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Kondziella D, Bender A, Diserens K, van Erp W, Estraneo A, Formisano R, Laureys S, Naccache L, Ozturk S, Rohaut B, Sitt JD, Stender J, Tiainen M, Rossetti AO, Gosseries O, Chatelle C. European Academy of Neurology guideline on the diagnosis of coma and other disorders of consciousness. Eur J Neurol 2020; 27:741-756. [PMID: 32090418 DOI: 10.1111/ene.14151] [Citation(s) in RCA: 291] [Impact Index Per Article: 72.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2019] [Accepted: 01/09/2020] [Indexed: 12/20/2022]
Abstract
BACKGROUND AND PURPOSE Patients with acquired brain injury and acute or prolonged disorders of consciousness (DoC) are challenging. Evidence to support diagnostic decisions on coma and other DoC is limited but accumulating. This guideline provides the state-of-the-art evidence regarding the diagnosis of DoC, summarizing data from bedside examination techniques, functional neuroimaging and electroencephalography (EEG). METHODS Sixteen members of the European Academy of Neurology (EAN) Scientific Panel on Coma and Chronic Disorders of Consciousness, representing 10 European countries, reviewed the scientific evidence for the evaluation of coma and other DoC using standard bibliographic measures. Recommendations followed the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system. The guideline was endorsed by the EAN. RESULTS Besides a comprehensive neurological examination, the following suggestions are made: probe for voluntary eye movements using a mirror; repeat clinical assessments in the subacute and chronic setting, using the Coma Recovery Scale - Revised; use the Full Outline of Unresponsiveness score instead of the Glasgow Coma Scale in the acute setting; obtain clinical standard EEG; search for sleep patterns on EEG, particularly rapid eye movement sleep and slow-wave sleep; and, whenever feasible, consider positron emission tomography, resting state functional magnetic resonance imaging (fMRI), active fMRI or EEG paradigms and quantitative analysis of high-density EEG to complement behavioral assessment in patients without command following at the bedside. CONCLUSIONS Standardized clinical evaluation, EEG-based techniques and functional neuroimaging should be integrated for multimodal evaluation of patients with DoC. The state of consciousness should be classified according to the highest level revealed by any of these three approaches.
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Affiliation(s)
- D Kondziella
- Department of Neurology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark.,Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark.,Department of Neurosciences, Norwegian University of Science and Technology, Trondheim, Norway
| | - A Bender
- Department of Neurology, Ludwig-Maximilians-Universität München, Munich, Germany.,Therapiezentrum Burgau, Burgau, Germany
| | - K Diserens
- Department of Clinical Neurosciences, Centre Hospitalier Universitaire Vaudois and University of Lausanne, Lausanne, Switzerland
| | - W van Erp
- Coma Science Group, GIGA Consciousness, University and University Hospital of Liège, Liège, Belgium.,Department of Primary Care, Radboud University Medical Center, Nijmegen, The Netherlands
| | - A Estraneo
- Neurology Unit, Santa Maria della Pietà General Hospital, Nola, Italy.,IRCCS Fondazione don Carlo Gnocchi ONLUS, Florence, Italy
| | - R Formisano
- Post-Coma Unit, Neurorehabilitation Hospital and Research Institution, Santa Lucia Foundation, Rome, Italy
| | - S Laureys
- Coma Science Group, GIGA Consciousness, University and University Hospital of Liège, Liège, Belgium
| | - L Naccache
- Department of Neurology, AP-HP, Groupe hospitalier Pitié-Salpêtrière, Paris, France.,Sorbonne Université, UPMC Univ Paris 06, Faculté de Médecine Pitié-Salpêtrière, Paris, France
| | - S Ozturk
- Department of Neurology, Faculty of Medicine, Selcuk University, Konya, Turkey
| | - B Rohaut
- Department of Neurology, AP-HP, Groupe hospitalier Pitié-Salpêtrière, Paris, France.,Sorbonne Université, UPMC Univ Paris 06, Faculté de Médecine Pitié-Salpêtrière, Paris, France.,Neuro-ICU, Department of Neurology, Columbia University, New York, NY, USA
| | - J D Sitt
- Sorbonne Université, UPMC Univ Paris 06, Faculté de Médecine Pitié-Salpêtrière, Paris, France
| | - J Stender
- Department of Neurosurgery, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - M Tiainen
- Department of Neurology, Helsinki University Hospital, Helsinki, Finland
| | - A O Rossetti
- Department of Clinical Neurosciences, Centre Hospitalier Universitaire Vaudois and University of Lausanne, Lausanne, Switzerland
| | - O Gosseries
- Coma Science Group, GIGA Consciousness, University and University Hospital of Liège, Liège, Belgium
| | - C Chatelle
- Coma Science Group, GIGA Consciousness, University and University Hospital of Liège, Liège, Belgium.,Laboratory for NeuroImaging of Coma and Consciousness - Department of Neurology, Harvard Medical School, Massachusetts General Hospital, Boston, MA, USA
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Kondziella D, Friberg CK, Frokjaer VG, Fabricius M, Møller K. Preserved consciousness in vegetative and minimal conscious states: systematic review and meta-analysis. J Neurol Neurosurg Psychiatry 2016; 87:485-92. [PMID: 26139551 DOI: 10.1136/jnnp-2015-310958] [Citation(s) in RCA: 159] [Impact Index Per Article: 19.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2015] [Accepted: 06/18/2015] [Indexed: 11/04/2022]
Abstract
Active, passive and resting state paradigms using functional MRI (fMRI) or EEG may reveal consciousness in the vegetative (VS) and the minimal conscious state (MCS). A meta-analysis was performed to assess the prevalence of preserved consciousness in VS and MCS as revealed by fMRI and EEG, including command following (active paradigms), cortical functional connectivity elicited by external stimuli (passive paradigms) and default mode networks (resting state). Studies were selected from multiple indexing databases until February 2015 and evaluated using the Quality Assessment of Diagnostic Accuracy Studies-2. 37 studies were identified, including 1041 patients (mean age 43 years, range 16-89; male/female 2.1:1; 39.5% traumatic brain injuries). MCS patients were more likely than VS patients to follow commands during active paradigms (32% vs 14%; OR 2.85 (95% CI 1.90 to 4.27; p<0.0001)) and to show preserved functional cortical connectivity during passive paradigms (55% vs 26%; OR 3.53 (95% CI 2.49 to 4.99; p<0.0001)). Passive paradigms suggested preserved consciousness more often than active paradigms (38% vs 24%; OR 1.98 (95% CI 1.54 to 2.54; p<0.0001)). Data on resting state paradigms were insufficient for statistical evaluation. In conclusion, active paradigms may underestimate the degree of consciousness as compared to passive paradigms. While MCS patients show signs of preserved consciousness more frequently in both paradigms, roughly 15% of patients with a clinical diagnosis of VS are able to follow commands by modifying their brain activity. However, there remain important limitations at the single-subject level; for example, patients from both categories may show command following despite negative passive paradigms.
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Affiliation(s)
- Daniel Kondziella
- Department of Neurology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark Institute of Neuroscience, Norwegian University of Science and Technology, Trondheim, Norway
| | - Christian K Friberg
- Department of Clinical Neurophysiology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Vibe G Frokjaer
- Neurobiology Research Unit, Copenhagen University Hospital and Center for Integrated Molecular Brain Imaging, Copenhagen, Denmark
| | - Martin Fabricius
- Department of Clinical Neurophysiology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Kirsten Møller
- Department of Neuroanesthesiology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
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McDowell MM, Kellner CP, Barton SM, Mikell CB, Sussman ES, Heuts SG, Connolly ES. The role of advanced neuroimaging in intracerebral hemorrhage. Neurosurg Focus 2014; 34:E2. [PMID: 23544408 DOI: 10.3171/2013.1.focus12409] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
In this report, the authors sought to summarize existing literature to provide an overview of the currently available techniques and to critically assess the evidence for or against their application in intracerebral hemorrhage (ICH) for management, prognostication, and research. Functional imaging in ICH represents a potential major step forward in the ability of physicians to assess patients suffering from this devastating illness due to the advantages over standing imaging modalities focused on general tissue structure alone, but its use is highly controversial due to the relative paucity of literature and the lack of consolidation of the predominantly small data sets that are currently in existence. Current data support that diffusion tensor imaging and tractography, diffusion-perfusion weighted MRI techniques, and functional MRI all possess major potential in the areas of highlighting motor deficits, motor recovery, and network reorganization. Novel clinical studies designed to objectively assess the value of each of these modalities on a wider scale in conjunction with other methods of investigation and management will allow for their rapid incorporation into standard practice.
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Affiliation(s)
- Michael M McDowell
- Department of Neurological Surgery, Columbia University, New York, New York, USA
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