1
|
Moretta P, Femiano C, Cavallo ND, Lanzillo A, Luciano F, Ferrante C, Maiorino A, Santangelo G, Marcuccio L. Family caregivers improve the diagnostic accuracy of disorders of consciousness: from remote to near-bed auditory stimulation. Eur J Phys Rehabil Med 2024; 60:198-206. [PMID: 38381451 PMCID: PMC11114155 DOI: 10.23736/s1973-9087.24.08179-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Revised: 10/20/2023] [Accepted: 01/17/2024] [Indexed: 02/22/2024]
Abstract
BACKGROUND Family caregivers (FC) contribute to reducing the misdiagnosis rate in patients with disorders of consciousness (DOC). Unfortunately, the recent pandemic of COVID-19 imposed drastic restrictions that limited the access of FC to the sensory/cognitive stimulation protocols. Telemedicine approaches have been implemented to avoid discontinuity in care pathways and to ensure caregivers involvement in rehabilitation programs. AIM The aim was to investigate whether the presence of FC remotely connected might help clinicians in eliciting higher cortically mediated behavioral responses in patients with DOC. DESIGN Cross-sectional study. SETTING Post-acute Unit of Neurorehabilitation. POPULATION DOC due to severe brain injury. METHODS Consecutive patients with DOC were assessed by means of the Coma Recovery Scale-Revised (CRS-R) by two expert examiners. Each patient underwent to five assessments in two weeks in three different conditions: 1) by the examiner only (standard); 2) with the verbal stimulation given by the FC remotely connected by PC tablet (caregiver in remote); and 3) with the verbal stimulation given by the FC physically present (caregiver in presence). RESULTS Thirty patients with DOC (VS/UWS=10; MCS=20; mean age: 51, range: 21-79; vascular: 16; anoxic: 6; TBI=8) and their FC were enrolled. Higher total scores of CRS-R were recorded both in "caregiver in remote" and in "caregiver in presence" than in standard condition (standard vs. remote, Z=2.942, P=0.003; standard vs. presence, Z=3.736, P<0.001). Furthermore, the administration of the CRS-R with a FC, elicited higher levels of behavioral responses in MCS patients, than CRS-R performed in standard condition. In particular, 2 patients out of 30 (6.66%) showed higher scores and better diagnosis when the CRS-R was administered with FC in remote. Similarly, 5 out of 30 patients (16.66%) showed better diagnoses when the CRS-R was administered with FC in presence. Five patients changed diagnosis between standard and presence conditions (3 MCS- were diagnosed as MCS+; 2 MCS+ were diagnosed as conscious). CONCLUSIONS Our findings add new evidence regarding the beneficial role of family members in the diagnosis of DOC, even mediated by telemedicine approach. CLINICAL REHABILITATION IMPACT In future guidelines, FC should have an active and supporting role in the diagnostic and rehabilitative process of DOC.
Collapse
Affiliation(s)
- Pasquale Moretta
- Istituti Clinici Scientifici Maugeri IRCCS, Neurological Rehabilitation Unit of Telese Terme, Telese Terme, Benevento, Italy -
| | - Cinzia Femiano
- Istituti Clinici Scientifici Maugeri IRCCS, Neurological Rehabilitation Unit of Telese Terme, Telese Terme, Benevento, Italy
| | - Nicola D Cavallo
- Department of Psychology, Luigi Vanvitelli University of Campania, Caserta, Italy
| | - Anna Lanzillo
- Istituti Clinici Scientifici Maugeri IRCCS, Neurological Rehabilitation Unit of Telese Terme, Telese Terme, Benevento, Italy
| | - Fabrizio Luciano
- Istituti Clinici Scientifici Maugeri IRCCS, Neurological Rehabilitation Unit of Telese Terme, Telese Terme, Benevento, Italy
| | - Cesario Ferrante
- Istituti Clinici Scientifici Maugeri IRCCS, Neurological Rehabilitation Unit of Telese Terme, Telese Terme, Benevento, Italy
| | - Antonio Maiorino
- Istituti Clinici Scientifici Maugeri IRCCS, Neurological Rehabilitation Unit of Telese Terme, Telese Terme, Benevento, Italy
| | - Gabriella Santangelo
- Department of Psychology, Luigi Vanvitelli University of Campania, Caserta, Italy
| | - Laura Marcuccio
- Istituti Clinici Scientifici Maugeri IRCCS, Neurological Rehabilitation Unit of Telese Terme, Telese Terme, Benevento, Italy
| |
Collapse
|
2
|
Aklepi G, Manolovitz B, Robayo LE, Sarafraz A, Blandino CF, Arwari B, Sobczak E, Bass D, Ghamasaee P, Bolaños Saavedra A, Samano D, Massad N, Kottapally M, Merenda A, Dib S, Dietrich WD, Rundek T, O'Phelan KH, Claassen J, Walker MF, Alkhachroum A. Covert Tracking to Immersive Stimuli in Traumatic Brain Injury Subjects With Disorders of Consciousness. J Neurotrauma 2024; 41:646-659. [PMID: 37624747 PMCID: PMC11265640 DOI: 10.1089/neu.2023.0188] [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] [Indexed: 08/27/2023] Open
Abstract
Eye tracking assessments are clinician dependent and can contribute to misclassification of coma. We investigated responsiveness to videos with and without audio in traumatic brain injury (TBI) subjects using video eye-tracking (VET). We recruited 20 healthy volunteers and 10 unresponsive TBI subjects. Clinicians were surveyed whether the subject was tracking on their bedside assessment. The Coma Recovery Scale-Revised (CRS-R) was also performed. Eye movements in response to three different 30-second videos with and without sound were recorded using VET. The videos consisted of moving characters (a dancer, a person skateboarding, and Spiderman). Tracking on VET was defined as visual fixation on the character and gaze movement in the same direction of the character on two separate occasions. Subjects were classified as "covert tracking" (tracking using VET only), "overt tracking" (VET and clinical exam by clinicians), and "no tracking". A k-nearest-neighbors model was also used to identify tracking computationally. Thalamocortical connectivity and structural integrity were evaluated with EEG and MRI. The ability to obey commands was evaluated at 6- and 12-month follow-up. The average age was 29 (± 17) years old. Three subjects demonstrated "covert tracking" (CRS-R of 6, 8, 7), two "overt tracking" (CRS-R 22, 11), and five subjects "no tracking" (CRS-R 8, 6, 5, 6, 7). Among the 84 tested trials in all subjects, 11 trials (13%) met the criteria for "covert tracking". Using the k-nearest approach, 14 trials (17%) were classified as "covert tracking". Subjects with "tracking" had higher thalamocortical connectivity, and had fewer structures injured in the eye-tracking network than those without tracking. At follow-up, 2 out of 3 "covert" and all "overt" subjects recovered consciousness versus only 2 subjects in the "no tracking" group. Immersive stimuli may serve as important objective tools to differentiate subtle tracking using VET.
Collapse
Affiliation(s)
- Gabriela Aklepi
- Department of Neurology, University of Miami, Miami, Florida, USA
- Jackson Memorial Hospital, Miami, Florida, USA
| | - Brian Manolovitz
- Department of Neurology, University of Miami, Miami, Florida, USA
| | - Linda E. Robayo
- Neuroscience Graduate Program, University of Miami, Miami, Florida, USA
- The Miami Project to Cure Paralysis, University of Miami, Miami, Florida, USA
| | - Amin Sarafraz
- Center for Computational Science, University of Miami, Miami, Florida, USA
| | | | - Brian Arwari
- Department of Kinesiology and Sport Sciences, University of Miami, Miami, Florida, USA
| | - Evie Sobczak
- Department of Neurology, University of Miami, Miami, Florida, USA
- Jackson Memorial Hospital, Miami, Florida, USA
| | - Danielle Bass
- Department of Neurology, University of Miami, Miami, Florida, USA
- Jackson Memorial Hospital, Miami, Florida, USA
| | - Pardis Ghamasaee
- Department of Neurology, University of Miami, Miami, Florida, USA
- Jackson Memorial Hospital, Miami, Florida, USA
| | - Ana Bolaños Saavedra
- Department of Neurology, University of Miami, Miami, Florida, USA
- Jackson Memorial Hospital, Miami, Florida, USA
| | - Daniel Samano
- Department of Neurology, University of Miami, Miami, Florida, USA
- Jackson Memorial Hospital, Miami, Florida, USA
| | - Nina Massad
- Department of Neurology, University of Miami, Miami, Florida, USA
- Jackson Memorial Hospital, Miami, Florida, USA
| | - Mohan Kottapally
- Department of Neurology, University of Miami, Miami, Florida, USA
- Jackson Memorial Hospital, Miami, Florida, USA
| | - Amedeo Merenda
- Department of Neurology, University of Miami, Miami, Florida, USA
- Jackson Memorial Hospital, Miami, Florida, USA
| | - Salim Dib
- Department of Neurology, University of Miami, Miami, Florida, USA
- Jackson Memorial Hospital, Miami, Florida, USA
| | - W. Dalton Dietrich
- Neuroscience Graduate Program, University of Miami, Miami, Florida, USA
- The Miami Project to Cure Paralysis, University of Miami, Miami, Florida, USA
| | - Tatjana Rundek
- Department of Neurology, University of Miami, Miami, Florida, USA
- Jackson Memorial Hospital, Miami, Florida, USA
| | - Kristine H. O'Phelan
- Department of Neurology, University of Miami, Miami, Florida, USA
- Jackson Memorial Hospital, Miami, Florida, USA
| | - Jan Claassen
- Department of Neurology, Columbia University, New York, New York, USA
| | - Mark F. Walker
- Department of Neurology, Case Western Reserve University, Louis Stokes Cleveland VA Medical Center, Cleveland, Ohio, USA
| | - Ayham Alkhachroum
- Department of Neurology, University of Miami, Miami, Florida, USA
- Jackson Memorial Hospital, Miami, Florida, USA
| |
Collapse
|
3
|
Kumar A, Ridha M, Claassen J. Prognosis of consciousness disorders in the intensive care unit. Presse Med 2023; 52:104180. [PMID: 37805070 PMCID: PMC10995112 DOI: 10.1016/j.lpm.2023.104180] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2023] [Accepted: 10/03/2023] [Indexed: 10/09/2023] Open
Abstract
Assessments of consciousness are a critical part of prognostic algorithms for critically ill patients suffering from severe brain injuries. There have been significant advances in the field of coma science over the past two decades, providing clinicians with more advanced and precise tools for diagnosing and prognosticating disorders of consciousness (DoC). Advanced neuroimaging and electrophysiological techniques have vastly expanded our understanding of the biological mechanisms underlying consciousness, and have helped identify new states of consciousness. One of these, termed cognitive motor dissociation, can predict functional recovery at 1 year post brain injury, and is present in up to 15-20% of patients with DoC. In this chapter, we review several tools that are used to predict DoC, describing their strengths and limitations, from the neurological examination to advanced imaging and electrophysiologic techniques. We also describe multimodal assessment paradigms that can be used to identify covert consciousness and thus help recognize patients with the potential for future recovery and improve our prognostication practices.
Collapse
Affiliation(s)
- Aditya Kumar
- Department of Neurology, Columbia University Medical Center, New York-Presbyterian Hospital, New York, NY, USA
| | - Mohamed Ridha
- Department of Neurology, Columbia University Medical Center, New York-Presbyterian Hospital, New York, NY, USA
| | - Jan Claassen
- Department of Neurology, Columbia University Medical Center, New York-Presbyterian Hospital, New York, NY, USA.
| |
Collapse
|
4
|
Liuzzi P, De Bellis F, Magliacano A, Estraneo A, Mannini A. Consciousness-Domain Index: a data-driven clustering-based consciousness labeling. ANNUAL INTERNATIONAL CONFERENCE OF THE IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. ANNUAL INTERNATIONAL CONFERENCE 2022; 2022:1062-1065. [PMID: 36086422 DOI: 10.1109/embc48229.2022.9871151] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
Assessing consciousness results in one of the most complex neurological diagnosis. Even more complex and uncertain is prognosticating on consciousness recovery. Currently, consciousness is assessed by using a six-items scale, the Coma Recovery Scale-Revised. Namely, scores on the sub-items can individually assign or not a specific level of consciousness to a patient. In our work, by using solely the six sub-items of the CRS-R, we implemented a clustering algorithm labeling patients with the Consciousness-Domains Index (CDI) starting from a dataset of 190 patients with a Disorder of Consciousness (DoC). Then, the CDI is compared with the clinical state at admission and at six months via univariate analysis. The number of clusters best dividing the groups resulted equal to two and the most influencing sub-items resulted the visual and motor one. The CDI closely resembles the clinical state at admission (CSA) (Cohen's k=0.85). On the other hand, when comparing CDI and CSA, a net improvement was found in the prognostic power of the neurological outcome at six months, targeted as presence/absence of a DoC ( ). Data-driven techniques pave the way for automated and model-based search of prognostic factors, together with the use of such prognostic factors in multivariate prognostic models. Future works will address the external validation of the CDI, together with the inclusion of the CDI in a multivariate supervised model, in order to assess the true potential of such novel index. Clinical Relevance- A completely data-driven index was derived from a clustering of CRS-R sub-items. It correlates with the neurological outcome at six months better than the state of consciousness at admission.
Collapse
|
5
|
Mat B, Sanz L, Arzi A, Boly M, Laureys S, Gosseries O. New behavioral signs of consciousness in patients with severe brain injuries. Semin Neurol 2022; 42:259-272. [PMID: 35738292 DOI: 10.1055/a-1883-0861] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Affiliation(s)
- Beril Mat
- Neurology, University of Wisconsin-Madison, Madison, United States.,Coma Science Group, University of Liege, Liege, Belgium
| | - Leandro Sanz
- Coma Science Group, University of Liege, Liege, Belgium
| | - Anat Arzi
- The Hebrew University of Jerusalem Department of Cognitive and Brain Sciences, Jerusalem, Israel
| | - Melanie Boly
- Neurology, University of Wisconsin-Madison, Madison, United States.,Psychiatry, University of Wisconsin-Madison, Madison, United States
| | | | | |
Collapse
|
6
|
Overbeek BUH, Lavrijsen JCM, van Gaal S, Kondziella D, Eilander HJ, Koopmans RTCM. Towards consensus on visual pursuit and visual fixation in patients with disorders of consciousness. A Delphi study. J Neurol 2022; 269:3204-3215. [PMID: 35001197 DOI: 10.1007/s00415-021-10905-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2021] [Revised: 11/10/2021] [Accepted: 11/11/2021] [Indexed: 10/19/2022]
Abstract
BACKGROUND The aim of this Delphi study was to reach consensus about definition, operationalization and assessment of visual pursuit (VP) and visual fixation (VF). METHODS In a three-round international Delphi study, clinical and research experts on disorders of consciousness indicated their level of agreement on 87 statements using a 5-point Likert scale. Consensus for agreement was defined by a median of 5, an interquartile range (IQR) ≤ 1, and ≥ 80% indicating moderate or strong agreement. RESULTS Forty-three experts from three continents participated, 32 completed all three rounds. For VP, the consensus statements with the highest levels of agreement were on the term 'pursuit of a visual stimulus', the description 'ability to follow visually in horizontal and/or vertical plane', a duration > 2 s, tracking in horizontal and vertical planes, and a frequency of more than 2 times per assessment. For VF, consensus statements with the highest levels of agreement were on the term 'sustained VF', the description 'sustained fixation in response to a salient stimulus', a duration of > 2 s and a frequency of 2 or more times per assessment. The assessment factors with the highest levels of agreement were personalized stimuli, the use of eye tracking technology, a patient dependent time of assessment, sufficient environmental light, upright posture, and the necessity to exclude ocular/oculomotor problems. CONCLUSION This first international Delphi study on VP and VF in patients with disorders of consciousness provides provisional operational definitions and an overview of the most relevant assessment factors.
Collapse
Affiliation(s)
- Berno U H Overbeek
- Department of Primary and Community Care, Radboud Institute of Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands. .,Kalorama, Beek Ubbergen, The Netherlands. .,Azora, Terborg, The Netherlands.
| | - Jan C M Lavrijsen
- Department of Primary and Community Care, Radboud Institute of Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Simon van Gaal
- Faculty of Social and Behavioural Sciences, Department of Psychology, University of Amsterdam, Amsterdam, The Netherlands
| | - Daniel Kondziella
- Department of Neurology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark.,Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Henk J Eilander
- Department of Primary and Community Care, Radboud Institute of Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Raymond T C M Koopmans
- Department of Primary and Community Care, Radboud Institute of Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands.,Center for Specialized Geriatric Care, Joachim en Anna, Nijmegen, The Netherlands
| |
Collapse
|
7
|
Naccache L, Luauté J, Silva S, Sitt JD, Rohaut B. Toward a coherent structuration of disorders of consciousness expertise at a country scale: A proposal for France. Rev Neurol (Paris) 2021; 178:9-20. [PMID: 34980510 DOI: 10.1016/j.neurol.2021.12.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Accepted: 12/15/2021] [Indexed: 12/23/2022]
Abstract
Probing consciousness and cognitive abilities in non-communicating patients is one of the most challenging diagnostic issues. A fast growing medical and scientific literature explores the various facets of this challenge, often coined under the generic expression of 'Disorders of Consciousness' (DoC). Crucially, a set of independent converging results demonstrated both (1) the diagnostic and prognostic importance of this expertise, and (2) the need to combine behavioural measures with brain structure and activity data to improve diagnostic and prognostication accuracy as well as potential therapeutic intervention. Thus, probing consciousness in DoC patients appears as a crucial activity rich of human, medical, economic and ethical consequences, but this activity needs to be organized in order to offer this expertise to each concerned patient. More precisely, diagnosis of consciousness differs in difficulty across patients: while a minimal set of data can be sufficient to reach a confident result, some patients need a higher level of expertise that relies on additional behavioural and brain activity and brain structure measures. In order to enable this service on a systematic mode, we present two complementary proposals in the present article. First, we sketch a structuration of DoC expertise at a country-scale, namely France. More precisely, we suggest that a 2-tiers network composed of local (Tier-1) and regional (Tier-2) centers backed by distant electronic databases and algorithmic centers could optimally enable the systematic implementation of DoC expertise in France. Second, we propose to create a national common register of DoC patients in order to better monitor this activity, to improve its performance on the basis of nation-wide collected evidence, and to promote rational decision-making.
Collapse
Affiliation(s)
- L Naccache
- Sorbonne université, institut du cerveau - Paris Brain Institute - ICM, Inserm, CNRS, Paris, France; Sorbonne université, UPMC Univ Paris 06, faculté de médecine Pitié-Salpêtrière, Paris, France; AP-HP, hôpital groupe hospitalier Pitié-Salpêtrière, DMU neurosciences, department of clinical neurophysiology, Paris, France; AP-HP, hôpital groupe hospitalier Pitié-Salpêtrière, DMU neurosciences, department of neurology, Neuro ICU, Paris, France.
| | - J Luauté
- Service de médecine physique et réadaptation, hôpital Henry-Gabrielle, Hospices Civils de Lyon, Saint-Genis Laval, France; Équipe « Trajectoires », centre de recherche en neurosciences de Lyon, Inserm UMR-S 1028, CNRS UMR 5292, université de Lyon, université Lyon 1, Bron, France
| | - S Silva
- Intensive Care Unit, Purpan University Hospital, 31000 Toulouse, France; Toulouse NeuroImaging Center (ToNIC lab) URM UPS/INSERM 1214, 31000 Toulouse, France
| | - J D Sitt
- Sorbonne université, institut du cerveau - Paris Brain Institute - ICM, Inserm, CNRS, Paris, France; Sorbonne université, UPMC Univ Paris 06, faculté de médecine Pitié-Salpêtrière, Paris, France
| | - B Rohaut
- Sorbonne université, institut du cerveau - Paris Brain Institute - ICM, Inserm, CNRS, Paris, France; Sorbonne université, UPMC Univ Paris 06, faculté de médecine Pitié-Salpêtrière, Paris, France; AP-HP, hôpital groupe hospitalier Pitié-Salpêtrière, DMU neurosciences, department of neurology, Neuro ICU, Paris, France
| |
Collapse
|
8
|
Kondziella D, Menon DK, Helbok R, Naccache L, Othman MH, Rass V, Rohaut B, Diringer MN, Stevens RD. A Precision Medicine Framework for Classifying Patients with Disorders of Consciousness: Advanced Classification of Consciousness Endotypes (ACCESS). Neurocrit Care 2021; 35:27-36. [PMID: 34236621 DOI: 10.1007/s12028-021-01246-9] [Citation(s) in RCA: 39] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2020] [Accepted: 03/30/2021] [Indexed: 12/25/2022]
Abstract
BACKGROUND Consciousness in patients with brain injury is traditionally assessed based on semiological evaluation at the bedside. This classification is limited because of low granularity, ill-defined and rigid nomenclatures incompatible with the highly fluctuating nature of consciousness, failure to identify specific brain states like cognitive motor dissociation, and neglect for underlying biological mechanisms. Here, the authors present a pragmatic framework based on consciousness endotypes that combines clinical phenomenology with all essential physiological and biological data, emphasizing recovery trajectories, therapeutic potentials and clinical feasibility. METHODS The Neurocritical Care Society's Curing Coma Campaign identified an international group of experts who convened in a series of online meetings between May and November 2020 to discuss and propose a novel framework for classifying consciousness. RESULTS The expert group proposes Advanced Classification of Consciousness Endotypes (ACCESS), a tiered multidimensional framework reflecting increasing complexity and an aspiration to consider emerging and future approaches. Tier 1 is based on clinical phenotypes and structural imaging. Tier 2 adds functional measures including EEG, PET and functional MRI, that can be summarized using the Arousal, Volition, Cognition and Mechanisms (AVCM) score (where "Volition" signifies volitional motor responses). Finally, Tier 3 reflects dynamic changes over time with a (theoretically infinite) number of physiologically distinct states to outline consciousness recovery and identify opportunities for therapeutic interventions. CONCLUSIONS Whereas Tiers 1 and 2 propose an approach for low-resource settings and state-of-the-art expertise at leading academic centers, respectively, Tier 3 is a visionary multidimensional consciousness paradigm driven by continuous incorporation of new knowledge while addressing the Curing Coma Campaign's aspirational goals.
Collapse
Affiliation(s)
- Daniel Kondziella
- Department of Neurology, Rigshospitalet, Copenhagen University Hospital, Inge Lehmanns Vej 8, 2100, Copenhagen, Denmark. .,Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark.
| | - David K Menon
- Division of Anaesthesia, University of Cambridge, Cambridge, CB2 0NU, UK.
| | - Raimund Helbok
- Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - Lionel Naccache
- PICNIC Lab Team, INSERM, U 1127, CNRS UMR 7225, Faculté de Médecine de Sorbonne Université, UMR S 1127 Institut du Cerveau et de la Moelle épinière, ICM, Hôpital Pitié-Salpêtrière, Paris, France.,APHP, Departments of Neurology and of Clinical Neurophysiology, Hôpital de la Salpêtriere, Paris, France
| | - Marwan H Othman
- Department of Neurology, Rigshospitalet, Copenhagen University Hospital, Inge Lehmanns Vej 8, 2100, Copenhagen, Denmark
| | - Verena Rass
- Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - Benjamin Rohaut
- Sorbonne Université, Faculté de Médecine Pitié-Salpêtrière, Paris, France.,Brain institute - ICM, Sorbonne Université, Inserm U1127, CNRS UMR 7225, Hôpital Pitié-Salpêtrière, Paris, France.,Department of Neurology, Neuro ICU, Groupe Hospitalier Universitaire APHP-Sorbonne Université, site Pitié-Salpêtrière, Paris, France
| | | | - Robert D Stevens
- Departments of Anesthesiology, Critical Care Medicine, Neurology, and Neurosurgery, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | | |
Collapse
|
9
|
Kanarskii M, Nekrasova J, Vitkovskaya S, Pradhan P, Peshkov S, Borisova E, Borisov I, Panasenkova O, Petrova MV, Pryanikov I. Effect of Retinohypothalamic Tract Dysfunction on Melatonin Level in Patients with Chronic Disorders of Consciousness. Brain Sci 2021; 11:brainsci11050559. [PMID: 33925097 PMCID: PMC8145260 DOI: 10.3390/brainsci11050559] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Revised: 04/23/2021] [Accepted: 04/26/2021] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVE The aim of this study is to compare the secretion level of nocturnal melatonin and the characteristics of the peripheral part of the visual analyzer in patients with chronic disorders of consciousness (DOC). MATERIALS AND METHODS We studied the level of melatonin in 22 patients with chronic DOC and in 11 healthy volunteers. The fundus condition was assessed using the ophthalmoscopic method. RESULTS The average level of nocturnal melatonin in patients with DOC differed by 80% from the level of indole in healthy volunteers. This reveals a direct relationship between etiology, the level of consciousness, gaze fixation, coma recovery scale-revised score and the level of melatonin secretion. Examination by an ophthalmologist revealed a decrease in the macular reflex in a significant number of DOC patients, which in turn correlates negatively with the time from brain injury and positively with low values of nocturnal melatonin.
Collapse
Affiliation(s)
- Mikhail Kanarskii
- Department for the Study of Chronic Disorder of Consciousness, Federal Research and Clinical Center of Intensive Care Medicine and Rehabilitology, 117647 Moscow, Russia; (M.K.); (J.N.); (S.V.); (S.P.); (E.B.); (I.B.); (O.P.); (M.V.P.); (I.P.)
| | - Julia Nekrasova
- Department for the Study of Chronic Disorder of Consciousness, Federal Research and Clinical Center of Intensive Care Medicine and Rehabilitology, 117647 Moscow, Russia; (M.K.); (J.N.); (S.V.); (S.P.); (E.B.); (I.B.); (O.P.); (M.V.P.); (I.P.)
| | - Svetlana Vitkovskaya
- Department for the Study of Chronic Disorder of Consciousness, Federal Research and Clinical Center of Intensive Care Medicine and Rehabilitology, 117647 Moscow, Russia; (M.K.); (J.N.); (S.V.); (S.P.); (E.B.); (I.B.); (O.P.); (M.V.P.); (I.P.)
| | - Pranil Pradhan
- Department for the Study of Chronic Disorder of Consciousness, Federal Research and Clinical Center of Intensive Care Medicine and Rehabilitology, 117647 Moscow, Russia; (M.K.); (J.N.); (S.V.); (S.P.); (E.B.); (I.B.); (O.P.); (M.V.P.); (I.P.)
- Correspondence:
| | - Sergey Peshkov
- Department for the Study of Chronic Disorder of Consciousness, Federal Research and Clinical Center of Intensive Care Medicine and Rehabilitology, 117647 Moscow, Russia; (M.K.); (J.N.); (S.V.); (S.P.); (E.B.); (I.B.); (O.P.); (M.V.P.); (I.P.)
| | - Elena Borisova
- Department for the Study of Chronic Disorder of Consciousness, Federal Research and Clinical Center of Intensive Care Medicine and Rehabilitology, 117647 Moscow, Russia; (M.K.); (J.N.); (S.V.); (S.P.); (E.B.); (I.B.); (O.P.); (M.V.P.); (I.P.)
| | - Ilya Borisov
- Department for the Study of Chronic Disorder of Consciousness, Federal Research and Clinical Center of Intensive Care Medicine and Rehabilitology, 117647 Moscow, Russia; (M.K.); (J.N.); (S.V.); (S.P.); (E.B.); (I.B.); (O.P.); (M.V.P.); (I.P.)
| | - Olga Panasenkova
- Department for the Study of Chronic Disorder of Consciousness, Federal Research and Clinical Center of Intensive Care Medicine and Rehabilitology, 117647 Moscow, Russia; (M.K.); (J.N.); (S.V.); (S.P.); (E.B.); (I.B.); (O.P.); (M.V.P.); (I.P.)
| | - Marina V. Petrova
- Department for the Study of Chronic Disorder of Consciousness, Federal Research and Clinical Center of Intensive Care Medicine and Rehabilitology, 117647 Moscow, Russia; (M.K.); (J.N.); (S.V.); (S.P.); (E.B.); (I.B.); (O.P.); (M.V.P.); (I.P.)
- Department of Anestesiology-Reanimatology, People’s Friendship University of Russia, 117198 Moscow, Russia
| | - Igor Pryanikov
- Department for the Study of Chronic Disorder of Consciousness, Federal Research and Clinical Center of Intensive Care Medicine and Rehabilitology, 117647 Moscow, Russia; (M.K.); (J.N.); (S.V.); (S.P.); (E.B.); (I.B.); (O.P.); (M.V.P.); (I.P.)
| |
Collapse
|
10
|
Arnoldi K. Traumatic Brain Injury in Children: Do the Eyes Have It? The Orthoptic Evaluation of Traumatic Brain Injury. J Binocul Vis Ocul Motil 2020; 70:122-127. [PMID: 33275080 DOI: 10.1080/2576117x.2020.1792030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2020] [Revised: 06/29/2020] [Accepted: 06/30/2020] [Indexed: 06/12/2023]
Abstract
Because the neuropathological changes caused by mild traumatic brain injury (mTBI) more often manifest as functional impairments than structural abnormalities, the clinical diagnosis of mTBI may rely too heavily on a combination of history and self-reported symptoms. The mechanism of injury in mild traumatic brain injury (mTBI) predicts that supranuclear pathways controlling eye movement systems would be vulnerable to damage, and diagnostic tests of these systems would be high-yield. In fact, tests of oculomotor function have proven to be highly sensitive in detecting neurological soft signs, but may require expensive, specialized equipment. Fortunately, Certified Orthoptists (COs) are skilled at the evaluation of accommodative dysfunction, abnormalities of saccades, smooth pursuit, and vestibular eye movements, and vergence errors using standard ophthalmic equipment. Because COs are accustomed to adapting the sensorimotor exam to infants and pre-verbal children, they are able to modify or design objective methods, the results of which may be difficult for the patient with a functional overlay to decipher and deceive. When the patient with a history of mTBI presents to the ophthalmologist with visual symptoms and a normal routine eye exam, it is important to order a sensorimotor examination by a CO to confirm the diagnosis.
Collapse
Affiliation(s)
- Kyle Arnoldi
- Ira G. Ross Eye Institute, University at Buffalo , Buffalo, New York
| |
Collapse
|
11
|
Othman MH, Bhattacharya M, Møller K, Kjeldsen S, Grand J, Kjaergaard J, Dutta A, Kondziella D. Resting-State NIRS-EEG in Unresponsive Patients with Acute Brain Injury: A Proof-of-Concept Study. Neurocrit Care 2020; 34:31-44. [PMID: 32333214 DOI: 10.1007/s12028-020-00971-x] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
BACKGROUND Neurovascular-based imaging techniques such as functional MRI (fMRI) may reveal signs of consciousness in clinically unresponsive patients but are often subject to logistical challenges in the intensive care unit (ICU). Near-infrared spectroscopy (NIRS) is another neurovascular imaging technique but low cost, can be performed serially at the bedside, and may be combined with electroencephalography (EEG), which are important advantages compared to fMRI. Combined NIRS-EEG, however, has never been evaluated for the assessment of neurovascular coupling and consciousness in acute brain injury. METHODS We explored resting-state oscillations in eight-channel NIRS oxyhemoglobin and eight-channel EEG band-power signals to assess neurovascular coupling, the prerequisite for neurovascular-based imaging detection of consciousness, in patients with acute brain injury in the ICU (n = 9). Conscious neurological patients from step-down units and wards served as controls (n = 14). Unsupervised adaptive mixture-independent component analysis (AMICA) was used to correlate NIRS-EEG data with levels of consciousness and clinical outcome. RESULTS Neurovascular coupling between NIRS oxyhemoglobin (0.07-0.13 Hz) and EEG band-power (1-12 Hz) signals at frontal areas was sensitive and prognostic to changing consciousness levels. AMICA revealed a mixture of five models from EEG data, with the relative probabilities of these models reflecting levels of consciousness over multiple days, although the accuracy was less than 85%. However, when combined with two channels of bilateral frontal neurovascular coupling, weighted k-nearest neighbor classification of AMICA probabilities distinguished unresponsive patients from conscious controls with > 90% accuracy (positive predictive value 93%, false discovery rate 7%) and, additionally, identified patients who subsequently failed to recover consciousness with > 99% accuracy. DISCUSSION We suggest that NIRS-EEG for monitoring of acute brain injury in the ICU is worthy of further exploration. Normalization of neurovascular coupling may herald recovery of consciousness after acute brain injury.
Collapse
Affiliation(s)
- Marwan H Othman
- Department of Neurology, Rigshospitalet, Copenhagen University Hospital, Blegdamsvej 9, 2100, Copenhagen, Denmark
| | - Mahasweta Bhattacharya
- Department of Biomedical Engineering, University at Buffalo, State University of New York, Buffalo, NY, USA
| | - Kirsten Møller
- Department of Neuroanesthesiology, Copenhagen University Hospital, Copenhagen, Denmark.,Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Søren Kjeldsen
- Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Johannes Grand
- Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Jesper Kjaergaard
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark.,Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Anirban Dutta
- Department of Biomedical Engineering, University at Buffalo, State University of New York, Buffalo, NY, USA
| | - Daniel Kondziella
- Department of Neurology, Rigshospitalet, Copenhagen University Hospital, Blegdamsvej 9, 2100, Copenhagen, Denmark. .,Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark.
| |
Collapse
|
12
|
Kondziella D, Bender A, Diserens K, van Erp W, Estraneo A, Formisano R, Laureys S, Naccache L, Ozturk S, Rohaut B, Sitt JD, Stender J, Tiainen M, Rossetti AO, Gosseries O, Chatelle C. European Academy of Neurology guideline on the diagnosis of coma and other disorders of consciousness. Eur J Neurol 2020; 27:741-756. [PMID: 32090418 DOI: 10.1111/ene.14151] [Citation(s) in RCA: 304] [Impact Index Per Article: 76.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2019] [Accepted: 01/09/2020] [Indexed: 12/20/2022]
Abstract
BACKGROUND AND PURPOSE Patients with acquired brain injury and acute or prolonged disorders of consciousness (DoC) are challenging. Evidence to support diagnostic decisions on coma and other DoC is limited but accumulating. This guideline provides the state-of-the-art evidence regarding the diagnosis of DoC, summarizing data from bedside examination techniques, functional neuroimaging and electroencephalography (EEG). METHODS Sixteen members of the European Academy of Neurology (EAN) Scientific Panel on Coma and Chronic Disorders of Consciousness, representing 10 European countries, reviewed the scientific evidence for the evaluation of coma and other DoC using standard bibliographic measures. Recommendations followed the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system. The guideline was endorsed by the EAN. RESULTS Besides a comprehensive neurological examination, the following suggestions are made: probe for voluntary eye movements using a mirror; repeat clinical assessments in the subacute and chronic setting, using the Coma Recovery Scale - Revised; use the Full Outline of Unresponsiveness score instead of the Glasgow Coma Scale in the acute setting; obtain clinical standard EEG; search for sleep patterns on EEG, particularly rapid eye movement sleep and slow-wave sleep; and, whenever feasible, consider positron emission tomography, resting state functional magnetic resonance imaging (fMRI), active fMRI or EEG paradigms and quantitative analysis of high-density EEG to complement behavioral assessment in patients without command following at the bedside. CONCLUSIONS Standardized clinical evaluation, EEG-based techniques and functional neuroimaging should be integrated for multimodal evaluation of patients with DoC. The state of consciousness should be classified according to the highest level revealed by any of these three approaches.
Collapse
Affiliation(s)
- D Kondziella
- Department of Neurology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark.,Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark.,Department of Neurosciences, Norwegian University of Science and Technology, Trondheim, Norway
| | - A Bender
- Department of Neurology, Ludwig-Maximilians-Universität München, Munich, Germany.,Therapiezentrum Burgau, Burgau, Germany
| | - K Diserens
- Department of Clinical Neurosciences, Centre Hospitalier Universitaire Vaudois and University of Lausanne, Lausanne, Switzerland
| | - W van Erp
- Coma Science Group, GIGA Consciousness, University and University Hospital of Liège, Liège, Belgium.,Department of Primary Care, Radboud University Medical Center, Nijmegen, The Netherlands
| | - A Estraneo
- Neurology Unit, Santa Maria della Pietà General Hospital, Nola, Italy.,IRCCS Fondazione don Carlo Gnocchi ONLUS, Florence, Italy
| | - R Formisano
- Post-Coma Unit, Neurorehabilitation Hospital and Research Institution, Santa Lucia Foundation, Rome, Italy
| | - S Laureys
- Coma Science Group, GIGA Consciousness, University and University Hospital of Liège, Liège, Belgium
| | - L Naccache
- Department of Neurology, AP-HP, Groupe hospitalier Pitié-Salpêtrière, Paris, France.,Sorbonne Université, UPMC Univ Paris 06, Faculté de Médecine Pitié-Salpêtrière, Paris, France
| | - S Ozturk
- Department of Neurology, Faculty of Medicine, Selcuk University, Konya, Turkey
| | - B Rohaut
- Department of Neurology, AP-HP, Groupe hospitalier Pitié-Salpêtrière, Paris, France.,Sorbonne Université, UPMC Univ Paris 06, Faculté de Médecine Pitié-Salpêtrière, Paris, France.,Neuro-ICU, Department of Neurology, Columbia University, New York, NY, USA
| | - J D Sitt
- Sorbonne Université, UPMC Univ Paris 06, Faculté de Médecine Pitié-Salpêtrière, Paris, France
| | - J Stender
- Department of Neurosurgery, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - M Tiainen
- Department of Neurology, Helsinki University Hospital, Helsinki, Finland
| | - A O Rossetti
- Department of Clinical Neurosciences, Centre Hospitalier Universitaire Vaudois and University of Lausanne, Lausanne, Switzerland
| | - O Gosseries
- Coma Science Group, GIGA Consciousness, University and University Hospital of Liège, Liège, Belgium
| | - C Chatelle
- Coma Science Group, GIGA Consciousness, University and University Hospital of Liège, Liège, Belgium.,Laboratory for NeuroImaging of Coma and Consciousness - Department of Neurology, Harvard Medical School, Massachusetts General Hospital, Boston, MA, USA
| | | |
Collapse
|
13
|
Can Salient Stimuli Enhance Responses in Disorders of Consciousness? A Systematic Review. Curr Neurol Neurosci Rep 2019; 19:98. [PMID: 31773300 DOI: 10.1007/s11910-019-1018-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
PURPOSE OF REVIEW Diagnostic classification of patients with disorders of consciousness (DoC) is based on clinician's observation of volitional behaviours. However, patients' caregivers often report higher levels of responsiveness with respect to those observed during the clinical assessment. Thus, increasing efforts have been aimed at comprehending the effects of self-referential and emotional stimuli on patients' responsiveness. Here we systematically reviewed the original experimental studies that compared behavioural and electrophysiological responses with salient vs. neutral material in patients in vegetative state/unresponsive wakefulness syndrome or in minimally conscious state. RECENT FINDINGS Most of the reviewed studies showed that salient stimuli (i.e. patient's own or familiar faces, patient's own name, and familiar voices) seem to elicit a higher amount of behavioural or electrophysiological responses with respect to neutral pictures or sounds. Importantly, a quite high percentage of patients seem to respond to salient stimuli only. The present review could foster use of personally salient stimuli in assessing DoC. However, the low overall quality of evidence and some limitations in the general reviewing process might induce caution in transferring these suggestions into clinical practice.
Collapse
|