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Ge Q, Lu H, Geng X, Chen X, Liu X, Sun H, Guo Z, Sun J, Qi F, Niu X, Wang A, He J, Sun W, Xu L. Serum metabolism alteration behind different etiology, diagnosis, and prognosis of disorders of consciousness. Chin Neurosurg J 2024; 10:12. [PMID: 38594757 PMCID: PMC11003070 DOI: 10.1186/s41016-024-00365-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2023] [Accepted: 03/26/2024] [Indexed: 04/11/2024] Open
Abstract
BACKGROUND Patients with disorders of consciousness (DoC) exhibit varied revival outcomes based on different etiologies and diagnoses, the mechanisms of which remain largely unknown. The fluctuating clinical presentations in DoC pose challenges in accurately assessing consciousness levels and prognoses, often leading to misdiagnoses. There is an urgent need for a deeper understanding of the physiological changes in DoC and the development of objective diagnostic and prognostic biomarkers to improve treatment guidance. METHODS To explore biomarkers and understand the biological processes, we conducted a comprehensive untargeted metabolomic analysis on serum samples from 48 patients with DoC. Patients were categorized based on etiology (TBI vs. non-TBI), CRS-R scores, and prognosis. Advanced analytical techniques, including PCA and OPLS-DA models, were employed to identify differential metabolites. RESULTS Our analysis revealed a distinct separation in metabolomic profiles among the different groups. The primary differential metabolites distinguishing patients with varying etiologies were predominantly phospholipids, with a notable decrease in glycerophospholipids observed in the TBI group. Patients with higher CRS-R scores exhibited a pattern of impaired carbohydrate metabolism coupled with enhanced lipid metabolism. Notably, serum concentrations of both LysoPE and PE were reduced in patients with improved outcomes, suggesting their potential as prognostic biomarkers. CONCLUSIONS Our study underscores the critical role of phospholipid metabolism in the brain's metabolic alterations in patients with DoC. It identifies key biomarkers for diagnosis and prognosis, offering insights that could lead to novel therapeutic targets. These findings highlight the value of metabolomic profiling in understanding and potentially treating DoC.
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Affiliation(s)
- Qianqian Ge
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Hezhen Lu
- China-Japan Union Hospital of Jilin University, Changchun, China
- Core Instrument Facility, Institute of Basic Medical Sciences, Chinese Academy of Medical Sciences, School of Basic Medicine, Peking Union Medical College, Beijing, China
| | - Xiaoli Geng
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Xueling Chen
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Xiaoyan Liu
- Core Instrument Facility, Institute of Basic Medical Sciences, Chinese Academy of Medical Sciences, School of Basic Medicine, Peking Union Medical College, Beijing, China
| | - Haidan Sun
- Core Instrument Facility, Institute of Basic Medical Sciences, Chinese Academy of Medical Sciences, School of Basic Medicine, Peking Union Medical College, Beijing, China
| | - Zhengguang Guo
- Core Instrument Facility, Institute of Basic Medical Sciences, Chinese Academy of Medical Sciences, School of Basic Medicine, Peking Union Medical College, Beijing, China
| | - Jiameng Sun
- Core Instrument Facility, Institute of Basic Medical Sciences, Chinese Academy of Medical Sciences, School of Basic Medicine, Peking Union Medical College, Beijing, China
| | - Feng Qi
- Core Instrument Facility, Institute of Basic Medical Sciences, Chinese Academy of Medical Sciences, School of Basic Medicine, Peking Union Medical College, Beijing, China
| | - Xia Niu
- Core Instrument Facility, Institute of Basic Medical Sciences, Chinese Academy of Medical Sciences, School of Basic Medicine, Peking Union Medical College, Beijing, China
| | - Aiwei Wang
- Core Instrument Facility, Institute of Basic Medical Sciences, Chinese Academy of Medical Sciences, School of Basic Medicine, Peking Union Medical College, Beijing, China
| | - Jianghong He
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases (NCRC-ND), Beijing, China
| | - Wei Sun
- Core Instrument Facility, Institute of Basic Medical Sciences, Chinese Academy of Medical Sciences, School of Basic Medicine, Peking Union Medical College, Beijing, China.
| | - Long Xu
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.
- China National Clinical Research Center for Neurological Diseases (NCRC-ND), Beijing, China.
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2
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Șerban CA, Barborică A, Roceanu AM, Mîndruță IR, Ciurea J, Stancu M, Pâslaru AC, Zăgrean AM, Zăgrean L, Moldovan M. Towards an electroencephalographic measure of awareness based on the reactivity of oscillatory macrostates to hearing a subject's own name. Eur J Neurosci 2024; 59:771-785. [PMID: 37675619 DOI: 10.1111/ejn.16138] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Revised: 08/09/2023] [Accepted: 08/16/2023] [Indexed: 09/08/2023]
Abstract
We proposed that the brain's electrical activity is composed of a sequence of alternating states with repeating topographic spectral distributions on scalp electroencephalogram (EEG), referred to as oscillatory macrostates. The macrostate showing the largest decrease in the probability of occurrence, measured as a percentage (reactivity), during sensory stimulation was labelled as the default EEG macrostate (DEM). This study aimed to assess the influence of awareness on DEM reactivity (DER). We included 11 middle cerebral artery ischaemic stroke patients with impaired awareness having a median Glasgow Coma Scale (GCS) of 6/15 and a group of 11 matched healthy controls. EEG recordings were carried out during auditory 1 min stimulation epochs repeating either the subject's own name (SON) or the SON in reverse (rSON). The DEM was identified across three SON epochs alternating with three rSON epochs. Compared with the patients, the DEM of controls contained more posterior theta activity reflecting source dipoles that could be mapped in the posterior cingulate cortex. The DER was measured from the 1 min quiet baseline preceding each stimulation epoch. The difference in mean DER between the SON and rSON epochs was measured by the salient EEG reactivity (SER) theoretically ranging from -100% to 100%. The SER was 12.4 ± 2.7% (Mean ± standard error of the mean) in controls and only 1.3 ± 1.9% in the patient group (P < 0.01). The patient SER decreased with the Glasgow Coma Scale. Our data suggest that awareness increases DER to SON as measured by SER.
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Affiliation(s)
- Cosmin-Andrei Șerban
- Physics Department, University of Bucharest, Bucharest, Romania
- Termobit Prod SRL, Bucharest, Romania
- FHC Inc, Bowdoin, Maine, USA
| | - Andrei Barborică
- Physics Department, University of Bucharest, Bucharest, Romania
- Termobit Prod SRL, Bucharest, Romania
- FHC Inc, Bowdoin, Maine, USA
| | | | | | - Jan Ciurea
- Department of Neurosurgery, Bagdasar-Arseni Emergency Hospital, Bucharest, Romania
| | - Mihai Stancu
- Division of Physiology and Neuroscience, Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
- Division of Neurobiology, Faculty of Biology, Ludwig Maximilian University, Munich, Germany
| | - Alexandru C Pâslaru
- Division of Physiology and Neuroscience, Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
| | - Ana-Maria Zăgrean
- Division of Physiology and Neuroscience, Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
| | - Leon Zăgrean
- Division of Physiology and Neuroscience, Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
| | - Mihai Moldovan
- Termobit Prod SRL, Bucharest, Romania
- Division of Physiology and Neuroscience, Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
- Department of Neuroscience, University of Copenhagen, Copenhagen, Denmark
- Clinical Neurophysiology and Neurology, Rigshospitalet, Copenhagen, Denmark
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3
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McLinden J, Rahimi N, Kumar C, Krusienski DJ, Shao M, Spencer KM, Shahriari Y. Investigation of electro-vascular phase-amplitude coupling during an auditory task. Comput Biol Med 2024; 169:107902. [PMID: 38159399 DOI: 10.1016/j.compbiomed.2023.107902] [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: 09/06/2023] [Revised: 11/24/2023] [Accepted: 12/23/2023] [Indexed: 01/03/2024]
Abstract
Multimodal neuroimaging using electroencephalography (EEG) and functional near-infrared spectroscopy (fNIRS) provides complementary views of cortical processes, including those related to auditory processing. However, current multimodal approaches often overlook potential insights that can be gained from nonlinear interactions between electrical and hemodynamic signals. Here, we explore electro-vascular phase-amplitude coupling (PAC) between low-frequency hemodynamic and high-frequency electrical oscillations during an auditory task. We further apply a temporally embedded canonical correlation analysis (tCCA)-general linear model (GLM)-based correction approach to reduce the possible effect of systemic physiology on fNIRS recordings. Before correction, we observed significant PAC between fNIRS and broadband EEG in the frontal region (p ≪ 0.05), β (p ≪ 0.05) and γ (p = 0.010) in the left temporal/temporoparietal (left auditory; LA) region, and γ (p = 0.032) in the right temporal/temporoparietal (right auditory; RA) region across the entire dataset. Significant differences in PAC across conditions (task versus silence) were observed in LA (p = 0.023) and RA (p = 0.049) γ sub-bands and in lower frequency (5-20 Hz) frontal activity (p = 0.005). After correction, significant fNIRS-γ-band PAC was observed in the frontal (p = 0.021) and LA (p = 0.025) regions, while fNIRS-α (p = 0.003) and fNIRS-β (p = 0.041) PAC were observed in RA. Decreased frontal γ-band (p = 0.008) and increased β-band (p ≪ 0.05) PAC were observed during the task. These outcomes represent the first characterization of electro-vascular PAC between fNIRS and EEG signals during an auditory task, providing insights into electro-vascular coupling in auditory processing.
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Affiliation(s)
- J McLinden
- Department of Electrical, Computer, and Biomedical Engineering, University of Rhode Island, Kingston, RI, USA
| | - N Rahimi
- Department of Computer and Information Science, University of Massachusetts Dartmouth, MA, USA
| | - C Kumar
- Department of Computer and Information Science, University of Massachusetts Dartmouth, MA, USA
| | - D J Krusienski
- Department of Biomedical Engineering, Virginia Commonwealth University, Richmond, VA, USA
| | - M Shao
- Department of Computer and Information Science, University of Massachusetts Dartmouth, MA, USA
| | - K M Spencer
- Department of Psychiatry, VA Boston Healthcare System and Harvard Medical School, Boston, MA, USA
| | - Y Shahriari
- Department of Electrical, Computer, and Biomedical Engineering, University of Rhode Island, Kingston, RI, USA.
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4
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Wang F, Wan Y, Li Z, Qi F, Li J. A cross-subject decoding algorithm for patients with disorder of consciousness based on P300 brain computer interface. Front Neurosci 2023; 17:1167125. [PMID: 37547152 PMCID: PMC10398338 DOI: 10.3389/fnins.2023.1167125] [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: 02/16/2023] [Accepted: 06/19/2023] [Indexed: 08/08/2023] Open
Abstract
Background Brain computer interface (BCI) technology may provide a new way of communication for some patients with disorder of consciousness (DOC), which can directly connect the brain and external devices. However, the DOC patients' EEG differ significantly from that of the normal person and are difficult to collected, the decoding algorithm currently only is trained based on a small amount of the patient's own data and performs poorly. Methods In this study, a decoding algorithm called WD-ADSTCN based on domain adaptation is proposed to improve the DOC patients' P300 signal detection. We used the Wasserstein distance to filter the normal population data to increase the training data. Furthermore, an adversarial approach is adopted to resolve the differences between the normal and patient data. Results The results showed that in the cross-subject P300 detection of DOC patients, 7 of 11 patients achieved an average accuracy of over 70%. Furthermore, their clinical diagnosis changed and CRS-R scores improved three months after the experiment. Conclusion These results demonstrated that the proposed method could be employed in the P300 BCI system for the DOC patients, which has important implications for the clinical diagnosis and prognosis of these patients.
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Affiliation(s)
- Fei Wang
- School of Software, South China Normal University, Guangzhou, China
- Pazhou Lab, Guangzhou, China
| | - Yinxing Wan
- School of Software, South China Normal University, Guangzhou, China
| | - Zhuorong Li
- School of Software, South China Normal University, Guangzhou, China
| | - Feifei Qi
- Pazhou Lab, Guangzhou, China
- School of Internet Finance and Information Engineering, Guangdong University of Finance, Guangzhou, China
| | - Jingcong Li
- School of Software, South China Normal University, Guangzhou, China
- Pazhou Lab, Guangzhou, China
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5
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Galiotta V, Quattrociocchi I, D'Ippolito M, Schettini F, Aricò P, Sdoia S, Formisano R, Cincotti F, Mattia D, Riccio A. EEG-based Brain-Computer Interfaces for people with Disorders of Consciousness: Features and applications. A systematic review. Front Hum Neurosci 2022; 16:1040816. [PMID: 36545350 PMCID: PMC9760911 DOI: 10.3389/fnhum.2022.1040816] [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: 09/09/2022] [Accepted: 11/17/2022] [Indexed: 12/11/2022] Open
Abstract
Background Disorders of Consciousness (DoC) are clinical conditions following a severe acquired brain injury (ABI) characterized by absent or reduced awareness, known as coma, Vegetative State (VS)/Unresponsive Wakefulness Syndrome (VS/UWS), and Minimally Conscious State (MCS). Misdiagnosis rate between VS/UWS and MCS is attested around 40% due to the clinical and behavioral fluctuations of the patients during bedside consciousness assessments. Given the large body of evidence that some patients with DoC possess "covert" awareness, revealed by neuroimaging and neurophysiological techniques, they are candidates for intervention with brain-computer interfaces (BCIs). Objectives The aims of the present work are (i) to describe the characteristics of BCI systems based on electroencephalography (EEG) performed on DoC patients, in terms of control signals adopted to control the system, characteristics of the paradigm implemented, classification algorithms and applications (ii) to evaluate the performance of DoC patients with BCI. Methods The search was conducted on Pubmed, Web of Science, Scopus and Google Scholar. The PRISMA guidelines were followed in order to collect papers published in english, testing a BCI and including at least one DoC patient. Results Among the 527 papers identified with the first run of the search, 27 papers were included in the systematic review. Characteristics of the sample of participants, behavioral assessment, control signals employed to control the BCI, the classification algorithms, the characteristics of the paradigm, the applications and performance of BCI were the data extracted from the study. Control signals employed to operate the BCI were: P300 (N = 19), P300 and Steady-State Visual Evoked Potentials (SSVEP; hybrid system, N = 4), sensorimotor rhythms (SMRs; N = 5) and brain rhythms elicited by an emotional task (N = 1), while assessment, communication, prognosis, and rehabilitation were the possible applications of BCI in DoC patients. Conclusion Despite the BCI is a promising tool in the management of DoC patients, supporting diagnosis and prognosis evaluation, results are still preliminary, and no definitive conclusions may be drawn; even though neurophysiological methods, such as BCI, are more sensitive to covert cognition, it is suggested to adopt a multimodal approach and a repeated assessment strategy.
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Affiliation(s)
- Valentina Galiotta
- Neuroelectric Imaging and Brain-Computer Interface Laboratory, Fondazione Santa Lucia (IRCCS), Rome, Italy,Department of Psychology, Sapienza University of Rome, Rome, Italy
| | - Ilaria Quattrociocchi
- Neuroelectric Imaging and Brain-Computer Interface Laboratory, Fondazione Santa Lucia (IRCCS), Rome, Italy,Department of Computer, Control, and Management Engineering “Antonio Ruberti”, Sapienza University of Rome, Rome, Italy
| | - Mariagrazia D'Ippolito
- Neuroelectric Imaging and Brain-Computer Interface Laboratory, Fondazione Santa Lucia (IRCCS), Rome, Italy,*Correspondence: Mariagrazia D'Ippolito
| | - Francesca Schettini
- Neuroelectric Imaging and Brain-Computer Interface Laboratory, Fondazione Santa Lucia (IRCCS), Rome, Italy,Servizio di Ausilioteca per la Riabilitazione Assistita con Tecnologia, Fondazione Santa Lucia (IRCCS), Rome, Italy
| | - Pietro Aricò
- Department of Computer, Control, and Management Engineering “Antonio Ruberti”, Sapienza University of Rome, Rome, Italy,Department of Molecular Medicine, Sapienza University of Rome, Rome, Italy,BrainSigns srl, Rome, Italy
| | - Stefano Sdoia
- Department of Psychology, Sapienza University of Rome, Rome, Italy
| | - Rita Formisano
- Neurorehabilitation 2 and Post-Coma Unit, Fondazione Santa Lucia (IRCCS), Rome, Italy
| | - Febo Cincotti
- Department of Computer, Control, and Management Engineering “Antonio Ruberti”, Sapienza University of Rome, Rome, Italy
| | - Donatella Mattia
- Neuroelectric Imaging and Brain-Computer Interface Laboratory, Fondazione Santa Lucia (IRCCS), Rome, Italy,Servizio di Ausilioteca per la Riabilitazione Assistita con Tecnologia, Fondazione Santa Lucia (IRCCS), Rome, Italy
| | - Angela Riccio
- Neuroelectric Imaging and Brain-Computer Interface Laboratory, Fondazione Santa Lucia (IRCCS), Rome, Italy,Servizio di Ausilioteca per la Riabilitazione Assistita con Tecnologia, Fondazione Santa Lucia (IRCCS), Rome, Italy
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6
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Pan J, Xiao J, Wang J, Wang F, Li J, Qiu L, Di H, Li Y. Brain-Computer Interfaces for Awareness Detection, Auxiliary Diagnosis, Prognosis and Rehabilitation in Patients with Disorders of Consciousness. Semin Neurol 2022; 42:363-374. [PMID: 35835448 DOI: 10.1055/a-1900-7261] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Affiliation(s)
- Jiahui Pan
- Pazhou Lab, Guangzhou, China.,South China Normal University, Guangzhou, China
| | - Jun Xiao
- Pazhou Lab, Guangzhou, China.,South China University of Technology, Guangzhou, China
| | - Jing Wang
- Hangzhou Normal University, Hangzhou, China
| | - Fei Wang
- Pazhou Lab, Guangzhou, China.,South China Normal University, Guangzhou, China
| | - Jingcong Li
- Pazhou Lab, Guangzhou, China.,South China Normal University, Guangzhou, China
| | - Lina Qiu
- South China Normal University, Guangzhou, China
| | - Haibo Di
- Hangzhou Normal University, Hangzhou, China
| | - Yuanqing Li
- Pazhou Lab, Guangzhou, China.,South China University of Technology, Guangzhou, China
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7
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Xiao J, He Y, Yu T, Pan J, Xie Q, Cao C, Zheng H, Huang W, Gu Z, Yu Z, Li Y. Towards Assessment of Sound Localization in Disorders of Consciousness Using a Hybrid Audiovisual Brain-Computer Interface. IEEE Trans Neural Syst Rehabil Eng 2022; 30:1422-1432. [PMID: 35584066 DOI: 10.1109/tnsre.2022.3176354] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Behavioral assessment of sound localization in the Coma Recovery Scale-Revised (CRS-R) poses a significant challenge due to motor disability in patients with disorders of consciousness (DOC). Brain-computer interfaces (BCIs), which can directly detect brain activities related to external stimuli, may thus provide an approach to assess DOC patients without the need for any physical behavior. In this study, a novel audiovisual BCI system was developed to simulate sound localization evaluation in CRS-R. Specifically, there were two alternatively flashed buttons on the left and right sides of the graphical user interface, one of which was randomly chosen as the target. The auditory stimuli of bell sounds were simultaneously presented by the ipsilateral loudspeaker during the flashing of the target button, which prompted patients to selectively attend to the target button. The recorded electroencephalography data were analyzed in real time to detect event-related potentials evoked by the target and further to determine whether the target was attended to or not. A significant BCI accuracy for a patient implied that he/she had sound localization. Among eighteen patients, eleven and four showed sound localization in the BCI and CRS-R, respectively. Furthermore, all patients showing sound localization in the CRS-R were among those detected by our BCI. The other seven patients who had no sound localization behavior in CRS-R were identified by the BCI assessment, and three of them showed improvements in the second CRS-R assessment after the BCI experiment. Thus, the proposed BCI system is promising for assisting the assessment of sound localization and improving the clinical diagnosis of DOC patients.
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8
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Värbu K, Muhammad N, Muhammad Y. Past, Present, and Future of EEG-Based BCI Applications. SENSORS (BASEL, SWITZERLAND) 2022; 22:3331. [PMID: 35591021 PMCID: PMC9101004 DOI: 10.3390/s22093331] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 02/23/2022] [Revised: 04/05/2022] [Accepted: 04/25/2022] [Indexed: 06/15/2023]
Abstract
An electroencephalography (EEG)-based brain-computer interface (BCI) is a system that provides a pathway between the brain and external devices by interpreting EEG. EEG-based BCI applications have initially been developed for medical purposes, with the aim of facilitating the return of patients to normal life. In addition to the initial aim, EEG-based BCI applications have also gained increasing significance in the non-medical domain, improving the life of healthy people, for instance, by making it more efficient, collaborative and helping develop themselves. The objective of this review is to give a systematic overview of the literature on EEG-based BCI applications from the period of 2009 until 2019. The systematic literature review has been prepared based on three databases PubMed, Web of Science and Scopus. This review was conducted following the PRISMA model. In this review, 202 publications were selected based on specific eligibility criteria. The distribution of the research between the medical and non-medical domain has been analyzed and further categorized into fields of research within the reviewed domains. In this review, the equipment used for gathering EEG data and signal processing methods have also been reviewed. Additionally, current challenges in the field and possibilities for the future have been analyzed.
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Affiliation(s)
- Kaido Värbu
- Institute of Computer Science, University of Tartu, 51009 Tartu, Estonia;
| | - Naveed Muhammad
- Institute of Computer Science, University of Tartu, 51009 Tartu, Estonia;
| | - Yar Muhammad
- Department of Computing & Games, School of Computing, Engineering & Digital Technologies, Teesside University, Middlesbrough TS1 3BX, UK;
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9
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Jamil N, Belkacem AN, Ouhbi S, Lakas A. Noninvasive Electroencephalography Equipment for Assistive, Adaptive, and Rehabilitative Brain-Computer Interfaces: A Systematic Literature Review. SENSORS (BASEL, SWITZERLAND) 2021; 21:4754. [PMID: 34300492 PMCID: PMC8309653 DOI: 10.3390/s21144754] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/06/2021] [Revised: 06/28/2021] [Accepted: 07/09/2021] [Indexed: 11/30/2022]
Abstract
Humans interact with computers through various devices. Such interactions may not require any physical movement, thus aiding people with severe motor disabilities in communicating with external devices. The brain-computer interface (BCI) has turned into a field involving new elements for assistive and rehabilitative technologies. This systematic literature review (SLR) aims to help BCI investigator and investors to decide which devices to select or which studies to support based on the current market examination. This examination of noninvasive EEG devices is based on published BCI studies in different research areas. In this SLR, the research area of noninvasive BCIs using electroencephalography (EEG) was analyzed by examining the types of equipment used for assistive, adaptive, and rehabilitative BCIs. For this SLR, candidate studies were selected from the IEEE digital library, PubMed, Scopus, and ScienceDirect. The inclusion criteria (IC) were limited to studies focusing on applications and devices of the BCI technology. The data used herein were selected using IC and exclusion criteria to ensure quality assessment. The selected articles were divided into four main research areas: education, engineering, entertainment, and medicine. Overall, 238 papers were selected based on IC. Moreover, 28 companies were identified that developed wired and wireless equipment as means of BCI assistive technology. The findings of this review indicate that the implications of using BCIs for assistive, adaptive, and rehabilitative technologies are encouraging for people with severe motor disabilities and healthy people. With an increasing number of healthy people using BCIs, other research areas, such as the motivation of players when participating in games or the security of soldiers when observing certain areas, can be studied and collaborated using the BCI technology. However, such BCI systems must be simple (wearable), convenient (sensor fabrics and self-adjusting abilities), and inexpensive.
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Affiliation(s)
- Nuraini Jamil
- Department of Computer Science and Software Engineering, College of Information Technology, United Arab Emirates University, Al Ain P.O. Box 15551, United Arab Emirates; (N.J.); (S.O.)
| | - Abdelkader Nasreddine Belkacem
- Department of Computer and Network Engineering, College of Information Technology, United Arab Emirates University, Al Ain P.O. Box 15551, United Arab Emirates;
| | - Sofia Ouhbi
- Department of Computer Science and Software Engineering, College of Information Technology, United Arab Emirates University, Al Ain P.O. Box 15551, United Arab Emirates; (N.J.); (S.O.)
| | - Abderrahmane Lakas
- Department of Computer and Network Engineering, College of Information Technology, United Arab Emirates University, Al Ain P.O. Box 15551, United Arab Emirates;
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10
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Zuo J, Tao Y, Liu M, Feng L, Yang Y, Liao L. The effect of family-centered sensory and affective stimulation on comatose patients with traumatic brain injury: A systematic review and meta-analysis. Int J Nurs Stud 2020; 115:103846. [PMID: 33485101 DOI: 10.1016/j.ijnurstu.2020.103846] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Revised: 11/04/2020] [Accepted: 11/13/2020] [Indexed: 11/25/2022]
Abstract
BACKGROUND Sensory stimulation has been used in the early rehabilitation of comatose patients with traumatic brain injury, but the effect of sensory stimulation involving family members is unclear. OBJECTIVES To evaluate the effects of family-centered sensory and affective stimulation on comatose patients with traumatic brain injury and explore the factors that affect the outcomes. DESIGN A systematic review with a meta-analysis. DATA SOURCES Electronic databases including PubMed, Web of Science, Google Scholar, Cochrane Library, CINAHL, China National Knowledge Infrastructure, and WanFang were searched from October 2019 to May 2020. REVIEW METHODS Two reviewers independently assessed eligibility of potential studies and extracted data. Quality of included studies was assessed according to the evaluation criteria of Cochrane Evaluation Manual 5.1.0. Outcome measures of the meta-analysis were the Glasgow Coma Scale scores, the Western Neuro Sensory Stimulation Profile scores, awakening time, and satisfaction rate. To explore whether there was a difference in the effect between variants of the intervention, variables as subgroups were time to start intervention, type of intervention, duration of each intervention, daily frequency of intervention, days of intervention, and patient's area. RESULT Seventeen randomized controlled trials were included in the review and meta-analysis. Most studies were of medium quality. The improvement of the Glasgow Coma Scale score is significantly greater with the intervention implemented within 24 h compared to the intervention implemented 24 h later (mean difference 3.91, 95% confidence interval 3.44-4.38 vs. mean difference 1.90, 95% confidence interval 1.69-2.12, respectively). The results of subgroup analyses show that auditory stimulation combined with tactile stimulation and multi-sensory stimulation are associated with better outcomes than a single use of auditory stimulation. Studies from Asia report more positive outcomes than those from America (mean difference 1.94, 95% confidence interval 1.73-2.16 vs. mean difference 0.44, 95% confidence interval -0.87-1.75). And the improvement of the Glasgow Coma Scale score with the stimulation performed by family members is greater than that with the stimulation implemented by nurses (mean difference 2.17, 95% confidence interval 1.67-2.66). Besides, it is associated with better awakening time, awakening rate, and satisfaction rate compared to routine care. CONCLUSION Early family-centered sensory and affective stimulation is more effective than routine care and nurse-implemented sensory stimulation in improving the level of consciousness and cognition of comatose patients with traumatic brain injury, and multi-sensory stimulation is more effective than single stimulation. More studies with larger sample size and high quality in different countries are warranted.
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Affiliation(s)
- Jiaojiao Zuo
- University of Electronic Science and Technology of China, Chengdu 610054, Sichuan, PR China.
| | - Yanling Tao
- Department of Nursing, Sichuan Academy of Medical Sciences and Sichuan Provincial People's Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu 610072, Sichuan, PR China.
| | - Min Liu
- University of Electronic Science and Technology of China, Chengdu 610054, Sichuan, PR China.
| | - Li Feng
- Department of Nursing, Sichuan Academy of Medical Sciences and Sichuan Provincial People's Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu 610072, Sichuan, PR China.
| | - Yang Yang
- University of Electronic Science and Technology of China, Chengdu 610054, Sichuan, PR China.
| | - Limei Liao
- University of Electronic Science and Technology of China, Chengdu 610054, Sichuan, PR China.
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Bai Y, Lin Y, Ziemann U. Managing disorders of consciousness: the role of electroencephalography. J Neurol 2020; 268:4033-4065. [PMID: 32915309 PMCID: PMC8505374 DOI: 10.1007/s00415-020-10095-z] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Revised: 07/18/2020] [Accepted: 07/18/2020] [Indexed: 02/07/2023]
Abstract
Disorders of consciousness (DOC) are an important but still underexplored entity in neurology. Novel electroencephalography (EEG) measures are currently being employed for improving diagnostic classification, estimating prognosis and supporting medicolegal decision-making in DOC patients. However, complex recording protocols, a confusing variety of EEG measures, and complicated analysis algorithms create roadblocks against broad application. We conducted a systematic review based on English-language studies in PubMed, Medline and Web of Science databases. The review structures the available knowledge based on EEG measures and analysis principles, and aims at promoting its translation into clinical management of DOC patients.
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Affiliation(s)
- Yang Bai
- International Vegetative State and Consciousness Science Institute, Hangzhou Normal University, Hangzhou, China
- Department of Neurology and Stroke, University of Tübingen, Hoppe‑Seyler‑Str. 3, 72076, Tübingen, Germany
- Hertie Institute for Clinical Brain Research, University of Tübingen, 72076, Tübingen, Germany
| | - Yajun Lin
- International Vegetative State and Consciousness Science Institute, Hangzhou Normal University, Hangzhou, China
| | - Ulf Ziemann
- Department of Neurology and Stroke, University of Tübingen, Hoppe‑Seyler‑Str. 3, 72076, Tübingen, Germany.
- Hertie Institute for Clinical Brain Research, University of Tübingen, 72076, Tübingen, Germany.
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12
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Annen J, Laureys S, Gosseries O. Brain-computer interfaces for consciousness assessment and communication in severely brain-injured patients. BRAIN-COMPUTER INTERFACES 2020; 168:137-152. [DOI: 10.1016/b978-0-444-63934-9.00011-1] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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13
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Wang J, Wang J, Hu X, Xu L, Tian J, Li J, Fang D, Huang W, Sun Y, He M, Laureys S, Di H. The Initiation of Swallowing Can Indicate the Prognosis of Disorders of Consciousness: A Self-Controlled Study. Front Neurol 2019; 10:1184. [PMID: 31798516 PMCID: PMC6868083 DOI: 10.3389/fneur.2019.01184] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2019] [Accepted: 10/24/2019] [Indexed: 11/23/2022] Open
Abstract
Objective: To detect the initiation of swallowing in patients with disorders of consciousness (DOC) as well as the relationship between the initiation of swallowing and the prognosis of DOC patients. Methods: Nineteen DOC patients were included in this study, and a self-controlled trial compared five different stimuli. The five different stimuli were as follows: (1) one command, as recommended by the Coma Recovery Scale-Revised (CRS-R), which was "open your mouth"; (2) placing a spoon in front of the patient's mouth without a command; (3) placing a spoon filled with water in front of the patient's mouth without a command; (4) one command-"there is a spoon; open your mouth"-with a spoon in front of the patient's mouth; (5) one command, "there is a spoon with water; open your mouth," with a spoon filled with water in front of the patient's mouth. All 19 patients were given these five stimuli randomly, and any one of the commands was presented four times to a patient, one at a time, at 15-s intervals. The sensitivity and specificity of the initiation of swallowing in detecting conscious awareness were determined. Results: None of the patients responded to the first four stimuli. However, six patients showed initiated swallowing toward the fifth stimulus. Among those six, five patients showed improvement in their consciousness state 6 months later. The sensitivity and specificity of the initiation of swallowing for DOC patients was 83.33% [95% CIs (36%, 100%)] and 92.31% [95% CIs (64%, 100%)], respectively. Conclusions: The initiation of swallowing can be an early indication of conscious behavior and can likely provide evidence of conscious awareness. Clinical Trial Registration: www.ClinicalTrials.gov, identifier: NCT03508336; Date of registration: 2018/4/16.
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Affiliation(s)
- Jianan Wang
- International Unresponsive Wakefulness Syndrome and Consciousness Science Institute, Hangzhou Normal University, Hangzhou, China
| | - Jing Wang
- International Unresponsive Wakefulness Syndrome and Consciousness Science Institute, Hangzhou Normal University, Hangzhou, China
| | - Xiaohua Hu
- Rehabilitation Center for Brain Damage, Wujing Hospital of Hangzhou City, Hangzhou, China
| | - Lingqi Xu
- International Unresponsive Wakefulness Syndrome and Consciousness Science Institute, Hangzhou Normal University, Hangzhou, China
| | - Jinna Tian
- International Unresponsive Wakefulness Syndrome and Consciousness Science Institute, Hangzhou Normal University, Hangzhou, China
| | - Jiayin Li
- International Unresponsive Wakefulness Syndrome and Consciousness Science Institute, Hangzhou Normal University, Hangzhou, China
| | - Danruo Fang
- International Unresponsive Wakefulness Syndrome and Consciousness Science Institute, Hangzhou Normal University, Hangzhou, China
| | - Wangshan Huang
- International Unresponsive Wakefulness Syndrome and Consciousness Science Institute, Hangzhou Normal University, Hangzhou, China
| | - Yuxiao Sun
- International Unresponsive Wakefulness Syndrome and Consciousness Science Institute, Hangzhou Normal University, Hangzhou, China
| | - Minhui He
- International Unresponsive Wakefulness Syndrome and Consciousness Science Institute, Hangzhou Normal University, Hangzhou, China
| | - Steven Laureys
- GIGA, GIGA-Consciousness, Coma Science Group, Neurology Department, University Hospital of Liege, University of Liège, Liège, Belgium
| | - Haibo Di
- International Unresponsive Wakefulness Syndrome and Consciousness Science Institute, Hangzhou Normal University, Hangzhou, China
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14
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Xiao J, Xie Q, Lin Q, Yu T, Yu R, Li Y. Assessment of Visual Pursuit in Patients With Disorders of Consciousness Based on a Brain-Computer Interface. IEEE Trans Neural Syst Rehabil Eng 2019; 26:1141-1151. [PMID: 29877838 DOI: 10.1109/tnsre.2018.2835813] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
Visual pursuit assessment is extensively applied in the behavioral scale-based clinical examination of patients with disorders of consciousness (DOC). However, this assessment is challenging because it relies on behavioral markers, and these patients severely lack behavioral responses. Brain-computer interfaces (BCIs) may provide a potential solution to detect brain responses to external stimuli without requiring behavioral expressions. A BCI system was designed to simulate visual pursuit detection in the coma recovery scale-revised (CRS-R). The graphical user interface included four buttons, one that moved on the screen and three that did not. These buttons flashed in a random order. The patients were prompted to follow the moving button. Based on the collected electroencephalography data, the algorithm determined whether the patient focused on the moving target. Among the 14 DOC patients who participated in the assessments based on the BCI system and the CRS-R, four patients exhibited visual pursuit, and three were nonresponsive in both assessments. More importantly, seven patients who did not exhibit visual pursuit in CRS-R were detected to be responsive to the moving target stimuli in the BCI assessment. Furthermore, five out of seven recovered consciousness to some degree and showed visual pursuit in the second CRS-R assessment. The proposed BCI system is better able to detect visual pursuit than the behavioral scale-based assessment and thus can assist in clinically evaluating the challenging population of DOC patients.
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15
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Wang F, He Y, Qu J, Cao Y, Liu Y, Li F, Yu Z, Yu R, Li Y. A Brain-Computer Interface Based on Three-Dimensional Stereo Stimuli for Assisting Clinical Object Recognition Assessment in Patients With Disorders of Consciousness. IEEE Trans Neural Syst Rehabil Eng 2019; 27:507-513. [PMID: 30714927 DOI: 10.1109/tnsre.2019.2896092] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
The coma recovery scale-revised (CRS-R) behavioral scale is commonly used for the clinical evaluation of patients with disorders of consciousness (DOC). However, since DOC patients generally cannot supply stable and efficient behavioral responses to external stimulation, evaluation results based on behavioral scales are not sufficiently accurate. In this paper, we proposed a novel brain-computer interface (BCI) based on 3D stereo audiovisual stimuli to supplement object recognition evaluation in the CRS-R. During the experiment, subjects needed to follow the instructions and to focus on the target object on the screen, whereas EEG data were recorded and analyzed in real time to determine the object of focus, and the detection result was output as feedback. Thirteen DOC patients participated in the object recognition assessments using the 3D audiovisual BCI and CRS-R. None of the patients showed object recognition function in the CRS-R assessment before the BCI experiment. However, six of these DOC patients achieved accuracies that were significantly higher than the chance level in the BCI-based assessment, indicating the successful detection of object recognition function in these six patients using our 3D audiovisual BCI system. These results suggest that the BCI method may provide a more sensitive object recognition evaluation compared with CRS-R and may be used to assist clinical CRS-R for DOC patients.
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16
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Hübner D, Schall A, Prange N, Tangermann M. Eyes-Closed Increases the Usability of Brain-Computer Interfaces Based on Auditory Event-Related Potentials. Front Hum Neurosci 2018; 12:391. [PMID: 30323749 PMCID: PMC6172854 DOI: 10.3389/fnhum.2018.00391] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2018] [Accepted: 09/10/2018] [Indexed: 11/13/2022] Open
Abstract
Recent research has demonstrated how brain-computer interfaces (BCI) based on auditory stimuli can be used for communication and rehabilitation. In these applications, users are commonly instructed to avoid eye movements while keeping their eyes open. This secondary task can lead to exhaustion and subjects may not succeed in suppressing eye movements. In this work, we investigate the option to use a BCI with eyes-closed. Twelve healthy subjects participated in a single electroencephalography (EEG) session where they were listening to a rapid stream of bisyllabic words while alternatively having their eyes open or closed. In addition, we assessed usability aspects for the two conditions with a questionnaire. Our analysis shows that eyes-closed does not reduce the number of eye artifacts and that event-related potential (ERP) responses and classification accuracies are comparable between both conditions. Importantly, we found that subjects expressed a significant general preference toward the eyes-closed condition and were also less tensed in that condition. Furthermore, switching between eyes-closed and eyes-open and vice versa is possible without a severe drop in classification accuracy. These findings suggest that eyes-closed should be considered as a viable alternative in auditory BCIs that might be especially useful for subjects with limited control over their eye movements.
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Affiliation(s)
- David Hübner
- Brain State Decoding Lab, Department of Computer Science, University of Freiburg, Freiburg, Germany.,Cluster of Excellence, BrainLinks-BrainTools, Freiburg, Germany
| | - Albrecht Schall
- Brain State Decoding Lab, Department of Computer Science, University of Freiburg, Freiburg, Germany
| | - Natalie Prange
- Brain State Decoding Lab, Department of Computer Science, University of Freiburg, Freiburg, Germany
| | - Michael Tangermann
- Brain State Decoding Lab, Department of Computer Science, University of Freiburg, Freiburg, Germany.,Cluster of Excellence, BrainLinks-BrainTools, Freiburg, Germany
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17
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Xiao J, Pan J, He Y, Xie Q, Yu T, Huang H, Lv W, Zhang J, Yu R, Li Y. Visual Fixation Assessment in Patients with Disorders of Consciousness Based on Brain-Computer Interface. Neurosci Bull 2018; 34:679-690. [PMID: 30014347 PMCID: PMC6060219 DOI: 10.1007/s12264-018-0257-z] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2018] [Accepted: 05/29/2018] [Indexed: 11/26/2022] Open
Abstract
Visual fixation is an item in the visual function subscale of the Coma Recovery Scale-Revised (CRS-R). Sometimes clinicians using the behavioral scales find it difficult to detect because of the motor impairment in patients with disorders of consciousness (DOCs). Brain-computer interface (BCI) can be used to improve clinical assessment because it directly detects the brain response to an external stimulus in the absence of behavioral expression. In this study, we designed a BCI system to assist the visual fixation assessment of DOC patients. The results from 15 patients indicated that three showed visual fixation in both CRS-R and BCI assessments and one did not show such behavior in the CRS-R assessment but achieved significant online accuracy in the BCI assessment. The results revealed that electroencephalography-based BCI can detect the brain response for visual fixation. Therefore, the proposed BCI may provide a promising method for assisting behavioral assessment using the CRS-R.
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Affiliation(s)
- Jun Xiao
- Center for Brain Computer Interfaces and Brain Information Processing, South China University of Technology, Guangzhou, 510640, China
| | - Jiahui Pan
- Center for Brain Computer Interfaces and Brain Information Processing, South China University of Technology, Guangzhou, 510640, China
| | - Yanbin He
- Coma Research Group, Centre for Hyperbaric Oxygen and Neurorehabilitation, General Hospital of Guangzhou Military Command, Guangzhou, 510010, China
| | - Qiuyou Xie
- Coma Research Group, Centre for Hyperbaric Oxygen and Neurorehabilitation, General Hospital of Guangzhou Military Command, Guangzhou, 510010, China
| | - Tianyou Yu
- Center for Brain Computer Interfaces and Brain Information Processing, South China University of Technology, Guangzhou, 510640, China
| | - Haiyun Huang
- Center for Brain Computer Interfaces and Brain Information Processing, South China University of Technology, Guangzhou, 510640, China
| | - Wei Lv
- Coma Research Group, Centre for Hyperbaric Oxygen and Neurorehabilitation, General Hospital of Guangzhou Military Command, Guangzhou, 510010, China
| | - Jiechun Zhang
- Coma Research Group, Centre for Hyperbaric Oxygen and Neurorehabilitation, General Hospital of Guangzhou Military Command, Guangzhou, 510010, China
| | - Ronghao Yu
- Coma Research Group, Centre for Hyperbaric Oxygen and Neurorehabilitation, General Hospital of Guangzhou Military Command, Guangzhou, 510010, China.
| | - Yuanqing Li
- Center for Brain Computer Interfaces and Brain Information Processing, South China University of Technology, Guangzhou, 510640, China.
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Heo J, Baek HJ, Hong S, Chang MH, Lee JS, Park KS. Music and natural sounds in an auditory steady-state response based brain-computer interface to increase user acceptance. Comput Biol Med 2017; 84:45-52. [PMID: 28342407 DOI: 10.1016/j.compbiomed.2017.03.011] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2017] [Accepted: 03/15/2017] [Indexed: 11/16/2022]
Abstract
Patients with total locked-in syndrome are conscious; however, they cannot express themselves because most of their voluntary muscles are paralyzed, and many of these patients have lost their eyesight. To improve the quality of life of these patients, there is an increasing need for communication-supporting technologies that leverage the remaining senses of the patient along with physiological signals. The auditory steady-state response (ASSR) is an electro-physiologic response to auditory stimulation that is amplitude-modulated by a specific frequency. By leveraging the phenomenon whereby ASSR is modulated by mind concentration, a brain-computer interface paradigm was proposed to classify the selective attention of the patient. In this paper, we propose an auditory stimulation method to minimize auditory stress by replacing the monotone carrier with familiar music and natural sounds for an ergonomic system. Piano and violin instrumentals were employed in the music sessions; the sounds of water streaming and cicadas singing were used in the natural sound sessions. Six healthy subjects participated in the experiment. Electroencephalograms were recorded using four electrodes (Cz, Oz, T7 and T8). Seven sessions were performed using different stimuli. The spectral power at 38 and 42Hz and their ratio for each electrode were extracted as features. Linear discriminant analysis was utilized to classify the selections for each subject. In offline analysis, the average classification accuracies with a modulation index of 1.0 were 89.67% and 87.67% using music and natural sounds, respectively. In online experiments, the average classification accuracies were 88.3% and 80.0% using music and natural sounds, respectively. Using the proposed method, we obtained significantly higher user-acceptance scores, while maintaining a high average classification accuracy.
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Affiliation(s)
- Jeong Heo
- Interdisciplinary Program of Bioengineering, Seoul National University, Seoul, Republic of Korea
| | - Hyun Jae Baek
- Mobile Communication Business, Samsung Electronics Co., Ltd., Suwon, Republic of Korea
| | - Seunghyeok Hong
- Interdisciplinary Program of Bioengineering, Seoul National University, Seoul, Republic of Korea
| | - Min Hye Chang
- Advanced Medical Device Research Division, Korea Electro-Technology Research Institute, Ansan, Republic of Korea
| | - Jeong Su Lee
- Mobile Communication Business, Samsung Electronics Co., Ltd., Suwon, Republic of Korea
| | - Kwang Suk Park
- Department of Biomedical Engineering, College of Medicine, Seoul National University, Seoul, Republic of Korea.
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