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Weitzel L, Bavishi S. Disorders of Consciousness. Phys Med Rehabil Clin N Am 2024; 35:493-506. [PMID: 38945646 DOI: 10.1016/j.pmr.2024.02.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/02/2024]
Abstract
This article reviews the definition, assessment, neuroimaging, treatment, and rehabilitation for disorders of consciousness after an acquired brain injury. It also explores special considerations and new neuromodulation treatment options.
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Affiliation(s)
- Levi Weitzel
- Department of Physical Medicine and Rehabilitation, Ohio State University College of Medicine, 370 W 9th Avenue, Columbus, OH 43210, USA.
| | - Sheital Bavishi
- Department of Physical Medicine and Rehabilitation, Brain Injury Program, Dodd Inpatient Rehabilitation Hospital, Ohio State University Wexner Medical Center, 480 Medical Center Drive, Room 1036, Columbus, OH 43210, USA
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Colomer C, Llorens R, Navarro MD, Noé E, Ferri J. Neurobehavioral Progress and Signs of Transition in Children With Prolonged Disorders of Consciousness: A Retrospective Longitudinal Study With the Coma Recovery Scale-Revised. Pediatr Neurol 2024; 155:187-192. [PMID: 38677241 DOI: 10.1016/j.pediatrneurol.2024.03.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Revised: 05/05/2023] [Accepted: 03/31/2024] [Indexed: 04/29/2024]
Abstract
BACKGROUND Research on disorders of consciousness in children is scarce and includes disparate and barely comparable participants and assessment instruments and therefore provides inconclusive information on the clinical progress and recovery in this population. This study retrospectively investigated the neurobehavioral progress and the signs of transition between states of consciousness in a group of children admitted to a rehabilitation program either with an unresponsive wakefulness syndrome (UWS) or in a minimally conscious state (MCS). METHODS Systematic weekly assessments were conducted with the Coma Recovery Scale-Revised (CRS-R) until emergence from MCS, discharge, or death. RESULTS Twenty-one children, nine admitted with a UWS and 12 admitted in an MCS, were included in the study. Four children with a UWS transitioned to an MCS with a CRS-R of 10 (9.2 to 12.2) by showing visual pursuit, visual fixation, or localization to noxious stimulation. Twelve children emerged from the MCS with a CRS-R of 20.5 (19 to 21.7). Children who emerged from the MCS had had a shorter time postinjury and higher CRS-R at admission, compared with those who did not emerge. CONCLUSIONS Almost half of the children who were admitted with a UWS transitioned to an MCS, and almost all who were admitted in an MCS emerged from this state. Children who emerged had shorter times since injury and higher scores on the CRS-R at admission, compared with those who did not emerge.
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Affiliation(s)
- Carolina Colomer
- IRENEA, Instituto de Rehabilitación Neurológica, Fundación Hospitales Vithas, València, Spain.
| | - Roberto Llorens
- IRENEA, Instituto de Rehabilitación Neurológica, Fundación Hospitales Vithas, València, Spain; Neurorehabilitation and Brain Research Group, Institute for Human-Centered Technology Research, Universitat Politècnica de València, València, Spain
| | - María Dolores Navarro
- IRENEA, Instituto de Rehabilitación Neurológica, Fundación Hospitales Vithas, València, Spain
| | - Enrique Noé
- IRENEA, Instituto de Rehabilitación Neurológica, Fundación Hospitales Vithas, València, Spain
| | - Joan Ferri
- IRENEA, Instituto de Rehabilitación Neurológica, Fundación Hospitales Vithas, València, Spain
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Caliendo E, Lowder R, McLaughlin MJ, Watson WD, Baum KT, Blackwell LS, Koterba CH, Hoskinson KR, Tlustos SJ, Shah SA, Suskauer SJ, Kurowski BG. The Use of Methylphenidate During Inpatient Rehabilitation After Pediatric Traumatic Brain Injury: Population Characteristics and Prescribing Patterns. J Head Trauma Rehabil 2024; 39:E122-E131. [PMID: 38709832 PMCID: PMC11076004 DOI: 10.1097/htr.0000000000000889] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/08/2024]
Abstract
OBJECTIVE To understand how methylphenidate (MPH) is used in youth with traumatic brain injury (TBI) during inpatient pediatric rehabilitation. SETTING Inpatient pediatric rehabilitation. PARTICIPANTS In total, 234 children with TBI; 62 of whom received MPH and 172 who did not. Patients were on average 11.6 years of age (range, 2 months to 21 years); 88 of 234 were female; the most common mechanism of injury was motor vehicle collision (49%); median (IQR) acute hospital length of stay (LOS) and inpatient rehabilitation LOS were 16 (10-29) and 23 (14-39), respectively; 51 of 234 were in a disorder of consciousness cognitive state at time of inpatient rehabilitation admission. DESIGN Multicenter, retrospective medical record review. MAIN MEASURES Patient demographic data, time to inpatient pediatric rehabilitation admission (TTA), cognitive state, MPH dosing (mg/kg/day). RESULTS Patients who received MPH were older (P = .011); TTA was significantly longer in patients who received MPH than those who did not (P =.002). The lowest recorded dose range by weight was 0.05 to 0.89 mg/kg/d, representing an 18-fold difference; the weight-based range for the maximum dose was 0.11 to 0.97 mg/kg/d, a 9-fold difference. Patients in lower cognitive states at admission (P = .001) and at discharge (P = .030) were more likely to receive MPH. Five patients had side effects known to be associated with MPH; no serious adverse events were reported. CONCLUSION This multicenter study indicates that there is variable use of MPH during acute inpatient rehabilitation for children with TBI. Children who receive MPH tend to be older with lower cognitive states. Dosing practices are likely consistent with underdosing. Clinical indications for MPH use during inpatient pediatric rehabilitation should be better defined. The use of MPH, as well as its combination with other medications and treatments, during inpatient rehabilitation needs to be further explored.
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Affiliation(s)
- Eric Caliendo
- Department of Medicine, Emory University, Atlanta, Georgia (Dr Caliendo); David Geffen School of Medicine at UCLA, Los Angeles, California (Ms Lowder); Department of Pediatrics, Children's Mercy-Kansas City, Kansas City, Missouri (Dr McLaughlin); University of Missouri-Kansas City School of Medicine (Dr McLaughlin); Blythedale Children's Hospital, Valhalla, New York (Dr Watson); Department of Rehabilitation and Regenerative Medicine, Columbia University Vagelos College of Physicians and Surgeons, New York City, New York (Dr Watson); Department of Radiology, Weill Cornell Medicine, New York City, New York (Dr Shah); Department of Rehabilitation, Children's Hospital Colorado, Aurora (Dr Tlustos); Department of Physical Medicine and Rehabilitation, University of Colorado School of Medicine, Aurora (Dr Tlustos); Department of Neuropsychology (Dr Koterba), and Center for Biobehavioral Health, Abigail Wexner Research Institute (Dr Hoskinson), Nationwide Children's Hospital, Columbus, Ohio; Department of Pediatrics, The Ohio State University, Columbus (Dr Koterba); Department of Pediatrics, The Ohio State University College of Medicine, Columbus (Dr Hoskinson); Division of Pediatric Rehabilitation Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio (Dr Kurowski); Departments of Pediatrics and Neurology and Rehabilitation Medicine, University of Cincinnati College of Medicine, Cincinnati, Ohio (Dr Kurowski); Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia (Dr Blackwell); Kennedy Krieger Institute, Baltimore, Maryland (Dr Suskauer); and Departments of Physical Medicine & Rehabilitation and Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland (Dr Suskauer). Dr Baum is in private practice, Paoli, Pennsylvania
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Kitano T, Giacino JT, Bodien Y, Waters A, Hioki D, Shinya J, Nakayama T, Ohgi S. Reliability and validation of the Japanese version of the coma recovery scale-revised (CRS-R). Brain Inj 2024; 38:249-259. [PMID: 38329043 DOI: 10.1080/02699052.2024.2309549] [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: 06/15/2022] [Accepted: 01/19/2024] [Indexed: 02/09/2024]
Abstract
PRIMARY OBJECTIVE This study aimed to verify the reliability and validity of the Japanese version of the Coma Recovery Scale-Revised (CRS-R). METHODS Subjects included 59 patients with disorders of consciousness (DOC) due to acquired brain injury. To validate test-retest reliability, Evaluator A assessed the CRS-R twice on the same day (A1, A2). To examine inter-rater reliability, Evaluators A (A2) and B (B) assessed the CRS-R without a time interval. To test concurrent validity, Evaluator A (A1) assessed the CRS-R, Japan Coma Scale (JCS), and the Glasgow Coma Scale (GCS) consecutively. To validate diagnostic accuracy, we evaluated the degree of agreement between A1 and A2 and between A2 and B in their diagnosis of DOC by CRS-R. RESULTS The test-retest (ρ = 0.92) and inter- (ρ = 0.98) reliability of CRS-R were excellent" and Concurrent validity of CRS-R with JCS (ρ = -0.82) and GCS (ρ = 0.92) were high. Results of DOC diagnosis were consistent for 48/59 cases (κ = 0.82) for A1 and A2 and for 54/59 cases (κ = 0.92) for A2 and B. CONLCUSION The Japanese version of the CRS-R may be as reliable and valid as the original English and other language versions.
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Affiliation(s)
- Takayuki Kitano
- Department of Rehabilitation, Hamamatsu Medical Center, Hamamatsu City, Shizuoka Prefecture, Japan
| | - Joseph T Giacino
- Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Charlestown, Massachusetts, USA
- Department of Physical Medicine and Rehabilitation, Harvard Medical School, Boston, Massachusetts, USA
| | - Yelena Bodien
- Department of Physical Medicine and Rehabilitation, Harvard Medical School, Boston, Massachusetts, USA
| | - Abigail Waters
- Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Charlestown, Massachusetts, USA
| | - Daichi Hioki
- Department of Rehabilitation, Hamamatsu Medical Center, Hamamatsu City, Shizuoka Prefecture, Japan
| | - Junko Shinya
- Department of Rehabilitation, Hamamatsu Medical Center, Hamamatsu City, Shizuoka Prefecture, Japan
| | - Teiji Nakayama
- Department of Neurosurgery, Hamamatsu Medical Center, Hamamatsu City, Shizuoka Prefecture, Japan
| | - Shohei Ohgi
- Faculty of Rehabilitation Studies, Seirei Christopher University, Hamamatsu City, Shizuoka Prefecture, Japan
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Slomine BS, Suskauer SJ. Disorders of Consciousness in Children: Assessment, Treatment, and Prognosis. Phys Med Rehabil Clin N Am 2024; 35:223-234. [PMID: 37993191 DOI: 10.1016/j.pmr.2023.06.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2023]
Abstract
Children with acquired brain injury may experience prolonged disorders of consciousness (DoC); research on children with DoC lags behind adult literature. Rigorous evaluation of assessment tools used in children with DoC is lacking, though recent developments may contribute to improvements in care, particularly for assessment of young children and those without overt command following. Literature on prognosis continues to grow, reinforcing that early signs of consciousness suggest better long-term outcome. Although large clinical trials for children with DoC are lacking, single-site and multisite programmatic data inform standards of care and treatment options for children with DoC.
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Affiliation(s)
- Beth S Slomine
- Kennedy Krieger Institute, 707 North Broadway, Balitmore, MD 21205, USA; Department of Psychiatry and Behavioral Health, Johns Hopkins University School of Medicine, 600 North Wolfe Street, Baltimore, MD 21205, USA; Department of Physical Medicine & Rehabilitation, Johns Hopkins University School of Medicine, 600 North Wolfe Street, Baltimore, MD 21205, USA
| | - Stacy J Suskauer
- Kennedy Krieger Institute, 707 North Broadway, Balitmore, MD 21205, USA; Department of Physical Medicine & Rehabilitation, Johns Hopkins University School of Medicine, 600 North Wolfe Street, Baltimore, MD 21205, USA; Departments of Pediatrics, Johns Hopkins University School of Medicine, 600 North Wolfe Street, Baltimore, MD 21205, USA.
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Schnakers C. Assessing consciousness and cognition in disorders of consciousness. NeuroRehabilitation 2024; 54:11-21. [PMID: 38251070 DOI: 10.3233/nre-230140] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2024]
Abstract
Detecting willful cognition in these patients is known to be challenging due to the patients' motor disabilities and high vigilance fluctuations but also due to the lack of expertise and use of adequate tools to assess these patients in specific settings. This review will discuss the main disorders of consciousness after severe brain injury, how to assess consciousness and cognition in these patients, as well as the challenges and tools available to overcome these challenges and reach an accurate diagnosis.
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Affiliation(s)
- Caroline Schnakers
- Research Institute, Casa Colina Hospital and Centers for Healthcare, 255 E. Bonita Avenue, Pomona, CA 91769, USA. Tel.: +1 909 596 7733 (ext. 3038); E-mail:
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Janas AM, Miller KR, Stence NV, Wyrwa JM, Ruzas CM, Messer R, Mourani PM, Fink EL, Maddux AB. Utility of Early Magnetic Resonance Imaging to Enhance Outcome Prediction in Critically Ill Children with Severe Traumatic Brain Injury. Neurocrit Care 2023:10.1007/s12028-023-01898-9. [PMID: 38148435 DOI: 10.1007/s12028-023-01898-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2023] [Accepted: 11/16/2023] [Indexed: 12/28/2023]
Abstract
BACKGROUND Many children with severe traumatic brain injury (TBI) receive magnetic resonance imaging (MRI) during hospitalization. There are insufficient data on how different patterns of injury on early MRI inform outcomes. METHODS Children (3-17 years) admitted in 2010-2021 for severe TBI (Glasgow Coma Scale [GCS] score < 9) were identified using our site's trauma registry. We used multivariable modeling to determine whether the hemorrhagic diffuse axonal injury (DAI) grade and the number of regions with restricted diffusion (subcortical white matter, corpus callosum, deep gray matter, and brainstem) on MRI obtained within 7 days of injury were independently associated with time to follow commands and with Functional Independence Measure for Children (WeeFIM) scores at the time of discharge from inpatient rehabilitation. We controlled for the clinical variables age, preadmission cardiopulmonary resuscitation, pupil reactivity, motor GCS score, and fever (> 38 °C) in the first 12 h. RESULTS Of 260 patients, 136 (52%) underwent MRI within 7 days of injury at a median of 3 days (interquartile range [IQR] 2-4). Patients with early MRI were a median age of 11 years (IQR 7-14), 8 (6%) patients received cardiopulmonary resuscitation, 19 (14%) patients had bilateral unreactive pupils, the median motor GCS score was 1 (IQR 1-4), and 82 (60%) patients had fever. Grade 3 DAI was present in 46 (34%) patients, and restricted diffusion was noted in the corpus callosum in 75 (55%) patients, deep gray matter in 29 (21%) patients, subcortical white matter in 23 (17%) patients, and the brainstem in 20 (15%) patients. After controlling for clinical variables, an increased number of regions with restricted diffusion, but not hemorrhagic DAI grade, was independently associated with longer time to follow commands (hazard ratio 0.68, 95% confidence interval 0.53-0.89) and worse WeeFIM scores (estimate β - 4.67, 95% confidence interval - 8.33 to - 1.01). CONCLUSIONS Regional restricted diffusion on early MRI is independently associated with short-term outcomes in children with severe TBI. Multicenter cohort studies are needed to validate these findings and elucidate the association of early MRI features with long-term outcomes in children with severe TBI.
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Affiliation(s)
- Anna M Janas
- Section of Critical Care, Department of Pediatrics, University of Colorado School of Medicine and Children's Hospital of Colorado, University of Colorado Anschutz Medical Campus, 13121 E. 17th Avenue, Ed2S, MS8414, Aurora, CO, 80045, USA.
| | - Kristen R Miller
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO, USA
| | - Nicholas V Stence
- Section of Neuroradiology, Department of Radiology, University of Colorado School of Medicine, Aurora, CO, USA
| | - Jordan M Wyrwa
- Department of Physical Medicine and Rehabilitation, University of Colorado School of Medicine and Children's Hospital of Colorado, Aurora, CO, USA
| | - Christopher M Ruzas
- Section of Critical Care, Department of Pediatrics, University of Colorado School of Medicine and Children's Hospital of Colorado, University of Colorado Anschutz Medical Campus, 13121 E. 17th Avenue, Ed2S, MS8414, Aurora, CO, 80045, USA
| | - Ricka Messer
- Section of Child Neurology, Department of Pediatrics, University of Colorado School of Medicine and Children's Hospital of Colorado, Aurora, CO, USA
| | - Peter M Mourani
- Section of Critical Care, Department of Pediatrics, University of Arkansas for Medical Sciences and Arkansas Children's Hospital, Little Rock, AR, USA
| | - Ericka L Fink
- Department of Critical Care Medicine, University of Pittsburgh Medical Center Children's Hospital of Pittsburgh, Pittsburgh, PA, USA
- Safar Center for Resuscitation Research, University of Pittsburgh, Pittsburgh, PA, USA
| | - Aline B Maddux
- Section of Critical Care, Department of Pediatrics, University of Colorado School of Medicine and Children's Hospital of Colorado, University of Colorado Anschutz Medical Campus, 13121 E. 17th Avenue, Ed2S, MS8414, Aurora, CO, 80045, USA
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Xu G, Hao F, Zhao W, Zhao P, Qiu J. Long-term psychological intervention for parents of children with prolonged disorders of consciousness: a pilot study. Front Psychol 2023; 14:1212014. [PMID: 38098536 PMCID: PMC10720583 DOI: 10.3389/fpsyg.2023.1212014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2023] [Accepted: 11/06/2023] [Indexed: 12/17/2023] Open
Abstract
Background Children with prolonged disorders of consciousness experience severe intellectual and behavioral disabilities that will last for decades or even a lifetime. Parents generally experience severe anxiety, stress, sadness, or family conflicts, which can lead to abnormal parenting behavior and can, in turn, adversely affect the cognitive, emotional, and behavioral well-being of the children. This causes a serious burden on children, families, and society. Psychological interventions targeting parents using online conversations provide an opportunity to improve the overall well-being of the parents, their children, and the family as a whole. Methods A total of 13 patients completed the protocol. Six were girls (46.2%), the mean age was 4.5 ± 3.0 years, and the length of time before emergent from minimally consciousness state was 244 ± 235 days. A staff member with psychological counseling qualifications implemented all psychological interventions. Regular online psychological interventions were performed annually before and after discharge. Evaluation data were collected before discharge and at 1 and 3-5 years post-discharge. Results With the extension of intervention time, the Strengths and Difficulties Questionnaire, the Depression Anxiety and Stress Scale-21, and the Parenting Sense of Competence Scale scores showed significant improvement (p < 0.05), while the Revised Scale for Caregiving Self-Efficacy scores did not. With the extension of intervention time, the Strengths and Difficulties Questionnaire (Total Difficulties scores, TD) scores showed significant improvement (p < 0.05), while the scores did not after 1 year compared with before intervention. The Index of Child Care Environment evaluation scores declined significantly (p < 0.05). Conclusion Psychological interventions aimed at the parents of children with prolonged disorders of consciousness performed at least once per year resulted in significant improvements in negative parental emotions, parental self-efficacy, and emotional and behavioral problems in their children. However, the childcare environment continued to decline.
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Affiliation(s)
- Gang Xu
- Rehabilitation Branch, Tianjin Children’s Hospital/Children’s Hospital, Tianjin University, Tianjin, China
- Tianjin Key Laboratory of Birth Defects for Prevention and Treatment, Tianjin Children’s Hospital/Children’s Hospital, Tianjin University, Tianjin, China
| | | | - Weiwei Zhao
- Tianjin Beichen Experimental Middle School, Tianjin, China
| | - Peng Zhao
- Rehabilitation Branch, Tianjin Children’s Hospital/Children’s Hospital, Tianjin University, Tianjin, China
- Tianjin Key Laboratory of Birth Defects for Prevention and Treatment, Tianjin Children’s Hospital/Children’s Hospital, Tianjin University, Tianjin, China
| | - Jiwen Qiu
- Research Center of Experimental Acupuncture Science, Tianjin University of Traditional Chinese Medicine, Tianjin, China
- School of Medical Technology, Tianjin University of Traditional Chinese Medicine, Tianjin, China
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Molteni E, Canas LDS, Briand MM, Estraneo A, Font CC, Formisano R, Fufaeva E, Gosseries O, Howarth RA, Lanteri P, Licandro GI, Magee WL, Veeramuthu V, Wilson P, Yamaki T, Slomine BS. Scoping Review on the Diagnosis, Prognosis, and Treatment of Pediatric Disorders of Consciousness. Neurology 2023; 101:e581-e593. [PMID: 37308301 PMCID: PMC10424839 DOI: 10.1212/wnl.0000000000207473] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Accepted: 04/17/2023] [Indexed: 06/14/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Comprehensive guidelines for the diagnosis, prognosis, and treatment of disorders of consciousness (DoC) in pediatric patients have not yet been released. We aimed to summarize available evidence for DoC with >14 days duration to support the future development of guidelines for children, adolescents and young adults aged 6 months-18 years. METHODS This scoping review was reported based on Preferred Reporting Items for Systematic reviews and Meta-Analyses-extension for Scoping Reviews guidelines. A systematic search identified records from 4 databases: PubMed, Embase, Cochrane Library, and Web of Science. Abstracts received 3 blind reviews. Corresponding full-text articles rated as "in-scope" and reporting data not published in any other retained article (i.e., no double reporting) were identified and assigned to 5 thematic evaluating teams. Full-text articles were reviewed using a double-blind standardized form. Level of evidence was graded, and summative statements were generated. RESULTS On November 9, 2022, 2,167 documents had been identified; 132 articles were retained, of which 33 (25%) were published over the past 5 years. Overall, 2,161 individuals met the inclusion criteria; female patients were 527 of 1,554 (33.9%) cases included, whose sex was identifiable. Of 132 articles, 57 (43.2%) were single case reports and only 5 (3.8%) clinical trials; the level of evidence was prevalently low (80/132; 60.6%). Most studies included neurobehavioral measures (84/127; 66.1%) and neuroimaging (81/127; 63.8%); 59 (46.5%) were mainly related to diagnosis, 56 (44.1%) to prognosis, and 44 (34.6%) to treatment. Most frequently used neurobehavioral tools included the Coma Recovery Scale-Revised, Coma/Near-Coma Scale, Level of Cognitive Functioning Assessment Scale, and Post-Acute Level of Consciousness scale. EEG, event-related potentials, structural CT, and MRI were the most frequently used instrumental techniques. In 29/53 (54.7%) cases, DoC improvement was observed, which was associated with treatment with amantadine. DISCUSSION The literature on pediatric DoCs is mainly observational, and clinical details are either inconsistently presented or absent. Conclusions drawn from many studies convey insubstantial evidence and have limited validity and low potential for translation in clinical practice. Despite these limitations, our work summarizes the extant literature and constitutes a base for future guidelines related to the diagnosis, prognosis, and treatment of pediatric DoC.
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Affiliation(s)
- Erika Molteni
- From the School of Biomedical Engineering & Imaging Sciences (E.M., L.S.S.C.), Faculty of Life Science & Medicine, King's College London, United Kingdom; Department of Physical Medicine and Rehabilitation (M.-M.B.), Hôpital du Sacré-Coeur de Montréal, Quebec, Canada; IRCCS Fondazione Don Gnocchi (A.E.), Florence, Sant'Angelo dei Lombardi, Italy; NEURORHB-Neuro Rehab Human Brain (C.C.F.), Fundación Hospitales Vithas, Valencia, Spain; IRCCS Santa Lucia Foundation (R.F.), Rome, Italy; Clinical and Research Institute of Emergency Pediatric Surgery and Trauma (CRIEPST) (E.F.), Moscow, Russia; Coma Science Group (O.G.), GIGA Consciousness & Centre du Cerveau2, University and University Hospital of Liège, Belgium; Department of Neuropsychology (R.A.H.), Children's Healthcare of Atlanta, GA; Neurophysiology Unit (P.L.), Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy; Centro de Rehabilitación Infantil CRI CETNA (G.I.L.), Fleni, Buenos Aires, Argentina; Boyer College of Music and Dance (W.L.M.), Temple University, Philadelphia, PA; Division of Clinical Neuropsychology (V.V.), Subang Jaya Medical Center, Selangor; Division of Clinical Neuropsychology (V.V.), Thompson Hospital Kota Damanasara, Selangor, Malaysia; Department of Physical Medicine and Rehabilitation (P.W.), University of Colorado, Children's Hospital Colorado, Aurora; Division of Neurosurgery (T.Y.), Rehabilitation Center for Traumatic Apallics Chiba, National Agency for Automotive Safety and Victims' Aid, Japan; and Department of Neuropsychology (B.S.S.), Kennedy Krieger Institute; Department of Psychiatry and Behavioral Sciences (B.S.S.), Johns Hopkins University, School of Medicine, Baltimore, MD.
| | - Liane Dos Santos Canas
- From the School of Biomedical Engineering & Imaging Sciences (E.M., L.S.S.C.), Faculty of Life Science & Medicine, King's College London, United Kingdom; Department of Physical Medicine and Rehabilitation (M.-M.B.), Hôpital du Sacré-Coeur de Montréal, Quebec, Canada; IRCCS Fondazione Don Gnocchi (A.E.), Florence, Sant'Angelo dei Lombardi, Italy; NEURORHB-Neuro Rehab Human Brain (C.C.F.), Fundación Hospitales Vithas, Valencia, Spain; IRCCS Santa Lucia Foundation (R.F.), Rome, Italy; Clinical and Research Institute of Emergency Pediatric Surgery and Trauma (CRIEPST) (E.F.), Moscow, Russia; Coma Science Group (O.G.), GIGA Consciousness & Centre du Cerveau2, University and University Hospital of Liège, Belgium; Department of Neuropsychology (R.A.H.), Children's Healthcare of Atlanta, GA; Neurophysiology Unit (P.L.), Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy; Centro de Rehabilitación Infantil CRI CETNA (G.I.L.), Fleni, Buenos Aires, Argentina; Boyer College of Music and Dance (W.L.M.), Temple University, Philadelphia, PA; Division of Clinical Neuropsychology (V.V.), Subang Jaya Medical Center, Selangor; Division of Clinical Neuropsychology (V.V.), Thompson Hospital Kota Damanasara, Selangor, Malaysia; Department of Physical Medicine and Rehabilitation (P.W.), University of Colorado, Children's Hospital Colorado, Aurora; Division of Neurosurgery (T.Y.), Rehabilitation Center for Traumatic Apallics Chiba, National Agency for Automotive Safety and Victims' Aid, Japan; and Department of Neuropsychology (B.S.S.), Kennedy Krieger Institute; Department of Psychiatry and Behavioral Sciences (B.S.S.), Johns Hopkins University, School of Medicine, Baltimore, MD
| | - Marie-Michèle Briand
- From the School of Biomedical Engineering & Imaging Sciences (E.M., L.S.S.C.), Faculty of Life Science & Medicine, King's College London, United Kingdom; Department of Physical Medicine and Rehabilitation (M.-M.B.), Hôpital du Sacré-Coeur de Montréal, Quebec, Canada; IRCCS Fondazione Don Gnocchi (A.E.), Florence, Sant'Angelo dei Lombardi, Italy; NEURORHB-Neuro Rehab Human Brain (C.C.F.), Fundación Hospitales Vithas, Valencia, Spain; IRCCS Santa Lucia Foundation (R.F.), Rome, Italy; Clinical and Research Institute of Emergency Pediatric Surgery and Trauma (CRIEPST) (E.F.), Moscow, Russia; Coma Science Group (O.G.), GIGA Consciousness & Centre du Cerveau2, University and University Hospital of Liège, Belgium; Department of Neuropsychology (R.A.H.), Children's Healthcare of Atlanta, GA; Neurophysiology Unit (P.L.), Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy; Centro de Rehabilitación Infantil CRI CETNA (G.I.L.), Fleni, Buenos Aires, Argentina; Boyer College of Music and Dance (W.L.M.), Temple University, Philadelphia, PA; Division of Clinical Neuropsychology (V.V.), Subang Jaya Medical Center, Selangor; Division of Clinical Neuropsychology (V.V.), Thompson Hospital Kota Damanasara, Selangor, Malaysia; Department of Physical Medicine and Rehabilitation (P.W.), University of Colorado, Children's Hospital Colorado, Aurora; Division of Neurosurgery (T.Y.), Rehabilitation Center for Traumatic Apallics Chiba, National Agency for Automotive Safety and Victims' Aid, Japan; and Department of Neuropsychology (B.S.S.), Kennedy Krieger Institute; Department of Psychiatry and Behavioral Sciences (B.S.S.), Johns Hopkins University, School of Medicine, Baltimore, MD
| | - Anna Estraneo
- From the School of Biomedical Engineering & Imaging Sciences (E.M., L.S.S.C.), Faculty of Life Science & Medicine, King's College London, United Kingdom; Department of Physical Medicine and Rehabilitation (M.-M.B.), Hôpital du Sacré-Coeur de Montréal, Quebec, Canada; IRCCS Fondazione Don Gnocchi (A.E.), Florence, Sant'Angelo dei Lombardi, Italy; NEURORHB-Neuro Rehab Human Brain (C.C.F.), Fundación Hospitales Vithas, Valencia, Spain; IRCCS Santa Lucia Foundation (R.F.), Rome, Italy; Clinical and Research Institute of Emergency Pediatric Surgery and Trauma (CRIEPST) (E.F.), Moscow, Russia; Coma Science Group (O.G.), GIGA Consciousness & Centre du Cerveau2, University and University Hospital of Liège, Belgium; Department of Neuropsychology (R.A.H.), Children's Healthcare of Atlanta, GA; Neurophysiology Unit (P.L.), Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy; Centro de Rehabilitación Infantil CRI CETNA (G.I.L.), Fleni, Buenos Aires, Argentina; Boyer College of Music and Dance (W.L.M.), Temple University, Philadelphia, PA; Division of Clinical Neuropsychology (V.V.), Subang Jaya Medical Center, Selangor; Division of Clinical Neuropsychology (V.V.), Thompson Hospital Kota Damanasara, Selangor, Malaysia; Department of Physical Medicine and Rehabilitation (P.W.), University of Colorado, Children's Hospital Colorado, Aurora; Division of Neurosurgery (T.Y.), Rehabilitation Center for Traumatic Apallics Chiba, National Agency for Automotive Safety and Victims' Aid, Japan; and Department of Neuropsychology (B.S.S.), Kennedy Krieger Institute; Department of Psychiatry and Behavioral Sciences (B.S.S.), Johns Hopkins University, School of Medicine, Baltimore, MD
| | - Carolina Colomer Font
- From the School of Biomedical Engineering & Imaging Sciences (E.M., L.S.S.C.), Faculty of Life Science & Medicine, King's College London, United Kingdom; Department of Physical Medicine and Rehabilitation (M.-M.B.), Hôpital du Sacré-Coeur de Montréal, Quebec, Canada; IRCCS Fondazione Don Gnocchi (A.E.), Florence, Sant'Angelo dei Lombardi, Italy; NEURORHB-Neuro Rehab Human Brain (C.C.F.), Fundación Hospitales Vithas, Valencia, Spain; IRCCS Santa Lucia Foundation (R.F.), Rome, Italy; Clinical and Research Institute of Emergency Pediatric Surgery and Trauma (CRIEPST) (E.F.), Moscow, Russia; Coma Science Group (O.G.), GIGA Consciousness & Centre du Cerveau2, University and University Hospital of Liège, Belgium; Department of Neuropsychology (R.A.H.), Children's Healthcare of Atlanta, GA; Neurophysiology Unit (P.L.), Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy; Centro de Rehabilitación Infantil CRI CETNA (G.I.L.), Fleni, Buenos Aires, Argentina; Boyer College of Music and Dance (W.L.M.), Temple University, Philadelphia, PA; Division of Clinical Neuropsychology (V.V.), Subang Jaya Medical Center, Selangor; Division of Clinical Neuropsychology (V.V.), Thompson Hospital Kota Damanasara, Selangor, Malaysia; Department of Physical Medicine and Rehabilitation (P.W.), University of Colorado, Children's Hospital Colorado, Aurora; Division of Neurosurgery (T.Y.), Rehabilitation Center for Traumatic Apallics Chiba, National Agency for Automotive Safety and Victims' Aid, Japan; and Department of Neuropsychology (B.S.S.), Kennedy Krieger Institute; Department of Psychiatry and Behavioral Sciences (B.S.S.), Johns Hopkins University, School of Medicine, Baltimore, MD
| | - Rita Formisano
- From the School of Biomedical Engineering & Imaging Sciences (E.M., L.S.S.C.), Faculty of Life Science & Medicine, King's College London, United Kingdom; Department of Physical Medicine and Rehabilitation (M.-M.B.), Hôpital du Sacré-Coeur de Montréal, Quebec, Canada; IRCCS Fondazione Don Gnocchi (A.E.), Florence, Sant'Angelo dei Lombardi, Italy; NEURORHB-Neuro Rehab Human Brain (C.C.F.), Fundación Hospitales Vithas, Valencia, Spain; IRCCS Santa Lucia Foundation (R.F.), Rome, Italy; Clinical and Research Institute of Emergency Pediatric Surgery and Trauma (CRIEPST) (E.F.), Moscow, Russia; Coma Science Group (O.G.), GIGA Consciousness & Centre du Cerveau2, University and University Hospital of Liège, Belgium; Department of Neuropsychology (R.A.H.), Children's Healthcare of Atlanta, GA; Neurophysiology Unit (P.L.), Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy; Centro de Rehabilitación Infantil CRI CETNA (G.I.L.), Fleni, Buenos Aires, Argentina; Boyer College of Music and Dance (W.L.M.), Temple University, Philadelphia, PA; Division of Clinical Neuropsychology (V.V.), Subang Jaya Medical Center, Selangor; Division of Clinical Neuropsychology (V.V.), Thompson Hospital Kota Damanasara, Selangor, Malaysia; Department of Physical Medicine and Rehabilitation (P.W.), University of Colorado, Children's Hospital Colorado, Aurora; Division of Neurosurgery (T.Y.), Rehabilitation Center for Traumatic Apallics Chiba, National Agency for Automotive Safety and Victims' Aid, Japan; and Department of Neuropsychology (B.S.S.), Kennedy Krieger Institute; Department of Psychiatry and Behavioral Sciences (B.S.S.), Johns Hopkins University, School of Medicine, Baltimore, MD
| | - Ekaterina Fufaeva
- From the School of Biomedical Engineering & Imaging Sciences (E.M., L.S.S.C.), Faculty of Life Science & Medicine, King's College London, United Kingdom; Department of Physical Medicine and Rehabilitation (M.-M.B.), Hôpital du Sacré-Coeur de Montréal, Quebec, Canada; IRCCS Fondazione Don Gnocchi (A.E.), Florence, Sant'Angelo dei Lombardi, Italy; NEURORHB-Neuro Rehab Human Brain (C.C.F.), Fundación Hospitales Vithas, Valencia, Spain; IRCCS Santa Lucia Foundation (R.F.), Rome, Italy; Clinical and Research Institute of Emergency Pediatric Surgery and Trauma (CRIEPST) (E.F.), Moscow, Russia; Coma Science Group (O.G.), GIGA Consciousness & Centre du Cerveau2, University and University Hospital of Liège, Belgium; Department of Neuropsychology (R.A.H.), Children's Healthcare of Atlanta, GA; Neurophysiology Unit (P.L.), Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy; Centro de Rehabilitación Infantil CRI CETNA (G.I.L.), Fleni, Buenos Aires, Argentina; Boyer College of Music and Dance (W.L.M.), Temple University, Philadelphia, PA; Division of Clinical Neuropsychology (V.V.), Subang Jaya Medical Center, Selangor; Division of Clinical Neuropsychology (V.V.), Thompson Hospital Kota Damanasara, Selangor, Malaysia; Department of Physical Medicine and Rehabilitation (P.W.), University of Colorado, Children's Hospital Colorado, Aurora; Division of Neurosurgery (T.Y.), Rehabilitation Center for Traumatic Apallics Chiba, National Agency for Automotive Safety and Victims' Aid, Japan; and Department of Neuropsychology (B.S.S.), Kennedy Krieger Institute; Department of Psychiatry and Behavioral Sciences (B.S.S.), Johns Hopkins University, School of Medicine, Baltimore, MD
| | - Olivia Gosseries
- From the School of Biomedical Engineering & Imaging Sciences (E.M., L.S.S.C.), Faculty of Life Science & Medicine, King's College London, United Kingdom; Department of Physical Medicine and Rehabilitation (M.-M.B.), Hôpital du Sacré-Coeur de Montréal, Quebec, Canada; IRCCS Fondazione Don Gnocchi (A.E.), Florence, Sant'Angelo dei Lombardi, Italy; NEURORHB-Neuro Rehab Human Brain (C.C.F.), Fundación Hospitales Vithas, Valencia, Spain; IRCCS Santa Lucia Foundation (R.F.), Rome, Italy; Clinical and Research Institute of Emergency Pediatric Surgery and Trauma (CRIEPST) (E.F.), Moscow, Russia; Coma Science Group (O.G.), GIGA Consciousness & Centre du Cerveau2, University and University Hospital of Liège, Belgium; Department of Neuropsychology (R.A.H.), Children's Healthcare of Atlanta, GA; Neurophysiology Unit (P.L.), Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy; Centro de Rehabilitación Infantil CRI CETNA (G.I.L.), Fleni, Buenos Aires, Argentina; Boyer College of Music and Dance (W.L.M.), Temple University, Philadelphia, PA; Division of Clinical Neuropsychology (V.V.), Subang Jaya Medical Center, Selangor; Division of Clinical Neuropsychology (V.V.), Thompson Hospital Kota Damanasara, Selangor, Malaysia; Department of Physical Medicine and Rehabilitation (P.W.), University of Colorado, Children's Hospital Colorado, Aurora; Division of Neurosurgery (T.Y.), Rehabilitation Center for Traumatic Apallics Chiba, National Agency for Automotive Safety and Victims' Aid, Japan; and Department of Neuropsychology (B.S.S.), Kennedy Krieger Institute; Department of Psychiatry and Behavioral Sciences (B.S.S.), Johns Hopkins University, School of Medicine, Baltimore, MD
| | - Robyn A Howarth
- From the School of Biomedical Engineering & Imaging Sciences (E.M., L.S.S.C.), Faculty of Life Science & Medicine, King's College London, United Kingdom; Department of Physical Medicine and Rehabilitation (M.-M.B.), Hôpital du Sacré-Coeur de Montréal, Quebec, Canada; IRCCS Fondazione Don Gnocchi (A.E.), Florence, Sant'Angelo dei Lombardi, Italy; NEURORHB-Neuro Rehab Human Brain (C.C.F.), Fundación Hospitales Vithas, Valencia, Spain; IRCCS Santa Lucia Foundation (R.F.), Rome, Italy; Clinical and Research Institute of Emergency Pediatric Surgery and Trauma (CRIEPST) (E.F.), Moscow, Russia; Coma Science Group (O.G.), GIGA Consciousness & Centre du Cerveau2, University and University Hospital of Liège, Belgium; Department of Neuropsychology (R.A.H.), Children's Healthcare of Atlanta, GA; Neurophysiology Unit (P.L.), Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy; Centro de Rehabilitación Infantil CRI CETNA (G.I.L.), Fleni, Buenos Aires, Argentina; Boyer College of Music and Dance (W.L.M.), Temple University, Philadelphia, PA; Division of Clinical Neuropsychology (V.V.), Subang Jaya Medical Center, Selangor; Division of Clinical Neuropsychology (V.V.), Thompson Hospital Kota Damanasara, Selangor, Malaysia; Department of Physical Medicine and Rehabilitation (P.W.), University of Colorado, Children's Hospital Colorado, Aurora; Division of Neurosurgery (T.Y.), Rehabilitation Center for Traumatic Apallics Chiba, National Agency for Automotive Safety and Victims' Aid, Japan; and Department of Neuropsychology (B.S.S.), Kennedy Krieger Institute; Department of Psychiatry and Behavioral Sciences (B.S.S.), Johns Hopkins University, School of Medicine, Baltimore, MD
| | - Paola Lanteri
- From the School of Biomedical Engineering & Imaging Sciences (E.M., L.S.S.C.), Faculty of Life Science & Medicine, King's College London, United Kingdom; Department of Physical Medicine and Rehabilitation (M.-M.B.), Hôpital du Sacré-Coeur de Montréal, Quebec, Canada; IRCCS Fondazione Don Gnocchi (A.E.), Florence, Sant'Angelo dei Lombardi, Italy; NEURORHB-Neuro Rehab Human Brain (C.C.F.), Fundación Hospitales Vithas, Valencia, Spain; IRCCS Santa Lucia Foundation (R.F.), Rome, Italy; Clinical and Research Institute of Emergency Pediatric Surgery and Trauma (CRIEPST) (E.F.), Moscow, Russia; Coma Science Group (O.G.), GIGA Consciousness & Centre du Cerveau2, University and University Hospital of Liège, Belgium; Department of Neuropsychology (R.A.H.), Children's Healthcare of Atlanta, GA; Neurophysiology Unit (P.L.), Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy; Centro de Rehabilitación Infantil CRI CETNA (G.I.L.), Fleni, Buenos Aires, Argentina; Boyer College of Music and Dance (W.L.M.), Temple University, Philadelphia, PA; Division of Clinical Neuropsychology (V.V.), Subang Jaya Medical Center, Selangor; Division of Clinical Neuropsychology (V.V.), Thompson Hospital Kota Damanasara, Selangor, Malaysia; Department of Physical Medicine and Rehabilitation (P.W.), University of Colorado, Children's Hospital Colorado, Aurora; Division of Neurosurgery (T.Y.), Rehabilitation Center for Traumatic Apallics Chiba, National Agency for Automotive Safety and Victims' Aid, Japan; and Department of Neuropsychology (B.S.S.), Kennedy Krieger Institute; Department of Psychiatry and Behavioral Sciences (B.S.S.), Johns Hopkins University, School of Medicine, Baltimore, MD
| | - Gimena Inès Licandro
- From the School of Biomedical Engineering & Imaging Sciences (E.M., L.S.S.C.), Faculty of Life Science & Medicine, King's College London, United Kingdom; Department of Physical Medicine and Rehabilitation (M.-M.B.), Hôpital du Sacré-Coeur de Montréal, Quebec, Canada; IRCCS Fondazione Don Gnocchi (A.E.), Florence, Sant'Angelo dei Lombardi, Italy; NEURORHB-Neuro Rehab Human Brain (C.C.F.), Fundación Hospitales Vithas, Valencia, Spain; IRCCS Santa Lucia Foundation (R.F.), Rome, Italy; Clinical and Research Institute of Emergency Pediatric Surgery and Trauma (CRIEPST) (E.F.), Moscow, Russia; Coma Science Group (O.G.), GIGA Consciousness & Centre du Cerveau2, University and University Hospital of Liège, Belgium; Department of Neuropsychology (R.A.H.), Children's Healthcare of Atlanta, GA; Neurophysiology Unit (P.L.), Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy; Centro de Rehabilitación Infantil CRI CETNA (G.I.L.), Fleni, Buenos Aires, Argentina; Boyer College of Music and Dance (W.L.M.), Temple University, Philadelphia, PA; Division of Clinical Neuropsychology (V.V.), Subang Jaya Medical Center, Selangor; Division of Clinical Neuropsychology (V.V.), Thompson Hospital Kota Damanasara, Selangor, Malaysia; Department of Physical Medicine and Rehabilitation (P.W.), University of Colorado, Children's Hospital Colorado, Aurora; Division of Neurosurgery (T.Y.), Rehabilitation Center for Traumatic Apallics Chiba, National Agency for Automotive Safety and Victims' Aid, Japan; and Department of Neuropsychology (B.S.S.), Kennedy Krieger Institute; Department of Psychiatry and Behavioral Sciences (B.S.S.), Johns Hopkins University, School of Medicine, Baltimore, MD
| | - Wendy L Magee
- From the School of Biomedical Engineering & Imaging Sciences (E.M., L.S.S.C.), Faculty of Life Science & Medicine, King's College London, United Kingdom; Department of Physical Medicine and Rehabilitation (M.-M.B.), Hôpital du Sacré-Coeur de Montréal, Quebec, Canada; IRCCS Fondazione Don Gnocchi (A.E.), Florence, Sant'Angelo dei Lombardi, Italy; NEURORHB-Neuro Rehab Human Brain (C.C.F.), Fundación Hospitales Vithas, Valencia, Spain; IRCCS Santa Lucia Foundation (R.F.), Rome, Italy; Clinical and Research Institute of Emergency Pediatric Surgery and Trauma (CRIEPST) (E.F.), Moscow, Russia; Coma Science Group (O.G.), GIGA Consciousness & Centre du Cerveau2, University and University Hospital of Liège, Belgium; Department of Neuropsychology (R.A.H.), Children's Healthcare of Atlanta, GA; Neurophysiology Unit (P.L.), Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy; Centro de Rehabilitación Infantil CRI CETNA (G.I.L.), Fleni, Buenos Aires, Argentina; Boyer College of Music and Dance (W.L.M.), Temple University, Philadelphia, PA; Division of Clinical Neuropsychology (V.V.), Subang Jaya Medical Center, Selangor; Division of Clinical Neuropsychology (V.V.), Thompson Hospital Kota Damanasara, Selangor, Malaysia; Department of Physical Medicine and Rehabilitation (P.W.), University of Colorado, Children's Hospital Colorado, Aurora; Division of Neurosurgery (T.Y.), Rehabilitation Center for Traumatic Apallics Chiba, National Agency for Automotive Safety and Victims' Aid, Japan; and Department of Neuropsychology (B.S.S.), Kennedy Krieger Institute; Department of Psychiatry and Behavioral Sciences (B.S.S.), Johns Hopkins University, School of Medicine, Baltimore, MD
| | - Vigneswaran Veeramuthu
- From the School of Biomedical Engineering & Imaging Sciences (E.M., L.S.S.C.), Faculty of Life Science & Medicine, King's College London, United Kingdom; Department of Physical Medicine and Rehabilitation (M.-M.B.), Hôpital du Sacré-Coeur de Montréal, Quebec, Canada; IRCCS Fondazione Don Gnocchi (A.E.), Florence, Sant'Angelo dei Lombardi, Italy; NEURORHB-Neuro Rehab Human Brain (C.C.F.), Fundación Hospitales Vithas, Valencia, Spain; IRCCS Santa Lucia Foundation (R.F.), Rome, Italy; Clinical and Research Institute of Emergency Pediatric Surgery and Trauma (CRIEPST) (E.F.), Moscow, Russia; Coma Science Group (O.G.), GIGA Consciousness & Centre du Cerveau2, University and University Hospital of Liège, Belgium; Department of Neuropsychology (R.A.H.), Children's Healthcare of Atlanta, GA; Neurophysiology Unit (P.L.), Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy; Centro de Rehabilitación Infantil CRI CETNA (G.I.L.), Fleni, Buenos Aires, Argentina; Boyer College of Music and Dance (W.L.M.), Temple University, Philadelphia, PA; Division of Clinical Neuropsychology (V.V.), Subang Jaya Medical Center, Selangor; Division of Clinical Neuropsychology (V.V.), Thompson Hospital Kota Damanasara, Selangor, Malaysia; Department of Physical Medicine and Rehabilitation (P.W.), University of Colorado, Children's Hospital Colorado, Aurora; Division of Neurosurgery (T.Y.), Rehabilitation Center for Traumatic Apallics Chiba, National Agency for Automotive Safety and Victims' Aid, Japan; and Department of Neuropsychology (B.S.S.), Kennedy Krieger Institute; Department of Psychiatry and Behavioral Sciences (B.S.S.), Johns Hopkins University, School of Medicine, Baltimore, MD
| | - Pamela Wilson
- From the School of Biomedical Engineering & Imaging Sciences (E.M., L.S.S.C.), Faculty of Life Science & Medicine, King's College London, United Kingdom; Department of Physical Medicine and Rehabilitation (M.-M.B.), Hôpital du Sacré-Coeur de Montréal, Quebec, Canada; IRCCS Fondazione Don Gnocchi (A.E.), Florence, Sant'Angelo dei Lombardi, Italy; NEURORHB-Neuro Rehab Human Brain (C.C.F.), Fundación Hospitales Vithas, Valencia, Spain; IRCCS Santa Lucia Foundation (R.F.), Rome, Italy; Clinical and Research Institute of Emergency Pediatric Surgery and Trauma (CRIEPST) (E.F.), Moscow, Russia; Coma Science Group (O.G.), GIGA Consciousness & Centre du Cerveau2, University and University Hospital of Liège, Belgium; Department of Neuropsychology (R.A.H.), Children's Healthcare of Atlanta, GA; Neurophysiology Unit (P.L.), Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy; Centro de Rehabilitación Infantil CRI CETNA (G.I.L.), Fleni, Buenos Aires, Argentina; Boyer College of Music and Dance (W.L.M.), Temple University, Philadelphia, PA; Division of Clinical Neuropsychology (V.V.), Subang Jaya Medical Center, Selangor; Division of Clinical Neuropsychology (V.V.), Thompson Hospital Kota Damanasara, Selangor, Malaysia; Department of Physical Medicine and Rehabilitation (P.W.), University of Colorado, Children's Hospital Colorado, Aurora; Division of Neurosurgery (T.Y.), Rehabilitation Center for Traumatic Apallics Chiba, National Agency for Automotive Safety and Victims' Aid, Japan; and Department of Neuropsychology (B.S.S.), Kennedy Krieger Institute; Department of Psychiatry and Behavioral Sciences (B.S.S.), Johns Hopkins University, School of Medicine, Baltimore, MD
| | - Tomohiro Yamaki
- From the School of Biomedical Engineering & Imaging Sciences (E.M., L.S.S.C.), Faculty of Life Science & Medicine, King's College London, United Kingdom; Department of Physical Medicine and Rehabilitation (M.-M.B.), Hôpital du Sacré-Coeur de Montréal, Quebec, Canada; IRCCS Fondazione Don Gnocchi (A.E.), Florence, Sant'Angelo dei Lombardi, Italy; NEURORHB-Neuro Rehab Human Brain (C.C.F.), Fundación Hospitales Vithas, Valencia, Spain; IRCCS Santa Lucia Foundation (R.F.), Rome, Italy; Clinical and Research Institute of Emergency Pediatric Surgery and Trauma (CRIEPST) (E.F.), Moscow, Russia; Coma Science Group (O.G.), GIGA Consciousness & Centre du Cerveau2, University and University Hospital of Liège, Belgium; Department of Neuropsychology (R.A.H.), Children's Healthcare of Atlanta, GA; Neurophysiology Unit (P.L.), Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy; Centro de Rehabilitación Infantil CRI CETNA (G.I.L.), Fleni, Buenos Aires, Argentina; Boyer College of Music and Dance (W.L.M.), Temple University, Philadelphia, PA; Division of Clinical Neuropsychology (V.V.), Subang Jaya Medical Center, Selangor; Division of Clinical Neuropsychology (V.V.), Thompson Hospital Kota Damanasara, Selangor, Malaysia; Department of Physical Medicine and Rehabilitation (P.W.), University of Colorado, Children's Hospital Colorado, Aurora; Division of Neurosurgery (T.Y.), Rehabilitation Center for Traumatic Apallics Chiba, National Agency for Automotive Safety and Victims' Aid, Japan; and Department of Neuropsychology (B.S.S.), Kennedy Krieger Institute; Department of Psychiatry and Behavioral Sciences (B.S.S.), Johns Hopkins University, School of Medicine, Baltimore, MD
| | - Beth S Slomine
- From the School of Biomedical Engineering & Imaging Sciences (E.M., L.S.S.C.), Faculty of Life Science & Medicine, King's College London, United Kingdom; Department of Physical Medicine and Rehabilitation (M.-M.B.), Hôpital du Sacré-Coeur de Montréal, Quebec, Canada; IRCCS Fondazione Don Gnocchi (A.E.), Florence, Sant'Angelo dei Lombardi, Italy; NEURORHB-Neuro Rehab Human Brain (C.C.F.), Fundación Hospitales Vithas, Valencia, Spain; IRCCS Santa Lucia Foundation (R.F.), Rome, Italy; Clinical and Research Institute of Emergency Pediatric Surgery and Trauma (CRIEPST) (E.F.), Moscow, Russia; Coma Science Group (O.G.), GIGA Consciousness & Centre du Cerveau2, University and University Hospital of Liège, Belgium; Department of Neuropsychology (R.A.H.), Children's Healthcare of Atlanta, GA; Neurophysiology Unit (P.L.), Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy; Centro de Rehabilitación Infantil CRI CETNA (G.I.L.), Fleni, Buenos Aires, Argentina; Boyer College of Music and Dance (W.L.M.), Temple University, Philadelphia, PA; Division of Clinical Neuropsychology (V.V.), Subang Jaya Medical Center, Selangor; Division of Clinical Neuropsychology (V.V.), Thompson Hospital Kota Damanasara, Selangor, Malaysia; Department of Physical Medicine and Rehabilitation (P.W.), University of Colorado, Children's Hospital Colorado, Aurora; Division of Neurosurgery (T.Y.), Rehabilitation Center for Traumatic Apallics Chiba, National Agency for Automotive Safety and Victims' Aid, Japan; and Department of Neuropsychology (B.S.S.), Kennedy Krieger Institute; Department of Psychiatry and Behavioral Sciences (B.S.S.), Johns Hopkins University, School of Medicine, Baltimore, MD
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Murtaugh B, Shapiro Rosenbaum A. Clinical application of recommendations for neurobehavioral assessment in disorders of consciousness: an interdisciplinary approach. Front Hum Neurosci 2023; 17:1129466. [PMID: 37502093 PMCID: PMC10368884 DOI: 10.3389/fnhum.2023.1129466] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Accepted: 06/05/2023] [Indexed: 07/29/2023] Open
Abstract
Accurate diagnosis, prognosis, and subsequent rehabilitation care planning for persons with Disorders of Consciousness (DoC) has historically posed a challenge for neurological care professionals. Evidence suggests rates of misdiagnosis may be as high as 40% when informal beside evaluations are used to determine level of consciousness. The presence of myriad medical, neurological, functional (motor, sensory, cognitive) and environmental confounds germane to these conditions complicates behavioral assessment. Achieving diagnostic certainty is elusive but critical to inform care planning, clinical decision making, and prognostication. Standardized neurobehavioral rating scales has been shown to improve accuracy in distinguishing between coma, unresponsive wakefulness syndrome/vegetative state and minimally consciousness state as compared to informal assessment methods. Thus, these scales are currently recommended for use as the informal "gold standard" for diagnostic assessment in DoC. The following paper will present an evidence-based approach to neurobehavioral assessment for use in clinical practice. Strategies for optimizing assessment and aiding in identification and management of confounds that can limit diagnostic accuracy will be provided. Finally, clinical application of an interdisciplinary approach to identifying and managing confounds will be discussed and how assessment results can be used to identify trends in performance and guide prognostic counseling with families.
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Affiliation(s)
- Brooke Murtaugh
- Department of Rehabilitation Programs, Madonna Rehabilitation Hospitals, Lincoln, NE, United States
| | - Amy Shapiro Rosenbaum
- Department of Brain Injury Rehabilitation, Park Terrace Care Center, Queens, NY, United States
- TBI Model System, Icahn School of Medicine at Mount Sinai, New York, NY, United States
- Brainmatters Neuropsychological Services, PLLC, Plainview, NY, United States
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Proceedings of the First Pediatric Coma and Disorders of Consciousness Symposium by the Curing Coma Campaign, Pediatric Neurocritical Care Research Group, and NINDS: Gearing for Success in Coma Advancements for Children and Neonates. Neurocrit Care 2023; 38:447-469. [PMID: 36759418 PMCID: PMC9910782 DOI: 10.1007/s12028-023-01673-w] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2022] [Accepted: 01/03/2023] [Indexed: 02/11/2023]
Abstract
This proceedings article presents the scope of pediatric coma and disorders of consciousness based on presentations and discussions at the First Pediatric Disorders of Consciousness Care and Research symposium held on September 14th, 2021. Herein we review the current state of pediatric coma care and research opportunities as well as shared experiences from seasoned researchers and clinicians. Salient current challenges and opportunities in pediatric and neonatal coma care and research were identified through the contributions of the presenters, who were Jose I. Suarez, MD, Nina F. Schor, MD, PhD, Beth S. Slomine, PhD Erika Molteni, PhD, and Jan-Marino Ramirez, PhD, and moderated by Varina L. Boerwinkle, MD, with overview by Mark Wainwright, MD, and subsequent audience discussion. The program, executively planned by Varina L. Boerwinkle, MD, Mark Wainwright, MD, and Michelle Elena Schober, MD, drove the identification and development of priorities for the pediatric neurocritical care community.
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Frigerio S, Molteni E, Colombo K, Pastore V, Fedeli C, Galbiati S, Strazzer S. Neuropsychological assessment through Coma Recovery Scale-Revised and Coma/Near Coma Scale in a sample of pediatric patients with disorder of consciousness. J Neurol 2023; 270:1019-1029. [PMID: 36335241 PMCID: PMC9886605 DOI: 10.1007/s00415-022-11456-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2022] [Revised: 10/20/2022] [Accepted: 10/25/2022] [Indexed: 11/07/2022]
Abstract
BACKGROUND The Coma Recovery Scale-Revised (CRS-R) has become a standard tool in assessing Disorders of consciousness (DoC) in adults. However, its measurement validity in pediatrics has only been ascertained in healthy cases. Increasing use of CRS-R in children with DoC imposes appropriate comparison against previously validated tools. The aims of the study were to describe the emergence to a conscious state (eMCS) in pediatric acquired brain injury (ABI); to explore the agreement between the CRS-R and Coma Near Coma Scale (CNCS) and to discuss the advantage of administering the CRS-R in pediatric age. MATERIALS AND METHODS In this observational prospective study, 40 patients were recruited. Inclusion criteria were age 5 to 18 years, Glasgow Coma Scale (GCS) score ≤ 8 at the insult, and unresponsive wakefulness syndrome (UWS) or minimally conscious state (MCS) at admission. Patients were assessed with CRS-R, and CNCS was used as standard. RESULTS The agreement between scales was moderate (r = - 0.71). The analysis of the CRS-R domain scores also confirmed that decreasing CNCS levels (from a coma to eMCS) corresponded to concurrent increas of CRS-R scores in all domains. Moreover, CRS-R better defined patients' status in the emergency phase from MCS. Conversely, CRS-R had lower DoC scoring ability in the presence of severe motor impairment. CONCLUSION We show that CRS-R can track changes in DoC in children as young as 5 years old, and we provide evidence that the agreement with CNCS scores is good.
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Affiliation(s)
- Susanna Frigerio
- Scientific Institute, IRCCS E. Medea, Neurophysiatric Department, Bosisio Parini, Lecco, Italy
| | - Erika Molteni
- School of Biomedical Engineering and Imaging Sciences, and Centre for Medical Engineering, King's College, London, SE1 7EU, UK
| | - Katia Colombo
- Scientific Institute, IRCCS E. Medea, Neurophysiatric Department, Bosisio Parini, Lecco, Italy
| | - Valentina Pastore
- Scientific Institute, IRCCS E. Medea, Neurophysiatric Department, Bosisio Parini, Lecco, Italy
| | - Claudia Fedeli
- Scientific Institute, IRCCS E. Medea, Neurophysiatric Department, Bosisio Parini, Lecco, Italy
| | - Susanna Galbiati
- Scientific Institute, IRCCS E. Medea, Neurophysiatric Department, Bosisio Parini, Lecco, Italy
| | - Sandra Strazzer
- Scientific Institute, IRCCS E. Medea, Neurophysiatric Department, Bosisio Parini, Lecco, Italy.
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13
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Watson WD, Lahey S, Baum KT, Hamner T, Koterba CH, Alvarez G, Chan JB, Davis KC, DiVirgilio EK, Howarth RA, Jones K, Kramer M, Tlustos SJ, Zafiris CM, Slomine BS. The role of the Neuropsychologist across the stages of recovery from acquired brain injury: a summary from the pediatric rehabilitation Neuropsychology collaborative. Child Neuropsychol 2023; 29:299-320. [PMID: 35726723 DOI: 10.1080/09297049.2022.2086691] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Neuropsychologists working in a pediatric neurorehabilitation setting provide care for children and adolescents with acquired brain injuries (ABI) and play a vital role on the interdisciplinary treatment team. This role draws on influences from the field of clinical neuropsychology and its pediatric subspecialty, as well as rehabilitation psychology. This combination of specialties is uniquely suited for working with ABI across the continuum of recovery. ABI recovery often involves a changing picture that spans across stages of recovery (e.g., disorders of consciousness, confusional state, acute cognitive impairment), where each stage presents with distinctive characteristics that warrant a specific evidence-based approach. Assessment and intervention are used reciprocally to inform diagnostics, treatment, and academic planning, and to support patient and family adjustment. Neuropsychologists work with the interdisciplinary teams to collect and integrate data related to brain injury recovery and use this data for treatment planning and clinical decision making. These approaches must often be adapted and adjusted in real time as patients recover, demanding a dynamic expertise that is currently not supported through formal training curriculum or practice guidelines. This paper outlines the roles and responsibilities of pediatric rehabilitation neuropsychologists across the stages of ABI recovery with the goal of increasing awareness in order to continue to develop and formalize this role.
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Affiliation(s)
- William D Watson
- Blythedale Children's Hospital, Valhalla, New York, USA.,Department of Rehabilitation and Regenerative Medicine, Columbia University Vagelos College of Physicians and Surgeons, New York, New York, USA
| | - Sarah Lahey
- Department of Psychology, Brooks Rehabilitation Hospital, Jacksonville, Florida, USA
| | - Katherine T Baum
- Comprehensive Neuropsychology Services, PLLC, Paoli, Pennsylvania, USA
| | - Taralee Hamner
- Pediatric Psychology and Neuropsychology, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Christine H Koterba
- Pediatric Psychology and Neuropsychology, Nationwide Children's Hospital, Columbus, Ohio, USA.,Department of Pediatrics, The Ohio State University College of Medicine, Columbus, Ohio, USA
| | - Gabrielle Alvarez
- Department of Rehabilitation Services, Seattle Children's Hospital, Seattle, Washington, USA
| | - Jana B Chan
- Department of Neuropsychology, Riley Hospital for Children at IU Health, Indianapolis, Indiana and Department of Neurology, IU School of Medicine, Indianapolis, Indiana, USA
| | - Kimberly C Davis
- Department of Psychology, Texas Children's Hospital, Houston, Texas, and Department of Pediatrics, Baylor College of Medicine, Houston, Texas, USA
| | | | - Robyn A Howarth
- Department of Neuropsychology, Children's Healthcare of Atlanta, Atlanta, Georgia, USA
| | - Kelly Jones
- Department of Neuropsychology, Kennedy Krieger Institute, Baltimore, Maryland, USA
| | - Megan Kramer
- Department of Neuropsychology, Kennedy Krieger Institute, Baltimore, Maryland, USA.,Departments of Physical Medicine & Rehabilitation and Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Sarah J Tlustos
- Department of Rehabilitation, Children's Hospital Colorado and Department of Physical Medicine and Rehabilitation, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Christina M Zafiris
- Department of Neuropsychology, Joe DiMaggio Children's Hospital, Hollywood, Florida, USA
| | - Beth S Slomine
- Department of Neuropsychology, Kennedy Krieger Institute, Baltimore, Maryland, USA.,Departments of Physical Medicine & Rehabilitation and Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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14
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Bower J, Magee WL, Catroppa C, Baker FA. Content Validity and Inter-rater Reliability of the Music Interventions in Pediatric DoC Behavior Observation Record. J Music Ther 2022; 60:13-35. [PMID: 36197798 DOI: 10.1093/jmt/thac013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Aligned with best practice guidelines for patients presenting with a disorder of consciousness (DoC), music therapy interventions with this population aim to increase arousal and awareness to support emergence to consciousness. There is a significant evidence base supporting music therapy for adults with a DoC; however, there are currently no published tools that systematically capture behavioral responses of this population during rehabilitative music therapy interventions. Further, the developmentally specific response to severe brain injury in the pediatric population means pediatric-specific research is required. The Music Interventions in Pediatric DoC Behavior Observation Record (Music Behavior Record [MBR]) was developed to objectively record responses during music therapy interventions for children presenting with a DoC. To establish content validity and inter-rater reliability, a pragmatic pilot study was undertaken. Results established that the MBR has content validity with 100% agreement among participants. Overall fair-substantial inter-rater reliability in >70% of the behavioral responses recorded in the MBR indicate the MBR is an early but promising tool to objectively capture responses during music therapy interventions. The use of the MBR may ultimately support clinical advancement and intervention research to optimize consciousness recovery for the pediatric DoC population.
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Affiliation(s)
- Janeen Bower
- Faculty of Fine Arts and Music, The University of Melbourne, Southbank, VIC, Australia.,Music Therapy Department, The Royal Children's Hospital Melbourne, Parkville, VIC, Australia
| | - Wendy L Magee
- Boyer College of Music and Dance, Temple University, Philadelphia, PA,USA
| | - Cathy Catroppa
- Brain and Mind, Clinical Sciences, The Murdoch Children's Research Institute, Parkville, VIC, Australia.,Melbourne School of Psychological Sciences and The Department of Paediatrics, The University of Melbourne, Parkville, VIC, Australia
| | - Felicity A Baker
- Faculty of Fine Arts and Music, The University of Melbourne, Southbank, VIC, Australia.,Centre of Research in Music and Health, Norwegian Academy of Music, Oslo, Norway
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15
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McLaughlin MJ, Caliendo E, Lowder R, Watson WD, Kurowski B, Baum KT, Blackwell LS, Koterba CH, Hoskinson KR, Tlustos SJ, Zimmerman KO, Shah SA, Suskauer SJ. Prescribing Patterns of Amantadine During Pediatric Inpatient Rehabilitation After Traumatic Brain Injury: A Multicentered Retrospective Review From the Pediatric Brain Injury Consortium. J Head Trauma Rehabil 2022; 37:240-248. [PMID: 34320554 PMCID: PMC8789935 DOI: 10.1097/htr.0000000000000709] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
OBJECTIVES To describe dosing practices for amantadine hydrochloride and related adverse effects among children and young adults with traumatic brain injury (TBI) admitted to pediatric inpatient rehabilitation units. SETTING Eight pediatric acute inpatient rehabilitation units located throughout the United States comprising the Pediatric Brain Injury Consortium. PARTICIPANTS Two-hundred thirty-four children and young adults aged 2 months to 21 years with TBI. DESIGN Retrospective data revie. MAIN OUTCOME MEASURES Demographic variables associated with the use of amantadine, amantadine dose, and reported adverse effects. RESULTS Forty-nine patients (21%) aged 0.9 to 20 years received amantadine during inpatient rehabilitation. Forty-five percent of patients admitted to inpatient rehabilitation with a disorder of consciousness (DoC) were treated with amantadine, while 14% of children admitted with higher levels of functioning received amantadine. Children with DoC who were not treated with amantadine were younger than those with DoC who received amantadine (median 3.0 vs 11.6 years, P = .008). Recorded doses of amantadine ranged from 0.7 to 13.5 mg/kg/d; the highest total daily dose was 400 mg/d. Adverse effects were reported in 8 patients (16%); nausea/abdominal discomfort and agitation were most common, each reported in 3 patients. The highest reported dose without an adverse effect was 10.1 mg/kg/d. CONCLUSION During pediatric inpatient rehabilitation, amantadine was prescribed to children across a range of ages and injury severity and was most commonly prescribed to older children with DoC. Dosing varied widely, with weight-based dosing for younger/smaller children at both lower and higher doses than what had been previously reported. Prospective studies are needed to characterize the safety and tolerability of higher amantadine doses and optimize amantadine dosing parameters for children with TBI.
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Affiliation(s)
- Matthew J. McLaughlin
- Division of Pediatric Rehabilitation Medicine, Children’s Mercy - Kansas City, Kansas City, Missouri
- University of Missouri-Kansas City School of Medicine, Kansas City, Missouri
| | - Eric Caliendo
- Weill Cornell School of Medicine, New York, New York
| | - Ryan Lowder
- David Geffen School of Medicine at UCLA, Los Angeles, California
| | - William D. Watson
- Blythedale Children’s Hospital, Valhalla, New York
- Department of Rehabilitation and Regenerative Medicine, Columbia University Vagelos College of Physicians and Surgeons, New York, New York
| | - Brad Kurowski
- Division of Pediatric Rehabilitation Medicine, Cincinnati Children’s Hospital Medical Center, Departments of Pediatrics and Neurology and Rehabilitation Medicine, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | | | - Laura S. Blackwell
- Department of Neuropsychology, Children’s Healthcare of Atlanta, Atlanta, Georgia
| | - Christine H. Koterba
- Department of Pediatric Psychology and Neuropsychology, Nationwide Children’s Hospital, Columbus, OH
- The Ohio State University College of Medicine, Columbus, Ohio
| | - Kristen R. Hoskinson
- The Ohio State University College of Medicine, Columbus, Ohio
- Center for Biobehavioral Health, The Abigail Wexner Research Institute at Nationwide Children’s Hospital, Columbus, Ohio
| | - Sarah J. Tlustos
- Department of Rehabilitation, Children’s Hospital Colorado and Department of Physical Medicine and Rehabilitation, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Kanecia O. Zimmerman
- Division of Critical Care Medicine, Department of Pediatrics, Duke University Medical Center, Duke Clinical Research Institute, Durham, North Carolina
| | - Sudhin A. Shah
- Blythedale Children’s Hospital, Valhalla, New York
- Department of Rehabilitation Medicine, Weill Cornell Medicine, New York, New York
| | - Stacy J. Suskauer
- Kennedy Krieger Institute, Baltimore, Maryland
- Departments of Physical Medicine & Rehabilitation and Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland
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16
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Bodien YG, Katz DI, Schiff ND, Giacino JT. Behavioral Assessment of Patients with Disorders of Consciousness. Semin Neurol 2022; 42:249-258. [PMID: 36100225 DOI: 10.1055/s-0042-1756298] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
Abstract
Severe brain injury is associated with a period of impaired level of consciousness that can last from days to months and results in chronic impairment. Systematic assessment of level of function in patients with disorders of consciousness (DoC) is critical for diagnosis, prognostication, and evaluation of treatment efficacy. Approximately 40% of patients who are thought to be unconscious based on clinical bedside behavioral assessment demonstrate some signs of consciousness on standardized behavioral assessment. This finding, in addition to a growing body of literature demonstrating the advantages of standardized behavioral assessment of DoC, has led multiple professional societies and clinical guidelines to recommend standardized assessment over routine clinical evaluation of consciousness. Nevertheless, even standardized assessment is susceptible to biases and misdiagnosis, and examiners should consider factors, such as fluctuating arousal and aphasia, that may confound evaluation. We review approaches to behavioral assessment of consciousness, recent clinical guideline recommendations for use of specific measures to evaluate patients with DoC, and strategies for mitigating common biases that may confound the examination.
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Affiliation(s)
- Yelena G Bodien
- Center for Neurotechnology and Neurorecovery, Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
- Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Harvard Medical School, Charlestown, Massachusetts
| | - Douglas I Katz
- Department of Neurology, Boston University School of Medicine, Boston, Massachusetts
- Brain Injury Program, Encompass Health Braintree Rehabilitation Hospital, Braintree, Massachusetts
| | - Nicholas D Schiff
- Feil Family Brain and Mind Institute, Weill Cornell Medicine, New York, New York
- Department of Neurology, Weill Cornell Brain and Spine Institute, Weill Cornell Medicine, New York, NY, United States
| | - Joseph T Giacino
- Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Harvard Medical School, Charlestown, Massachusetts
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17
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Vitello MM, Szymkowicz E, Laureys S, Alnagger N, Gosseries O, Thibaut A. Neuroimaging and neurophysiological diagnosis and prognosis in paediatric disorders of consciousness. Dev Med Child Neurol 2022; 64:681-690. [PMID: 35089596 DOI: 10.1111/dmcn.15150] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2021] [Revised: 12/10/2021] [Accepted: 12/14/2021] [Indexed: 12/01/2022]
Abstract
The diagnosis and prognosis of disorders of consciousness (DOC) such as coma, unresponsive wakefulness syndrome, or minimally conscious state are especially challenging in children. In some paediatric patients with severe acquired brain injury, medical comorbidities or developmental factors may obscure the detection of signs of consciousness via clinical assessments, thus leading to misdiagnosis. To circumvent these biases, patients benefit from multimodal assessments that combine behavioural, neuroimaging, and neurophysiological measures. In this review, we provide original data for such diagnostic procedures in children. Neuroimaging is largely underdocumented in children and most neurophysiological research consists of a cohort study design aimed at providing prognostic markers for clinical outcomes. The scarcity of available data on complementary diagnostic approaches in children makes it difficult to establish clear paediatric guidelines. Although there is preliminary evidence for the applicability of paradigms involving event-related potentials as support for diagnosis in children, more well-designed studies need to be conducted to promote evidence-based practices in paediatric DOC.
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Affiliation(s)
- Marie M Vitello
- Coma Science Group, GIGA-Consciousness, University of Liège, Liège, Belgium.,Centre du Cerveau, University Hospital of Liège, Liège, Belgium
| | - Emilie Szymkowicz
- Coma Science Group, GIGA-Consciousness, University of Liège, Liège, Belgium.,Centre du Cerveau, University Hospital of Liège, Liège, Belgium
| | - Steven Laureys
- Coma Science Group, GIGA-Consciousness, University of Liège, Liège, Belgium.,Centre du Cerveau, University Hospital of Liège, Liège, Belgium
| | - Naji Alnagger
- Coma Science Group, GIGA-Consciousness, University of Liège, Liège, Belgium.,Centre du Cerveau, University Hospital of Liège, Liège, Belgium
| | - Olivia Gosseries
- Coma Science Group, GIGA-Consciousness, University of Liège, Liège, Belgium.,Centre du Cerveau, University Hospital of Liège, Liège, Belgium
| | - Aurore Thibaut
- Coma Science Group, GIGA-Consciousness, University of Liège, Liège, Belgium.,Centre du Cerveau, University Hospital of Liège, Liège, Belgium
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18
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Irzan H, Pozzi M, Chikhladze N, Cebanu S, Tadevosyan A, Calcii C, Tsiskaridze A, Melbourne A, Strazzer S, Modat M, Molteni E. Emerging Treatments for Disorders of Consciousness in Paediatric Age. Brain Sci 2022; 12:198. [PMID: 35203961 PMCID: PMC8870410 DOI: 10.3390/brainsci12020198] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2021] [Revised: 01/28/2022] [Accepted: 01/29/2022] [Indexed: 11/17/2022] Open
Abstract
The number of paediatric patients living with a prolonged Disorder of Consciousness (DoC) is growing in high-income countries, thanks to substantial improvement in intensive care. Life expectancy is extending due to the clinical and nursing management achievements of chronic phase needs, including infections. However, long-known pharmacological therapies such as amantadine and zolpidem, as well as novel instrumental approaches using direct current stimulation and, more recently, stem cell transplantation, are applied in the absence of large paediatric clinical trials and rigorous age-balanced and dose-escalated validations. With evidence building up mainly through case reports and observational studies, there is a need for well-designed paediatric clinical trials and specific research on 0-4-year-old children. At such an early age, assessing residual and recovered abilities is most challenging due to the early developmental stage, incompletely learnt motor and cognitive skills, and unreliable communication; treatment options are also less explored in early age. In middle-income countries, the lack of rehabilitation services and professionals focusing on paediatric age hampers the overall good assistance provision. Young and fast-evolving health insurance systems prevent universal access to chronic care in some countries. In low-income countries, rescue networks are often inadequate, and there is a lack of specialised and intensive care, difficulty in providing specific pharmaceuticals, and lower compliance to intensive care hygiene standards. Despite this, paediatric cases with DoC are reported, albeit in fewer numbers than in countries with better-resourced healthcare systems. For patients with a poor prospect of recovery, withdrawal of care is inhomogeneous across countries and still heavily conditioned by treatment costs as well as ethical and cultural factors, rather than reliant on protocols for assessment and standardised treatments. In summary, there is a strong call for multicentric, international, and global health initiatives on DoC to devote resources to the paediatric age, as there is now scope for funders to invest in themes specific to DoC affecting the early years of the life course.
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Affiliation(s)
- Hassna Irzan
- School of Biomedical Engineering & Imaging Sciences, King’s College London, London WC2R 2LS, UK; (H.I.); (A.M.); (M.M.)
- Department of Medical Physics and Biomedical Engineering, University College London, London WC1E 7JE, UK
| | - Marco Pozzi
- Scientific Institute IRCCS E. Medea, Acquired Brain Injury Unit, 22040 Bosisio Parini, Italy; (M.P.); (S.S.)
| | - Nino Chikhladze
- Faculty of Medicine, Ivane Javakhishvili Tbilisi State University, Tbilisi 0179, Georgia; (N.C.); (A.T.)
| | - Serghei Cebanu
- Faculty of Medicine, Nicolae Testemitanu State University of Medicine and Pharmacy, MD-2004 Chišināu, Moldova; (S.C.); (C.C.)
| | - Artashes Tadevosyan
- Department of Public Health and Healthcare Organization, Yerevan State Medical University, Yerevan 0025, Armenia;
| | - Cornelia Calcii
- Faculty of Medicine, Nicolae Testemitanu State University of Medicine and Pharmacy, MD-2004 Chišināu, Moldova; (S.C.); (C.C.)
| | - Alexander Tsiskaridze
- Faculty of Medicine, Ivane Javakhishvili Tbilisi State University, Tbilisi 0179, Georgia; (N.C.); (A.T.)
| | - Andrew Melbourne
- School of Biomedical Engineering & Imaging Sciences, King’s College London, London WC2R 2LS, UK; (H.I.); (A.M.); (M.M.)
- Department of Medical Physics and Biomedical Engineering, University College London, London WC1E 7JE, UK
| | - Sandra Strazzer
- Scientific Institute IRCCS E. Medea, Acquired Brain Injury Unit, 22040 Bosisio Parini, Italy; (M.P.); (S.S.)
- Rehabilitation Service, “Usratuna” Health and Rehabilitation Centre, Juba, South Sudan
| | - Marc Modat
- School of Biomedical Engineering & Imaging Sciences, King’s College London, London WC2R 2LS, UK; (H.I.); (A.M.); (M.M.)
| | - Erika Molteni
- School of Biomedical Engineering & Imaging Sciences, King’s College London, London WC2R 2LS, UK; (H.I.); (A.M.); (M.M.)
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19
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Liang P, Xu H, Li S, Ren L, Zhao X. Virtual Reality-Based Sensory Stimulation for Pediatric Disorders of Consciousness: A Pilot Study. Front Pediatr 2022; 10:879422. [PMID: 35769213 PMCID: PMC9234395 DOI: 10.3389/fped.2022.879422] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2022] [Accepted: 05/16/2022] [Indexed: 11/21/2022] Open
Abstract
OBJECTIVE The purpose of this study was to determine whether virtual reality-based sensory stimulation has the ability to improve the level of consciousness in pediatric disorders of consciousness compared with general rehabilitation. METHODS Thirty subjects were divided into a virtual reality (VR) group (n = 15) and a control group (n = 15). Subjects in the VR group received both general rehabilitation and exposure to VR videos; the control group received only general rehabilitation. The Glasgow Coma Scale (GCS), Coma Recovery Scale-Revised (CRS-R), and amplitude-integrated electroencephalogram (EEG) (aEEG) were used to measure the clinical behavioral response and neuroelectrophysiology before and after the treatment. The Glasgow Outcome Scale Extended Pediatric Revised (GOS-E Peds) was used to measure the social and personal functional ability after 3 months. RESULTS After 2 weeks of treatment, the CRS-R and GCS improved in both groups. However, the VR group had better results than the control group in the CRS-R (p = 0.003) and GCS (p = 0.045). There were no significant differences on aEEG in the two groups after treatment. According to the GOS-E Peds, the improvement of social and personal functional ability had no significant differences in the two groups. Additionally, there were no obvious adverse reactions in the two group during the treatment. CONCLUSIONS This pilot study indicates potential benefit from the addition of VR to standard rehabilitation in pediatric disorders of consciousness. To further explore the efficacy of VR, a large-sample randomized controlled trial is warranted.
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Affiliation(s)
- Piao Liang
- Department of Rehabilitation, Children's Hospital of Nanjing Medical University, Nanjing, China
| | - Hong Xu
- Department of Rehabilitation, Children's Hospital of Nanjing Medical University, Nanjing, China
| | - Sinan Li
- Department of Rehabilitation, Children's Hospital of Nanjing Medical University, Nanjing, China
| | - Lei Ren
- Department of Nursing, Children's Hospital of Nanjing Medical University, Nanjing, China
| | - Xiaoke Zhao
- Department of Rehabilitation, Children's Hospital of Nanjing Medical University, Nanjing, China
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20
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Ismail FY, Saleem GT, Ljubisavljevic MR. Brain Data in Pediatric Disorders of Consciousness: Special Considerations. J Clin Neurophysiol 2022; 39:49-58. [PMID: 34474425 DOI: 10.1097/wnp.0000000000000772] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
SUMMARY The diagnosis and management of disorders of consciousness in children continue to present a clinical, research, and ethical challenge. Though the practice guidelines for diagnosis and management of disorders of consciousness in adults are supported by decades of empirical and pragmatic evidence, similar guidelines for infants and children are lacking. The maturing conscious experience and the limited behavioral repertoire to report consciousness in this age group restrict extrapolation from the adult literature. Equally challenging is the process of heightened structural and functional neuroplasticity in the developing brain, which adds a layer of complexity to the investigation of the neural correlates of consciousness in infants and children. This review discusses the clinical assessment of pediatric disorders of consciousness and delineates the diagnostic and prognostic utility of neurophysiological and neuroimaging correlates of consciousness. The potential relevance of these correlates for the developing brain based on existing theoretical models of consciousness in adults is outlined.
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Affiliation(s)
- Fatima Y Ismail
- Department of Pediatrics, College of Medicine and Health Sciences, United Arab Emirates University, Al Ain, United Arab Emirates
- Department of Neurology (Adjunct), Johns Hopkins School of Medicine, Baltimore, Maryland, U.S.A
| | - Ghazala T Saleem
- Department of Rehabilitation Science, School of Public Health and Health Professions, State University of New York at Buffalo, Buffalo, New York, U.S.A.; and
| | - Milos R Ljubisavljevic
- Department of Physiology, College of Medicine and Health Sciences, United Arab Emirates University, Al Ain, United Arab Emirates
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21
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Fins JJ. Consciousness, Conflations, and Disability Rights: Denials of Care for Children in the "Minimally Conscious State". THE JOURNAL OF LAW, MEDICINE & ETHICS : A JOURNAL OF THE AMERICAN SOCIETY OF LAW, MEDICINE & ETHICS 2022; 50:181-183. [PMID: 35243988 DOI: 10.1017/jme.2022.22] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
This essay critiques the fiercely utilitarian allocation scheme of Cameron et al. Children have no hope of recovery if their lives are cut short based on administrative protocols that misrepresent the nature of their conditions. Unilateral futility judgements - especially those based on a false predicate - are discriminatory. When considering the best interests of children, we should see possibility in disability and not advance ill-informed utilitarianism.
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22
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Treating Traumatic Brain Injuries with Electroceuticals: Implications for the Neuroanatomy of Consciousness. NEUROSCI 2021. [DOI: 10.3390/neurosci2030018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
According to the Centers for Disease Control and Prevention (CDC), traumatic brain injury (TBI) is the leading cause of loss of consciousness, long-term disability, and death in children and young adults (age 1 to 44). Currently, there are no United States Food and Drug Administration (FDA) approved pharmacological treatments for post-TBI regeneration and recovery, particularly related to permanent disability and level of consciousness. In some cases, long-term disorders of consciousness (DoC) exist, including the vegetative state/unresponsive wakefulness syndrome (VS/UWS) characterized by the exhibition of reflexive behaviors only or a minimally conscious state (MCS) with few purposeful movements and reflexive behaviors. Electroceuticals, including non-invasive brain stimulation (NIBS), vagus nerve stimulation (VNS), and deep brain stimulation (DBS) have proved efficacious in some patients with TBI and DoC. In this review, we examine how electroceuticals have improved our understanding of the neuroanatomy of consciousness. However, the level of improvements in general arousal or basic bodily and visual pursuit that constitute clinically meaningful recovery on the Coma Recovery Scale-Revised (CRS-R) remain undefined. Nevertheless, these advancements demonstrate the importance of the vagal nerve, thalamus, reticular activating system, and cortico-striatal-thalamic-cortical loop in the process of consciousness recovery.
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23
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Watson WD, Suskauer SJ, Askin G, Nowak S, Baum KT, Gerber LM, Blackwell LS, Koterba CH, Hoskinson KR, Kurowski BG, Mclaughlin MJ, Tlustos SJ, Zimmerman KO, Shah SA. Cognitive Recovery During Inpatient Rehabilitation Following Pediatric Traumatic Brain Injury: A Pediatric Brain Injury Consortium Study. J Head Trauma Rehabil 2021; 36:253-263. [PMID: 33656473 DOI: 10.1097/htr.0000000000000650] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To characterize the demographics, clinical course, and predictors of cognitive recovery among children and young adults receiving inpatient rehabilitation following pediatric traumatic brain injury (TBI). DESIGN Retrospective observational, multicenter study. SETTING Eight acute pediatric inpatient rehabilitation facilities in the United States with specialized programs for treating patients with TBI. PARTICIPANTS Children and young adults (0-21 years) with TBI (n = 234) receiving inpatient rehabilitation. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES Admission and discharge status assessed by the WeeFIM Cognitive Developmental Functional Quotient (DFQ) and Cognitive and Linguistic Scale (CALS). RESULTS Patients admitted to pediatric inpatient rehabilitation are diverse in cognitive functioning. While the majority of patients make improvements, cognitive recovery is constrained for those admitted with the most severe cognitive impairments. Age, time since injury to rehabilitation admission, and admission WeeFIM Cognitive DFQ are significant predictors of cognitive functioning at discharge from inpatient rehabilitation. CONCLUSIONS This work establishes a multicenter Pediatric Brain Injury Consortium and characterized the demographics and clinical course of cognitive recovery during inpatient rehabilitation of pediatric patients with TBI to aid in prospective study design.
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Affiliation(s)
- William D Watson
- Department of Rehabilitation and Regenerative Medicine, Columbia University Vagelos College of Physicians and Surgeons, New York, New York (Dr Watson); Blythedale Children's Hospital, Valhalla, New York (Drs Watson and Shah and Ms Nowak); Kennedy Krieger Institute, and Departments of Physical Medicine and Rehabilitation and Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland (Dr Suskauer); Departments of Population Health Sciences (Ms Askin and Dr Gerber) and Rehabilitation Medicine (Dr Shah), Weill Cornell Medicine, New York, New York; Children's Hospital of Philadelphia, Philadelphia, Pennsylvania (Dr Baum); Department of Neuropsychology, Children's Hospital of Atlanta, Atlanta, Georgia (Dr Blackwell); Center for Biobehavioral Health, The Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, Ohio (Drs Koterba and Hoskinson); Department of Pediatrics, The Ohio State University College of Medicine, Columbus (Dr Hoskinson); Division of Pediatric Rehabilitation Medicine, Cincinnati Children's Hospital Medical Center, and Departments of Pediatrics and Neurology and Rehabilitation Medicine, University of Cincinnati College of Medicine, Ohio (Dr Kurowski); Division of Pediatric Rehabilitation Medicine, Children's Mercy-Kansas City, Kansas City, Missouri, and Department of Pediatrics, University of Missouri-Kansas City School of Medicine, Kansas City, Missouri (Dr Mclaughlin); Department of Rehabilitation, Children's Hospital Colorado, and Department of Physical Medicine and Rehabilitation, University of Colorado Anshutz Medical Campus, Aurora (Dr Tlustos); and Division of Critical Care Medicine, Department of Pediatrics, Duke University Medical Center, Duke Clinical Research Institute, Durham, North Carolina (Dr Zimmerman)
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Defining catastrophic brain injury in children leading to coma and disorders of consciousness and the scope of the problem. Curr Opin Pediatr 2020; 32:750-758. [PMID: 33009124 DOI: 10.1097/mop.0000000000000951] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW Severe brain injury in children resulting in coma and disorders of consciousness (DOC) is a catastrophic event for the life and function of children and their families. The present article summarizes the recently published pediatric literature on validated diagnostic assessments, potential predictors of recovery, and outcome measures used in children with catastrophic brain injury (CBI). Literature search terms included variants of consciousness, diagnostic tests, predictors of outcome, and outcome measures. RECENT FINDINGS Developmentally appropriate diagnostic tools, outcome predictors, and outcome measures are lacking for children with CBI leading to coma and DOC. Individual case prognosis relies on serial clinical examinations and experience. Evidence regarding optimal diagnosis of the highest level of consciousness and management of children with CBI is needed. Global efforts through the ongoing Curing Coma Campaign are aimed at: developing common data elements for information capture; streamlining the classification of coma endotypes; describing trajectories with biomarkers to monitor recovery or disease progression; and devising effective treatments for adults and children. SUMMARY Standardized, developmentally appropriate diagnostic and outcome assessments for CBI in children are needed. Future research should use these content standards to update our understanding of children with CBI leading to coma and DOC, and evaluate effective practices using acute adjunctive and rehabilitation therapies.
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Abstract
INTRODUCTION New guidelines regarding the diagnosis of disorders of consciousness (DOC) (such as vegetative state and minimally conscious state) have recently been published by the American Academy of Neurology and the European Academy of Neurology. This follows an impressive number of prospective studies performed on DOC and recent multi-centric studies with larger sample size, which have gathered precious information on the recovery of cohort of patients through years and which now call for a better management of patients with DOC. AREAS COVERED This review will discuss recent updates on the clinical entities of DOC, the challenges for an accurate diagnosis and the last developments in diagnostic tools. EXPERT OPINION The authors will also discuss the impact of the new guidelines on their way of diagnosing patients and how diagnosis will most likely change in a near future.
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Affiliation(s)
- Caroline Schnakers
- Research Institute, Casa Colina Hospital and Centers for Healthcare , Pomona, CA, USA
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Molteni E, Colombo K, Pastore V, Galbiati S, Recla M, Locatelli F, Galbiati S, Fedeli C, Strazzer S. Joint Neuropsychological Assessment through Coma/Near Coma and Level of Cognitive Functioning Assessment Scales Reduces Negative Findings in Pediatric Disorders of Consciousness. Brain Sci 2020; 10:E162. [PMID: 32178348 PMCID: PMC7140001 DOI: 10.3390/brainsci10030162] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2020] [Revised: 02/28/2020] [Accepted: 03/10/2020] [Indexed: 01/26/2023] Open
Abstract
The present study aimed to: (a) characterize the emergence to a conscious state (CS) in a sample of children and adolescents with severe brain injury during the post-acute rehabilitation and through two different neuropsychological assessment tools: the Rappaport Coma/Near Coma Scale (CNCS) and Level of Cognitive Functioning Assessment Scale (LOCFAS); (b) compare the evolution in patients with brain lesions due to traumatic and non-traumatic etiologies; and (c) describe the relationship between the emergence to a CS and some relevant clinical variables. In this observational prospective longitudinal study, 92 consecutive patients were recruited. Inclusion criteria were severe disorders of consciousness (DOC), Glasgow Coma Scale (GCS) score ≤8 at insult, age 0 to 18 years, and direct admission to inpatient rehabilitation from acute care. The main outcome measures were CNCS and LOCFAS, both administered three and six months after injury. The cohort globally shifted towards milder DOC over time, moving from overall 'moderate/near coma' at three months to 'near/no coma' at six months post-injury. The shift was captured by both CNCS and LOCFAS. CNCS differentiated levels of coma at best, while LOCFAS was superior in characterizing the emergence from coma. Agreement between scales was fair, and reduced negative findings at less than 10%. Patients with traumatic brain injury (TBI) vs. non-traumatic brain injury (NTBI) were older and had neurosurgical intervention more frequently. No relation between age and the level of consciousness was found overall. Concurrent administration of CNCS and LOCFAS reduced the rate of false negatives and better detected signs of arousal and awareness. This provides indication to administer both tools to increase measurement precision.
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Affiliation(s)
- Erika Molteni
- School of Biomedical Engineering & Imaging Sciences, and Centre for Medical Engineering, King’s College, London SE1 7EU, UK
| | - Katia Colombo
- Neuropsychological and Cognitive-behavioral Service, Neurophysiatric Department, Scientific Institute, I.R.C.C.S. Eugenio Medea, 23842 Bosisio Parini, Italy; (V.P.); (S.G.); (M.R.); (C.F.)
| | - Valentina Pastore
- Neuropsychological and Cognitive-behavioral Service, Neurophysiatric Department, Scientific Institute, I.R.C.C.S. Eugenio Medea, 23842 Bosisio Parini, Italy; (V.P.); (S.G.); (M.R.); (C.F.)
| | - Susanna Galbiati
- Neuropsychological and Cognitive-behavioral Service, Neurophysiatric Department, Scientific Institute, I.R.C.C.S. Eugenio Medea, 23842 Bosisio Parini, Italy; (V.P.); (S.G.); (M.R.); (C.F.)
| | - Monica Recla
- Neuropsychological and Cognitive-behavioral Service, Neurophysiatric Department, Scientific Institute, I.R.C.C.S. Eugenio Medea, 23842 Bosisio Parini, Italy; (V.P.); (S.G.); (M.R.); (C.F.)
| | - Federica Locatelli
- Neurophysiatric Department, Scientific Institute, I.R.C.C.S. Eugenio Medea, 23842 Bosisio Parini, Italy; (F.L.); (S.G.); (S.S.)
| | - Sara Galbiati
- Neurophysiatric Department, Scientific Institute, I.R.C.C.S. Eugenio Medea, 23842 Bosisio Parini, Italy; (F.L.); (S.G.); (S.S.)
| | - Claudia Fedeli
- Neuropsychological and Cognitive-behavioral Service, Neurophysiatric Department, Scientific Institute, I.R.C.C.S. Eugenio Medea, 23842 Bosisio Parini, Italy; (V.P.); (S.G.); (M.R.); (C.F.)
| | - Sandra Strazzer
- Neurophysiatric Department, Scientific Institute, I.R.C.C.S. Eugenio Medea, 23842 Bosisio Parini, Italy; (F.L.); (S.G.); (S.S.)
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