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Barra ME, Solt K, Yu X, Edlow BL. Restoring consciousness with pharmacologic therapy: Mechanisms, targets, and future directions. Neurotherapeutics 2024; 21:e00374. [PMID: 39019729 DOI: 10.1016/j.neurot.2024.e00374] [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: 12/01/2023] [Revised: 04/16/2024] [Accepted: 05/03/2024] [Indexed: 07/19/2024] Open
Abstract
Severe brain injury impairs consciousness by disrupting a broad spectrum of neurotransmitter systems. Emerging evidence suggests that pharmacologic modulation of specific neurotransmitter systems, such as dopamine, promotes recovery of consciousness. Clinical guidelines now endorse the use of amantadine in individuals with traumatic disorders of consciousness (DoC) based on level 1 evidence, and multiple neurostimulants are used off-label in clinical practice, including methylphenidate, modafinil, bromocriptine, levodopa, and zolpidem. However, the relative contributions of monoaminergic, glutamatergic, cholinergic, GABAergic, and orexinergic neurotransmitter systems to recovery of consciousness after severe brain injury are unknown, and personalized approaches to targeted therapy have yet to be developed. This review summarizes the state-of-the-science in the neurochemistry and neurobiology of neurotransmitter systems involved in conscious behaviors, followed by a discussion of how pharmacologic therapies may be used to modulate these neurotransmitter systems and promote recovery of consciousness. We consider pharmacologic modulation of consciousness at the synapse, circuit, and network levels, with a focus on the mesocircuit model that has been proposed to explain the consciousness-promoting effects of various monoaminergic, glutamatergic, and paradoxically, GABAergic therapies. Though fundamental questions remain about neurotransmitter mechanisms, target engagement and optimal therapy selection for individual patients, we propose that pharmacologic therapies hold great promise to promote recovery and improve quality of life for patients with severe brain injuries.
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Affiliation(s)
- Megan E Barra
- Department of Pharmacy, Massachusetts General Hospital, Boston, MA, USA; Center for Neurotechnology and Neurorecovery, Massachusetts General Hospital, Boston, MA, USA
| | - Ken Solt
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Xin Yu
- Department of Radiology, Athinoula A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital, Boston, MA, USA
| | - Brian L Edlow
- Center for Neurotechnology and Neurorecovery, Massachusetts General Hospital, Boston, MA, USA; Department of Radiology, Athinoula A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital, Boston, MA, USA; Department of Neurology, Massachusetts General Hospital, Boston, MA, USA.
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2
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Leslie-Mazwi TM. Neurocritical Care for Patients With Ischemic Stroke. Continuum (Minneap Minn) 2024; 30:611-640. [PMID: 38830065 DOI: 10.1212/con.0000000000001427] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/05/2024]
Abstract
OBJECTIVE Management of stroke due to large vessel occlusion (LVO) has undergone unprecedented change in the past decade. Effective treatment with thrombectomy has galvanized the field and led to advancements in all aspects of care. This article provides a comprehensive examination of neurologic intensive care unit (ICU) management of patients with stroke due to LVO. The role of the neurocritical care team in stroke systems of care and the importance of prompt diagnosis, initiation of treatment, and continued monitoring of patients with stroke due to LVO is highlighted. LATEST DEVELOPMENTS The management of complications commonly associated with stroke due to LVO, including malignant cerebral edema and respiratory failure, are addressed, stressing the importance of early identification and aggressive treatment in mitigating negative effects on patients' prognoses. In the realm of medical management, this article discusses various medical therapies, including antithrombotic therapy, blood pressure management, and glucose control, outlining evidence-based strategies for optimizing patient outcomes. It further emphasizes the importance of a multidisciplinary approach to provide a comprehensive care model. Lastly, the critical aspect of family communication and prognostication in the neurologic ICU is addressed. ESSENTIAL POINTS This article emphasizes the multidimensional aspects of neurocritical care in treating patients with stroke due to LVO.
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Edlow BL, Olchanyi M, Freeman HJ, Li J, Maffei C, Snider SB, Zöllei L, Iglesias JE, Augustinack J, Bodien YG, Haynes RL, Greve DN, Diamond BR, Stevens A, Giacino JT, Destrieux C, van der Kouwe A, Brown EN, Folkerth RD, Fischl B, Kinney HC. Multimodal MRI reveals brainstem connections that sustain wakefulness in human consciousness. Sci Transl Med 2024; 16:eadj4303. [PMID: 38691619 DOI: 10.1126/scitranslmed.adj4303] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2023] [Accepted: 04/10/2024] [Indexed: 05/03/2024]
Abstract
Consciousness is composed of arousal (i.e., wakefulness) and awareness. Substantial progress has been made in mapping the cortical networks that underlie awareness in the human brain, but knowledge about the subcortical networks that sustain arousal in humans is incomplete. Here, we aimed to map the connectivity of a proposed subcortical arousal network that sustains wakefulness in the human brain, analogous to the cortical default mode network (DMN) that has been shown to contribute to awareness. We integrated data from ex vivo diffusion magnetic resonance imaging (MRI) of three human brains, obtained at autopsy from neurologically normal individuals, with immunohistochemical staining of subcortical brain sections. We identified nodes of the proposed default ascending arousal network (dAAN) in the brainstem, hypothalamus, thalamus, and basal forebrain. Deterministic and probabilistic tractography analyses of the ex vivo diffusion MRI data revealed projection, association, and commissural pathways linking dAAN nodes with one another and with DMN nodes. Complementary analyses of in vivo 7-tesla resting-state functional MRI data from the Human Connectome Project identified the dopaminergic ventral tegmental area in the midbrain as a widely connected hub node at the nexus of the subcortical arousal and cortical awareness networks. Our network-based autopsy methods and connectivity data provide a putative neuroanatomic architecture for the integration of arousal and awareness in human consciousness.
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Affiliation(s)
- Brian L Edlow
- Center for Neurotechnology and Neurorecovery, Department of Neurology, Massachusetts General Hospital and Harvard Medical School, Boston, MA 02114, USA
- Athinoula A. Martinos Center for Biomedical Imaging, Department of Radiology, Massachusetts General Hospital and Harvard Medical School, Charlestown, MA 02129, USA
| | - Mark Olchanyi
- Center for Neurotechnology and Neurorecovery, Department of Neurology, Massachusetts General Hospital and Harvard Medical School, Boston, MA 02114, USA
- Institute for Medical Engineering and Science, Massachusetts Institute of Technology, Cambridge, MA 02142, USA
| | - Holly J Freeman
- Center for Neurotechnology and Neurorecovery, Department of Neurology, Massachusetts General Hospital and Harvard Medical School, Boston, MA 02114, USA
- Athinoula A. Martinos Center for Biomedical Imaging, Department of Radiology, Massachusetts General Hospital and Harvard Medical School, Charlestown, MA 02129, USA
| | - Jian Li
- Center for Neurotechnology and Neurorecovery, Department of Neurology, Massachusetts General Hospital and Harvard Medical School, Boston, MA 02114, USA
- Athinoula A. Martinos Center for Biomedical Imaging, Department of Radiology, Massachusetts General Hospital and Harvard Medical School, Charlestown, MA 02129, USA
| | - Chiara Maffei
- Center for Neurotechnology and Neurorecovery, Department of Neurology, Massachusetts General Hospital and Harvard Medical School, Boston, MA 02114, USA
- Athinoula A. Martinos Center for Biomedical Imaging, Department of Radiology, Massachusetts General Hospital and Harvard Medical School, Charlestown, MA 02129, USA
| | - Samuel B Snider
- Department of Neurology, Brigham and Women's Hospital and Harvard Medical School, Boston, MA 02115, USA
| | - Lilla Zöllei
- Athinoula A. Martinos Center for Biomedical Imaging, Department of Radiology, Massachusetts General Hospital and Harvard Medical School, Charlestown, MA 02129, USA
| | - J Eugenio Iglesias
- Athinoula A. Martinos Center for Biomedical Imaging, Department of Radiology, Massachusetts General Hospital and Harvard Medical School, Charlestown, MA 02129, USA
| | - Jean Augustinack
- Athinoula A. Martinos Center for Biomedical Imaging, Department of Radiology, Massachusetts General Hospital and Harvard Medical School, Charlestown, MA 02129, USA
| | - Yelena G Bodien
- Center for Neurotechnology and Neurorecovery, Department of Neurology, Massachusetts General Hospital and Harvard Medical School, Boston, MA 02114, USA
- Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital and Harvard Medical School, Charlestown, MA 02129, USA
| | - Robin L Haynes
- Department of Pathology, Boston Children's Hospital and Harvard Medical School, Boston, MA 02115, USA
| | - Douglas N Greve
- Athinoula A. Martinos Center for Biomedical Imaging, Department of Radiology, Massachusetts General Hospital and Harvard Medical School, Charlestown, MA 02129, USA
| | - Bram R Diamond
- Center for Neurotechnology and Neurorecovery, Department of Neurology, Massachusetts General Hospital and Harvard Medical School, Boston, MA 02114, USA
- Athinoula A. Martinos Center for Biomedical Imaging, Department of Radiology, Massachusetts General Hospital and Harvard Medical School, Charlestown, MA 02129, USA
| | - Allison Stevens
- Athinoula A. Martinos Center for Biomedical Imaging, Department of Radiology, Massachusetts General Hospital and Harvard Medical School, Charlestown, MA 02129, USA
| | - Joseph T Giacino
- Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital and Harvard Medical School, Charlestown, MA 02129, USA
| | - Christophe Destrieux
- UMR 1253, iBrain, Université de Tours, Inserm, 10 Boulevard Tonnellé, 37032, Tours, France
- CHRU de Tours, 2 Boulevard Tonnellé, Tours, France
| | - Andre van der Kouwe
- Athinoula A. Martinos Center for Biomedical Imaging, Department of Radiology, Massachusetts General Hospital and Harvard Medical School, Charlestown, MA 02129, USA
| | - Emery N Brown
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA 02114, USA
- Department of Brain and Cognitive Sciences, Massachusetts Institute of Technology, Cambridge, MA 02142, USA
| | | | - Bruce Fischl
- Athinoula A. Martinos Center for Biomedical Imaging, Department of Radiology, Massachusetts General Hospital and Harvard Medical School, Charlestown, MA 02129, USA
| | - Hannah C Kinney
- Department of Pathology, Boston Children's Hospital and Harvard Medical School, Boston, MA 02115, USA
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4
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Slomine BS, Suskauer SJ. Disorders of Consciousness in Children: Assessment, Treatment, and Prognosis. Phys Med Rehabil Clin N Am 2024; 35:223-234. [PMID: 37993191 DOI: 10.1016/j.pmr.2023.06.012] [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: 11/24/2023]
Abstract
Children with acquired brain injury may experience prolonged disorders of consciousness (DoC); research on children with DoC lags behind adult literature. Rigorous evaluation of assessment tools used in children with DoC is lacking, though recent developments may contribute to improvements in care, particularly for assessment of young children and those without overt command following. Literature on prognosis continues to grow, reinforcing that early signs of consciousness suggest better long-term outcome. Although large clinical trials for children with DoC are lacking, single-site and multisite programmatic data inform standards of care and treatment options for children with DoC.
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Affiliation(s)
- Beth S Slomine
- Kennedy Krieger Institute, 707 North Broadway, Balitmore, MD 21205, USA; Department of Psychiatry and Behavioral Health, Johns Hopkins University School of Medicine, 600 North Wolfe Street, Baltimore, MD 21205, USA; Department of Physical Medicine & Rehabilitation, Johns Hopkins University School of Medicine, 600 North Wolfe Street, Baltimore, MD 21205, USA
| | - Stacy J Suskauer
- Kennedy Krieger Institute, 707 North Broadway, Balitmore, MD 21205, USA; Department of Physical Medicine & Rehabilitation, Johns Hopkins University School of Medicine, 600 North Wolfe Street, Baltimore, MD 21205, USA; Departments of Pediatrics, Johns Hopkins University School of Medicine, 600 North Wolfe Street, Baltimore, MD 21205, USA.
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Abstract
Covert consciousness is a state of residual awareness following severe brain injury or neurological disorder that evades routine bedside behavioral detection. Patients with covert consciousness have preserved awareness but are incapable of self-expression through ordinary means of behavior or communication. Growing recognition of the limitations of bedside neurobehavioral examination in reliably detecting consciousness, along with advances in neurotechnologies capable of detecting brain states or subtle signs indicative of consciousness not discernible by routine examination, carry promise to transform approaches to classifying, diagnosing, prognosticating and treating disorders of consciousness. Here we describe and critically evaluate the evolving clinical category of covert consciousness, including approaches to its diagnosis through neuroimaging, electrophysiology, and novel behavioral tools, its prognostic relevance, and open questions pertaining to optimal clinical management of patients with covert consciousness recovering from severe brain injury.
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Affiliation(s)
- Michael J. Young
- Department of Neurology, Center for Neurotechnology and Neurorecovery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Brian L. Edlow
- Department of Neurology, Center for Neurotechnology and Neurorecovery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
- Athinoula A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital, Charlestown, MA, USA
| | - Yelena G. Bodien
- Department of Neurology, Center for Neurotechnology and Neurorecovery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
- Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Harvard Medical School, Boston, MA, USA
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6
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Russell ME, Hammond FM, Murtaugh B. Prognosis and enhancement of recovery in disorders of consciousness. NeuroRehabilitation 2024; 54:43-59. [PMID: 38277313 DOI: 10.3233/nre-230148] [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: 01/28/2024]
Abstract
Disorders of consciousness after severe brain injury encompass conditions of coma, vegetative state/unresponsive wakefulness syndrome, and minimally conscious state. DoC clinical presentation pose perplexing challenges to medical professionals, researchers, and families alike. The outcome is uncertain in the first weeks to months after a brain injury, with families and medical providers often making important decisions that require certainty. Prognostication for individuals with these conditions has been the subject of intense scientific investigation that continues to strive for valid prognostic indicators and algorithms for predicting recovery of consciousness. This manuscript aims to provide an overview of the current clinical landscape surrounding prognosis and optimizing recovery in DoC and the current and future research that could improve prognostic accuracy after severe brain injury. Improved understanding of these factors will aid healthcare professionals in providing optimal care, fostering hope, and advocating for ethical practices in the management of individuals with DoC.
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Affiliation(s)
- Mary E Russell
- Department of Physical Medicine and Rehabilitation, University of Texas McGovern Medical School, Houston, TX, USA
- TIRR Memorial Hermann - The Woodlands, Shenandoah, TX, USA
| | - Flora M Hammond
- Department of Physical Medicine and Rehabilitation, Indiana University School of Medicine, Indianapolis, IN, USA
- Rehabilitation Hospital of Indiana, Indianapolis, IN, USA
| | - Brooke Murtaugh
- Department of Rehabilitation Programs, Madonna Rehabilitation Hospitals, Lincoln, NE, USA
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Boerwinkle VL, Gillette K, Rubinos CA, Broman-Fulks J, Aseem F, DeHoff GK, Arhin M, Cediel E, Strohm T. Functional MRI for Acute Covert Consciousness: Emerging Data and Implementation Case Series. Semin Neurol 2023; 43:712-734. [PMID: 37788679 DOI: 10.1055/s-0043-1775845] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/05/2023]
Abstract
Although research studies have begun to demonstrate relationships between disorders of consciousness and brain network biomarkers, there are limited data on the practical aspects of obtaining such network biomarkers to potentially guide care. As the state of knowledge continues to evolve, guidelines from professional societies such as the American and European Academies of Neurology and many experts have advocated that the risk-benefit ratio for the assessment of network biomarkers has begun to favor their application toward potentially detecting covert consciousness. Given the lack of detailed operationalization guidance and the context of the ethical implications, herein we offer a roadmap based on local institutional experience with the implementation of functional MRI in the neonatal, pediatric, and adult intensive care units of our local government-supported health system. We provide a case-based demonstrative approach intended to review the current literature and to assist with the initiation of such services at other facilities.
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Affiliation(s)
- Varina L Boerwinkle
- Division of Child Neurology, University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - Kirsten Gillette
- Division of Child Neurology, University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - Clio A Rubinos
- Division of Neurocritical Care, University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - Jordan Broman-Fulks
- Division of Child Neurology, University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - Fazila Aseem
- Division of Neurocritical Care, University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - Grace K DeHoff
- Division of Neurocritical Care, University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - Martin Arhin
- Division of Child Neurology, University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - Emilio Cediel
- Division of Child Neurology, University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - Tamara Strohm
- Division of Neurocritical Care, University of North Carolina School of Medicine, Chapel Hill, North Carolina
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Hofmann A, Blum C, Single C, Adeyemi K, Schwarz P, Siokas V, Rattay TW, Häberle HA, Riessen R, Brendel B, Haug I, Bösel R, Zago M, Martus P, Ziemann U, Mengel A, Feil K. Amantadine for NeuroenhaNcement in acutE patients Study - a protocol for a prospective pilot proof of concept phase IIb study in intensive and intermediate care unit patients (ANNES). BMC Neurol 2023; 23:308. [PMID: 37608315 PMCID: PMC10464325 DOI: 10.1186/s12883-023-03345-w] [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: 04/03/2023] [Accepted: 07/27/2023] [Indexed: 08/24/2023] Open
Abstract
BACKGROUND Persisting coma is a common complication in (neuro)intensive care in neurological disease such as acute ischemic stroke, intracerebral hemorrhage or subarachnoid hemorrhage. Amantadine acts as a nicotinic receptor antagonist, dopamine receptor agonist and non-competitive N-Methyl-D-aspartate receptor antagonist. Amantadine is a long-known drug, originally approved for treatment of influenza A and Parkinson`s Disease. It has been proven effective in improving vigilance after traumatic brain injury. The underlying mechanisms remain largely unknown, albeit anti-glutamatergic and dopaminergic effects might be most relevant. With limited evidence of amantadine efficacy in non-traumatic pathologies, the aim of our study is to assess the effects of amantadine for neuroenhancement in non-traumatic neurointensive patients with persisting coma. METHODS An investigator-initiated, monocenter, phase IIb proof of concept open-label pilot study will be carried out. Based on the Simon design, 43 adult (neuro)intensive care patients who meet the clinical criteria of persisting coma not otherwise explained and < 8 points on the Glasgow Coma Scale (GCS) will be recruited. Amantadine will be administered intravenously for five days at a dosage of 100 mg bid. The primary endpoint is an improvement of at least 3 points on the GCS. If participants present as non-responders (increase < 3 points or decrease on the GCS) within the first 48 h, the dosage will be doubled from day three to five. Secondary objectives aim to demonstrate that amantadine improves vigilance via alternative scales. Furthermore, the incidence of adverse events will be investigated and electroencephalography (EEG) will be recorded at baseline and end of treatment. DISCUSSION The results of our study will help to systematically assess the clinical utility of amantadine for treatment of persisting coma in non-traumatic brain injury. We expect that, in the face of only moderate treatment risk, a relevant number of patients will benefit from amantadine medication by improved vigilance (GCS increase of at least 3 points) finally leading to a better rehabilitation potential and improved functional neurological outcome. Further, the EEG data will allow evaluation of brain network states in relation to vigilance and potentially outcome prediction in this study cohort. TRIAL REGISTRATION NCT05479032.
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Affiliation(s)
- Anna Hofmann
- Department of Neurology/neurodegenerative diseases, University Hospital Tübingen, Tübingen, Germany
| | - Corinna Blum
- Department of Neurology & Stroke, University Hospital Tübingen, Tübingen, Germany
| | - Constanze Single
- Department of Neurology & Stroke, University Hospital Tübingen, Tübingen, Germany.
| | - Kamal Adeyemi
- Department of Neurology & Stroke, University Hospital Tübingen, Tübingen, Germany
| | - Patricia Schwarz
- Department of Neurology & Stroke, University Hospital Tübingen, Tübingen, Germany
| | - Vasileios Siokas
- Department of Neurology & Stroke, University Hospital Tübingen, Tübingen, Germany
- Department of Neurology, Faculty of Medicine, School of Health Sciences, University Hospital of Larissa, University of Thessaly, Larissa, 41100, Greece
| | - Tim W Rattay
- Department of Neurology/neurodegenerative diseases, University Hospital Tübingen, Tübingen, Germany
- Department of Neurology & Stroke, University Hospital Tübingen, Tübingen, Germany
| | - Helene A Häberle
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Tübingen, Tübingen, Germany
| | - Reimer Riessen
- Department of Medicine, Medical Intensive Care Unit, University Hospital Tübingen, Tübingen, Germany
| | - Bettina Brendel
- Institute for Clinical Epidemiology and Applied Biometry, Faculty of Medicine, Eberhard-Karls- University Tübingen, Tübingen, Germany
| | - Iris Haug
- Institute for Clinical Epidemiology and Applied Biometry, Faculty of Medicine, Eberhard-Karls- University Tübingen, Tübingen, Germany
| | - Ruth Bösel
- Institute for Clinical Epidemiology and Applied Biometry, Faculty of Medicine, Eberhard-Karls- University Tübingen, Tübingen, Germany
| | - Manola Zago
- Center for Clinical Studies ZKS Tübingen, University Hospital Tübingen, Tübingen, Germany
| | - Peter Martus
- Institute for Clinical Epidemiology and Applied Biometry, Faculty of Medicine, Eberhard-Karls- University Tübingen, Tübingen, Germany
| | - Ulf Ziemann
- Department of Neurology & Stroke, University Hospital Tübingen, Tübingen, Germany
- Hertie Institute for Clinical Brain Research, University of Tübingen, Tübingen, Germany
| | - Annerose Mengel
- Department of Neurology & Stroke, University Hospital Tübingen, Tübingen, Germany
- Hertie Institute for Clinical Brain Research, University of Tübingen, Tübingen, Germany
| | - Katharina Feil
- Department of Neurology & Stroke, University Hospital Tübingen, Tübingen, Germany
- Hertie Institute for Clinical Brain Research, University of Tübingen, Tübingen, Germany
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Edlow BL, Olchanyi M, Freeman HJ, Li J, Maffei C, Snider SB, Zöllei L, Iglesias JE, Augustinack J, Bodien YG, Haynes RL, Greve DN, Diamond BR, Stevens A, Giacino JT, Destrieux C, van der Kouwe A, Brown EN, Folkerth RD, Fischl B, Kinney HC. Sustaining wakefulness: Brainstem connectivity in human consciousness. BIORXIV : THE PREPRINT SERVER FOR BIOLOGY 2023:2023.07.13.548265. [PMID: 37502983 PMCID: PMC10369992 DOI: 10.1101/2023.07.13.548265] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/29/2023]
Abstract
Consciousness is comprised of arousal (i.e., wakefulness) and awareness. Substantial progress has been made in mapping the cortical networks that modulate awareness in the human brain, but knowledge about the subcortical networks that sustain arousal is lacking. We integrated data from ex vivo diffusion MRI, immunohistochemistry, and in vivo 7 Tesla functional MRI to map the connectivity of a subcortical arousal network that we postulate sustains wakefulness in the resting, conscious human brain, analogous to the cortical default mode network (DMN) that is believed to sustain self-awareness. We identified nodes of the proposed default ascending arousal network (dAAN) in the brainstem, hypothalamus, thalamus, and basal forebrain by correlating ex vivo diffusion MRI with immunohistochemistry in three human brain specimens from neurologically normal individuals scanned at 600-750 μm resolution. We performed deterministic and probabilistic tractography analyses of the diffusion MRI data to map dAAN intra-network connections and dAAN-DMN internetwork connections. Using a newly developed network-based autopsy of the human brain that integrates ex vivo MRI and histopathology, we identified projection, association, and commissural pathways linking dAAN nodes with one another and with cortical DMN nodes, providing a structural architecture for the integration of arousal and awareness in human consciousness. We release the ex vivo diffusion MRI data, corresponding immunohistochemistry data, network-based autopsy methods, and a new brainstem dAAN atlas to support efforts to map the connectivity of human consciousness.
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Affiliation(s)
- Brian L. Edlow
- Center for Neurotechnology and Neurorecovery, Department of Neurology, Massachusetts General Hospital and Harvard Medical School, Boston, MA 02114, USA
- Athinoula A. Martinos Center for Biomedical Imaging, Department of Radiology, Massachusetts General Hospital and Harvard Medical School, Charlestown MA 02129, USA
| | - Mark Olchanyi
- Center for Neurotechnology and Neurorecovery, Department of Neurology, Massachusetts General Hospital and Harvard Medical School, Boston, MA 02114, USA
| | - Holly J. Freeman
- Center for Neurotechnology and Neurorecovery, Department of Neurology, Massachusetts General Hospital and Harvard Medical School, Boston, MA 02114, USA
- Athinoula A. Martinos Center for Biomedical Imaging, Department of Radiology, Massachusetts General Hospital and Harvard Medical School, Charlestown MA 02129, USA
| | - Jian Li
- Center for Neurotechnology and Neurorecovery, Department of Neurology, Massachusetts General Hospital and Harvard Medical School, Boston, MA 02114, USA
- Athinoula A. Martinos Center for Biomedical Imaging, Department of Radiology, Massachusetts General Hospital and Harvard Medical School, Charlestown MA 02129, USA
| | - Chiara Maffei
- Center for Neurotechnology and Neurorecovery, Department of Neurology, Massachusetts General Hospital and Harvard Medical School, Boston, MA 02114, USA
- Athinoula A. Martinos Center for Biomedical Imaging, Department of Radiology, Massachusetts General Hospital and Harvard Medical School, Charlestown MA 02129, USA
| | - Samuel B. Snider
- Department of Neurology, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA 02115, USA
| | - Lilla Zöllei
- Athinoula A. Martinos Center for Biomedical Imaging, Department of Radiology, Massachusetts General Hospital and Harvard Medical School, Charlestown MA 02129, USA
| | - J. Eugenio Iglesias
- Athinoula A. Martinos Center for Biomedical Imaging, Department of Radiology, Massachusetts General Hospital and Harvard Medical School, Charlestown MA 02129, USA
| | - Jean Augustinack
- Athinoula A. Martinos Center for Biomedical Imaging, Department of Radiology, Massachusetts General Hospital and Harvard Medical School, Charlestown MA 02129, USA
| | - Yelena G. Bodien
- Center for Neurotechnology and Neurorecovery, Department of Neurology, Massachusetts General Hospital and Harvard Medical School, Boston, MA 02114, USA
- Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital and Harvard Medical School, Charlestown, MA 02129 USA
| | - Robin L. Haynes
- Department of Pathology, Boston Children’s Hospital and Harvard Medical School, Boston, MA 02115, USA
| | - Douglas N. Greve
- Athinoula A. Martinos Center for Biomedical Imaging, Department of Radiology, Massachusetts General Hospital and Harvard Medical School, Charlestown MA 02129, USA
| | - Bram R. Diamond
- Center for Neurotechnology and Neurorecovery, Department of Neurology, Massachusetts General Hospital and Harvard Medical School, Boston, MA 02114, USA
- Athinoula A. Martinos Center for Biomedical Imaging, Department of Radiology, Massachusetts General Hospital and Harvard Medical School, Charlestown MA 02129, USA
| | - Allison Stevens
- Athinoula A. Martinos Center for Biomedical Imaging, Department of Radiology, Massachusetts General Hospital and Harvard Medical School, Charlestown MA 02129, USA
| | - Joseph T. Giacino
- Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital and Harvard Medical School, Charlestown, MA 02129 USA
| | - Christophe Destrieux
- UMR 1253, iBrain, Université de Tours, Inserm, 10 Boulevard Tonnellé, 37032, Tours, France
- CHRU de Tours, 2 Boulevard Tonnellé, Tours, France
| | - Andre van der Kouwe
- Athinoula A. Martinos Center for Biomedical Imaging, Department of Radiology, Massachusetts General Hospital and Harvard Medical School, Charlestown MA 02129, USA
| | - Emery N. Brown
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
- Department of Brain and Cognitive Sciences, Massachusetts Institute of Technology, Cambridge, MA, USA
| | | | - Bruce Fischl
- Athinoula A. Martinos Center for Biomedical Imaging, Department of Radiology, Massachusetts General Hospital and Harvard Medical School, Charlestown MA 02129, USA
- Computer Science and Artificial Intelligence Laboratory, Massachusetts Institute of Technology, Cambridge, MA, USA
| | - Hannah C. Kinney
- Department of Pathology, Boston Children’s Hospital and Harvard Medical School, Boston, MA 02115, USA
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10
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Luauté J, Beaudoin-Gobert M. Optimising recovery of consciousness after coma. From bench to bedside and vice versa. Presse Med 2023; 52:104165. [PMID: 36948412 DOI: 10.1016/j.lpm.2023.104165] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2023] [Accepted: 03/13/2023] [Indexed: 03/24/2023] Open
Abstract
BACKGROUND Several methods have been proposed to foster recovery of consciousness in patients with disorders of consciousness (DoC). OBJECTIVE Critically assess pharmacological and non-pharmacological treatments for patients with chronic DoC. METHODS A narrative mini-review, and critical analysis of the scientific literature on the various proposed therapeutic approaches, with particular attention to level of evidence, risk-benefit ratio, and feasibility. RESULTS AND DISCUSSION Personalised sensory stimulation, median nerve stimulation, transcranial direct current stimulation (tDCS), amantadine and zolpidem all have favourable risk-benefit ratios and are easy to implement in clinical practice. These treatments should be proposed to every patient with chronic DoC. Comprehensive patient management should also include regular lifting, pain assessment and treatment, attempts to restore sleep and circadian rhythms, implementation of rest periods, comfort and nursing care, and a rehabilitation program with a multi-disciplinary team with expertise in this field. More invasive treatments may cause adverse effects and require further investigation to confirm preliminary, encouraging results and to better define responders' intervention parameters. Scientific studies are essential and given the severity of the disability and handicap that results from DoC, research in this area should aim to develop new therapeutic approaches.
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Affiliation(s)
- Jacques Luauté
- Université Claude Bernard Lyon 1, CNRS, INSERM, Centre de Recherche en Neurosciences de Lyon CRNL U1028 UMR5292, Trajectoires, F-69500 Bron, France; Hôpital Henry Gabrielle, Saint-Genis Laval, Hospices Civils de Lyon, 69230 France.
| | - Maude Beaudoin-Gobert
- Université Claude Bernard Lyon 1, CNRS, INSERM, Centre de Recherche en Neurosciences de Lyon CRNL U1028 UMR5292, Trajectoires, F-69500 Bron, France
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Sivakumar S, Ghasemi M, Schachter SC. Targeting NMDA Receptor Complex in Management of Epilepsy. Pharmaceuticals (Basel) 2022; 15:ph15101297. [PMID: 36297409 PMCID: PMC9609646 DOI: 10.3390/ph15101297] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2022] [Revised: 10/17/2022] [Accepted: 10/20/2022] [Indexed: 11/05/2022] Open
Abstract
N-methyl-D-aspartate receptors (NMDARs) are widely distributed in the central nervous system (CNS) and play critical roles in neuronal excitability in the CNS. Both clinical and preclinical studies have revealed that the abnormal expression or function of these receptors can underlie the pathophysiology of seizure disorders and epilepsy. Accordingly, NMDAR modulators have been shown to exert anticonvulsive effects in various preclinical models of seizures, as well as in patients with epilepsy. In this review, we provide an update on the pathologic role of NMDARs in epilepsy and an overview of the NMDAR antagonists that have been evaluated as anticonvulsive agents in clinical studies, as well as in preclinical seizure models.
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Affiliation(s)
- Shravan Sivakumar
- Department of Neurology, University of Massachusetts Chan Medical School, Worcester, MA 01655, USA
| | - Mehdi Ghasemi
- Department of Neurology, University of Massachusetts Chan Medical School, Worcester, MA 01655, USA
- Correspondence: (M.G.); (S.C.S.)
| | - Steven C. Schachter
- Department of Neurology, Beth Israel Deaconess Medical Center, Boston, MA 02215, USA
- Harvard Medical School, Boston, MA 02114, USA
- Consortia for Improving Medicine with Innovation & Technology (CIMIT), Boston, MA 02114, USA
- Correspondence: (M.G.); (S.C.S.)
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