1
|
Carlson JM, Lin DJ. Prognostication in Prolonged and Chronic Disorders of Consciousness. Semin Neurol 2023; 43:744-757. [PMID: 37758177 DOI: 10.1055/s-0043-1775792] [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: 10/03/2023]
Abstract
Patients with prolonged disorders of consciousness (DOCs) longer than 28 days may continue to make significant gains and achieve functional recovery. Occasionally, this recovery trajectory may extend past 3 (for nontraumatic etiologies) and 12 months (for traumatic etiologies) into the chronic period. Prognosis is influenced by several factors including state of DOC, etiology, and demographics. There are several testing modalities that may aid prognostication under active investigation including electroencephalography, functional and anatomic magnetic resonance imaging, and event-related potentials. At this time, only one treatment (amantadine) has been routinely recommended to improve functional recovery in prolonged DOC. Given that some patients with prolonged or chronic DOC have the potential to recover both consciousness and functional status, it is important for neurologists experienced in prognostication to remain involved in their care.
Collapse
Affiliation(s)
- Julia M Carlson
- Division of Neurocritical Care, Department of Neurology, University of North Carolina Hospital, University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - David J Lin
- Center for Neurotechnology and Neurorecovery, Division of Neurocritical Care and Stroke Service, Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
- Center for Neurorestoration and Neurotechnology, Rehabilitation Research and Development Service, Department of Veterans Affairs, Providence, Rhode Island
| |
Collapse
|
2
|
Noé E, Ferri J, Olaya J, Navarro MD, O’Valle M, Colomer C, Moliner B, Ippoliti C, Maza A, Llorens R. When, How, and to What Extent Are Individuals with Unresponsive Wakefulness Syndrome Able to Progress? Neurobehavioral Progress. Brain Sci 2021; 11:126. [PMID: 33478033 PMCID: PMC7835897 DOI: 10.3390/brainsci11010126] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2020] [Revised: 01/09/2021] [Accepted: 01/15/2021] [Indexed: 01/21/2023] Open
Abstract
Accurate estimation of the neurobehavioral progress of patients with unresponsive wakefulness syndrome (UWS) is essential to anticipate their most likely clinical course and guide clinical decision making. Although different studies have described this progress and possible predictors of neurobehavioral improvement in these patients, they have methodological limitations that could restrict the validity and generalization of the results. This study investigates the neurobehavioral progress of 100 patients with UWS consecutively admitted to a neurorehabilitation center using systematic weekly assessments based on standardized measures, and the prognostic factors of changes in their neurobehavioral condition. Our results showed that, during the analyzed period, 34% of the patients were able to progress from UWS to minimally conscious state (MCS), 12% of the total sample (near one third from those who progressed to MCS) were able to emerge from MCS, and 10% of the patients died. Transition to MCS was mostly denoted by visual signs, which appeared either alone or in combination with motor signs, and was predicted by etiology and the score on the Coma Recovery Scale-Revised at admission with an accuracy of 75%. Emergence from MCS was denoted in the same proportion by functional communication and object use. Predictive models of emergence from MCS and mortality were not valid and the identified predictors could not be accounted for.
Collapse
Affiliation(s)
- Enrique Noé
- NEURORHB, Servicio de Neurorrehabilitación de Hospitales Vithas, Fundación Vithas, Callosa d’En Sarrià 12, 46007 València, Spain; (J.F.); (J.O.); (M.D.N.); (M.O.); (C.C.); (B.M.); (C.I.); (R.L.)
| | - Joan Ferri
- NEURORHB, Servicio de Neurorrehabilitación de Hospitales Vithas, Fundación Vithas, Callosa d’En Sarrià 12, 46007 València, Spain; (J.F.); (J.O.); (M.D.N.); (M.O.); (C.C.); (B.M.); (C.I.); (R.L.)
| | - José Olaya
- NEURORHB, Servicio de Neurorrehabilitación de Hospitales Vithas, Fundación Vithas, Callosa d’En Sarrià 12, 46007 València, Spain; (J.F.); (J.O.); (M.D.N.); (M.O.); (C.C.); (B.M.); (C.I.); (R.L.)
| | - María Dolores Navarro
- NEURORHB, Servicio de Neurorrehabilitación de Hospitales Vithas, Fundación Vithas, Callosa d’En Sarrià 12, 46007 València, Spain; (J.F.); (J.O.); (M.D.N.); (M.O.); (C.C.); (B.M.); (C.I.); (R.L.)
| | - Myrtha O’Valle
- NEURORHB, Servicio de Neurorrehabilitación de Hospitales Vithas, Fundación Vithas, Callosa d’En Sarrià 12, 46007 València, Spain; (J.F.); (J.O.); (M.D.N.); (M.O.); (C.C.); (B.M.); (C.I.); (R.L.)
| | - Carolina Colomer
- NEURORHB, Servicio de Neurorrehabilitación de Hospitales Vithas, Fundación Vithas, Callosa d’En Sarrià 12, 46007 València, Spain; (J.F.); (J.O.); (M.D.N.); (M.O.); (C.C.); (B.M.); (C.I.); (R.L.)
| | - Belén Moliner
- NEURORHB, Servicio de Neurorrehabilitación de Hospitales Vithas, Fundación Vithas, Callosa d’En Sarrià 12, 46007 València, Spain; (J.F.); (J.O.); (M.D.N.); (M.O.); (C.C.); (B.M.); (C.I.); (R.L.)
| | - Camilla Ippoliti
- NEURORHB, Servicio de Neurorrehabilitación de Hospitales Vithas, Fundación Vithas, Callosa d’En Sarrià 12, 46007 València, Spain; (J.F.); (J.O.); (M.D.N.); (M.O.); (C.C.); (B.M.); (C.I.); (R.L.)
| | - Anny Maza
- Neurorehabilitation and Brain Research Group, Instituto de Investigación e Innovación en Bioingeniería, Universitat Politècnica de València, Camino de Vera s/n, 46011 València, Spain;
| | - Roberto Llorens
- NEURORHB, Servicio de Neurorrehabilitación de Hospitales Vithas, Fundación Vithas, Callosa d’En Sarrià 12, 46007 València, Spain; (J.F.); (J.O.); (M.D.N.); (M.O.); (C.C.); (B.M.); (C.I.); (R.L.)
- Neurorehabilitation and Brain Research Group, Instituto de Investigación e Innovación en Bioingeniería, Universitat Politècnica de València, Camino de Vera s/n, 46011 València, Spain;
| |
Collapse
|
3
|
Olaya J, Noé E, Navarro MD, O’Valle M, Colomer C, Moliner B, Ippoliti C, Ferri J, Maza A, Llorens R. When, How, and to What Extent Are Individuals with Unresponsive Wakefulness Syndrome Able to Progress? Functional Independence. Brain Sci 2020; 10:E990. [PMID: 33339138 PMCID: PMC7765669 DOI: 10.3390/brainsci10120990] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2020] [Revised: 12/03/2020] [Accepted: 12/07/2020] [Indexed: 12/04/2022] Open
Abstract
Accurate estimation of the functional independence of patients with unresponsive wakefulness syndrome (UWS) is essential to adjust family and clinical expectations and plan long-term necessary resources. Although different studies have described the clinical course of these patients, they have methodological limitations that could restrict generalization of the results. This study investigates the neurobehavioral progress of 100 patients with UWS consecutively admitted to a neurorehabilitation center using systematic weekly assessments based on standardized measures, and the functional independence staging of those patients who emerged from a minimally conscious state (MCS) during the first year post-emergence. Our results showed that one year after emergence, most patients were severely dependent, although some of them showed extreme or moderate severity. Clinically meaningful functional improvement was less likely to occur in cognitively-demanding activities, such as activities of daily living and executive function. Consequently, the use of specific and staging functional independence measures, with domain-specific evaluations, are recommended to detect the functional changes that might be expected in these patients. The information provided by these instruments, together with that obtained from repeated assessments of the preserved consciousness with standardized instruments, could help clinicians to adjust expectations and plan necessary resources for this population.
Collapse
Affiliation(s)
- José Olaya
- NEURORHB, Servicio de Neurorrehabilitación de Hospitales Vithas, Fundación Vithas, Callosa d’En Sarrià 12, 46007 València, Spain; (J.O.); (M.D.N.); (M.O.); (C.C.); (B.M.); (C.I.); (J.F.); or (R.L.)
| | - Enrique Noé
- NEURORHB, Servicio de Neurorrehabilitación de Hospitales Vithas, Fundación Vithas, Callosa d’En Sarrià 12, 46007 València, Spain; (J.O.); (M.D.N.); (M.O.); (C.C.); (B.M.); (C.I.); (J.F.); or (R.L.)
| | - María Dolores Navarro
- NEURORHB, Servicio de Neurorrehabilitación de Hospitales Vithas, Fundación Vithas, Callosa d’En Sarrià 12, 46007 València, Spain; (J.O.); (M.D.N.); (M.O.); (C.C.); (B.M.); (C.I.); (J.F.); or (R.L.)
| | - Myrtha O’Valle
- NEURORHB, Servicio de Neurorrehabilitación de Hospitales Vithas, Fundación Vithas, Callosa d’En Sarrià 12, 46007 València, Spain; (J.O.); (M.D.N.); (M.O.); (C.C.); (B.M.); (C.I.); (J.F.); or (R.L.)
| | - Carolina Colomer
- NEURORHB, Servicio de Neurorrehabilitación de Hospitales Vithas, Fundación Vithas, Callosa d’En Sarrià 12, 46007 València, Spain; (J.O.); (M.D.N.); (M.O.); (C.C.); (B.M.); (C.I.); (J.F.); or (R.L.)
| | - Belén Moliner
- NEURORHB, Servicio de Neurorrehabilitación de Hospitales Vithas, Fundación Vithas, Callosa d’En Sarrià 12, 46007 València, Spain; (J.O.); (M.D.N.); (M.O.); (C.C.); (B.M.); (C.I.); (J.F.); or (R.L.)
| | - Camilla Ippoliti
- NEURORHB, Servicio de Neurorrehabilitación de Hospitales Vithas, Fundación Vithas, Callosa d’En Sarrià 12, 46007 València, Spain; (J.O.); (M.D.N.); (M.O.); (C.C.); (B.M.); (C.I.); (J.F.); or (R.L.)
| | - Joan Ferri
- NEURORHB, Servicio de Neurorrehabilitación de Hospitales Vithas, Fundación Vithas, Callosa d’En Sarrià 12, 46007 València, Spain; (J.O.); (M.D.N.); (M.O.); (C.C.); (B.M.); (C.I.); (J.F.); or (R.L.)
| | - Anny Maza
- Neurorehabilitation and Brain Research Group, Instituto de Investigación e Innovación en Bioingeniería, Universitat Politècnica de València, Camino de Vera s/n, 46011 València, Spain;
| | - Roberto Llorens
- NEURORHB, Servicio de Neurorrehabilitación de Hospitales Vithas, Fundación Vithas, Callosa d’En Sarrià 12, 46007 València, Spain; (J.O.); (M.D.N.); (M.O.); (C.C.); (B.M.); (C.I.); (J.F.); or (R.L.)
- Neurorehabilitation and Brain Research Group, Instituto de Investigación e Innovación en Bioingeniería, Universitat Politècnica de València, Camino de Vera s/n, 46011 València, Spain;
| |
Collapse
|
4
|
Memory During the Presumed Vegetative State: Implications for Patient Quality of Life. Camb Q Healthc Ethics 2020; 29:501-510. [DOI: 10.1017/s0963180120000274] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
AbstractA growing number of studies show that a significant proportion of patients, who meet the clinical criteria for the diagnosis of the vegetative state (VS), demonstrate evidence of covert awareness through successful performance of neuroimaging tasks. Despite these important advances, the day-to-day life experiences of any such patient remain unknown. This presents a major challenge for optimizing the patient’s standard of care and quality of life (QoL). We describe a patient who, following emergence from a state of complete behavioral unresponsiveness and a clinical diagnosis of VS, reported rich memories of his experience during this time. This case demonstrates the potential for a sophisticated mental life enabled by preserved memory in a proportion of patients who, similarly, are thought to be unconscious. Therefore, it presents an important opportunity to examine the implications for patient QoL and standard of care, both during the period of presumed unconsciousness and after recovery.
Collapse
|
5
|
The patient with severe traumatic brain injury: clinical decision-making: the first 60 min and beyond. Curr Opin Crit Care 2020; 25:622-629. [PMID: 31574013 DOI: 10.1097/mcc.0000000000000671] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
PURPOSE OF REVIEW There is an urgent need to discuss the uncertainties and paradoxes in clinical decision-making after severe traumatic brain injury (s-TBI). This could improve transparency, reduce variability of practice and enhance shared decision-making with proxies. RECENT FINDINGS Clinical decision-making on initiation, continuation and discontinuation of medical treatment may encompass substantial consequences as well as lead to presumed patient benefits. Such decisions, unfortunately, often lack transparency and may be controversial in nature. The very process of decision-making is frequently characterized by both a lack of objective criteria and the absence of validated prognostic models that could predict relevant outcome measures, such as long-term quality and satisfaction with life. In practice, while treatment-limiting decisions are often made in patients during the acute phase immediately after s-TBI, other such severely injured TBI patients have been managed with continued aggressive medical care, and surgical or other procedural interventions have been undertaken in the context of pursuing a more favorable patient outcome. Given this spectrum of care offered to identical patient cohorts, there is clearly a need to identify and decrease existing selectivity, and better ascertain the objective criteria helpful towards more consistent decision-making and thereby reduce the impact of subjective valuations of predicted patient outcome. SUMMARY Recent efforts by multiple medical groups have contributed to reduce uncertainty and to improve care and outcome along the entire chain of care. Although an unlimited endeavor for sustaining life seems unrealistic, treatment-limiting decisions should not deprive patients of a chance on achieving an outcome they would have considered acceptable.
Collapse
|
6
|
Fleck-Prediger CM, Ghosh Hajra S, Liu CC, Gray DS, Weaver DF, Gopinath S, Dick BD, D'Arcy RCN. Point-of-care brain injury evaluation of conscious awareness: wide scale deployment of portable HCS EEG evaluation. Neurosci Conscious 2018; 2018:niy011. [PMID: 30488005 PMCID: PMC6251986 DOI: 10.1093/nc/niy011] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2018] [Revised: 09/16/2018] [Accepted: 09/22/2018] [Indexed: 11/14/2022] Open
Abstract
Survivors of severe brain injury may remain in a decreased state of conscious awareness for an extended period of time. Clinical scales are used to describe levels of consciousness but rely on behavioural responses, precipitating misdiagnosis. We have previously utilized event-related potentials (ERPs) to circumvent reliance on behavioural responses. However, practical implementation barriers limit the clinical utility of ERP assessment at point-of-care (POC). To address this challenge, we developed the Halifax Consciousness Scanner (HCS)-a rapid, semi-automated electroencephalography system. The current study evaluated: (i) HCS feasibility in sub-acute, POC settings nationwide; (ii) ERP P300 responses in patients with acquired brain injury versus healthy controls; and (iii) correlations within and between clinical measures and P300 latencies. We assessed 28 patients with severe, chronic impairments from brain injuries and contrasted the results with healthy control data (n = 100). Correlational analyses examined relationships between P300 latencies and the commonly used clinical scales. P300 latencies were significantly delayed in patients compared to healthy controls (P < 0.05). Clinical assessment scores were significantly inter-correlated and correlated significantly with P300 latencies (P < 0.05). In sub-acute and chronic care settings, the HCS provided a physiological measure of neurocognitive processing at POC for patients with severe acquired brain injury, including those with disorders of consciousness.
Collapse
Affiliation(s)
- Carolyn M Fleck-Prediger
- Neuroscience and Mental Health Institute, University of Alberta, Canada.,Halvar Jonson Centre for Brain Injury, Canada
| | - Sujoy Ghosh Hajra
- Faculty of Applied Sciences (Engineering Science and Computing Science), Simon Fraser University, Canada.,NeuroTech Lab, Simon Fraser University and Fraser Health Authority, Surrey, BC, Canada
| | - Careesa C Liu
- Faculty of Applied Sciences (Engineering Science and Computing Science), Simon Fraser University, Canada.,NeuroTech Lab, Simon Fraser University and Fraser Health Authority, Surrey, BC, Canada
| | - D Shaun Gray
- Neuroscience and Mental Health Institute, University of Alberta, Canada.,Halvar Jonson Centre for Brain Injury, Canada.,Division of Physical Medicine and Rehabilitation, University of Alberta, Canada
| | - Donald F Weaver
- Krembil Research Institute, UHN, University of Toronto, Canada
| | - Shishir Gopinath
- NeuroTech Lab, Simon Fraser University and Fraser Health Authority, Surrey, BC, Canada
| | - Bruce D Dick
- Neuroscience and Mental Health Institute, University of Alberta, Canada.,Departments of Anesthesiology and Pain Medicine, Psychiatry & Pediatrics, University of Alberta, Canada
| | - Ryan C N D'Arcy
- Faculty of Applied Sciences (Engineering Science and Computing Science), Simon Fraser University, Canada.,NeuroTech Lab, Simon Fraser University and Fraser Health Authority, Surrey, BC, Canada
| |
Collapse
|
7
|
Soeterik SM, Connolly S, Riazi A. “Neither a wife nor a widow”: an interpretative phenomenological analysis of the experiences of female family caregivers in disorders of consciousness. Neuropsychol Rehabil 2018; 28:1392-1407. [DOI: 10.1080/09602011.2018.1529603] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Affiliation(s)
- Sonja M. Soeterik
- Department of Psychology, Royal Holloway University of London, Egham, UK
- Institute of Neuro-palliative Rehabilitation, Royal Hospital for Neuro-disability, London, UK
| | - Sarah Connolly
- Institute of Neuro-palliative Rehabilitation, Royal Hospital for Neuro-disability, London, UK
- Ascot Rehab, Surrey, UK
| | - Afsane Riazi
- Department of Psychology, Royal Holloway University of London, Egham, UK
| |
Collapse
|