and the clinical consensus were analyzed. RESULTS In this study, 137 patients with a clinical-consensus diagnosis of prolonged DOC were enrolled. It was found that 24.7% of patients with clinical UWS were actually in MCS after a single CRS-R behavior evaluation, while the repeated CRS-R evaluation results showed that the proportion of misdiagnosis of MCS was 38.2%. A total of 16.7% of EMCS patients were misdiagnosed with clinical MCS, and 1.1% of EMCS patients were misdiagnosed with clinical UWS. CONCLUSIONS The rate of the misdiagnosis by clinical consensus is still relatively high. Therefore, clinicians should be aware of the importance of the bedside CRS-R behavior assessment and should apply the CRS-R tool in daily procedures. TRIAL REGISTRATION ClinicalTrials.gov ID: NCT04139239 ; Registered 24 October 2019 - Retrospectively registered.
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Affiliation(s)
- Jing Wang
- International Unresponsive Wakefulness Syndrome and Consciousness Science Institute, Hangzhou Normal University, Hangzhou, 310036 China
| | - Xiaohua Hu
- Rehabilitation Center for Brain Damage, Wujing Hospital of Hangzhou City, Hangzhou, China
| | - Zhouyao Hu
- International Unresponsive Wakefulness Syndrome and Consciousness Science Institute, Hangzhou Normal University, Hangzhou, 310036 China
| | - Ziwei Sun
- International Unresponsive Wakefulness Syndrome and Consciousness Science Institute, Hangzhou Normal University, Hangzhou, 310036 China
| | - Steven Laureys
- Coma Science Group, GIGA Consciousness, University and University Hospital of Liège, Liège, Belgium
| | - Haibo Di
- International Unresponsive Wakefulness Syndrome and Consciousness Science Institute, Hangzhou Normal University, Hangzhou, 310036 China
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Scarpino M, Lolli F, Hakiki B, Lanzo G, Sterpu R, Atzori T, Portaccio E, Draghi F, Amantini A, Grippo A. EEG and Coma Recovery Scale-Revised prediction of neurological outcome in Disorder of Consciousness patients. Acta Neurol Scand 2020; 142:221-228. [PMID: 32219851 DOI: 10.1111/ane.13247] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2019] [Revised: 03/09/2020] [Accepted: 03/19/2020] [Indexed: 11/27/2022]
Abstract
OBJECTIVE According to electroencephalogram (EEG) descriptors included in the American Clinical Neurophysiology Society (ACNS) terminology, we generated a score, and we compared it to the EEG scores previously proposed in order to identify the one with the best prognostic power for neurological outcome at post-acute stages in patients with severe disorders of consciousness (DoC). MATERIALS AND METHODS Patients included in the analysis were clinically evaluated with the Coma Recovery Scale-Revised (CRS-R). An EEG was performed within the first week after admission to Intensive Rehabilitation Unit (IRU). EEGs were classified according to the ACNS terminology and to the scores of Bagnato and Estraneo. RESULTS A total of 260 patients admitted to the IRU were analysed. A total of 160 patients (61%) improved their consciousness level during IRU stay. EEG score based on the ANCS terminology showed higher overall performance (receiver-operating area under the curve = 0.79) and greater sensitivity (65%), at comparable specificities (80%), for clinical improvement as compared to both CRS-R admission score and other EEG scores. Combining our EEG score with CRS-R score at admission, the cumulative sensitivity increased to 76% when at least one good prognostic index test was present in the same patient, whereas specificity increased up to 93% if both the good prognostic patterns of clinical and instrumental parameters were simultaneously present. CONCLUSION The EEG scored according to the ACNS terminology is the best among those looked at for the prediction of short-term clinical improvement in patients with DoC and represents a useful instrumental test, complementary to clinical evaluation at admission, to be added in post-acute neurological prognostication methods.
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Affiliation(s)
- Maenia Scarpino
- IRCCS Fondazione Don Carlo Gnocchi Firenze Italy
- SODc Neurofisiopatologia Dipartimento Neuromuscolo‐Scheletrico e degli Organi di Senso AOU Careggi Firenze Italy
| | - Francesco Lolli
- SODc Neurofisiopatologia Dipartimento Neuromuscolo‐Scheletrico e degli Organi di Senso AOU Careggi Firenze Italy
- Dipartimento di Scienze Biomediche Sperimentali e Cliniche Mario Serio Università degli studi di Firenze Firenze Italy
| | - Bahia Hakiki
- IRCCS Fondazione Don Carlo Gnocchi Firenze Italy
| | - Giovanni Lanzo
- SODc Neurofisiopatologia Dipartimento Neuromuscolo‐Scheletrico e degli Organi di Senso AOU Careggi Firenze Italy
| | - Raisa Sterpu
- IRCCS Fondazione Don Carlo Gnocchi Firenze Italy
| | | | | | | | - Aldo Amantini
- IRCCS Fondazione Don Carlo Gnocchi Firenze Italy
- SODc Neurofisiopatologia Dipartimento Neuromuscolo‐Scheletrico e degli Organi di Senso AOU Careggi Firenze Italy
| | - Antonello Grippo
- IRCCS Fondazione Don Carlo Gnocchi Firenze Italy
- SODc Neurofisiopatologia Dipartimento Neuromuscolo‐Scheletrico e degli Organi di Senso AOU Careggi Firenze Italy
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A Neurologic Examination for Anesthesiologists: Assessing Arousal Level during Induction, Maintenance, and Emergence. Anesthesiology 2020; 130:462-471. [PMID: 30664547 DOI: 10.1097/aln.0000000000002559] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Anesthetics have profound effects on the brain and central nervous system. Vital signs, along with the electroencephalogram and electroencephalogram-based indices, are commonly used to assess the brain states of patients receiving general anesthesia and sedation. Important information about the patient's arousal state during general anesthesia can also be obtained through use of the neurologic examination. This article reviews the main components of the neurologic examination focusing primarily on the brainstem examination. It details the components of the brainstem examination that are most relevant for patient management during induction, maintenance, and emergence from general anesthesia. The examination is easy to apply and provides important complementary information about the patient's arousal level that cannot be discerned from vital signs and electroencephalogram measures.
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Abstract
This comprehensive review discusses clinical studies of patients following brain injuries (traumatic, acquired, or stroke), who have been treated with amantadine or memantine. Both amantadine and memantine are commonly used in the acute rehabilitation setting following brain injuries, despite their lack of FDA-approval for neuro-recovery. Given the broad utilization of such agents, there is a need to review the evidence supporting this common off-label prescribing. The purpose of this review is to describe the mechanisms of action for memantine and amantadine, as well as to complete a comprehensive review of the clinical uses of these agents. We included 119 original, clinical research articles from NCBI Medline, published before 2019. We focused on the domains of neuroplasticity, functional recovery, motor recovery, arousal, fatigue, insomnia, behavior, agitation, and cognition. Most of the existing research supporting the use of amantadine and memantine in recovery from brain injuries was done in very small populations, limiting the significance of conclusions. While most studies are positive; small effect sizes are usually reported, or populations are subject to bias. Furthermore, evidence is so limited that this review includes research regarding both acute and chronic acquired brain injury populations. Fortunately, reported short-term side effects generally are modest, and stop soon after amantadine/memantine is discontinued. However, responses are inconsistent, and the phenotype of responders remains elusive.
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Affiliation(s)
- Heather M Ma
- Physical Medicine and Rehabilitation, University of Rochester Medical Center, Rochester, New York, USA
| | - Ross D Zafonte
- Spaulding Rehabilitation Hospital, Massachusetts General Hospital, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
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Scarpino M, Lolli F, Hakiki B, Atzori T, Lanzo G, Sterpu R, Portaccio E, Romoli AM, Morrocchesi A, Amantini A, Macchi C, Grippo A. Prognostic value of post-acute EEG in severe disorders of consciousness, using American Clinical Neurophysiology Society terminology. Neurophysiol Clin 2019; 49:317-327. [DOI: 10.1016/j.neucli.2019.07.001] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2019] [Revised: 07/01/2019] [Accepted: 07/01/2019] [Indexed: 12/15/2022] Open
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Wutzl B, Leibnitz K, Rattay F, Kronbichler M, Murata M, Golaszewski SM. Genetic algorithms for feature selection when classifying severe chronic disorders of consciousness. PLoS One 2019; 14:e0219683. [PMID: 31295332 PMCID: PMC6622536 DOI: 10.1371/journal.pone.0219683] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2018] [Accepted: 06/30/2019] [Indexed: 11/18/2022] Open
Abstract
The diagnosis and prognosis of patients with severe chronic disorders of consciousness are still challenging issues and a high rate of misdiagnosis is evident. Hence, new tools are needed for an accurate diagnosis, which will also have an impact on the prognosis. In recent years, functional Magnetic Resonance Imaging (fMRI) has been gaining more and more importance when diagnosing this patient group. Especially resting state scans, i.e., an examination when the patient does not perform any task in particular, seems to be promising for these patient groups. After preprocessing the resting state fMRI data with a standard pipeline, we extracted the correlation matrices of 132 regions of interest. The aim was to find the regions of interest which contributed most to the distinction between the different patient groups and healthy controls. We performed feature selection using a genetic algorithm and a support vector machine. Moreover, we show by using only those regions of interest for classification that are most often selected by our algorithm, we get a much better performance of the classifier.
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Affiliation(s)
- Betty Wutzl
- Graduate School of Information Science and Technology, Osaka University, Osaka, Japan
- Center for Information and Neural Networks, National Institute of Information and Communications Technology and Osaka University, Osaka, Japan
- Institute for Analysis and Scientific Computing, TU Wien, Vienna, Austria
- Department of Neurology, Paracelsus Medical University, Salzburg, Austria
- * E-mail:
| | - Kenji Leibnitz
- Graduate School of Information Science and Technology, Osaka University, Osaka, Japan
- Center for Information and Neural Networks, National Institute of Information and Communications Technology and Osaka University, Osaka, Japan
| | - Frank Rattay
- Institute for Analysis and Scientific Computing, TU Wien, Vienna, Austria
| | - Martin Kronbichler
- Neuroscience Institute, Christian-Doppler Medical Centre, Paracelsus Medical University, Salzburg, Austria
- Centre for Cognitive Neuroscience and Department of Psychology, University of Salzburg, Salzburg, Austria
| | - Masayuki Murata
- Graduate School of Information Science and Technology, Osaka University, Osaka, Japan
- Center for Information and Neural Networks, National Institute of Information and Communications Technology and Osaka University, Osaka, Japan
| | - Stefan Martin Golaszewski
- Department of Neurology, Paracelsus Medical University, Salzburg, Austria
- Neuroscience Institute, Christian-Doppler Medical Centre, Paracelsus Medical University, Salzburg, Austria
- Karl Landsteiner Institute for Neurorehabilitation and Space Neurology, Vienna, Austria
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Mochalova EG, Legostaeva LA, Zimin AA, Yusupova DG, Sergeev DV, Ryabinkina YV, Bodien Y, Suponeva NA, Piradov MA. [The Russian version of Coma Recovery Scale-revised - a standardized method for assessment of patients with disorders of consciousness]. Zh Nevrol Psikhiatr Im S S Korsakova 2019; 118:25-31. [PMID: 29798977 DOI: 10.17116/jnevro20181183225-31] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The authors officially present for the first time the Russian version of Coma Recovery Scale-Revised (CRS-R). Today CRS-R is the only validated scale in Russian for assessment of patients with chronic disorders of consciousness (DOC). The study showed high consistency for different researchers, high sensitivity in the evaluation of patients over time as well as high concurrent validity. This article contains the text of the scale and recommendations how to use CRS-R and interpret the data. Presented version of the CRS-R is recommended for use in DOC patients. Russian version of the CRS-R is a standardized, comprehensive and systematic approach to the examination and assessment of patients with chronic DOS. It ensures the standard approach to examination and assessment that warrants the accuracy and homogeneity of the obtained results.
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Affiliation(s)
| | | | - A A Zimin
- Research Center of Neurology, Moscow, Russia
| | | | - D V Sergeev
- Research Center of Neurology, Moscow, Russia
| | | | - Y Bodien
- Spaulding Rehabilitation Hospital Harvard Medical School, Boston, MA, USA
| | | | - M A Piradov
- Research Center of Neurology, Moscow, Russia
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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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Chen X, Tang C, Zhou H, Li Z. Effect of amantadine on vegetative state after traumatic brain injury: a functional magnetic resonance imaging study. J Int Med Res 2018; 47:1015-1024. [PMID: 30514146 PMCID: PMC6381504 DOI: 10.1177/0300060518814127] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVE We assessed the use of functional magnetic resonance imaging (fMRI) to observe residual brain function and responsiveness to amantadine in a patient in a vegetative state (VS) following traumatic brain injury. METHOD We observed cerebral cortex activation in a 52-year-old man in a VS, and in a healthy individual using fMRI during passive listening and motor-imagery tasks. The patient received oral amantadine for 3 months. fMRI was repeated after treatment. RESULTS Activation around the left insular regions occurred during stimulation by a familiar voice, and activity in the left temporal and bi-occipital cortices occurred during stimulation by a familiar/unfamiliar voice. Activity in the bilateral frontal and parietal cortices occurred during the motor-imagination task. Brain cortex activation was reduced in the VS patient compared with the healthy volunteer. However, the patient responded to certain auditory stimuli and motor imagery, suggesting that he retained some intact auditory and motor cortical functions. fMRI scans after 3 months of treatment showed increased activation of brain areas corresponding to task instructions. CONCLUSION fMRI could be used to observe the effects of amantadine on brain function, and to aid the diagnosis and prognostic prediction in VS patients in terms of recovery and rehabilitation planning.
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Affiliation(s)
- Xiaowei Chen
- 1 Department of Physical Medicine and Rehabilitation, The First Hospital of Jilin University, Changchun, Jilin, China
| | - CheukYing Tang
- 2 Department of Radiology, Mount Sinai School of Medicine, New York, NY, United States
| | - Hongwei Zhou
- 3 Department of Radiology, The First Hospital of Jilin University, Changchun, Jilin, China
| | - Zhenlan Li
- 1 Department of Physical Medicine and Rehabilitation, The First Hospital of Jilin University, Changchun, Jilin, China
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40
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Klingshirn H, Mittrach R, Braitmayer K, Strobl R, Bender A, Grill E, Müller M. RECAPDOC - a questionnaire for the documentation of rehabilitation care utilization in individuals with disorders of consciousness in long-term care in Germany: development and pretesting. BMC Health Serv Res 2018; 18:329. [PMID: 29728154 PMCID: PMC5936017 DOI: 10.1186/s12913-018-3153-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2017] [Accepted: 04/25/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND A multitude of different rehabilitation interventions and other specific health care services are offered for individuals with disorders of consciousness in long-term care settings. To investigate the association of those services and patient-relevant outcomes, a specific instrument to document the utilization of those services is needed. The purpose of this study was to develop such a questionnaire administered to caregivers in epidemiological studies or patient registries in Germany. METHODS The development process of the RECAPDOC questionnaire was carried out in three steps. Step 1 consisted of a systematic literature review and an online-based expert survey to define the general content. Step 2 was an expert interview to evaluate the preliminary content of the questionnaire. Step 3 was a pretest including cognitive interviews with caregivers. After each step, the results were combined into a new version of the questionnaire. RESULTS The first version of the questionnaire included items on utilization of medical care, medical aids, nursing and therapeutic care. The results of the expert interview led to the integration of five new items and the modification of six other items. The pretest led to some minor modifications of the questionnaire since it was rated as feasible and acceptable. The final questionnaire consisted of 29 items covering the domains "living situation", "social insurance status", "utilisation of home health care", "domestic services", "outpatient health care", "specific diagnostic measures", "adaptive technologies", "medical aids" and "utilization of therapies". Also the experience of family support and multidisciplinary collaboration of health professionals is covered. CONCLUSIONS The developed questionnaire is a first step to make the situation of patients with disorders of consciousness in the long-term care setting accessible for evaluation in epidemiological studies and in the context of patient registries. However, further reliability and validity studies are needed.
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Affiliation(s)
- Hanna Klingshirn
- Institute of Medical Information Processing, Biometry and Epidemiology, Ludwig-Maximilians-Universität München, Marchioninistr. 17, 81377, München, Germany
| | - Rene Mittrach
- Institute of Medical Information Processing, Biometry and Epidemiology, Ludwig-Maximilians-Universität München, Marchioninistr. 17, 81377, München, Germany
| | - Kathrin Braitmayer
- Institute of Medical Information Processing, Biometry and Epidemiology, Ludwig-Maximilians-Universität München, Marchioninistr. 17, 81377, München, Germany
| | - Ralf Strobl
- Institute of Medical Information Processing, Biometry and Epidemiology, Ludwig-Maximilians-Universität München, Marchioninistr. 17, 81377, München, Germany.,German Center for Vertigo and Balance Disorders, Ludwig-Maximilians-Universität München, Marchioninistr. 15, 81377, München, Germany
| | - Andreas Bender
- Department of Neurology, Ludwig-Maximilians-Universität München, Marchioninistr. 15, 81377, München, Germany.,Therapiezentrum Burgau, Kapuzinerstraße 34, 89331, Burgau, Germany
| | - Eva Grill
- Institute of Medical Information Processing, Biometry and Epidemiology, Ludwig-Maximilians-Universität München, Marchioninistr. 17, 81377, München, Germany.,German Center for Vertigo and Balance Disorders, Ludwig-Maximilians-Universität München, Marchioninistr. 15, 81377, München, Germany
| | - Martin Müller
- Institute of Medical Information Processing, Biometry and Epidemiology, Ludwig-Maximilians-Universität München, Marchioninistr. 17, 81377, München, Germany. .,Faculty of Applied Health and Social Sciences, Rosenheim University of Applied Sciences, Hochschulstr.1, 83024, Rosenheim, Germany.
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Boly M, Laureys S. Functional ‘unlocking’: bedside detection of covert awareness after severe brain damage. Brain 2018; 141:1239-1241. [DOI: 10.1093/brain/awy080] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Melanie Boly
- Department of Neurology, University of Wisconsin, Madison, USA
- Department of Psychiatry, University of Wisconsin, Madison, USA
| | - Steven Laureys
- Coma Science Group, GIGA-Consciousness, University and University Hospital of Liege, Belgium
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Portaccio E, Morrocchesi A, Romoli AM, Hakiki B, Taglioli MP, Lippi E, Di Renzone M, Grippo A, Macchi C. Score on Coma Recovery Scale-Revised at admission predicts outcome at discharge in intensive rehabilitation after severe brain injury. Brain Inj 2018; 32:730-734. [DOI: 10.1080/02699052.2018.1440420] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Affiliation(s)
- Emilio Portaccio
- Intensive Rehabilitation Unit, IRCCS Don Gnocchi Foundation, Florence, Italy
- Intensive Rehabilitation Unit Study Group of the IRCCS Don Gnocchi Foundation, Italy
| | - Azzurra Morrocchesi
- Intensive Rehabilitation Unit, IRCCS Don Gnocchi Foundation, Florence, Italy
- Intensive Rehabilitation Unit Study Group of the IRCCS Don Gnocchi Foundation, Italy
| | - Anna Maria Romoli
- Intensive Rehabilitation Unit, IRCCS Don Gnocchi Foundation, Florence, Italy
- Intensive Rehabilitation Unit Study Group of the IRCCS Don Gnocchi Foundation, Italy
| | - Bahia Hakiki
- Intensive Rehabilitation Unit, IRCCS Don Gnocchi Foundation, Florence, Italy
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
- Intensive Rehabilitation Unit Study Group of the IRCCS Don Gnocchi Foundation, Italy
| | - Maria Pia Taglioli
- Intensive Rehabilitation Unit, IRCCS Don Gnocchi Foundation, Florence, Italy
- Intensive Rehabilitation Unit Study Group of the IRCCS Don Gnocchi Foundation, Italy
| | - Elena Lippi
- Intensive Rehabilitation Unit, IRCCS Don Gnocchi Foundation, Florence, Italy
- Intensive Rehabilitation Unit Study Group of the IRCCS Don Gnocchi Foundation, Italy
| | - Martina Di Renzone
- Intensive Rehabilitation Unit, IRCCS Don Gnocchi Foundation, Florence, Italy
- Intensive Rehabilitation Unit Study Group of the IRCCS Don Gnocchi Foundation, Italy
| | - Antonello Grippo
- Intensive Rehabilitation Unit, IRCCS Don Gnocchi Foundation, Florence, Italy
- Intensive Rehabilitation Unit Study Group of the IRCCS Don Gnocchi Foundation, Italy
| | - Claudio Macchi
- Intensive Rehabilitation Unit, IRCCS Don Gnocchi Foundation, Florence, Italy
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
- Intensive Rehabilitation Unit Study Group of the IRCCS Don Gnocchi Foundation, Italy
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Portaccio E, Morrocchesi A, Romoli AM, Hakiki B, Taglioli MP, Lippi E, Di Renzone M, Grippo A, Macchi C. Improvement on the Coma Recovery Scale-Revised During the First Four Weeks of Hospital Stay Predicts Outcome at Discharge in Intensive Rehabilitation After Severe Brain Injury. Arch Phys Med Rehabil 2018; 99:914-919. [PMID: 29428346 DOI: 10.1016/j.apmr.2018.01.015] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2017] [Revised: 01/11/2018] [Accepted: 01/13/2018] [Indexed: 12/01/2022]
Abstract
OBJECTIVES To evaluate the prognostic utility of serial assessment on the Coma Recovery Scale-Revised (CRS-R) during the first 4 weeks of intensive rehabilitation in patients surviving a severe brain injury. DESIGN Prospective cohort study. SETTING An intensive rehabilitation unit. PARTICIPANTS Patients (N=110) consecutively admitted to the intensive rehabilitation unit. Inclusion criteria were (1) a diagnosis of unresponsive wakefulness syndrome (UWS) or minimally conscious state (MCS) caused by an acquired brain injury, and (2) aged >18 years. INTERVENTIONS All patients underwent clinical evaluations using the Italian version of the CRS-R during the first month of hospital stay. MAIN OUTCOME MEASURES Behavioral classification on the CRS-R and the score on the Glasgow Outcome Scale (GOS) at final discharge. Patients transitioning from UWS to MCS or emergence from MCS (E-MCS), and from MCS to E-MCS were classified as patients with improved responsiveness (IR). RESULTS After a mean ± SD hospital stay of 5.3±2.7 months, 59 of 110 patients (53.6%) achieved IR. In the multivariable analysis, a higher CRS-R score change at week 4 (odds ratio =1.99; 95% confidence interval [CI], 1.49-2.66; P<.001) was the only significant predictor of IR at discharge. Fifty-three patients (48.2%) were classified as severely impaired at discharge (GOS=3). In the multivariable analysis, higher GOS scores were related to a higher CRS-R score at admission (B=.051; 95% CI, .027-.074; P<.001), a higher CRS-R score change at week 4 (B=.087; 95% CI, .064-.110; P<.001), and an absence of severe infections (B=-.477; 95% CI, -.778 to -.176; P=.002). CONCLUSIONS An improvement on the total CRS-R score and on different subscales across the first 4 weeks of inpatient rehabilitation discriminates patients who will have a better outcome at discharge, providing information for rehabilitation planning and for communication with patients and their caregivers.
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Affiliation(s)
| | | | | | - Bahia Hakiki
- IRCCS Don Gnocchi Foundation, Florence, Italy; University of Florence, Florence, Italy
| | | | - Elena Lippi
- IRCCS Don Gnocchi Foundation, Florence, Italy
| | | | | | - Claudio Macchi
- IRCCS Don Gnocchi Foundation, Florence, Italy; University of Florence, Florence, Italy
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Techniques of cognitive rehabilitation in patients with disorders of consciousness: a systematic review. Neurol Sci 2018; 39:641-645. [PMID: 29305661 DOI: 10.1007/s10072-017-3235-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2017] [Accepted: 12/18/2017] [Indexed: 12/17/2022]
Abstract
Acquired brain injury can produce severe impairments of alertness, cognition, behavior, and, sometimes, an impairment of consciousness. Several studies defined the criteria to distinguish the different level of disorders of consciousness (DOC) and many tools to evaluate awareness, alertness, and response to stimuli were created. The aim of this review is to assess the advanced research of rehabilitative protocols and which rehabilitative techniques are used in the care of DOC patients.
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45
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Bodien YG, Giacino JT, Edlow BL. Functional MRI Motor Imagery Tasks to Detect Command Following in Traumatic Disorders of Consciousness. Front Neurol 2017; 8:688. [PMID: 29326648 PMCID: PMC5741595 DOI: 10.3389/fneur.2017.00688] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2017] [Accepted: 12/01/2017] [Indexed: 11/15/2022] Open
Abstract
Severe traumatic brain injury impairs arousal and awareness, the two components of consciousness. Accurate diagnosis of a patient’s level of consciousness is critical for determining treatment goals, access to rehabilitative services, and prognosis. The bedside behavioral examination, the current clinical standard for diagnosis of disorders of consciousness, is prone to misdiagnosis, a finding that has led to the development of advanced neuroimaging techniques aimed at detection of conscious awareness. Although a variety of paradigms have been used in functional magnetic resonance imaging (fMRI) to reveal covert consciousness, the relative accuracy of these paradigms in the patient population is unknown. Here, we compare the rate of covert consciousness detection by hand squeezing and tennis playing motor imagery paradigms in 10 patients with traumatic disorders of consciousness [six male, six acute, mean ± SD age = 27.9 ± 9.1 years, one coma, four unresponsive wakefulness syndrome, two minimally conscious without language function, and three minimally conscious with language function, per bedside examination with the Coma Recovery Scale-Revised (CRS-R)]. We also tested the same paradigms in 10 healthy subjects (nine male, mean ± SD age = 28.5 ± 9.4 years). In healthy subjects, the hand squeezing paradigm detected covert command following in 7/10 and the tennis playing paradigm in 9/10 subjects. In patients who followed commands on the CRS-R, the hand squeezing paradigm detected covert command following in 2/3 and the tennis playing paradigm in 0/3 subjects. In patients who did not follow commands on the CRS-R, the hand squeezing paradigm detected command following in 1/7 and the tennis playing paradigm in 2/7 subjects. The sensitivity, specificity, and accuracy (ACC) of detecting covert command following in patients who demonstrated this behavior on the CRS-R was 66.7, 85.7, and 80% for the hand squeezing paradigm and 0, 71.4, and 50% for the tennis playing paradigm, respectively. Overall, the tennis paradigm performed better than the hand squeezing paradigm in healthy subjects, but in patients, the hand squeezing paradigm detected command following with greater ACC. These findings indicate that current fMRI motor imagery paradigms frequently fail to detect command following and highlight the need for paradigm optimization to improve the accuracy of covert consciousness detection.
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Affiliation(s)
- Yelena G Bodien
- Center for Neurotechnology and Neurorecovery, and Laboratory for NeuroImaging of Coma and Consciousness, Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States.,Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Harvard Medical School, Boston, MA, United States
| | - Joseph T Giacino
- Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Harvard Medical School, Boston, MA, United States.,Department of Psychiatry, Massachusetts General Hospital and Harvard Medical School, Boston, MA, United States
| | - Brian L Edlow
- Center for Neurotechnology and Neurorecovery, and Laboratory for NeuroImaging of Coma and Consciousness, Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States.,Athinoula A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital and Harvard Medical School, Charlestown, MA, United States
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Khanmohammadi S, Kummer TT, Ching S. Identifying Disruptions in Intrinsic Brain Dynamics due to Severe Brain Injury. CONFERENCE RECORD. ASILOMAR CONFERENCE ON SIGNALS, SYSTEMS & COMPUTERS 2017; 2017:344-348. [PMID: 31896930 PMCID: PMC6939854 DOI: 10.1109/acssc.2017.8335197] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Recent studies suggest that disruptions in resting state functional connectivity - a measure of stationary statistical association between brain regions - can be used as an objective marker of brain injury. However, fewer characterizations have examined the disruption of intrinsic brain dynamics after brain injury. Here, we examine this issue using electroencephalographic (EEG) data from brain-injured patients, together with a control analysis wherein we quantify the effect of the injury on the ability of intrinsic event responses to traverse their respective state spaces. More specifically, the lability of intrinsically evoked brain activity was assessed by collapsing three sigma event responses in all channels of the obtained EEG signals into a low-dimensional space. The directional derivative of these responses was then used to assay the extent to which brain activity reaches low-variance subspaces. Our findings suggest that intrinsic dynamics extracted from resting state EEG signals can differentiate various levels of consciousness in severe cases of coma. More specifically the cost of moving from one state to another in the state-space trajectories of the underlying dynamics becomes lower as the level of consciousness of patients deteriorates.
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Affiliation(s)
- Sina Khanmohammadi
- Department of Electrical & Systems Engineering, Washington University in St. Louis, St. Louis, MO-63130, USA
- Department of Neurology, Washington University School of Medicine, St. Louis, MO-63110, USA
| | - Terrance T Kummer
- Department of Neurology, Washington University School of Medicine, St. Louis, MO-63110, USA
| | - ShiNung Ching
- Department of Electrical & Systems Engineering, Washington University in St. Louis, St. Louis, MO-63130, USA
- Department of Biomedical Engineering, Washington University in St. Louis, St. Louis, MO-63130, USA
- Division of Biology and Biomedical Science, Washington University in St. Louis, St. Louis, MO-63130, USA
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Wannez S, Heine L, Thonnard M, Gosseries O, Laureys S. The repetition of behavioral assessments in diagnosis of disorders of consciousness. Ann Neurol 2017; 81:883-889. [PMID: 28543735 DOI: 10.1002/ana.24962] [Citation(s) in RCA: 226] [Impact Index Per Article: 32.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2016] [Revised: 05/11/2017] [Accepted: 05/12/2017] [Indexed: 11/08/2022]
Abstract
OBJECTIVE To determine whether repeated examinations using the Coma Recovery Scale-Revised (CRS-R) have an impact on diagnostic accuracy of patients with disorders of consciousness and to provide guidelines regarding the number of assessments required for obtaining a reliable diagnosis. METHODS One hundred twenty-three adult patients with chronic disorders of consciousness were referred to our tertiary center. They were assessed at least six times with the CRS-R within a 10-day period. Clinical diagnoses based on one, two, three, four, and five Coma Recovery Scale-Revised assessments were compared with a reference diagnosis (ie, the highest behavioral diagnosis obtained after six evaluations) using nonparametric statistics. Results were considered significant at p < 0.05 corrected for multiple comparisons. RESULTS The number of assessments had a significant effect on the clinical diagnosis. Up to the fourth examination, the diagnosis was still statistically different from the reference diagnosis based on six CRS-R assessments. Compared to this reference diagnosis, the first evaluation led to 36% of misdiagnoses. INTERPRETATION The number of CRS-R assessments has an impact on the clinical diagnosis of patients with chronic disorders of consciousness. Up to the fourth examinations, behavioral fluctuations may still impact the diagnostic accuracy. We here suggest performing at least five assessments in each patient with disorders of consciousness within a short time interval (eg, 2 weeks) to reduce misdiagnosis. Ann Neurol 2017;81:883-889 Ann Neurol 2017;81:883-889.
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Affiliation(s)
- Sarah Wannez
- Coma Science Group, GIGA-Research & Neurology Department, University and University Hospital of Liege, Liege, Belgium
| | - Lizette Heine
- Coma Science Group, GIGA-Research & Neurology Department, University and University Hospital of Liege, Liege, Belgium.,Centre de recherche en neuroscience de Lyon (CRNL), équipe CAP, INSERM, U1028, CNRS, UMR5292, Lyon, France
| | - Marie Thonnard
- Coma Science Group, GIGA-Research & Neurology Department, University and University Hospital of Liege, Liege, Belgium
| | - Olivia Gosseries
- Coma Science Group, GIGA-Research & Neurology Department, University and University Hospital of Liege, Liege, Belgium.,Department of Psychiatry, University of Wisconsin, Madison, WI
| | - Steven Laureys
- Coma Science Group, GIGA-Research & Neurology Department, University and University Hospital of Liege, Liege, Belgium
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Pallesen H, Lund LB, Jensen M, Roenn-Smidt H. The body participating: a qualitative study of early rehabilitation participation for patients with severe brain injury and low level of consciousness. EUROPEAN JOURNAL OF PHYSIOTHERAPY 2017. [DOI: 10.1080/21679169.2017.1347706] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Affiliation(s)
- Hanne Pallesen
- Hammel Neurorehabilitation Centre and University Research Clinic, RM, University of Aarhus, Arhus, Denmark
| | | | - Marianne Jensen
- Hammel Neurorehabilitation Centre and University Research Clinic, RM, University of Aarhus, Arhus, Denmark
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Zhang J, Wei RL, Peng GP, Zhou JJ, Wu M, He FP, Pan G, Gao J, Luo BY. Correlations between diffusion tensor imaging and levels of consciousness in patients with traumatic brain injury: a systematic review and meta-analysis. Sci Rep 2017; 7:2793. [PMID: 28584256 PMCID: PMC5459858 DOI: 10.1038/s41598-017-02950-3] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2017] [Accepted: 04/26/2017] [Indexed: 12/19/2022] Open
Abstract
Traumatic brain injury (TBI) often leads to impaired consciousness. Recent diffusion tensor imaging studies associated consciousness with imaging metrics including fractional anisotropy (FA) and apparent diffusion coefficient (ADC). We evaluated their correlations and determined the best index in candidate regions. Six databases were searched, including PubMed and Embase, and 16 studies with 701 participants were included. Data from region-of-interest and whole-brain analysis methods were meta-analysed separately. The FA-consciousness correlation was marginal in the whole-brain white matter (r = 0.63, 95% CI [0.47, 0.79], p = 0.000) and the corpus callosum (CC) (r = 0.60, 95% CI [0.48, 0.71], p = 0.000), and moderate in the internal capsule (r = 0.48, 95% CI [0.24, 0.72], p = 0.000). Correlations with ADC trended negative and lacked significance. Further subgroup analysis revealed that consciousness levels correlated strongly with FA in the CC body (r = 0.66, 95% CI [0.43, 0.89]), moderately in the splenium (r = 0.58, 95% CI [0.38, 0.78]), but insignificantly in the genu. In conclusion, FA correlates better with consciousness levels than ADC in TBI. The degree of correlation varies among brain regions. The CC (especially its splenium and body) is a reliable candidate region to quantitatively reflect consciousness levels.
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Affiliation(s)
- Jie Zhang
- Department of Neurology & Brain Medical Centre, The First Affiliated Hospital, Zhejiang University, Hangzhou, China
| | - Rui-Li Wei
- Department of Neurology & Brain Medical Centre, The First Affiliated Hospital, Zhejiang University, Hangzhou, China
| | - Guo-Ping Peng
- Department of Neurology & Brain Medical Centre, The First Affiliated Hospital, Zhejiang University, Hangzhou, China
| | - Jia-Jia Zhou
- Department of Neurology & Brain Medical Centre, The First Affiliated Hospital, Zhejiang University, Hangzhou, China
| | - Min Wu
- Department of Neurology & Brain Medical Centre, The First Affiliated Hospital, Zhejiang University, Hangzhou, China
| | - Fang-Ping He
- Department of Neurology & Brain Medical Centre, The First Affiliated Hospital, Zhejiang University, Hangzhou, China
| | - Gang Pan
- Department of Computer Science, Zhejiang University, Hangzhou, China
| | - Jian Gao
- Department of Rehabilitation, Hangzhou Hospital of Zhejiang CAPR, Hangzhou, China
| | - Ben-Yan Luo
- Department of Neurology & Brain Medical Centre, The First Affiliated Hospital, Zhejiang University, Hangzhou, China.
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50
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Day KV, DiNapoli MV, Whyte J. Detecting early recovery of consciousness: a comparison of methods. Neuropsychol Rehabil 2017; 28:1233-1241. [PMID: 28385054 DOI: 10.1080/09602011.2017.1309322] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Early detection of the return of consciousness has important implications for prognosis and rehabilitation access. The aim of this study was to compare the Coma Recovery Scale-Revised (CRS-R) with individualised quantitative behavioural assessments (IQBA) to determine which method is capable of detecting command-following earlier and more consistently in persons with disorders of consciousness (DoC). Data from 27 patients with DoC, who underwent both assessments concurrently during inpatient rehabilitation, were retrospectively analysed. For each person, performance trajectories on the CRS-R auditory subscale item and IQBA dual command protocols were graphed together to identify earlier and more consistent evidence of consciousness; grouped data were analysed statistically. For 22 patients, IQBA more consistently documented consciousness than the CRS-R, whereas no patients showed the reverse pattern. For 14 of 20 analysable patients, IQBA provided earlier evidence of consciousness, for two patients CRS-R provided earlier evidence, and for four patients both methods provided initial evidence on the same day. These findings suggest that IQBA approaches can provide more consistent and earlier evidence of command-following than the comparable item on the CRS-R. Whether this advantage is due to the individualisation of IQBA or the greater volume of data gathered requires further research.
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Affiliation(s)
- Kristin V Day
- a Department of Physical Therapy , Arcadia University , Glenside , PA , USA.,b Moss Rehabilitation Research Institute, Einstein Healthcare Network , Elkins Park , PA , USA
| | | | - John Whyte
- b Moss Rehabilitation Research Institute, Einstein Healthcare Network , Elkins Park , PA , USA
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