Dissociating speech perception and comprehension at reduced levels of awareness

Detecting awareness after acute brain injury

Advances over the past two decades in functional neuroimaging have provided new diagnostic and prognostic tools for patients with severe brain injury. Some of the most pertinent developments in this area involve the assessment of residual brain function in patients in the intensive care unit during the acute phase of severe injury, when they are at their most vulnerable and prognosis is uncertain. Advanced neuroimaging techniques, such as functional MRI and EEG, have now been used to identify preserved cognitive processing, including covert conscious awareness, and to relate them to outcome in patients who are behaviourally unresponsive. Yet, technical and logistical challenges to clinical integration of these advanced neuroimaging techniques remain, such as the need for specialised expertise to acquire, analyse, and interpret data and to determine the appropriate timing for such assessments. Once these barriers are overcome, advanced functional neuroimaging technologies could improve diagnosis and prognosis for millions of patients worldwide.

Disclosing Results of Tests for Covert Consciousness: A Framework for Ethical Translation

The advent of neurotechnologies including advanced functional magnetic resonance imaging and electroencephalography to detect states of awareness not detectable by traditional bedside neurobehavioral techniques (i.e., covert consciousness) promises to transform neuroscience research and clinical practice for patients with brain injury. As these interventions progress from research tools into actionable, guideline-endorsed clinical tests, ethical guidance for clinicians on how to responsibly communicate the sensitive results they yield is crucial yet remains underdeveloped. Drawing on insights from empirical and theoretical neuroethics research and our clinical experience with advanced neurotechnologies to detect consciousness in behaviorally unresponsive patients, we critically evaluate ethical promises and perils associated with disclosing the results of clinical covert consciousness assessments and describe a semistructured approach to responsible data sharing to mitigate potential risks.

The Effect of Hearing Loss and Working Memory Capacity on Context Use and Reliance on Context in Older Adults

OBJECTIVES

Older adults often complain of difficulty in communicating in noisy environments. Contextual information is considered an important cue for identifying everyday speech. To date, it has not been clear exactly how context use (CU) and reliance on context in older adults are affected by hearing status and cognitive function. The present study examined the effects of semantic context on the performance of speech recognition, recall, perceived listening effort (LE), and noise tolerance, and further explored the impacts of hearing loss and working memory capacity on CU and reliance on context among older adults.

DESIGN

Fifty older adults with normal hearing and 56 older adults with mild-to-moderate hearing loss between the ages of 60 and 95 years participated in this study. A median split of the backward digit span further classified the participants into high working memory (HWM) and low working memory (LWM) capacity groups. Each participant performed high- and low-context Repeat and Recall tests, including a sentence repeat and delayed recall task, subjective assessments of LE, and tolerable time under seven signal to noise ratios (SNRs). CU was calculated as the difference between high- and low-context sentences for each outcome measure. The proportion of context use (PCU) in high-context performance was taken as the reliance on context to explain the degree to which participants relied on context when they repeated and recalled high-context sentences.

RESULTS

Semantic context helps improve the performance of speech recognition and delayed recall, reduces perceived LE, and prolongs noise tolerance in older adults with and without hearing loss. In addition, the adverse effects of hearing loss on the performance of repeat tasks were more pronounced in low context than in high context, whereas the effects on recall tasks and noise tolerance time were more significant in high context than in low context. Compared with other tasks, the CU and PCU in repeat tasks were more affected by listening status and working memory capacity. In the repeat phase, hearing loss increased older adults' reliance on the context of a relatively challenging listening environment, as shown by the fact that when the SNR was 0 and -5 dB, the PCU (repeat) of the hearing loss group was significantly greater than that of the normal-hearing group, whereas there was no significant difference between the two hearing groups under the remaining SNRs. In addition, older adults with LWM had significantly greater CU and PCU in repeat tasks than those with HWM, especially at SNRs with moderate task demands.

CONCLUSIONS

Taken together, semantic context not only improved speech perception intelligibility but also released cognitive resources for memory encoding in older adults. Mild-to-moderate hearing loss and LWM capacity in older adults significantly increased the use and reliance on semantic context, which was also modulated by the level of SNR.

Covert cortical processing: a diagnosis in search of a definition

Historically, clinical evaluation of unresponsive patients following brain injury has relied principally on serial behavioral examination to search for emerging signs of consciousness and track recovery. Advances in neuroimaging and electrophysiologic techniques now enable clinicians to peer into residual brain functions even in the absence of overt behavioral signs. These advances have expanded clinicians' ability to sub-stratify behaviorally unresponsive and seemingly unaware patients following brain injury by querying and classifying covert brain activity made evident through active or passive neuroimaging or electrophysiologic techniques, including functional MRI, electroencephalography (EEG), transcranial magnetic stimulation-EEG, and positron emission tomography. Clinical research has thus reciprocally influenced clinical practice, giving rise to new diagnostic categories including cognitive-motor dissociation (i.e. 'covert consciousness') and covert cortical processing (CCP). While covert consciousness has received extensive attention and study, CCP is relatively less understood. We describe that CCP is an emerging and clinically relevant state of consciousness marked by the presence of intact association cortex responses to environmental stimuli in the absence of behavioral evidence of stimulus processing. CCP is not a monotonic state but rather encapsulates a spectrum of possible association cortex responses from rudimentary to complex and to a range of possible stimuli. In constructing a roadmap for this evolving field, we emphasize that efforts to inform clinicians, philosophers, and researchers of this condition are crucial. Along with strategies to sensitize diagnostic criteria and disorders of consciousness nosology to these vital discoveries, democratizing access to the resources necessary for clinical identification of CCP is an emerging clinical and ethical imperative.

Propofol-mediated Unconsciousness Disrupts Progression of Sensory Signals through the Cortical Hierarchy

A critical component of anesthesia is the loss of sensory perception. Propofol is the most widely used drug for general anesthesia, but the neural mechanisms of how and when it disrupts sensory processing are not fully understood. We analyzed local field potential and spiking recorded from Utah arrays in auditory cortex, associative cortex, and cognitive cortex of nonhuman primates before and during propofol-mediated unconsciousness. Sensory stimuli elicited robust and decodable stimulus responses and triggered periods of stimulus-related synchronization between brain areas in the local field potential of Awake animals. By contrast, propofol-mediated unconsciousness eliminated stimulus-related synchrony and drastically weakened stimulus responses and information in all brain areas except for auditory cortex, where responses and information persisted. However, we found stimuli occurring during spiking Up states triggered weaker spiking responses than in Awake animals in auditory cortex, and little or no spiking responses in higher order areas. These results suggest that propofol's effect on sensory processing is not just because of asynchronous Down states. Rather, both Down states and Up states reflect disrupted dynamics.

Preliminary evidence for selective cortical responses to music in one-month-old infants

Prior studies have observed selective neural responses in the adult human auditory cortex to music and speech that cannot be explained by the differing lower-level acoustic properties of these stimuli. Does infant cortex exhibit similarly selective responses to music and speech shortly after birth? To answer this question, we attempted to collect functional magnetic resonance imaging (fMRI) data from 45 sleeping infants (2.0- to 11.9-weeks-old) while they listened to monophonic instrumental lullabies and infant-directed speech produced by a mother. To match acoustic variation between music and speech sounds we (1) recorded music from instruments that had a similar spectral range as female infant-directed speech, (2) used a novel excitation-matching algorithm to match the cochleagrams of music and speech stimuli, and (3) synthesized "model-matched" stimuli that were matched in spectrotemporal modulation statistics to (yet perceptually distinct from) music or speech. Of the 36 infants we collected usable data from, 19 had significant activations to sounds overall compared to scanner noise. From these infants, we observed a set of voxels in non-primary auditory cortex (NPAC) but not in Heschl's Gyrus that responded significantly more to music than to each of the other three stimulus types (but not significantly more strongly than to the background scanner noise). In contrast, our planned analyses did not reveal voxels in NPAC that responded more to speech than to model-matched speech, although other unplanned analyses did. These preliminary findings suggest that music selectivity arises within the first month of life. A video abstract of this article can be viewed at https://youtu.be/c8IGFvzxudk. RESEARCH HIGHLIGHTS: Responses to music, speech, and control sounds matched for the spectrotemporal modulation-statistics of each sound were measured from 2- to 11-week-old sleeping infants using fMRI. Auditory cortex was significantly activated by these stimuli in 19 out of 36 sleeping infants. Selective responses to music compared to the three other stimulus classes were found in non-primary auditory cortex but not in nearby Heschl's Gyrus. Selective responses to speech were not observed in planned analyses but were observed in unplanned, exploratory analyses.

Propofol Mediated Unconsciousness Disrupts Progression of Sensory Signals through the Cortical Hierarchy

A critical component of anesthesia is the loss sensory perception. Propofol is the most widely used drug for general anesthesia, but the neural mechanisms of how and when it disrupts sensory processing are not fully understood. We analyzed local field potential (LFP) and spiking recorded from Utah arrays in auditory cortex, associative cortex, and cognitive cortex of non-human primates before and during propofol mediated unconsciousness. Sensory stimuli elicited robust and decodable stimulus responses and triggered periods of stimulus-induced coherence between brain areas in the LFP of awake animals. By contrast, propofol mediated unconsciousness eliminated stimulus-induced coherence and drastically weakened stimulus responses and information in all brain areas except for auditory cortex, where responses and information persisted. However, we found stimuli occurring during spiking Up states triggered weaker spiking responses than in awake animals in auditory cortex, and little or no spiking responses in higher order areas. These results suggest that propofol's effect on sensory processing is not just due to asynchronous down states. Rather, both Down states and Up states reflect disrupted dynamics.

Sleep-like changes in neural processing emerge during sleep deprivation in early auditory cortex

Insufficient sleep is commonplace in modern lifestyle and can lead to grave outcomes, yet the changes in neuronal activity accumulating over hours of extended wakefulness remain poorly understood. Specifically, which aspects of cortical processing are affected by sleep deprivation (SD), and whether they also affect early sensory regions, remain unclear. Here, we recorded spiking activity in the rat auditory cortex along with polysomnography while presenting sounds during SD followed by recovery sleep. We found that frequency tuning, onset responses, and spontaneous firing rates were largely unaffected by SD. By contrast, SD decreased entrainment to rapid (≥20 Hz) click trains, increased population synchrony, and increased the prevalence of sleep-like stimulus-induced silent periods, even when ongoing activity was similar. Recovery NREM sleep was associated with similar effects as SD with even greater magnitude, while auditory processing during REM sleep was similar to vigilant wakefulness. Our results show that processes akin to those in NREM sleep invade the activity of cortical circuits during SD, even in the early sensory cortex.

Aloud real- time reading of intensive care unit diaries: A feasibility study

OBJECTIVES

Memories of frightening/delusional intensive care unit experiences are a major risk factor for subsequent psychiatric morbidity of critical illness survivors; factual memories are protective. Systematically providing factual information during initial memory consolidation could mitigate the emotional character of the formed memories. We explored feasibility and obtained stakeholder feedback of a novel approach to intensive care unit diaries whereby entries were read aloud to the patients right after they were written to facilitate systematic real time orientation and formation of factual memories.

RESEARCH METHODOLOGY

Prospective interventional pilot study involving reading diary entries aloud. We have also interviewed involved stakeholders for feedback and collected exploratory data on psychiatric symptoms from patients right after the intensive care stay.

SETTING

Various intensive care units in a single academic center.

MAIN OUTCOME MEASURES

Feasibility was defined as intervention delivery on ≥80% of days following patient recruitment. Content analysis was performed on stakeholder interview responses. Questionnaire data were compared for patients who received real-time reading to the historical cohort who did not.

RESULTS

Overall, 57% (17 of 30) of patients achieved the set feasibility threshold. Following protocol adjustment, we achieved 86% feasibility in the last subset of patients. Patients reported the intervention as comforting and appreciated the reorientation aspect. Nurses overwhelmingly liked the idea; most common concern was not knowing what to write. Some therapists were unsure whether reading entries aloud might overwhelm the patients. There were no significant differences in psychiatric symptoms when compared to the historic cohort.

CONCLUSION

We encountered several implementation obstacles; once these were addressed, we achieved set feasibility target for the last group of patients. Reading diary entries aloud was welcomed by stakeholders. Designing a trial to assess efficacy of the intervention on psychiatric outcomes appears warranted.

IMPLICATIONS FOR CLINICAL PRACTICE

There is no recommendation to change current practice as benefits of the intervention are unproven.

Functional Neuroimaging as an Assessment Tool in Critically Ill Patients

OBJECTIVE

Little is known about residual cognitive function in the earliest stages of serious brain injury. Functional neuroimaging has yielded valuable diagnostic and prognostic information in chronic disorders of consciousness, such as the vegetative state (also termed unresponsive wakefulness syndrome). The objective of the current study was to determine if functional neuroimaging could be efficacious in the assessment of cognitive function in acute disorders of consciousness, such as coma, where decisions about the withdrawal of life-sustaining therapies are often made.

METHODS

A hierarchical functional magnetic resonance imaging (fMRI) approach assessed sound perception, speech perception, language comprehension, and covert command following in 17 critically ill patients admitted to the intensive care unit (ICU).

RESULTS

Preserved auditory function was observed in 15 patients (88%), whereas 5 (29%) also had preserved higher-order language comprehension. Notably, one patient could willfully modulate his brain activity when instructed to do so, suggesting a level of covert conscious awareness that was entirely inconsistent with his clinical diagnosis at the time of the scan. Across patients, a positive relationship was also observed between fMRI responsivity and the level of functional recovery, such that patients with the greatest functional recovery had neural responses most similar to those observed in healthy control participants.

INTERPRETATION

These results suggest that fMRI may provide important diagnostic and prognostic information beyond standard clinical assessment in acutely unresponsive patients, which may aid discussions surrounding the continuation or removal of life-sustaining therapies during the early post-injury period. ANN NEUROL 2023;93:131-141.

Default mode network overshadow executive control network in coma emergence and awakening prediction of patients with sTBI

OBJECTIVE

We aimed to explore the pathogenesis of traumatic coma related to functional connectivity (FC) within the default mode network (DMN), within the executive control network (ECN) and between the DMN and ECN and to investigate its capacity for predicting awakening.

METHODS

We carried out resting-state functional magnetic resonance imaging (fMRI) examinations on 28 traumatic coma patients and 28 age-matched healthy controls. DMN and ECN nodes were split into regions of interest (ROIs), and node-to-node FC analysis was conducted on individual participants. To identify coma pathogenesis, we compared the pairwise FC differences between coma patients and healthy controls. Meanwhile, we divided the traumatic coma patients into different subgroups based on their clinical outcome scores at 6 months postinjury. Considering the awakening prediction, we calculated the area under the curve (AUC) to evaluate the predictive ability of changed FC pairs.

RESULTS

We found a massive pairwise FC alteration in the patients with traumatic coma compared to the healthy controls [45% (33/74) pairwise FC located in the DMN, 27% (20/74) pairwise FC located in the ECN, and 28% (21/74) pairwise FC located between the DMN and ECN]. Moreover, in the awake and coma groups, there were 67% (12/18) pairwise FC alterations located in the DMN and 33% (6/18) pairwise FC alterations located between the DMN and ECN. We also indicated that pairwise FC that showed a predictive value of 6-month awakening was mainly located in the DMN rather than in the ECN. Specifically, decreased FC between the right superior frontal gyrus and right parahippocampal gyrus (in the DMN) showed the highest predictive ability (AUC = 0.827).

CONCLUSION

In the acute phase of severe traumatic brain injury (sTBI), the DMN plays a more prominent role than the ECN and the DMN-ECN interaction in the emergence of traumatic coma and the prediction of 6-month awakening.

Propofol anesthesia concentration rather than abrupt behavioral unresponsiveness linearly degrades responses in the rat primary auditory cortex

Despite extensive knowledge of its molecular and cellular effects, how anesthesia affects sensory processing remains poorly understood. In particular, it remains unclear whether anesthesia modestly or robustly degrades activity in primary sensory regions, and whether such changes are linked to anesthesia drug concentration versus behavioral unresponsiveness, which are typically confounded. Here, we used slow gradual intravenous propofol anesthesia induction together with auditory stimulation and intermittent assessment of behavioral responsiveness while recording epidural electroencephalogram, and neuronal spiking activity in primary auditory cortex (PAC) of eight rats. We found that all main components of neuronal activity including spontaneous firing rates, onset response magnitudes, onset response latencies, postonset neuronal silence duration, late-locking to 40 Hz click-trains, and offset responses, gradually changed in a dose-dependent manner with increasing anesthesia levels without showing abrupt shifts around loss of righting reflex or other time-points. Thus, the dominant factor affecting PAC responses is the anesthesia drug concentration rather than any sudden, dichotomous behavioral state changes. Our findings explain a wide array of seemingly conflicting results in the literature that, depending on the precise definition of wakefulness (vigilant vs. drowsy) and anesthesia (light vs. deep/surgical), report a spectrum of effects in primary regions ranging from minimal to dramatic differences.

A Theoretical Framework for Human and Nonhuman Vocal Interaction

Vocal communication is a critical feature of social interaction across species; however, the relation between such behavior in humans and nonhumans remains unclear. To enable comparative investigation of this topic, we review the literature pertinent to interactive language use and identify the superset of cognitive operations involved in generating communicative action. We posit these functions comprise three intersecting multistep pathways: (a) the Content Pathway, which selects the movements constituting a response; (b) the Timing Pathway, which temporally structures responses; and (c) the Affect Pathway, which modulates response parameters according to internal state. These processing streams form the basis of the Convergent Pathways for Interaction framework, which provides a conceptual model for investigating the cognitive and neural computations underlying vocal communication across species.

Neuroscientific Evidence for Processing Without Awareness

The extent to which we are affected by perceptual input of which we are unaware is widely debated. By measuring neural responses to sensory stimulation, neuroscientific data could complement behavioral results with valuable evidence. Here we review neuroscientific findings of processing of high-level information, as well as interactions with attention and memory. Although the results are mixed, we find initial support for processing object categories and words, possibly to the semantic level, as well as emotional expressions. Robust neural evidence for face individuation and integration of sentences or scenes is lacking. Attention affects the processing of stimuli that are not consciously perceived, and such stimuli may exogenously but not endogenously capture attention when relevant, and be maintained in memory over time. Sources of inconsistency in the literature include variability in control for awareness as well as individual differences, calling for future studies that adopt stricter measures of awareness and probe multiple processes within subjects.

The neural hierarchy of consciousness

The chief undertaking in the studies of consciousness is that of unravelling "the minimal set of neural processes that are together sufficient for the conscious experience of a particular content - the neural correlates of consciousness". To this day, this crusade remains at an impasse, with a clash of two main theories: consciousness may arise either in a graded and cortically-localised fashion, or in an all-or-none and widespread one. In spite of the long-lasting theoretical debates, neurophysiological theories of consciousness have been mostly dissociated from them. Herein, a theoretical review will be put forth with the aim to change that. In its first half, we will cover the hard available evidence on the neurophysiology of consciousness, whereas in its second half we will weave a series of considerations on both theories and substantiate a novel take on conscious awareness: the levels of processing approach, partitioning the conscious architecture into lower- and higher-order, graded and nonlinear.

Morphometry and functional connectivity of auditory cortex in school-age children with profound language disabilities: Five comparative case studies

Many neurodevelopmental conditions imply absent or severely reduced language capacities at school age. Evidence from functional magnetic resonance imaging is highly limited. We selected a series of five cases scanned with the same fMRI paradigm and the aim of relating individual language profiles onto underlying patterns of functional connectivity (FC) across auditory language cortex: three with neurogenetic syndromes (Coffin-Siris, Landau-Kleffner, and Fragile-X), one with idiopathic intellectual disability, one with autism spectrum disorder (ASD). Compared to both a group with typical development (TD) and a verbal ASD group (total N = 110), they all showed interhemispheric FC below two standard deviations of the TD mean. Children with higher language scores showed higher intrahemispheric FC between Heschl's gyrus and other auditory language regions, as well as an increase of FC during language stimulation compared to rest. An increase of FC in forward vs. reversed speech in the posterior and middle temporal gyri was seen across all cases. The Coffin-Siris case, the most severe, also had the most anomalous FC patterns and showed reduced myelin content, while the Landau-Kleffner case showed reduced cortical thickness. These results suggest potential for neural markers and mechanisms of severe language processing deficits under highly heterogeneous etiological conditions.

Reemergence of the language network during recovery from severe traumatic brain injury: A pilot functional MRI study

PRIMARY OBJECTIVE

We hypothesized that, in patients with acute severe traumatic brain injury (TBI) who recover basic language function, speech-evoked blood-oxygen-level-dependent (BOLD) functional MRI (fMRI) responses within the canonical language network increase over the first 6 months post-injury.

RESEARCH DESIGN

We conducted a prospective, longitudinal fMRI pilot study of adults with acute severe TBI admitted to the intensive care unit. We also enrolled age- and sex-matched healthy subjects.

METHODS AND PROCEDURES

We evaluated BOLD signal in bilateral superior temporal gyrus (STG) and inferior frontal gyrus (IFG) regions of interest acutely and approximately 6 months post-injury. Given evidence that regions outside the canonical language network contribute to language processing, we also performed exploratory whole-brain analyses.

MAIN OUTCOMES AND RESULTS

Of the 16 patients enrolled, eight returned for follow-up fMRI, all of whom recovered basic language function. We observed speech-evoked longitudinal BOLD increases in the left STG, but not in the right STG, right IFG, or left IFG. Whole-brain analysis revealed increases in the right supramarginal and middle temporal gyri but no differences between patients and healthy subjects (n = 16).

CONCLUSION

This pilot study suggests that, in patients with severe TBI who recover llanguage function, speech-evoked responses in bihemispheric language-processing cortex reemerge by 6 months post-injury.

Asymmetric neural dynamics characterize loss and recovery of consciousness

Anesthetics are known to disrupt neural interactions in cortical and subcortical brain circuits. While the effect of anesthetic drugs on consciousness is reversible, the neural mechanism mediating induction and recovery may be different. Insight into these distinct mechanisms can be gained from a systematic comparison of neural dynamics during slow induction of and emergence from anesthesia. To this end, we used functional magnetic resonance imaging (fMRI) data obtained in healthy volunteers before, during, and after the administration of propofol at incrementally adjusted target concentrations. We analyzed functional connectivity of corticocortical and subcorticocortical networks and the temporal autocorrelation of fMRI signal as an index of neural processing timescales. We found that en route to unconsciousness, temporal autocorrelation across the entire brain gradually increased, whereas functional connectivity gradually decreased. In contrast, regaining consciousness was associated with an abrupt restoration of cortical but not subcortical temporal autocorrelation and an abrupt boost of subcorticocortical functional connectivity. Pharmacokinetic effects could not account for the difference in neural dynamics between induction and emergence. We conclude that the induction and recovery phases of anesthesia follow asymmetric neural dynamics. A rapid increase in the speed of cortical neural processing and subcorticocortical neural interactions may be a mechanism that reboots consciousness.

Cortical Responses to Vowel Sequences in Awake and Anesthetized States: A Human Intracranial Electrophysiology Study

Elucidating neural signatures of sensory processing across consciousness states is a major focus in neuroscience. Noninvasive human studies using the general anesthetic propofol reveal differential effects on auditory cortical activity, with a greater impact on nonprimary and auditory-related areas than primary auditory cortex. This study used intracranial electroencephalography to examine cortical responses to vowel sequences during induction of general anesthesia with propofol. Subjects were adult neurosurgical patients with intracranial electrodes placed to identify epileptic foci. Data were collected before electrode removal surgery. Stimuli were vowel sequences presented in a target detection task during awake, sedated, and unresponsive states. Averaged evoked potentials (AEPs) and high gamma (70-150 Hz) power were measured in auditory, auditory-related, and prefrontal cortex. In the awake state, AEPs were found throughout studied brain areas; high gamma activity was limited to canonical auditory cortex. Sedation led to a decrease in AEP magnitude. Upon LOC, there was a decrease in the superior temporal gyrus and adjacent auditory-related cortex and a further decrease in AEP magnitude in core auditory cortex, changes in the temporal structure and increased trial-to-trial variability of responses. The findings identify putative biomarkers of LOC and serve as a foundation for future investigations of altered sensory processing.

Anterior insula regulates brain network transitions that gate conscious access

Conscious access to sensory information is likely gated at an intermediate site between primary sensory and transmodal association cortices, but the structure responsible remains unknown. We perform functional neuroimaging to determine the neural correlates of conscious access using a volitional mental imagery task, a report paradigm not confounded by motor behavior. Titrating propofol to loss of behavioral responsiveness in healthy volunteers creates dysfunction of the anterior insular cortex (AIC) in association with an impairment of dynamic transitions of default-mode and dorsal attention networks. Candidate subcortical regions mediating sensory gating or arousal (thalamus, basal forebrain) fail to show this association. The gating role of the AIC is consistent with findings in awake participants, whose conscious access is predicted by pre-stimulus AIC activity near perceptual threshold. These data support the hypothesis that AIC, situated at an intermediate position of the cortical hierarchy, regulates brain network transitions that gate conscious access.

In a human neuroimaging study, Huang et al. manipulate the level and content of consciousness using independent experimental protocols to demonstrate that the anterior insula, situated between unimodal and transmodal cortical areas along the brain’s functional hierarchy, serves as a gate for conscious access of sensory information.

Largest scale dissociation of brain activity at propofol-induced loss of consciousness

The brain is a functional unit made up of multilevel connected elements showing a pattern of synchronized activity that varies in different states. The wake-sleep cycle is a major variation of brain functional condition that is ultimately regulated by subcortical arousal- and sleep-promoting cell groups. We analyzed the evolution of functional MRI (fMRI) signal in the whole cortex and in a deep region including most sleep- and wake-regulating subcortical nuclei at loss of consciousness induced by the hypnotic agent propofol. Optimal data were obtained in 21 of the 30 healthy participants examined. A dynamic analysis of fMRI time courses on a time-scale of seconds was conducted to characterize consciousness transition, and functional connectivity maps were generated to detail the anatomy of structures showing different dynamics. Inside the magnet, loss of consciousness was marked by the participants ceasing to move their hands. We observed activity synchronization after loss of consciousness within both the cerebral cortex and subcortical structures. However, the evolution of fMRI signal was dissociated, showing a transient reduction of global cortico-subcortical coupling that was restored during the unconscious state. An exception to cortico-subcortical decoupling was a brain network related to self-awareness (i.e. the default mode network) that remained connected to subcortical brain structures. Propofol-induced unconsciousness is thus characterized by an initial, transitory dissociated synchronization at the largest scale of brain activity. Such cortico-subcortical decoupling and subsequent recoupling may allow the brain to detach from waking activity and reorganize into a functionally distinct state.

Common fronto-temporal effective connectivity in humans and monkeys

Human brain pathways supporting language and declarative memory are thought to have differentiated substantially during evolution. However, cross-species comparisons are missing on site-specific effective connectivity between regions important for cognition. We harnessed functional imaging to visualize the effects of direct electrical brain stimulation in macaque monkeys and human neurosurgery patients. We discovered comparable effective connectivity between caudal auditory cortex and both ventro-lateral prefrontal cortex (VLPFC, including area 44) and parahippocampal cortex in both species. Human-specific differences were clearest in the form of stronger hemispheric lateralization effects. In humans, electrical tractography revealed remarkably rapid evoked potentials in VLPFC following auditory cortex stimulation and speech sounds drove VLPFC, consistent with prior evidence in monkeys of direct auditory cortex projections to homologous vocalization-responsive regions. The results identify a common effective connectivity signature in human and nonhuman primates, which from auditory cortex appears equally direct to VLPFC and indirect to the hippocampus. VIDEO ABSTRACT.

Covert Speech Comprehension Predicts Recovery From Acute Unresponsive States

OBJECTIVE

Patients with traumatic brain injury who fail to obey commands after sedation-washout pose one of the most significant challenges for neurological prognostication. Reducing prognostic uncertainty will lead to more appropriate care decisions and ensure provision of limited rehabilitation resources to those most likely to benefit. Bedside markers of covert residual cognition, including speech comprehension, may reduce this uncertainty.

METHODS

We recruited 28 patients with acute traumatic brain injury who were 2 to 7 days sedation-free and failed to obey commands. Patients heard streams of isochronous monosyllabic words that built meaningful phrases and sentences while their brain activity via electroencephalography (EEG) was recorded. In healthy individuals, EEG activity only synchronizes with the rhythm of phrases and sentences when listeners consciously comprehend the speech. This approach therefore provides a measure of residual speech comprehension in unresponsive patients.

RESULTS

Seventeen and 16 patients were available for assessment with the Glasgow Outcome Scale Extended (GOSE) at 3 months and 6 months, respectively. Outcome significantly correlated with the strength of patients' acute cortical tracking of phrases and sentences (r > 0.6, p < 0.007), quantified by inter-trial phase coherence. Linear regressions revealed that the strength of this comprehension response (beta = 0.603, p = 0.006) significantly improved the accuracy of prognoses relative to clinical characteristics alone (eg, Glasgow Coma Scale [GCS], computed tomography [CT] grade).

INTERPRETATION

A simple, passive, auditory EEG protocol improves prognostic accuracy in a critical period of clinical decision making. Unlike other approaches to probing covert cognition for prognostication, this approach is entirely passive and therefore less susceptible to cognitive deficits, increasing the number of patients who may benefit. ANN NEUROL 2021;89:646-656.

Neuropsychopharmacological effects of midazolam on the human brain

As a commonly used anesthetic agent, midazolam has the properties of water-soluble, rapid onset, and short duration of action. With the rapid development in the field of neuroimaging, numerous studies have investigated how midazolam acts on the human brain to induce the alteration of consciousness. However, the neural bases of midazolam-induced sedation or anesthesia remain beginning to be understood in detail. In this review, we summarize findings from neuroimaging studies that have used midazolam to study altered consciousness at different levels and content. We also compare the results to those of neuroimaging studies using diverse anesthetic agents and describe the common neural correlates of anesthetic-induced alteration of consciousness.

Stress and Fear: Clinical Implications for Providers and Patients (in the Time of COVID-19 and Beyond)

In light of the coronavirus disease 2019 pandemic, we explore the role of stress, fear, and the impact of positive and negative emotions on health and disease. We then introduce strategies to help mitigate stress within the health care team, and provide a rationale for their efficacy. Additionally, we identify strategies to optimize patient care and explain their heightened importance in today's environment.

Lack of selectivity for syntax relative to word meanings throughout the language network

To understand what you are reading now, your mind retrieves the meanings of words and constructions from a linguistic knowledge store (lexico-semantic processing) and identifies the relationships among them to construct a complex meaning (syntactic or combinatorial processing). Do these two sets of processes rely on distinct, specialized mechanisms or, rather, share a common pool of resources? Linguistic theorizing, empirical evidence from language acquisition and processing, and computational modeling have jointly painted a picture whereby lexico-semantic and syntactic processing are deeply inter-connected and perhaps not separable. In contrast, many current proposals of the neural architecture of language continue to endorse a view whereby certain brain regions selectively support syntactic/combinatorial processing, although the locus of such "syntactic hub", and its nature, vary across proposals. Here, we searched for selectivity for syntactic over lexico-semantic processing using a powerful individual-subjects fMRI approach across three sentence comprehension paradigms that have been used in prior work to argue for such selectivity: responses to lexico-semantic vs. morpho-syntactic violations (Experiment 1); recovery from neural suppression across pairs of sentences differing in only lexical items vs. only syntactic structure (Experiment 2); and same/different meaning judgments on such sentence pairs (Experiment 3). Across experiments, both lexico-semantic and syntactic conditions elicited robust responses throughout the left fronto-temporal language network. Critically, however, no regions were more strongly engaged by syntactic than lexico-semantic processing, although some regions showed the opposite pattern. Thus, contra many current proposals of the neural architecture of language, syntactic/combinatorial processing is not separable from lexico-semantic processing at the level of brain regions-or even voxel subsets-within the language network, in line with strong integration between these two processes that has been consistently observed in behavioral and computational language research. The results further suggest that the language network may be generally more strongly concerned with meaning than syntactic form, in line with the primary function of language-to share meanings across minds.

The Neural Basis of Metaphor Comprehension: Evidence from Left Hemisphere Degeneration

Despite the ubiquity of metaphor in cognition and communication, it is absent from standard clinical assessments of language, and the neural systems that support metaphor processing are debated. Previous research shows that patients with focal brain lesions can display selective impairments in processing metaphor, suggesting that figurative language abilities may be disproportionately vulnerable to brain injury. We hypothesized that metaphor processing is especially vulnerable to neurodegenerative disease, and that the left hemisphere is critical for normal metaphor processing. To evaluate these hypotheses, we tested metaphor comprehension in patients with left-hemisphere neurodegeneration, and in demographically matched healthy comparison participants. Stimuli consisted of moderately familiar metaphors and closely matched literal sentences sharing the same source term (e.g., The interview was a painful crawl / The infant's motion was a crawl). Written sentences were presented, followed by four modifier-noun answer choices (one target and three foils). Healthy controls, though reliably better at literal than metaphor trials, comprehended both sentence conditions well. By contrast, participants with left-hemisphere neurodegeneration performed disproportionately poorly on metaphor comprehension. Anatomical analyses show relationships between metaphor accuracy and patient atrophy in the left middle and superior temporal gyri, and the left inferior frontal gyrus, areas that have been implicated in supporting metaphor comprehension in previous imaging research. The behavioral results also suggest deficits of metaphor comprehension may be a sensitive measure of cognitive dysfunction in some forms of neurodegenerative disease.

Lack of selectivity for syntax relative to word meanings throughout the language network

To understand what you are reading now, your mind retrieves the meanings of words and constructions from a linguistic knowledge store (lexico-semantic processing) and identifies the relationships among them to construct a complex meaning (syntactic or combinatorial processing). Do these two sets of processes rely on distinct, specialized mechanisms or, rather, share a common pool of resources? Linguistic theorizing, empirical evidence from language acquisition and processing, and computational modeling have jointly painted a picture whereby lexico-semantic and syntactic processing are deeply inter-connected and perhaps not separable. In contrast, many current proposals of the neural architecture of language continue to endorse a view whereby certain brain regions selectively support syntactic/combinatorial processing, although the locus of such "syntactic hub", and its nature, vary across proposals. Here, we searched for selectivity for syntactic over lexico-semantic processing using a powerful individual-subjects fMRI approach across three sentence comprehension paradigms that have been used in prior work to argue for such selectivity: responses to lexico-semantic vs. morpho-syntactic violations (Experiment 1); recovery from neural suppression across pairs of sentences differing in only lexical items vs. only syntactic structure (Experiment 2); and same/different meaning judgments on such sentence pairs (Experiment 3). Across experiments, both lexico-semantic and syntactic conditions elicited robust responses throughout the left fronto-temporal language network. Critically, however, no regions were more strongly engaged by syntactic than lexico-semantic processing, although some regions showed the opposite pattern. Thus, contra many current proposals of the neural architecture of language, syntactic/combinatorial processing is not separable from lexico-semantic processing at the level of brain regions-or even voxel subsets-within the language network, in line with strong integration between these two processes that has been consistently observed in behavioral and computational language research. The results further suggest that the language network may be generally more strongly concerned with meaning than syntactic form, in line with the primary function of language-to share meanings across minds.

Modeling an auditory stimulated brain under altered states of consciousness using the generalized Ising model

Propofol is a short-acting medication that results in decreased levels of consciousness and is used for general anesthesia. Although it is the most commonly used anesthetic in the world, much remains unknown about the mechanisms by which it induces a loss of consciousness. Characterizing anesthesia-induced alterations to brain network activity might provide a powerful framework for understanding the neural mechanisms of unconsciousness. The aim of this work was to model brain activity in healthy brains during various stages of consciousness, as induced by propofol, in the auditory paradigm. We used the generalized Ising model (GIM) to fit the empirical fMRI data of healthy subjects while they listened to an audio clip from a movie. The external stimulus (audio clip) is believed to be at least partially driving a synchronization process of the brain activity and provides a similar conscious experience in different subjects. In order to observe the common synchronization among the subjects, a novel technique called the inter subject correlation (ISC) was implemented. We showed that the GIM-modified to incorporate the naturalistic external field-was able to fit the empirical task fMRI data in the awake state, in mild sedation, in deep sedation, and in recovery, at a temperature T* which is well above the critical temperature. To our knowledge this is the first study that captures human brain activity in response to real-life external stimuli at different levels of conscious awareness using mathematical modeling. This study might be helpful in the future to assess the level of consciousness of patients with disorders of consciousness and help in regaining their consciousness.

Anesthesia-induced loss of consciousness disrupts auditory responses beyond primary cortex

Despite its ubiquitous use in medicine, and extensive knowledge of its molecular and cellular effects, how anesthesia induces loss of consciousness (LOC) and affects sensory processing remains poorly understood. Specifically, it is unclear whether anesthesia primarily disrupts thalamocortical relay or intercortical signaling. Here we recorded intracranial electroencephalogram (iEEG), local field potentials (LFPs), and single-unit activity in patients during wakefulness and light anesthesia. Propofol infusion was gradually increased while auditory stimuli were presented and patients responded to a target stimulus until they became unresponsive. We found widespread iEEG responses in association cortices during wakefulness, which were attenuated and restricted to auditory regions upon LOC. Neuronal spiking and LFP responses in primary auditory cortex (PAC) persisted after LOC, while responses in higher-order auditory regions were variable, with neuronal spiking largely attenuated. Gamma power induced by word stimuli increased after LOC while its frequency profile slowed, thus differing from local spiking activity. In summary, anesthesia-induced LOC disrupts auditory processing in association cortices while relatively sparing responses in PAC, opening new avenues for future research into mechanisms of LOC and the design of anesthetic monitoring devices.

The Neural Time Course of Semantic Ambiguity Resolution in Speech Comprehension

Semantically ambiguous words challenge speech comprehension, particularly when listeners must select a less frequent (subordinate) meaning at disambiguation. Using combined magnetoencephalography (MEG) and EEG, we measured neural responses associated with distinct cognitive operations during semantic ambiguity resolution in spoken sentences: (i) initial activation and selection of meanings in response to an ambiguous word and (ii) sentence reinterpretation in response to subsequent disambiguation to a subordinate meaning. Ambiguous words elicited an increased neural response approximately 400-800 msec after their acoustic offset compared with unambiguous control words in left frontotemporal MEG sensors, corresponding to sources in bilateral frontotemporal brain regions. This response may reflect increased demands on processes by which multiple alternative meanings are activated and maintained until later selection. Disambiguating words heard after an ambiguous word were associated with marginally increased neural activity over bilateral temporal MEG sensors and a central cluster of EEG electrodes, which localized to similar bilateral frontal and left temporal regions. This later neural response may reflect effortful semantic integration or elicitation of prediction errors that guide reinterpretation of previously selected word meanings. Across participants, the amplitude of the ambiguity response showed a marginal positive correlation with comprehension scores, suggesting that sentence comprehension benefits from additional processing around the time of an ambiguous word. Better comprehenders may have increased availability of subordinate meanings, perhaps due to higher quality lexical representations and reflected in a positive correlation between vocabulary size and comprehension success.

Settling Into Semantic Space: An Ambiguity-Focused Account of Word-Meaning Access

Most words are ambiguous: Individual word forms (e.g., run) can map onto multiple different interpretations depending on their sentence context (e.g., the athlete/politician/river runs). Models of word-meaning access must therefore explain how listeners and readers can rapidly settle on a single, contextually appropriate meaning for each word that they encounter. I present a new account of word-meaning access that places semantic disambiguation at its core and integrates evidence from a wide variety of experimental approaches to explain this key aspect of language comprehension. The model has three key characteristics. (a) Lexical-semantic knowledge is viewed as a high-dimensional space; familiar word meanings correspond to stable states within this lexical-semantic space. (b) Multiple linguistic and paralinguistic cues can influence the settling process by which the system resolves on one of these familiar meanings. (c) Learning mechanisms play a vital role in facilitating rapid word-meaning access by shaping and maintaining high-quality lexical-semantic knowledge throughout the life span. In contrast to earlier models of word-meaning access, I highlight individual differences in lexical-semantic knowledge: Each person's lexicon is uniquely structured by specific, idiosyncratic linguistic experiences.

Assessment of Covert Consciousness in the Intensive Care Unit: Clinical and Ethical Considerations

OBJECTIVE

To propose a practical ethical framework for how task-based functional magnetic resonance imaging (fMRI) and electroencephalography (EEG) may be used in the intensive care unit (ICU) to identify covert consciousness in patients with acute severe traumatic brain injury (TBI).

METHODS

We present 2 clinical scenarios in which investigational task-based fMRI and EEG were performed in critically ill patients with acute severe TBI who appeared unconscious on the bedside behavioral assessment. From these cases, we consider the clinical and ethical challenges that emerge and suggest how to reconcile them. We also provide recommendations regarding communication with families about ICU patients with covert consciousness.

RESULTS

Covert consciousness was detected acutely in a patient who died in the ICU due to withdrawal of life-sustaining therapy, whereas covert consciousness was not detected in a patient who subsequently recovered consciousness, communication, and functional independence. These cases raise ethical challenges about how assessment of covert consciousness in the ICU might inform treatment decisions, prognostication, and perceptions about the benefits and burdens of ongoing care.

CONCLUSIONS

Given that covert consciousness can be detected acutely in the ICU, we recommend that clinicians reconsider evaluative norms for ICU patients. As our clinical appreciation of covert consciousness evolves and its ethical import unfolds, we urge prognostic humility and transparency when clinicians communicate with families in the ICU about goals of care.

Regional entropy of functional imaging signals varies differently in sensory and cognitive systems during propofol-modulated loss and return of behavioral responsiveness

The level and richness of consciousness depend on information integration in the brain. Altered interregional functional interactions may indicate disrupted information integration during anesthetic-induced unconsciousness. How anesthetics modulate the amount of information in various brain regions has received less attention. Here, we propose a novel approach to quantify regional information content in the brain by the entropy of the principal components of regional blood oxygen-dependent imaging signals during graded propofol sedation. Fifteen healthy individuals underwent resting-state scans in wakeful baseline, light sedation (conscious), deep sedation (unconscious), and recovery (conscious). Light sedation characterized by lethargic behavioral responses was associated with global reduction of entropy in the brain. Deep sedation with completely suppressed overt responsiveness was associated with further reductions of entropy in sensory (primary and higher sensory plus orbital prefrontal cortices) but not high-order cognitive (dorsal and medial prefrontal, cingulate, parietotemporal cortices and hippocampal areas) systems. Upon recovery of responsiveness, entropy was restored in the sensory but not in high-order cognitive systems. These findings provide novel evidence for a reduction of information content of the brain as a potential systems-level mechanism of reduced consciousness during propofol anesthesia. The differential changes of entropy in the sensory and high-order cognitive systems associated with losing and regaining overt responsiveness are consistent with the notion of "disconnected consciousness", in which a complete sensory-motor disconnection from the environment occurs with preserved internal mentation.

No language unification without neural feedback: How awareness affects sentence processing

How does the human brain combine a finite number of words to form an infinite variety of sentences? According to the Memory, Unification and Control (MUC) model, sentence processing requires long-range feedback from the left inferior frontal cortex (LIFC) to left posterior temporal cortex (LPTC). Single word processing however may only require feedforward propagation of semantic information from sensory regions to LPTC. Here we tested the claim that long-range feedback is required for sentence processing by reducing visual awareness of words using a masking technique. Masking disrupts feedback processing while leaving feedforward processing relatively intact. Previous studies have shown that masked single words still elicit an N400 ERP effect, a neural signature of semantic incongruency. However, whether multiple words can be combined to form a sentence under reduced levels of awareness is controversial. To investigate this issue, we performed two experiments in which we measured electroencephalography (EEG) while 40 subjects performed a masked priming task. Words were presented either successively or simultaneously, thereby forming a short sentence that could be congruent or incongruent with a target picture. This sentence condition was compared with a typical single word condition. In the masked condition we only found an N400 effect for single words, whereas in the unmasked condition we observed an N400 effect for both unmasked sentences and single words. Our findings suggest that long-range feedback processing is required for sentence processing, but not for single word processing.

Neural networks for sentence comprehension and production: An ALE-based meta-analysis of neuroimaging studies

Comprehending and producing sentences is a complex endeavor requiring the coordinated activity of multiple brain regions. We examined three issues related to the brain networks underlying sentence comprehension and production in healthy individuals: First, which regions are recruited for sentence comprehension and sentence production? Second, are there differences for auditory sentence comprehension vs. visual sentence comprehension? Third, which regions are specifically recruited for the comprehension of syntactically complex sentences? Results from activation likelihood estimation (ALE) analyses (from 45 studies) implicated a sentence comprehension network occupying bilateral frontal and temporal lobe regions. Regions implicated in production (from 15 studies) overlapped with the set of regions associated with sentence comprehension in the left hemisphere, but did not include inferior frontal cortex, and did not extend to the right hemisphere. Modality differences between auditory and visual sentence comprehension were found principally in the temporal lobes. Results from the analysis of complex syntax (from 37 studies) showed engagement of left inferior frontal and posterior temporal regions, as well as the right insula. The involvement of the right hemisphere in the comprehension of these structures has potentially important implications for language treatment and recovery in individuals with agrammatic aphasia following left hemisphere brain damage.

Rapid Transformation from Auditory to Linguistic Representations of Continuous Speech

During speech perception, a central task of the auditory cortex is to analyze complex acoustic patterns to allow detection of the words that encode a linguistic message [1]. It is generally thought that this process includes at least one intermediate, phonetic, level of representations [2-6], localized bilaterally in the superior temporal lobe [7-9]. Phonetic representations reflect a transition from acoustic to linguistic information, classifying acoustic patterns into linguistically meaningful units, which can serve as input to mechanisms that access abstract word representations [10, 11]. While recent research has identified neural signals arising from successful recognition of individual words in continuous speech [12-15], no explicit neurophysiological signal has been found demonstrating the transition from acoustic and/or phonetic to symbolic, lexical representations. Here, we report a response reflecting the incremental integration of phonetic information for word identification, dominantly localized to the left temporal lobe. The short response latency, approximately 114 ms relative to phoneme onset, suggests that phonetic information is used for lexical processing as soon as it becomes available. Responses also tracked word boundaries, confirming previous reports of immediate lexical segmentation [16, 17]. These new results were further investigated using a cocktail-party paradigm [18, 19] in which participants listened to a mix of two talkers, attending to one and ignoring the other. Analysis indicates neural lexical processing of only the attended, but not the unattended, speech stream. Thus, while responses to acoustic features reflect attention through selective amplification of attended speech, responses consistent with a lexical processing model reveal categorically selective processing.

Disrupted neural variability during propofol-induced sedation and unconsciousness

Variability quenching is a widespread neural phenomenon in which trial-to-trial variability (TTV) of neural activity is reduced by repeated presentations of a sensory stimulus. However, its neural mechanism and functional significance remain poorly understood. Recurrent network dynamics are suggested as a candidate mechanism of TTV, and they play a key role in consciousness. We thus asked whether the variability-quenching phenomenon is related to the level of consciousness. We hypothesized that TTV reduction would be compromised during reduced level of consciousness by propofol anesthetics. We recorded functional magnetic resonance imaging signals of resting-state and stimulus-induced activities in three conditions: wakefulness, sedation, and unconsciousness (i.e., deep anesthesia). We measured the average (trial-to-trial mean, TTM) and variability (TTV) of auditory stimulus-induced activity under the three conditions. We also examined another form of neural variability (temporal variability, TV), which quantifies the overall dynamic range of ongoing neural activity across time, during both the resting-state and the task. We found that (a) TTM deceased gradually from wakefulness through sedation to anesthesia, (b) stimulus-induced TTV reduction normally seen during wakefulness was abolished during both sedation and anesthesia, and (c) TV increased in the task state as compared to resting-state during both wakefulness and sedation, but not anesthesia. Together, our results reveal distinct effects of propofol on the two forms of neural variability (TTV and TV). They imply that the anesthetic disrupts recurrent network dynamics, thus prevents the stabilization of cortical activity states. These findings shed new light on the temporal dynamics of neuronal variability and its alteration during anesthetic-induced unconsciousness.

Do New Neuroimaging Findings Challenge the Ethical Basis of Advance Directives in Disorders of Consciousness?

Some authors have questioned the moral authority of advance directives (ADs) in cases in which it is not clear if the author of the AD is identical to the person to whom it later applies. This article focuses on the question of whether the latest results of neuroimaging studies have moral significance with regard to the moral authority of ADs in patients with disorders of consciousness (DOCs). Some neuroimaging findings could provide novel insights into the question of whether patients with DOCs exhibit sufficient psychological continuity to be ascribed diachronic personal identity. If those studies were to indicate that psychological continuity is present, they could justify the moral authority of ADs in patients with DOCs. This holds at least if respect for self-determination is considered as the foundation for the moral authority of ADs. The non-identity thesis in DOCs could no longer be applied, in line with clinical and social practice.

Functional diversity of brain networks supports consciousness and verbal intelligence

How are the myriad stimuli arriving at our senses transformed into conscious thought? To address this question, in a series of studies, we asked whether a common mechanism underlies loss of information processing in unconscious states across different conditions, which could shed light on the brain mechanisms of conscious cognition. With a novel approach, we brought together for the first time, data from the same paradigm-a highly engaging auditory-only narrative-in three independent domains: anesthesia-induced unconsciousness, unconsciousness after brain injury, and individual differences in intellectual abilities during conscious cognition. During external stimulation in the unconscious state, the functional differentiation between the auditory and fronto-parietal systems decreased significantly relatively to the conscious state. Conversely, we found that stronger functional differentiation between these systems in response to external stimulation predicted higher intellectual abilities during conscious cognition, in particular higher verbal acuity scores in independent cognitive testing battery. These convergent findings suggest that the responsivity of sensory and higher-order brain systems to external stimulation, especially through the diversification of their functional responses is an essential feature of conscious cognition and verbal intelligence.

Brain imaging reveals covert consciousness during behavioral unresponsiveness induced by propofol

Detecting covert consciousness in behaviorally unresponsive patients by brain imaging is of great interest, but a reproducible model and evidence from independent sources is still lacking. Here we demonstrate the possibility of using general anesthetics in a within-subjects study design to test methods or statistical paradigms of assessing covert consciousness. Using noninvasive neuroimaging in healthy volunteers, we identified a healthy study participant who was able to exhibit the specific fMRI signatures of volitional mental imagery while behaviorally unresponsive due to sedation with propofol. Our findings reveal a novel model that may accelerate the development of new approaches to reproducibly detect covert consciousness, which is difficult to achieve in patients with heterogeneous and sometimes clinically unstable neuropathology.

Functional networks reemerge during recovery of consciousness after acute severe traumatic brain injury

Integrity of the default mode network (DMN) is believed to be essential for human consciousness. However, the effects of acute severe traumatic brain injury (TBI) on DMN functional connectivity are poorly understood. Furthermore, the temporal dynamics of DMN reemergence during recovery of consciousness have not been studied longitudinally in patients with acute severe TBI. We performed resting-state functional magnetic resonance imaging (rs-fMRI) to measure DMN connectivity in 17 patients admitted to the intensive care unit (ICU) with acute severe TBI and in 16 healthy control subjects. Eight patients returned for follow-up rs-fMRI and behavioral assessment six months post-injury. At each time point, we analyzed DMN connectivity by measuring intra-network correlations (i.e. positive correlations between DMN nodes) and inter-network anticorrelations (i.e. negative correlations between the DMN and other resting-state networks). All patients were comatose upon arrival to the ICU and had a disorder of consciousness (DoC) at the time of acute rs-fMRI (9.2 ± 4.6 days post-injury): 2 coma, 4 unresponsive wakefulness syndrome, 7 minimally conscious state, and 4 post-traumatic confusional state. We found that, while DMN anticorrelations were absent in patients with acute DoC, patients who recovered from coma to a minimally conscious or confusional state while in the ICU showed partially preserved DMN correlations. Patients who remained in coma or unresponsive wakefulness syndrome in the ICU showed no DMN correlations. All eight patients assessed longitudinally recovered beyond the confusional state by 6 months post-injury and showed normal DMN correlations and anticorrelations, indistinguishable from those of healthy subjects. Collectively, these findings suggest that recovery of consciousness after acute severe TBI is associated with partial preservation of DMN correlations in the ICU, followed by long-term normalization of DMN correlations and anticorrelations. Both intra-network DMN correlations and inter-network DMN anticorrelations may be necessary for full recovery of consciousness after acute severe TBI.

Spoken words are processed during dexmedetomidine-induced unresponsiveness

BACKGROUND

Studying the effects of anaesthetic drugs on the processing of semantic stimuli could yield insights into how brain functions change in the transition from wakefulness to unresponsiveness. Here, we explored the N400 event-related potential during dexmedetomidine- and propofol-induced unresponsiveness.

METHODS

Forty-seven healthy subjects were randomised to receive either dexmedetomidine (n=23) or propofol (n=24) in this open-label parallel-group study. Loss of responsiveness was achieved by stepwise increments of pseudo-steady-state plasma concentrations, and presumed loss of consciousness was induced using 1.5 times the concentration required for loss of responsiveness. Pre-recorded spoken sentences ending either with an expected (congruous) or an unexpected (incongruous) word were presented during unresponsiveness. The resulting electroencephalogram data were analysed for the presence of the N400 component, and for the N400 effect defined as the difference between the N400 components elicited by congruous and incongruous stimuli, in the time window 300-600 ms post-stimulus. Recognition of the presented stimuli was tested after recovery of responsiveness.

RESULTS

The N400 effect was not observed during dexmedetomidine- or propofol-induced unresponsiveness. The N400 component, however, persisted during dexmedetomidine administration. The N400 component elicited by congruous stimuli during unresponsiveness in the dexmedetomidine group resembled the large component evoked by incongruous stimuli at the awake baseline. After recovery, no recognition of the stimuli heard during unresponsiveness occurred.

CONCLUSIONS

Dexmedetomidine and propofol disrupt the discrimination of congruous and incongruous spoken sentences, and recognition memory at loss of responsiveness. However, the processing of words is partially preserved during dexmedetomidine-induced unresponsiveness.

CLINICAL TRIAL REGISTRATION

NCT01889004.

Neural Signatures of the Processing of Temporal Patterns in Sound

The ability to detect regularities in sound (i.e., recurring structure) is critical for effective perception, enabling, for example, change detection and prediction. Two seemingly unconnected lines of research concern the neural operations involved in processing regularities: one investigates how neural activity synchronizes with temporal regularities (e.g., frequency modulation; FM) in sounds, whereas the other focuses on increases in sustained activity during stimulation with repeating tone-frequency patterns. In three electroencephalography studies with male and female human participants, we investigated whether neural synchronization and sustained neural activity are dissociable, or whether they are functionally interdependent. Experiment I demonstrated that neural activity synchronizes with temporal regularity (FM) in sounds, and that sustained activity increases concomitantly. In Experiment II, phase coherence of FM in sounds was parametrically varied. Although neural synchronization was more sensitive to changes in FM coherence, such changes led to a systematic modulation of both neural synchronization and sustained activity, with magnitude increasing as coherence increased. In Experiment III, participants either performed a duration categorization task on the sounds, or a visual object tracking task to distract attention. Neural synchronization was observed regardless of task, whereas the sustained response was observed only when attention was on the auditory task, not under (visual) distraction. The results suggest that neural synchronization and sustained activity levels are functionally linked: both are sensitive to regularities in sounds. However, neural synchronization might reflect a more sensory-driven response to regularity, compared with sustained activity which may be influenced by attentional, contextual, or other experiential factors.SIGNIFICANCE STATEMENT Optimal perception requires that the auditory system detects regularities in sounds. Synchronized neural activity and increases in sustained neural activity both appear to index the detection of a regularity, but the functional interrelation of these two neural signatures is unknown. In three electroencephalography experiments, we measured both signatures concomitantly while listeners were presented with sounds containing frequency modulations that differed in their regularity. We observed that both neural signatures are sensitive to temporal regularity in sounds, although they functionally decouple when a listener is distracted by a demanding visual task. Our data suggest that neural synchronization reflects a more automatic response to regularity compared with sustained activity, which may be influenced by attentional, contextual, or other experiential factors.

The Impact of Age, Background Noise, Semantic Ambiguity, and Hearing Loss on Recognition Memory for Spoken Sentences

PURPOSE

The goal of this study was to determine how background noise, linguistic properties of spoken sentences, and listener abilities (hearing sensitivity and verbal working memory) affect cognitive demand during auditory sentence comprehension.

METHOD

We tested 30 young adults and 30 older adults. Participants heard lists of sentences in quiet and in 8-talker babble at signal-to-noise ratios of +15 dB and +5 dB, which increased acoustic challenge but left the speech largely intelligible. Half of the sentences contained semantically ambiguous words to additionally manipulate cognitive challenge. Following each list, participants performed a visual recognition memory task in which they viewed written sentences and indicated whether they remembered hearing the sentence previously.

RESULTS

Recognition memory (indexed by d') was poorer for acoustically challenging sentences, poorer for sentences containing ambiguous words, and differentially poorer for noisy high-ambiguity sentences. Similar patterns were observed for Z-transformed response time data. There were no main effects of age, but age interacted with both acoustic clarity and semantic ambiguity such that older adults' recognition memory was poorer for acoustically degraded high-ambiguity sentences than the young adults'. Within the older adult group, exploratory correlation analyses suggested that poorer hearing ability was associated with poorer recognition memory for sentences in noise, and better verbal working memory was associated with better recognition memory for sentences in noise.

CONCLUSIONS

Our results demonstrate listeners' reliance on domain-general cognitive processes when listening to acoustically challenging speech, even when speech is highly intelligible. Acoustic challenge and semantic ambiguity both reduce the accuracy of listeners' recognition memory for spoken sentences.

SUPPLEMENTAL MATERIALS

https://doi.org/10.23641/asha.5848059.

Listening under difficult conditions: An activation likelihood estimation meta-analysis

The brain networks supporting speech identification and comprehension under difficult listening conditions are not well specified. The networks hypothesized to underlie effortful listening include regions responsible for executive control. We conducted meta-analyses of auditory neuroimaging studies to determine whether a common activation pattern of the frontal lobe supports effortful listening under different speech manipulations. Fifty-three functional neuroimaging studies investigating speech perception were divided into three independent Activation Likelihood Estimate analyses based on the type of speech manipulation paradigm used: Speech-in-noise (SIN, 16 studies, involving 224 participants); spectrally degraded speech using filtering techniques (15 studies involving 270 participants); and linguistic complexity (i.e., levels of syntactic, lexical and semantic intricacy/density, 22 studies, involving 348 participants). Meta-analysis of the SIN studies revealed higher effort was associated with activation in left inferior frontal gyrus (IFG), left inferior parietal lobule, and right insula. Studies using spectrally degraded speech demonstrated increased activation of the insula bilaterally and the left superior temporal gyrus (STG). Studies manipulating linguistic complexity showed activation in the left IFG, right middle frontal gyrus, left middle temporal gyrus and bilateral STG. Planned contrasts revealed left IFG activation in linguistic complexity studies, which differed from activation patterns observed in SIN or spectral degradation studies. Although there were no significant overlap in prefrontal activation across these three speech manipulation paradigms, SIN and spectral degradation showed overlapping regions in left and right insula. These findings provide evidence that there is regional specialization within the left IFG and differential executive networks underlie effortful listening.

Feasibility of 15O-water PET studies of auditory system activation during general anesthesia in children

Background

¹⁵O-Water positron emission tomography (PET) enables functional imaging of the auditory system during stimulation via a promontory electrode or cochlear implant, which is not possible using functional magnetic resonance imaging (fMRI). Although PET has been introduced in this context decades ago, its feasibility when performed during general anesthesia has not yet been explored. However, due to a shift to earlier (and bilateral) auditory implantation, the need to study children during general anesthesia appeared, since they are not able to cooperate during scanning. Therefore, we evaluated retrospectively results of individual SPM (statistical parametric mapping) analysis of ¹⁵O-water PET in 17 children studied during general anesthesia and compared them to those in 9 adults studied while awake. Specifically, the influence of scan duration, smoothing filter kernel employed during preprocessing, and cut-off value used for statistical inferences were evaluated. Frequencies, peak heights, and extents of activations in auditory and extra-auditory brain regions (AR and eAR) were registered.

Results

It was possible to demonstrate activations in auditory brain regions during general anesthesia; however, the frequency and markedness of positive findings were dependent on some of the abovementioned influence factors. Scan duration (60 vs. 90 s) had no significant influence on peak height of auditory cortex activations. To achieve a similar frequency and extent of AR activations during general anesthesia compared to waking state, a lower cut-off for statistical inferences (p < 0.05 or p < 0.01 vs. p < 0.001) had to be applied. However, this lower cut-off was frequently associated with unexpected, “artificial” activations in eAR. These activations in eAR could be slightly reduced by the use of a stronger smoothing filter kernel during preprocessing of the data (e.g., [30 mm]³).

Conclusions

Our data indicate that it is feasible to detect auditory cortex activations in ¹⁵O-water PET during general anesthesia. Combined with the improved signal to noise ratios of modern PET scanners, this suggests reasonable prospects for further evaluation of the method for clinical use in auditory implant users. Adapted parameters for data analysis seem to be helpful to improve the proportion of signals in AR versus eAR.

Timescales of Intrinsic BOLD Signal Dynamics and Functional Connectivity in Pharmacologic and Neuropathologic States of Unconsciousness

Environmental events are processed on multiple timescales via hierarchical organization of temporal receptive windows (TRWs) in the brain. The dependence of neural timescales and TRWs on altered states of consciousness is unclear. States of reduced consciousness are marked by a shift toward slowing of neural dynamics (<1 Hz) in EEG/ECoG signals. We hypothesize that such prolongation of intrinsic timescales are also seen in blood-oxygen-level-dependent (BOLD) signals. To test this hypothesis, we measured the timescales of intrinsic BOLD signals using mean frequency (MF) and temporal autocorrelation (AC) in healthy volunteers (n = 23; male/female 14/9) during graded sedation with propofol. We further examined the relationship between the intrinsic timescales (local/voxel level) and its regional connectivity (across neighboring voxels; regional homogeneity, ReHo), global (whole-brain level) functional connectivity (GFC), and topographical similarity (Topo). Additional results were obtained from patients undergoing deep general anesthesia (n = 12; male/female: 5/7) and in patients with disorders of consciousness (DOC) (n = 21; male/female: 14/7). We found that MF, AC, and ReHo increased, whereas GFC and Topo decreased, during propofol sedation. The local alterations occur before changes of distant connectivity. Conversely, all of these parameters decreased in deep anesthesia and in patients with DOC. We conclude that propofol synchronizes local neuronal interactions and prolongs the timescales of intrinsic BOLD signals. These effects may impede communication among distant brain regions. Furthermore, the intrinsic timescales exhibit distinct dynamic signatures in sedation, deep anesthesia, and DOC. These results improve our understanding of the neural mechanisms of unconsciousness in pharmacologic and neuropathologic states.

SIGNIFICANCE STATEMENT Information processing in the brain occurs through a hierarchy of temporal receptive windows (TRWs) in multiple timescales. Anesthetic drugs induce a reversible suppression of consciousness and thus offer a unique opportunity to investigate the state dependence of neural timescales. Here, we demonstrate for the first time that sedation with propofol is accompanied by the prolongation of the timescales of intrinsic BOLD signals presumably reflecting enlarged TRWs. We show that this is accomplished by an increase of local and regional signal synchronization, effects that may disrupt information exchange among distant brain regions. Furthermore, we show that the timescales of intrinsic BOLD signals exhibit distinct dynamic signatures in sedation, deep anesthesia, and disorders of consciousness.