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Duarte S, Ou Z, Cao M, Cho SM, Thakor NV, Ritzl EK, Geocadin RG. High frequency oscillations may improve somatosensory evoked potential detection of good outcomes in disorders of consciousness secondary to acute neurologic injury. Resuscitation 2024; 203:110377. [PMID: 39187152 DOI: 10.1016/j.resuscitation.2024.110377] [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: 07/16/2024] [Revised: 08/19/2024] [Accepted: 08/20/2024] [Indexed: 08/28/2024]
Abstract
BACKGROUND Somatosensory evoked potentials (SEPs) are highly specific predictors of poor prognosis in hypoxic-ischemic coma when cortical responses (N20s) are absent. However, bilateral N20 presence is nonspecific for good outcomes. High-frequency oscillations (HFOs) in the SEP waveform predict neurologic recovery in animals, but clinical applications are poorly understood. We sought to develop a clinical measure of HFOs to potentially improve detection of good outcomes in coma. MATERIALS AND METHODS We collected SEP waveform data from all comatose inpatients (GCS<=8) who underwent neurologic prognostication from 2020 to 2022 at Johns Hopkins Hospital. We developed a novel measure - HFO evoked to spontaneous ratios (HFO-ESRs) - and applied this to those patients with bilaterally present N20s using both standard univariate classification and cubic kernal vector machine (SVM) models to predict the last documented in-hospital Glasgow Coma Scale (GCS) prior to discharge or death. RESULTS Of 58 total patients, 34 (58.6%) had bilaterally present N20s. Of these, 14 had final GCS>=9, and 20 had final GCS<=8. Mean age was 52 (+/- 17) years, 20.1% female. Etiologies of coma were primarily global hypoxic-ischemic brain injury (79.4%), intracranial hemorrhage (11.8%), and traumatic brain injury (2.9%). In univariate classification, the addition of averaged HFO-ESRs to bilaterally present N20s predicted final GCS>=9 with 68% specificity. The SVM model further improved specificity to 85%. CONCLUSIONS In this pilot investigation, we developed a novel clinical measure of SEP HFOs. Incorporation of this measure may improve the specificity of the SEP to predict in-hospital GCS outcomes in coma, but requires further validation in specific neurologic injuries and with longitudinal outcomes.
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Affiliation(s)
- Siena Duarte
- Department of Neurology - Division of Neurocritical Care, University of California, San Francisco, USA.
| | - Ze Ou
- Medical Scientist Training Program, Washington University in St. Louis School of Medicine, St. Louis, MO 63110, USA.
| | - Mingfeng Cao
- Department of Biomedical Engineering, Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA.
| | - Sung-Min Cho
- Departments of Neurology, Anesthesiology, Critical Care Medicine and Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA.
| | - Nitish V Thakor
- Department of Biomedical Engineering, Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA.
| | - Eva K Ritzl
- Department of Neurology, Mass General Brigham, Boston, MA, USA.
| | - Romergryko G Geocadin
- Departments of Neurology, Anesthesiology, Critical Care Medicine and Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA.
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Xiao Q, Zheng X, Wen Y, Yuan Z, Chen Z, Lan Y, Li S, Huang X, Zhong H, Xu C, Zhan C, Pan J, Xie Q. Individualized music induces theta-gamma phase-amplitude coupling in patients with disorders of consciousness. Front Neurosci 2024; 18:1395627. [PMID: 39010944 PMCID: PMC11248187 DOI: 10.3389/fnins.2024.1395627] [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: 03/04/2024] [Accepted: 06/18/2024] [Indexed: 07/17/2024] Open
Abstract
Objective This study aimed to determine whether patients with disorders of consciousness (DoC) could experience neural entrainment to individualized music, which explored the cross-modal influences of music on patients with DoC through phase-amplitude coupling (PAC). Furthermore, the study assessed the efficacy of individualized music or preferred music (PM) versus relaxing music (RM) in impacting patient outcomes, and examined the role of cross-modal influences in determining these outcomes. Methods Thirty-two patients with DoC [17 with vegetative state/unresponsive wakefulness syndrome (VS/UWS) and 15 with minimally conscious state (MCS)], alongside 16 healthy controls (HCs), were recruited for this study. Neural activities in the frontal-parietal network were recorded using scalp electroencephalography (EEG) during baseline (BL), RM and PM. Cerebral-acoustic coherence (CACoh) was explored to investigate participants' abilitiy to track music, meanwhile, the phase-amplitude coupling (PAC) was utilized to evaluate the cross-modal influences of music. Three months post-intervention, the outcomes of patients with DoC were followed up using the Coma Recovery Scale-Revised (CRS-R). Results HCs and patients with MCS showed higher CACoh compared to VS/UWS patients within musical pulse frequency (p = 0.016, p = 0.045; p < 0.001, p = 0.048, for RM and PM, respectively, following Bonferroni correction). Only theta-gamma PAC demonstrated a significant interaction effect between groups and music conditions (F (2,44) = 2.685, p = 0.036). For HCs, the theta-gamma PAC in the frontal-parietal network was stronger in the PM condition compared to the RM (p = 0.016) and BL condition (p < 0.001). For patients with MCS, the theta-gamma PAC was stronger in the PM than in the BL (p = 0.040), while no difference was observed among the three music conditions in patients with VS/UWS. Additionally, we found that MCS patients who showed improved outcomes after 3 months exhibited evident neural responses to preferred music (p = 0.019). Furthermore, the ratio of theta-gamma coupling changes in PM relative to BL could predict clinical outcomes in MCS patients (r = 0.992, p < 0.001). Conclusion Individualized music may serve as a potential therapeutic method for patients with DoC through cross-modal influences, which rely on enhanced theta-gamma PAC within the consciousness-related network.
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Affiliation(s)
- Qiuyi Xiao
- Joint Research Centre for Disorders of Consciousness, Department of Rehabilitation Medicine, Zhujiang Hospital, Southern Medical University, Guangzhou, Guangdong, China
- School of Laboratory Medicine and Biotechnology, Southern Medical University, Guangzhou, Guangdong, China
| | - Xiaochun Zheng
- Joint Research Centre for Disorders of Consciousness, Department of Rehabilitation Medicine, Zhujiang Hospital, Southern Medical University, Guangzhou, Guangdong, China
- School of Laboratory Medicine and Biotechnology, Southern Medical University, Guangzhou, Guangdong, China
| | - Yun Wen
- Music and Reflection Incorporated, Guangzhou, Guangdong, China
| | - Zhanxing Yuan
- Joint Research Centre for Disorders of Consciousness, Department of Rehabilitation Medicine, Zhujiang Hospital, Southern Medical University, Guangzhou, Guangdong, China
| | - Zerong Chen
- Joint Research Centre for Disorders of Consciousness, Department of Rehabilitation Medicine, Zhujiang Hospital, Southern Medical University, Guangzhou, Guangdong, China
- School of Laboratory Medicine and Biotechnology, Southern Medical University, Guangzhou, Guangdong, China
| | - Yue Lan
- Joint Research Centre for Disorders of Consciousness, Department of Rehabilitation Medicine, Zhujiang Hospital, Southern Medical University, Guangzhou, Guangdong, China
| | - Shuiyan Li
- Joint Research Centre for Disorders of Consciousness, Department of Rehabilitation Medicine, Zhujiang Hospital, Southern Medical University, Guangzhou, Guangdong, China
- School of Laboratory Medicine and Biotechnology, Southern Medical University, Guangzhou, Guangdong, China
| | - Xiyan Huang
- Joint Research Centre for Disorders of Consciousness, Department of Rehabilitation Medicine, Zhujiang Hospital, Southern Medical University, Guangzhou, Guangdong, China
| | - Haili Zhong
- Joint Research Centre for Disorders of Consciousness, Department of Rehabilitation Medicine, Zhujiang Hospital, Southern Medical University, Guangzhou, Guangdong, China
| | - Chengwei Xu
- Joint Research Centre for Disorders of Consciousness, Department of Rehabilitation Medicine, Zhujiang Hospital, Southern Medical University, Guangzhou, Guangdong, China
| | - Chang'an Zhan
- Guangdong Provincial Key Laboratory of Medical Image Processing, Southern Medical University, Guangzhou, Guangdong, China
| | - Jiahui Pan
- School of Software, South China Normal University, Guangzhou, Guangdong, China
| | - Qiuyou Xie
- Joint Research Centre for Disorders of Consciousness, Department of Rehabilitation Medicine, Zhujiang Hospital, Southern Medical University, Guangzhou, Guangdong, China
- School of Laboratory Medicine and Biotechnology, Southern Medical University, Guangzhou, Guangdong, China
- Department of Hyperbaric Oxygen, Zhujiang Hospital, Southern Medical University, Guangzhou, Guangdong, China
- School of Rehabilitation Sciences, Southern Medical University, Guangzhou, Guangdong, China
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Pavlov YG, Spiegelsberger F, Kotchoubey B. Predicting outcome in disorders of consciousness: A mega-analysis. Ann Clin Transl Neurol 2024; 11:1465-1477. [PMID: 38591650 PMCID: PMC11187962 DOI: 10.1002/acn3.52061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2024] [Revised: 03/28/2024] [Accepted: 03/30/2024] [Indexed: 04/10/2024] Open
Abstract
OBJECTIVE Assessing recovery potential in patients with disorders of consciousness (DoC) is pivotal for guiding clinical and ethical decisions. We conducted a mega-analysis of individual patient data to understand (1) if a time threshold exists, beyond which regaining consciousness is almost impossible, and (2) how recovery varies based on factors such as diagnosis, etiology, age, sex, and neuropsychological status. METHODS A systematic literature search revealed a total of 3290 patients. In this sample, we performed a Cox proportional hazards analysis for interval censored data. RESULTS We observed a late saturation of probability to regain consciousness in Kaplan-Meier curves, and the annual rate of recovery was remarkably stable, in that approximately 35% of patients regained consciousness per year. Patients in minimally conscious state (MCS) recovered more frequently than patients in unresponsive wakefulness syndrome (UWS). No significant difference was observed between the recovery dynamics of MCS subgroups: MCS+ and MCS-. Patients with hypoxic brain lesions showed worse recovery rate than patients with traumatic brain injury and patients with vascular brain lesions, while the latter two categories did not differ from each other. Male patients had moderately better chance to regain consciousness. While younger UWS patients recovered more frequently than older patients, it was not the case in MCS. INTERPRETATION Our findings highlight the necessity for neurologists to exercise caution when making negative predictions in individual cases, challenge traditional beliefs regarding recovery timelines, and underscore the importance of conducting detailed and prolonged assessments to better understand recovery prospects in DoC.
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Affiliation(s)
- Yuri G. Pavlov
- Institute of Medical Psychology and Behavioral NeurobiologyUniversity of TübingenTübingen72076Germany
| | - Franziska Spiegelsberger
- Institute of Medical Psychology and Behavioral NeurobiologyUniversity of TübingenTübingen72076Germany
| | - Boris Kotchoubey
- Institute of Medical Psychology and Behavioral NeurobiologyUniversity of TübingenTübingen72076Germany
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Ge Q, Lu H, Geng X, Chen X, Liu X, Sun H, Guo Z, Sun J, Qi F, Niu X, Wang A, He J, Sun W, Xu L. Serum metabolism alteration behind different etiology, diagnosis, and prognosis of disorders of consciousness. Chin Neurosurg J 2024; 10:12. [PMID: 38594757 PMCID: PMC11003070 DOI: 10.1186/s41016-024-00365-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2023] [Accepted: 03/26/2024] [Indexed: 04/11/2024] Open
Abstract
BACKGROUND Patients with disorders of consciousness (DoC) exhibit varied revival outcomes based on different etiologies and diagnoses, the mechanisms of which remain largely unknown. The fluctuating clinical presentations in DoC pose challenges in accurately assessing consciousness levels and prognoses, often leading to misdiagnoses. There is an urgent need for a deeper understanding of the physiological changes in DoC and the development of objective diagnostic and prognostic biomarkers to improve treatment guidance. METHODS To explore biomarkers and understand the biological processes, we conducted a comprehensive untargeted metabolomic analysis on serum samples from 48 patients with DoC. Patients were categorized based on etiology (TBI vs. non-TBI), CRS-R scores, and prognosis. Advanced analytical techniques, including PCA and OPLS-DA models, were employed to identify differential metabolites. RESULTS Our analysis revealed a distinct separation in metabolomic profiles among the different groups. The primary differential metabolites distinguishing patients with varying etiologies were predominantly phospholipids, with a notable decrease in glycerophospholipids observed in the TBI group. Patients with higher CRS-R scores exhibited a pattern of impaired carbohydrate metabolism coupled with enhanced lipid metabolism. Notably, serum concentrations of both LysoPE and PE were reduced in patients with improved outcomes, suggesting their potential as prognostic biomarkers. CONCLUSIONS Our study underscores the critical role of phospholipid metabolism in the brain's metabolic alterations in patients with DoC. It identifies key biomarkers for diagnosis and prognosis, offering insights that could lead to novel therapeutic targets. These findings highlight the value of metabolomic profiling in understanding and potentially treating DoC.
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Affiliation(s)
- Qianqian Ge
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Hezhen Lu
- China-Japan Union Hospital of Jilin University, Changchun, China
- Core Instrument Facility, Institute of Basic Medical Sciences, Chinese Academy of Medical Sciences, School of Basic Medicine, Peking Union Medical College, Beijing, China
| | - Xiaoli Geng
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Xueling Chen
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Xiaoyan Liu
- Core Instrument Facility, Institute of Basic Medical Sciences, Chinese Academy of Medical Sciences, School of Basic Medicine, Peking Union Medical College, Beijing, China
| | - Haidan Sun
- Core Instrument Facility, Institute of Basic Medical Sciences, Chinese Academy of Medical Sciences, School of Basic Medicine, Peking Union Medical College, Beijing, China
| | - Zhengguang Guo
- Core Instrument Facility, Institute of Basic Medical Sciences, Chinese Academy of Medical Sciences, School of Basic Medicine, Peking Union Medical College, Beijing, China
| | - Jiameng Sun
- Core Instrument Facility, Institute of Basic Medical Sciences, Chinese Academy of Medical Sciences, School of Basic Medicine, Peking Union Medical College, Beijing, China
| | - Feng Qi
- Core Instrument Facility, Institute of Basic Medical Sciences, Chinese Academy of Medical Sciences, School of Basic Medicine, Peking Union Medical College, Beijing, China
| | - Xia Niu
- Core Instrument Facility, Institute of Basic Medical Sciences, Chinese Academy of Medical Sciences, School of Basic Medicine, Peking Union Medical College, Beijing, China
| | - Aiwei Wang
- Core Instrument Facility, Institute of Basic Medical Sciences, Chinese Academy of Medical Sciences, School of Basic Medicine, Peking Union Medical College, Beijing, China
| | - Jianghong He
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases (NCRC-ND), Beijing, China
| | - Wei Sun
- Core Instrument Facility, Institute of Basic Medical Sciences, Chinese Academy of Medical Sciences, School of Basic Medicine, Peking Union Medical College, Beijing, China.
| | - Long Xu
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.
- China National Clinical Research Center for Neurological Diseases (NCRC-ND), Beijing, China.
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Russell ME, Ivanhoe CB, Reed EA. Prognostication and Trajectories of Recovery in Disorders of Consciousness. Phys Med Rehabil Clin N Am 2024; 35:167-173. [PMID: 37993187 DOI: 10.1016/j.pmr.2023.09.001] [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
Historically, there has been a pessimistic view regarding outcomes for patients with disorders of consciousness (DoC). There is a paucity of clinical diagnostic tools and prognostic protocols. Guidelines for the care of patients with DoC require behavioral observation, time, resources, and knowledge of the population. Many nonclinical factors such as patient wishes, family perception, and personal finances can indirectly influence long-term outcomes. Prognostic expectations need to be considered but we health-care professional cannot fully appreciate the decisions and influence of those decisions on the person served or on the care providers involved.
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Affiliation(s)
- Mary E Russell
- Physical Medicine and Rehabilitation Department, UT McGovern School of Medicine, TIRR Memorial Hermann-The Woodlands, Houston, TX 77030, USA.
| | - Cindy B Ivanhoe
- Physical Medicine and Rehabilitation Department, UT McGovern School of Medicine, TIRR Memorial Hermann, Houston, TX 77030, USA
| | - Eboni A Reed
- Physical Medicine and Rehabilitation Department, Baylor College of Medicine, Houston, TX 77030, USA
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Abstract
In this article, we discuss the taxonomy associated with the four major disorders of consciousness (DoC): coma, vegetative state or unresponsive wakefulness syndrome, minimally conscious state, and post-traumatic confusional state. We briefly review the history of each disorder and then provide operational definitions and diagnostic criteria for each one. We rely heavily on recently released practice guidelines and, where appropriate, identify knowledge gaps and discuss future directions to advance DoC research and practice.
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Affiliation(s)
- Katherine Golden
- School of Health & Rehabilitation Sciences, MGH Institute of Health Professions, 36 1st Avenue, Boston, MA 02129, USA
| | - Yelena G Bodien
- Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, 300 1st Avenue, Charlestown, MA, 02129, USA; Center for Neurotechnology and Neurorecovery, Department of Neurology, Massachusetts General Hospital and Harvard Medical School, 55 Fruit Street, Boston, MA 02114, USA; Department of Physical Medicine and Rehabilitation, Harvard Medical School, 25 Shattuck Street, Boston, MA, USA
| | - Joseph T Giacino
- Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, 300 1st Avenue, Charlestown, MA, 02129, USA; Center for Neurotechnology and Neurorecovery, Department of Neurology, Massachusetts General Hospital and Harvard Medical School, 55 Fruit Street, Boston, MA 02114, 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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Zasler ND. Medicolegal issues and disorders of consciousness. NeuroRehabilitation 2024; 54:149-165. [PMID: 38217622 DOI: 10.3233/nre-230242] [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: 01/15/2024]
Abstract
BACKGROUND The tasks and responsibilities that come with clinician involvement in medicolegal proceedings can be daunting and particularly so in challenging areas such as provision of medicolegal opinions in cases involving disorders of consciousness (DoC). OBJECTIVE The aim of this narrative review was to provide education and advice to healthcare practitioners who by choice or circumstance are asked and/or required to provide medicolegal opinions in cases involving patients with DoC. METHODS A literature search was conducted using PubMed Central and MedlinePlus for articles dealing with clinician involvement in medicolegal cases involving persons with DoC. The information provided also integrates the authors' nearly 40 years of clinical experience, brain injury medicine practice and "trials and tribulations" associated with medicolegal involvement in such cases. RESULTS The literature was found to be replete with articles on brain death and withdrawal/withholding of care (which are not the focus of this review). The extant medical literature in brain injury medicine on the other hand is currently lacking in practical information for clinicians working "in the trenches" regarding the challenges and caveats of medicolegal involvement in such cases. CONCLUSION This review provides the reader with a big picture overview of the most pertinent medicolegal topics inherent in clinical work with patients with DOC including pertinent nomenclature, caveats regarding forensic consultation including independent medical examinations, testimony tips, discussion of life expectancy/median survival concepts, prognostication in a medicolegal context, documentation and record keeping as well as some of the specific challenges pertinent to these types of brain injury cases that are not per se relevant in less severe injuries.
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Affiliation(s)
- Nathan D Zasler
- Concussion Care Centre of Virginia, Ltd., Richmond, VA, USA
- Tree of Life, Richmond, VA, USA
- Department of Physical Medicine and Rehabilitation, Virginia Commonwealth University, Richmond, VA, USA
- Department of Physical Medicine and Rehabilitation, University of Virginia, Charlottesville, VA, USA
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Zhou Y, Sun Y, He P, Xiong Q, Kang J, Tang Y, Feng Z, Dong X. The efficacy and safety of transcutaneous auricular vagus nerve stimulation for patients with minimally conscious state: a sham-controlled randomized double-blind clinical trial. Front Neurosci 2023; 17:1323079. [PMID: 38156271 PMCID: PMC10752952 DOI: 10.3389/fnins.2023.1323079] [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: 10/17/2023] [Accepted: 11/29/2023] [Indexed: 12/30/2023] Open
Abstract
Background Transcutaneous auricular vagus nerve stimulation (taVNS) has emerged as a potentially effective neuromodulation technique for addressing neurological disorders, including disorders of consciousness. Expanding upon our prior clinical study, which demonstrated the superior effectiveness of a 4-week taVNS treatment in patients with minimally conscious state (MCS) compared to those in a vegetative state/unresponsive wakefulness state, the aim of this investigation was to evaluate the safety and therapeutic efficacy of taVNS in individuals with MCS through a sham-controlled randomized double-blind clinical trial. Methods A cohort of 50 adult patients (male = 33, female = 17) diagnosed with a MCS were randomly assigned to either the active taVNS (N = 25) or sham taVNS (N = 25) groups. The treatment period lasted for 4 weeks, followed by an 8-week follow-up period. The Coma Recovery Scale-Revised (CRS-R) and Glasgow Coma Scale (GCS) were administered at baseline and weekly during the initial 4 weeks. Additionally, the Disability Rating Scale (DRS) was used to assess the patients' functional abilities via telephone at week 12. Furthermore, various neurophysiological measures, including electroencephalogram (EEG), upper-limb somatosensory evoked potentials (USEP), brainstem auditory evoked potentials (BAEP), and P300 event-related potentials (P300), were employed to monitor changes in brain activity and neural conduction pathways. Results The scores for the active taVNS group in the CRS-R and GCS showed greater improvement over time compared to the sham taVNS group (CRS-R: 1-week, Z = -1.248, p = 0.212; 2-week, Z = -1.090, p = 0.276; 3-week, Z = -2.017, p = 0.044; 4-week, Z = -2.267, p = 0.023. GCS: 1-week, Z = -1.325, p = 0.185; 2-week, Z = -1.245, p = 0.213; 3-week, Z = -1.848, p = 0.065; 4-week, Z = -1.990, p = 0.047). Additionally, the EEG, USEP, BAEP, and P300 also demonstrated significant improvement in the active taVNS group compared to the sham taVNS group at week 4 (EEG, Z = -2.086, p = 0.037; USEP, Z = -2.014, p = 0.044; BAEP, Z = -2.298, p = 0.022; P300 amplitude, Z = -1.974, p = 0.049; P300 latency, t = 2.275, p = 0.027). Subgroup analysis revealed that patients with MCS derived greater benefits from receiving taVNS treatment earlier (CRS-R, Disease duration ≤ 1-month, mean difference = 8.50, 95% CI = [2.22, 14.78], p = 0.027; GCS, Disease duration ≤ 1-month, mean difference = 3.58, 95% CI = [0.14, 7.03], p = 0.044). By week 12, the active taVNS group exhibited lower Disability Rating Scale (DRS) scores compared to the sham taVNS group (Z = -2.105, p = 0.035), indicating a more favorable prognosis for MCS patients who underwent taVNS. Furthermore, no significant adverse events related to taVNS were observed during treatment. Conclusion The findings of this study suggest that taVNS may serve as a potentially effective and safe intervention for facilitating the restoration of consciousness in individuals diagnosed with MCS. This therapeutic approach appears to enhance cerebral functioning and optimize neural conduction pathways. Clinical trial registration http://www.chictr.org.cn, Identifier ChiCTR2200066629.
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Affiliation(s)
- Yifan Zhou
- Department of Rehabilitation Medicine, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China
- Rehabilitation Medicine Clinical Research Center of Jiangxi Province, Nanchang, Jiangxi, China
| | - Yejing Sun
- Department of Rehabilitation Medicine, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China
- Rehabilitation Medicine Clinical Research Center of Jiangxi Province, Nanchang, Jiangxi, China
| | - Pei He
- Department of Rehabilitation Medicine, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China
- Rehabilitation Medicine Clinical Research Center of Jiangxi Province, Nanchang, Jiangxi, China
| | - Qi Xiong
- Department of Rehabilitation Medicine, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China
- Rehabilitation Medicine Clinical Research Center of Jiangxi Province, Nanchang, Jiangxi, China
| | - Junwei Kang
- Department of Rehabilitation Medicine, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China
- Rehabilitation Medicine Clinical Research Center of Jiangxi Province, Nanchang, Jiangxi, China
| | - Yunliang Tang
- Department of Rehabilitation Medicine, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China
- Rehabilitation Medicine Clinical Research Center of Jiangxi Province, Nanchang, Jiangxi, China
| | - Zhen Feng
- Department of Rehabilitation Medicine, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China
- Rehabilitation Medicine Clinical Research Center of Jiangxi Province, Nanchang, Jiangxi, China
| | - Xiaoyang Dong
- Department of Rehabilitation Medicine, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China
- Rehabilitation Medicine Clinical Research Center of Jiangxi Province, Nanchang, Jiangxi, China
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Oujamaa L, Delon-Martin C, Jaroszynski C, Termenon M, Silva S, Payen JF, Achard S. Functional hub disruption emphasizes consciousness recovery in severe traumatic brain injury. Brain Commun 2023; 5:fcad319. [PMID: 38757093 PMCID: PMC11098044 DOI: 10.1093/braincomms/fcad319] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2022] [Revised: 08/20/2023] [Accepted: 11/21/2023] [Indexed: 05/18/2024] Open
Abstract
Severe traumatic brain injury can lead to transient or even chronic disorder of consciousness. To increase diagnosis and prognosis accuracy of disorder of consciousness, functional neuroimaging is recommended 1 month post-injury. Here, we investigated brain networks remodelling on longitudinal data between 1 and 3 months post severe traumatic brain injury related to change of consciousness. Thirty-four severe traumatic brain-injured patients were included in a cross-sectional and longitudinal clinical study, and their MRI data were compared to those of 20 healthy subjects. Long duration resting-state functional MRI were acquired in minimally conscious and conscious patients at two time points after their brain injury. The first time corresponds to the exit from intensive care unit and the second one to the discharge from post-intensive care rehabilitation ward. Brain networks data were extracted using graph analysis and metrics at each node quantifying local (clustering) and global (degree) connectivity characteristics. Comparison with brain networks of healthy subjects revealed patterns of hyper- and hypo-connectivity that characterize brain networks reorganization through the hub disruption index, a value quantifying the functional disruption in each individual severe traumatic brain injury graph. At discharge from intensive care unit, 24 patients' graphs (9 minimally conscious and 15 conscious) were fully analysed and demonstrated significant network disruption. Clustering and degree nodal metrics, respectively, related to segregation and integration properties of the network, were relevant to distinguish minimally conscious and conscious groups. At discharge from post-intensive care rehabilitation unit, 15 patients' graphs (2 minimally conscious, 13 conscious) were fully analysed. The conscious group still presented a significant difference with healthy subjects. Using mixed effects models, we showed that consciousness state, rather than time, explained the hub disruption index differences between minimally conscious and conscious groups. While severe traumatic brain-injured patients recovered full consciousness, regional functional connectivity evolved towards a healthy pattern. More specifically, the restoration of a healthy brain functional segregation could be necessary for consciousness recovery after severe traumatic brain injury. For the first time, extracting the hub disruption index directly from each patient's graph, we were able to track the clinical alteration and subsequent recovery of consciousness during the first 3 months following a severe traumatic brain injury.
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Affiliation(s)
- Lydia Oujamaa
- University Grenoble Alpes, Inserm, U1216, Grenoble Institut Neurosciences, 38000 Grenoble, France
| | - Chantal Delon-Martin
- University Grenoble Alpes, Inserm, U1216, Grenoble Institut Neurosciences, 38000 Grenoble, France
| | - Chloé Jaroszynski
- University Grenoble Alpes, Inserm, U1216, Grenoble Institut Neurosciences, 38000 Grenoble, France
| | - Maite Termenon
- Faculty of Engineering, Biomedical Engineering Department, Mondragon Unibertsitatea (MU-ENG), 20500 Mondragon, Spain
| | - Stein Silva
- Toulouse NeuroImaging Center, Toulouse III Paul Sabatier University, Inserm, 31062 Toulouse, France
- Critical Care Unit, University Teaching Hospital of Purpan, 31059 Toulouse, France
| | - Jean-François Payen
- University Grenoble Alpes, Inserm U1216, Grenoble Institut Neurosciences, CHU Grenoble Alpes, 38000 Grenoble, France
| | - Sophie Achard
- University Grenoble Alpes, CNRS, Inria, Grenoble INP, LJK, 38000 Grenoble, France
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Franzova E, Shen Q, Doyle K, Chen JM, Egbebike J, Vrosgou A, Carmona JC, Grobois L, Heinonen GA, Velazquez A, Gonzales IJ, Egawa S, Agarwal S, Roh D, Park S, Connolly ES, Claassen J. Injury patterns associated with cognitive motor dissociation. Brain 2023; 146:4645-4658. [PMID: 37574216 PMCID: PMC10629765 DOI: 10.1093/brain/awad197] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Revised: 04/14/2023] [Accepted: 05/28/2023] [Indexed: 08/15/2023] Open
Abstract
In unconscious appearing patients with acute brain injury, wilful brain activation to motor commands without behavioural signs of command following, known as cognitive motor dissociation (CMD), is associated with functional recovery. CMD can be detected by applying machine learning to EEG recorded during motor command presentation in behaviourally unresponsive patients. Identifying patients with CMD carries clinical implications for patient interactions, communication with families, and guidance of therapeutic decisions but underlying mechanisms of CMD remain unknown. By analysing structural lesion patterns and network level dysfunction we tested the hypothesis that, in cases with preserved arousal and command comprehension, a failure to integrate comprehended motor commands with motor outputs underlies CMD. Manual segmentation of T2-fluid attenuated inversion recovery and diffusion weighted imaging sequences quantifying structural injury was performed in consecutive unresponsive patients with acute brain injury (n = 107) who underwent EEG-based CMD assessments and MRI. Lesion pattern analysis was applied to identify lesion patterns common among patients with (n = 21) and without CMD (n = 86). Thalamocortical and cortico-cortical network connectivity were assessed applying ABCD classification of power spectral density plots and weighted pairwise phase consistency (WPPC) to resting EEG, respectively. Two distinct structural lesion patterns were identified on MRI for CMD and three for non-CMD patients. In non-CMD patients, injury to brainstem arousal pathways including the midbrain were seen, while no CMD patients had midbrain lesions. A group of non-CMD patients was identified with injury to the left thalamus, implicating possible language comprehension difficulties. Shared lesion patterns of globus pallidus and putamen were seen for a group of CMD patients, which have been implicated as part of the anterior forebrain mesocircuit in patients with reversible disorders of consciousness. Thalamocortical network dysfunction was less common in CMD patients [ABCD-index 2.3 (interquartile range, IQR 2.1-3.0) versus 1.4 (IQR 1.0-2.0), P < 0.0001; presence of D 36% versus 3%, P = 0.0006], but WPPC was not different. Bilateral cortical lesions were seen in patients with and without CMD. Thalamocortical disruption did not differ for those with CMD, but long-range WPPC was decreased in 1-4 Hz [odds ratio (OR) 0.8; 95% confidence interval (CI) 0.7-0.9] and increased in 14-30 Hz frequency ranges (OR 1.2; 95% CI 1.0-1.5). These structural and functional data implicate a failure of motor command integration at the anterior forebrain mesocircuit level with preserved thalamocortical network function for CMD patients with subcortical lesions. Amongst patients with bilateral cortical lesions preserved cortico-cortical network function is associated with CMD detection. These data may allow screening for CMD based on widely available structural MRI and resting EEG.
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Affiliation(s)
- Eva Franzova
- Department of Neurology, Columbia University Medical Center, NewYork-Presbyterian Hospital, New York, NY, USA
| | - Qi Shen
- Department of Neurology, Columbia University Medical Center, NewYork-Presbyterian Hospital, New York, NY, USA
| | - Kevin Doyle
- Department of Neurology, Columbia University Medical Center, NewYork-Presbyterian Hospital, New York, NY, USA
| | - Justine M Chen
- Department of Neurology, Columbia University Medical Center, NewYork-Presbyterian Hospital, New York, NY, USA
| | - Jennifer Egbebike
- Department of Neurology, Columbia University Medical Center, NewYork-Presbyterian Hospital, New York, NY, USA
| | - Athina Vrosgou
- Department of Neurology, Columbia University Medical Center, NewYork-Presbyterian Hospital, New York, NY, USA
| | - Jerina C Carmona
- Department of Neurology, Columbia University Medical Center, NewYork-Presbyterian Hospital, New York, NY, USA
| | - Lauren Grobois
- Department of Neurology, Columbia University Medical Center, NewYork-Presbyterian Hospital, New York, NY, USA
| | - Gregory A Heinonen
- Department of Neurology, Columbia University Medical Center, NewYork-Presbyterian Hospital, New York, NY, USA
| | - Angela Velazquez
- Department of Neurology, Columbia University Medical Center, NewYork-Presbyterian Hospital, New York, NY, USA
| | | | - Satoshi Egawa
- Department of Neurology, Columbia University Medical Center, NewYork-Presbyterian Hospital, New York, NY, USA
| | - Sachin Agarwal
- Department of Neurology, Columbia University Medical Center, NewYork-Presbyterian Hospital, New York, NY, USA
| | - David Roh
- Department of Neurology, Columbia University Medical Center, NewYork-Presbyterian Hospital, New York, NY, USA
| | - Soojin Park
- Department of Neurology, Columbia University Medical Center, NewYork-Presbyterian Hospital, New York, NY, USA
| | - E Sander Connolly
- Department of Neurological Surgery, Columbia University Medical Center, NewYork-Presbyterian Hospital, New York, NY, USA
| | - Jan Claassen
- Department of Neurology, Columbia University Medical Center, NewYork-Presbyterian Hospital, New York, NY, USA
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12
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Liuzzi P, Hakiki B, Draghi F, Romoli AM, Burali R, Scarpino M, Cecchi F, Grippo A, Mannini A. EEG fractal dimensions predict high-level behavioral responses in minimally conscious patients. J Neural Eng 2023; 20:046038. [PMID: 37494926 DOI: 10.1088/1741-2552/aceaac] [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: 06/14/2023] [Accepted: 07/26/2023] [Indexed: 07/28/2023]
Abstract
Objective.Brain-injured patients may enter a state of minimal or inconsistent awareness termed minimally conscious state (MCS). Such patient may (MCS+) or may not (MCS-) exhibit high-level behavioral responses, and the two groups retain two inherently different rehabilitative paths and expected outcomes. We hypothesized that brain complexity may be treated as a proxy of high-level cognition and thus could be used as a neural correlate of consciousness.Approach.In this prospective observational study, 68 MCS patients (MCS-: 30; women: 31) were included (median [IQR] age 69 [20]; time post-onset 83 [28]). At admission to intensive rehabilitation, 30 min resting-state closed-eyes recordings were performed together with consciousness diagnosis following international guidelines. The width of the multifractal singularity spectrum (MSS) was computed for each channel time series and entered nested cross-validated interpretable machine learning models targeting the differential diagnosis of MCS±.Main results.Frontal MSS widths (p< 0.05), as well as the ones deriving from the left centro-temporal network (C3:p= 0.018, T3:p= 0.017; T5:p= 0.003) were found to be significantly higher in the MCS+ cohort. The best performing solution was found to be the K-nearest neighbor model with an aggregated test accuracy of 75.5% (median [IQR] AuROC for 100 executions 0.88 [0.02]). Coherently, the electrodes with highest Shapley values were found to be Fz and Cz, with four out the first five ranked features belonging to the fronto-central network.Significance.MCS+ is a frequent condition associated with a notably better prognosis than the MCS-. High fractality in the left centro-temporal network results coherent with neurological networks involved in the language function, proper of MCS+ patients. Using EEG-based interpretable algorithm to complement differential diagnosis of consciousness may improve rehabilitation pathways and communications with caregivers.
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Affiliation(s)
- Piergiuseppe Liuzzi
- IRCCS Fondazione Don Carlo Gnocchi ONLUS, Via di Scandicci 269, Firenze, FI, Italy
- The Biorobotics Institute, Scuola Superiore Sant'Anna Istituto di BioRobotica, Viale Rinaldo Piaggio 34, Pontedera, PI, Italy
| | - Bahia Hakiki
- IRCCS Fondazione Don Carlo Gnocchi ONLUS, Via di Scandicci 269, Firenze, FI, Italy
| | - Francesca Draghi
- IRCCS Fondazione Don Carlo Gnocchi ONLUS, Via di Scandicci 269, Firenze, FI, Italy
| | - Anna Maria Romoli
- IRCCS Fondazione Don Carlo Gnocchi ONLUS, Via di Scandicci 269, Firenze, FI, Italy
| | - Rachele Burali
- IRCCS Fondazione Don Carlo Gnocchi ONLUS, Via di Scandicci 269, Firenze, FI, Italy
| | - Maenia Scarpino
- IRCCS Fondazione Don Carlo Gnocchi ONLUS, Via di Scandicci 269, Firenze, FI, Italy
| | - Francesca Cecchi
- IRCCS Fondazione Don Carlo Gnocchi ONLUS, Via di Scandicci 269, Firenze, FI, Italy
- Department of Experimental and Clinical Medicine, University of Florence, Largo Brambilla 3, Florence, 50143 FI, Italy
| | - Antonello Grippo
- IRCCS Fondazione Don Carlo Gnocchi ONLUS, Via di Scandicci 269, Firenze, FI, Italy
| | - Andrea Mannini
- IRCCS Fondazione Don Carlo Gnocchi ONLUS, Via di Scandicci 269, Firenze, FI, Italy
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13
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Monti MM, Spivak NM, Edlow BL, Bodien YG. What is a minimal clinically important difference for clinical trials in patients with disorders of consciousness? a novel probabilistic approach. PLoS One 2023; 18:e0290290. [PMID: 37616196 PMCID: PMC10449161 DOI: 10.1371/journal.pone.0290290] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2023] [Accepted: 08/03/2023] [Indexed: 08/26/2023] Open
Abstract
Over the last 30 years, there has been a growing trend in clinical trials towards assessing novel interventions not only against the benchmark of statistical significance, but also with respect to whether they lead to clinically meaningful changes for patients. In the context of Disorders of Consciousness (DOC), despite a growing landscape of experimental interventions, there is no agreed standard as to what counts as a minimal clinically important difference (MCID). In part, this issue springs from the fact that, by definition, DOC patients are either unresponsive (i.e., in a Vegetative State; VS) or non-communicative (i.e., in a Minimally Conscious State; MCS), which renders it impossible to assess any subjective perception of benefit, one of the two core aspects of MCIDs. Here, we develop a novel approach that leverages published, international diagnostic guidelines to establish a probability-based minimal clinically important difference (pMCID), and we apply it to the most validated and frequently used scale in DOC: the Coma Recovery Scale-Revised (CRS-R). This novel method is objective (i.e., based on published criteria for patient diagnosis) and easy to recalculate as the field refines its agreed-upon criteria for diagnosis. We believe this new approach can help clinicians determine whether observed changes in patients' behavior are clinically important, even when patients cannot communicate their experiences, and can align the landscape of clinical trials in DOC with the practices in other medical fields.
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Affiliation(s)
- Martin M. Monti
- Department of Psychology, University of California Los Angeles, Los Angeles, California, United States of America
- Department of Neurosurgery, Brain Injury Research Center, University of California Los Angeles, Los Angeles, California, United States of America
| | - Norman M. Spivak
- Department of Neurosurgery, Brain Injury Research Center, University of California Los Angeles, Los Angeles, California, United States of America
- UCLA-Caltech Medical Scientist Training Program, David Geffen School of Medicine, UCLA, Los Angeles, California, United States of America
| | - Brian L. Edlow
- Department of Neurology, Center for Neurotechnology and Neurorecovery, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, United States of America
- Athinoula A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital, Charlestown, Massachusetts, United States of America
| | - Yelena G. Bodien
- Department of Neurology, Center for Neurotechnology and Neurorecovery, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, United States of America
- Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital and Harvard Medical School Charlestown, Massachusetts, United States of America
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14
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Kumar A, Ridha M, Claassen J. Prognosis of consciousness disorders in the intensive care unit. Presse Med 2023; 52:104180. [PMID: 37805070 PMCID: PMC10995112 DOI: 10.1016/j.lpm.2023.104180] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2023] [Accepted: 10/03/2023] [Indexed: 10/09/2023] Open
Abstract
Assessments of consciousness are a critical part of prognostic algorithms for critically ill patients suffering from severe brain injuries. There have been significant advances in the field of coma science over the past two decades, providing clinicians with more advanced and precise tools for diagnosing and prognosticating disorders of consciousness (DoC). Advanced neuroimaging and electrophysiological techniques have vastly expanded our understanding of the biological mechanisms underlying consciousness, and have helped identify new states of consciousness. One of these, termed cognitive motor dissociation, can predict functional recovery at 1 year post brain injury, and is present in up to 15-20% of patients with DoC. In this chapter, we review several tools that are used to predict DoC, describing their strengths and limitations, from the neurological examination to advanced imaging and electrophysiologic techniques. We also describe multimodal assessment paradigms that can be used to identify covert consciousness and thus help recognize patients with the potential for future recovery and improve our prognostication practices.
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Affiliation(s)
- Aditya Kumar
- Department of Neurology, Columbia University Medical Center, New York-Presbyterian Hospital, New York, NY, USA
| | - Mohamed Ridha
- Department of Neurology, Columbia University Medical Center, New York-Presbyterian Hospital, New York, NY, USA
| | - Jan Claassen
- Department of Neurology, Columbia University Medical Center, New York-Presbyterian Hospital, New York, NY, USA.
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15
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Ma H, Fan S, Xu Z, Wan X, Yang Q, Yin Y, Wu X, Wu S, Zhang H, Ma C. Trigeminal nerve stimulation for prolonged disorders of consciousness: A randomized double-blind sham-controlled study. Brain Stimul 2023; 16:819-827. [PMID: 37182683 DOI: 10.1016/j.brs.2023.05.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Revised: 04/19/2023] [Accepted: 05/03/2023] [Indexed: 05/16/2023] Open
Abstract
BACKGROUND Trigeminal nerve stimulation (TNS) has been proposed as a promising intervention for coma awakening. However, the effect of TNS on patients with prolonged disorders of consciousness (pDoC) is still unclear. OBJECTIVE This study aimed to investigate the therapeutic effects of TNS in pDoC caused by stroke, trauma, and anoxia. METHODS A total of 60 patients (male =25, female =35) aged over 18 who were in a vegetative state or minimally conscious state were randomly assigned to the TNS (N = 30) or sham TNS (N = 30) groups. 4 weeks of intervention and a followed up for 8 weeks were performed. The Glasgow Coma Scale (GCS) and Coma Recovery Scale-Revised (CRS-R) scores as primary outcomes were assessed at baseline and at 2, 4, 8, and 12 weeks. RESULTS The score changes in the TNS group over time for CRS-R (2-week: mean difference = 0.9, 95% CI = [0.3, 1.5], P = 0.006; 4-week: 1.6, 95% CI = [0.8, 2.5], P < 0.001; 8-week: mean difference = 2.4, 95% CI = [1.3, 3.5], P < 0.001; 12-week: mean difference = 2.3, 95% CI = [1.1, 3.4], P < 0.001) and GCS (4-week: mean difference = 0.7, 95% CI = [0.3, 1.2], P = 0.002; 8-week: mean difference = 1.1, 95% CI = [0.6, 1.7], P < 0.001; 12-week: 1.1, 95% CI = [0.5, 1.7], P = 0.003) were higher than those in the sham group. 18-Fluorodeoxyglucose Positron Emission Tomography (FDG-PET) revealed that the metabolism of the right parahippocampal cortex, right precuneus, and bilateral middle cingulate cortex was significantly increased in TNS group. CONCLUSION The results of this study indicate that TNS could increase local brain metabolism and may promote functional recovery in patients with prolonged disorders of consciousness. REGISTRATION INFORMATION Name of the registry: Chinese Clinical Trial Registry. REGISTRATION NUMBER ChiCTR1900025573. The date that the study was submitted to a registry: 2019-09-01. The date when the first patient was enrolled was 2021-01-20.
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Affiliation(s)
- Haiyun Ma
- Department of Rehabilitation Medicine, Sun Yat-sen Memorial Hospital, Guangzhou, Guangdong, People's Republic of China
| | - Shengnuo Fan
- Department of Rehabilitation Medicine, Sun Yat-sen Memorial Hospital, Guangzhou, Guangdong, People's Republic of China
| | - Zhen Xu
- Department of Rehabilitation Medicine, Sun Yat-sen Memorial Hospital, Guangzhou, Guangdong, People's Republic of China
| | - Xiaoting Wan
- Department of Nuclear Medicine, Sun Yat-sen Memorial Hospital, Guangzhou, Guangdong, People's Republic of China
| | - Qian Yang
- Department of Rehabilitation Medicine, Sun Yat-sen Memorial Hospital, Guangzhou, Guangdong, People's Republic of China
| | - Yuping Yin
- Department of Nuclear Medicine, Sun Yat-sen Memorial Hospital, Guangzhou, Guangdong, People's Republic of China
| | - Xuemeng Wu
- Department of Rehabilitation Medicine, Sun Yat-sen Memorial Hospital, Guangzhou, Guangdong, People's Republic of China
| | - Shaoling Wu
- Department of Rehabilitation Medicine, Sun Yat-sen Memorial Hospital, Guangzhou, Guangdong, People's Republic of China.
| | - Hong Zhang
- Department of Nuclear Medicine, Sun Yat-sen Memorial Hospital, Guangzhou, Guangdong, People's Republic of China.
| | - Chao Ma
- Department of Rehabilitation Medicine, Sun Yat-sen Memorial Hospital, Guangzhou, Guangdong, People's Republic of China.
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16
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Kreitzer N, Murtaugh B, Creutzfeldt C, Fins JJ, Manley G, Sarwal A, Dangayach N. Prognostic humility and ethical dilemmas after severe brain injury: Summary, recommendations, and qualitative analysis of Curing Coma Campaign virtual event proceedings. Front Hum Neurosci 2023; 17:1128656. [PMID: 37063099 PMCID: PMC10102639 DOI: 10.3389/fnhum.2023.1128656] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Accepted: 03/09/2023] [Indexed: 04/03/2023] Open
Abstract
BackgroundPatients with severe acute brain injuries (SABI) are at risk of living with long-term disability, frequent medical complications and high rates of mortality. Determining an individual patient’s prognosis and conveying this to family members/caregivers can be challenging. We conducted a webinar with experts in neurosurgery, neurocritical care, neuro-palliative care, neuro-ethics, and rehabilitation as part of the Curing Coma Campaign, which is supported by the Neurocritical Care Society. The webinar discussed topics focused on prognostic uncertainty, communicating prognosis to family members/caregivers, gaps within healthcare systems, and research infrastructure as it relates to patients experiencing SABI. The purpose of this manuscript is to describe the themes that emerged from this virtual discussion.MethodsA qualitative analysis of a webinar “Prognostic Humility and Ethical Dilemmas in Acute Brain Injury” was organized as part of the Neurocritical Care Society’s Curing Coma Campaign. A multidisciplinary group of experts was invited as speakers and moderators of the webinar. The content of the webinar was transcribed verbatim. Two qualitative researchers (NK and BM) read and re-read the transcription, and familiarized themselves with the text. The two coders developed and agreed on a code book, independently coded the transcript, and discussed any discrepancies. The transcript was analyzed using inductive thematic analysis of codes and themes that emerged within the expert discussion.ResultsWe coded 168 qualitative excerpts within the transcript. Two main themes were discussed: (1) the concept of prognostic uncertainty in the acute setting, and (2) lack of access to and evidence for quality rehabilitation and specialized continuum of care efforts specific to coma research. Within these two main themes, we found 5 sub-themes, which were broken down into 23 unique codes. The most frequently described code was the need for clinicians to acknowledge our own uncertainties when we discuss prognosis with families, which was mentioned 13 times during the webinar. Several strategies were described for speaking with surrogates of patients who have had a severe brain injury resulting in SABI. We also identified important gaps in the United States health system and in research to improve the care of patients with severe brain injuries.ConclusionAs a result of this webinar and expert discussion, authors identified and analyzed themes related to prognostic uncertainty with SABI. Recommendations were outlined for clinicians who engage with surrogates of patients with SABI to foster informed decisions for their loved one. Finally, recommendations for changes in healthcare systems and research support are provided in order to continue to propel SABI science forward to improve future prognostic certainty.
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Affiliation(s)
- Natalie Kreitzer
- Department of Emergency Medicine, University of Cincinnati, Cincinnati, OH, United States
- *Correspondence: Natalie Kreitzer,
| | - Brooke Murtaugh
- Brain Injury Program Manager, Department of Rehabilitation Programs, Madonna Rehabilitation Hospital, Lincoln, NE, United States
| | | | - Joseph J. Fins
- Division of Medical Ethics, Weill Cornell Medicine, New York, NY, United States
- Yale Law School, New Haven, CT, United States
| | - Geoff Manley
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, CA, United States
| | - Aarti Sarwal
- Department of Neurology, Wake Forest University, Winston-Salem, NC, United States
| | - Neha Dangayach
- Departments of Neurosurgery and Neurology, Icahn School of Medicine at Mount Sinai, New York, NY, United States
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17
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Outcome Measurement in Children With a History of Disorders of Consciousness After Severe Brain Injury: Telephone Administration of the Vineland Adaptive Behavior Scales, Third Edition, and Glasgow Outcome Scale-Extended Pediatric Revision. Pediatr Crit Care Med 2023; 24:e76-e83. [PMID: 36661427 DOI: 10.1097/pcc.0000000000003121] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
OBJECTIVES Examine initial feasibility and utility of a battery of measures administered via telephone interview with a caregiver for describing long-term outcomes in individuals with a history of disorders of consciousness (DoC) after pediatric acquired brain injury (ABI). DESIGN Cross-sectional. SETTING Caregiver interview administered via telephone. PATIENTS Convenience sample admitted to an inpatient pediatric neurorehabilitation unit with DoC after ABI at least 1 year prior to assessment (n = 41, 5-22 yr old at assessment). INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS The Vineland Adaptive Behavior Scales, Third Edition (Vineland-3), and Glasgow Outcome Scale-Extended Pediatric Revision (GOS-E Peds) were examined. Administration time of the Vineland-3 ranged from 13 to 101 minutes (m = 50) and the GOS-E Peds ranged from 2 to 10 minutes (m = 3). Vineland-3 Adaptive Behavior Composite (ABC) ranged from standard scores (SSs) of 20 (exceptionally low) to 100 (average) and GOS-E Peds scores ranged from 3 (i.e., upper moderate disability) to 7 (vegetative state). Lower adaptive functioning on the Vineland-3 ABC was strongly associated with greater disability on the GOS-E Peds (r = -0.805). On the Vineland-3 ABC, 19.5% earned the lowest possible score, whereas 12.2% obtained the lowest possible score for survivors on the GOS-E Peds; only 7.3% earned lowest scores on both measures. CONCLUSIONS The Vineland-3 and GOS-E Peds were feasibly administered by telephone and were complementary in this cohort; the GOS-E provided a quick and easy measure of gross functional outcome, whereas the Vineland-3 took longer to administer but provided a greater level of detail about functioning. When both measures were used together, the range and variability of scores were maximized.
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18
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Bodien YG, Barber J, Taylor SR, Boase K, Corrigan JD, Dikmen S, Gardner RC, Kramer JH, Levin H, Machamer J, McAllister T, Nelson LD, Ngwenya LB, Sherer M, Stein MB, Vassar M, Whyte J, Yue JK, Markowitz A, McCrea MA, Manley GT, Temkin N, Giacino JT. Feasibility and Utility of a Flexible Outcome Assessment Battery for Longitudinal Traumatic Brain Injury Research: A TRACK-TBI Study. J Neurotrauma 2023; 40:337-348. [PMID: 36097759 PMCID: PMC9902043 DOI: 10.1089/neu.2022.0141] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
The effects of traumatic brain injury (TBI) are difficult to measure in longitudinal cohort studies, because disparate pre-injury characteristics and injury mechanisms produce variable impairment profiles and recovery trajectories. In preparation for the Transforming Research and Clinical Knowledge in TBI (TRACK-TBI) study, which followed patients with injuries ranging from uncomplicated mild TBI to coma, we designed a multi-dimensional Flexible outcome Assessment Battery (FAB). The FAB relies on a decision-making algorithm that assigns participants to a Comprehensive (CAB) or Abbreviated Assessment Battery (AAB) and guides test selection across all phases of recovery. To assess feasibility of the FAB, we calculated the proportion of participants followed at 2 weeks (2w) and at 3, 6, and 12 months (3m, 6m, 12m) post-injury who completed the FAB and received valid scores. We evaluated utility of the FAB by examining differences in 6m and 12m Glasgow Outcome Scale-Extended (GOSE) scores between participant subgroups derived from the FAB-enabled versus traditional approach to outcome assessment applied at 2w. Among participants followed at 2w (n = 2094), 3m (n = 1871), 6m (n = 1736), and 12m (n = 1607) post-injury, 95-99% received valid completion scores on the FAB, in full or in part, either in person or by telephone. Level of function assessed by the FAB-enabled approach at 2w was associated with 6m and 12m GOSE scores (proportional odds p < 0.001). These findings suggest that the participant classification methodology afforded by the FAB may enable more effective data collection to improve detection of natural history changes and TBI treatment effects.
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Affiliation(s)
- Yelena G. Bodien
- Massachusetts General Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
- Spaulding Rehabilitation Hospital, Charlestown, Massachusetts, USA
| | - Jason Barber
- University of Washington, Seattle, Washington, USA
| | - Sabrina R. Taylor
- University of California, San Francisco, San Francisco, California, USA
| | - Kim Boase
- University of Washington, Seattle, Washington, USA
| | | | | | - Raquel C. Gardner
- University of California, San Francisco, San Francisco, California, USA
| | - Joel H. Kramer
- University of California, San Francisco, San Francisco, California, USA
| | | | | | - Thomas McAllister
- University of Indiana School of Medicine, Indianapolis, Indiana, USA
| | | | | | - Mark Sherer
- Baylor College of Medicine, Houston, Texas, USA
- TIRR Memorial Hermann, Houston, Texas, USA
| | - Murray B. Stein
- University of California San Diego, La Jolla, California, USA
| | - Mary Vassar
- University of California, San Francisco, San Francisco, California, USA
| | - John Whyte
- Moss Rehabilitation Research Institute, Elkins Park, Pennsylvania, USA
| | - John K. Yue
- University of California, San Francisco, San Francisco, California, USA
| | - Amy Markowitz
- University of California, San Francisco, San Francisco, California, USA
| | | | | | - Nancy Temkin
- University of Washington, Seattle, Washington, USA
| | - Joseph T. Giacino
- Massachusetts General Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
- Spaulding Rehabilitation Hospital, Charlestown, Massachusetts, USA
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19
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Li H, Zhang X, Sun X, Dong L, Lu H, Yue S, Zhang H. Functional networks in prolonged disorders of consciousness. Front Neurosci 2023; 17:1113695. [PMID: 36875660 PMCID: PMC9981972 DOI: 10.3389/fnins.2023.1113695] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Accepted: 01/25/2023] [Indexed: 02/19/2023] Open
Abstract
Prolonged disorders of consciousness (DoC) are characterized by extended disruptions of brain activities that sustain wakefulness and awareness and are caused by various etiologies. During the past decades, neuroimaging has been a practical method of investigation in basic and clinical research to identify how brain properties interact in different levels of consciousness. Resting-state functional connectivity within and between canonical cortical networks correlates with consciousness by a calculation of the associated temporal blood oxygen level-dependent (BOLD) signal process during functional MRI (fMRI) and reveals the brain function of patients with prolonged DoC. There are certain brain networks including the default mode, dorsal attention, executive control, salience, auditory, visual, and sensorimotor networks that have been reported to be altered in low-level states of consciousness under either pathological or physiological states. Analysis of brain network connections based on functional imaging contributes to more accurate judgments of consciousness level and prognosis at the brain level. In this review, neurobehavioral evaluation of prolonged DoC and the functional connectivity within brain networks based on resting-state fMRI were reviewed to provide reference values for clinical diagnosis and prognostic evaluation.
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Affiliation(s)
- Hui Li
- Rehabilitation Center, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, Shandong, China.,Department of Neurorehabilitation, China Rehabilitation Research Center, Beijing, China.,University of Health and Rehabilitation Sciences, Qingdao, Shandong, China
| | - Xiaonian Zhang
- Department of Neurorehabilitation, China Rehabilitation Research Center, Beijing, China
| | - Xinting Sun
- Department of Neurorehabilitation, China Rehabilitation Research Center, Beijing, China
| | - Linghui Dong
- Rehabilitation Center, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, Shandong, China.,Department of Neurorehabilitation, China Rehabilitation Research Center, Beijing, China.,University of Health and Rehabilitation Sciences, Qingdao, Shandong, China
| | - Haitao Lu
- Department of Neurorehabilitation, China Rehabilitation Research Center, Beijing, China
| | - Shouwei Yue
- Rehabilitation Center, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, Shandong, China.,University of Health and Rehabilitation Sciences, Qingdao, Shandong, China
| | - Hao Zhang
- Rehabilitation Center, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, Shandong, China.,Department of Neurorehabilitation, China Rehabilitation Research Center, Beijing, China.,University of Health and Rehabilitation Sciences, Qingdao, Shandong, China
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20
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Eagle SR, Nwachuku E, Elmer J, Deng H, Okonkwo DO, Pease M. Performance of CRASH and IMPACT Prognostic Models for Traumatic Brain Injury at 12 and 24 Months Post-Injury. Neurotrauma Rep 2023; 4:118-123. [PMID: 36895818 PMCID: PMC9989509 DOI: 10.1089/neur.2022.0082] [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: 03/05/2023] Open
Abstract
The Corticoid Randomization after Significant Head Injury (CRASH) and International Mission for Prognosis and Analysis of Clinical Trials (IMPACT) prognostic models are the most reported prognostic models for traumatic brain injury (TBI) in the scientific literature. However, these models were developed and validated to predict 6-month unfavorable outcome and mortality, and growing evidence supports continuous improvements in functional outcome after severe TBI up to 2 years post-injury. The purpose of this study was to evaluate CRASH and IMPACT model performance beyond 6 months post-injury to include 12 and 24 months post-injury. Discriminative validity remained consistent over time and comparable to earlier recovery time points (area under the curve = 0.77-0.83). Both models had poor fit for unfavorable outcomes, explaining less than one quarter of the variation in outcomes for severe TBI patients. The CRASH model had significant values for the Hosmer-Lemeshow test at 12 and 24 months, indicating poor model fit past the previous validation point. There is concern in the scientific literature that TBI prognostic models are being used by neurotrauma clinicians to support clinical decision making despite the goal of the models' development being to support research study design. The results of this study indicate that the CRASH and IMPACT models should not be used in routine clinical practice because of poor model fit that worsens over time and the large, unexplained variance in outcomes.
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Affiliation(s)
- Shawn R Eagle
- Department of Neurological Surgery, University of Pittsburgh Medical Center, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Enyinna Nwachuku
- Department of Neurological Surgery, Cleveland Clinic, Akron, Ohio, USA
| | - Jonathan Elmer
- Department of Clinical Care Medicine, University of Pittsburgh Medical Center, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Hansen Deng
- Department of Neurological Surgery, University of Pittsburgh Medical Center, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - David O Okonkwo
- Department of Neurological Surgery, University of Pittsburgh Medical Center, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Matthew Pease
- Department of Neurological Surgery, Memorial Sloan Kettering, New York, New York, USA
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21
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Li J, Huang B, Wang F, Xie Q, Xu C, Huang H, Pan J. A Potential Prognosis Indicator Based on P300 Brain-Computer Interface for Patients with Disorder of Consciousness. Brain Sci 2022; 12:1556. [PMID: 36421880 PMCID: PMC9688541 DOI: 10.3390/brainsci12111556] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Revised: 10/30/2022] [Accepted: 11/11/2022] [Indexed: 08/08/2023] Open
Abstract
For patients with disorders of consciousness, such as unresponsive wakefulness syndrome (UWS) patients and minimally conscious state (MCS) patients, their long treatment cycle and high cost commonly put a heavy burden on the patient's family and society. Therefore, it is vital to accurately diagnose and predict consciousness recovery for such patients. In this paper, we explored the role of the P300 signal based on an audiovisual BCI in the classification and prognosis prediction of patients with disorders of consciousness. This experiment included 18 patients: 10 UWS patients and 8 MCS- patients. At the three-month follow-up, we defined patients with an improved prognosis (from UWS to MCS-, from UWS to MCS+, or from MCS- to MCS+) as "improved patients" and those who stayed in UWS/MCS as "not improved patients". First, we compared and analyzed different types of patients, and the results showed that the P300 detection accuracy rate of "improved" patients was significantly higher than that of "not improved" patients. Furthermore, the P300 detection accuracy of traumatic brain injury (TBI) patients was significantly higher than that of non-traumatic brain injury (NTBI, including acquired brain injury and cerebrovascular disease) patients. We also found that there was a positive linear correlation between P300 detection accuracy and CRS-R score, and patients with higher P300 detection accuracy were likely to achieve higher CRS-R scores. In addition, we found that the patients with higher P300 detection accuracies tend to have better prognosis in this audiovisual BCI. These findings indicate that the detection accuracy of P300 is significantly correlated with the level of consciousness, etiology, and prognosis of patients. P300 can be used to represent the preservation level of consciousness in clinical neurophysiology and predict the possibility of recovery in patients with disorders of consciousness.
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Affiliation(s)
- Jingcong Li
- School of Software, South China Normal University, Guangzhou 510631, China
- Pazhou Lab, Guangzhou 510631, China
| | - Biao Huang
- School of Software, South China Normal University, Guangzhou 510631, China
| | - Fei Wang
- School of Software, South China Normal University, Guangzhou 510631, China
- Pazhou Lab, Guangzhou 510631, China
| | - Qiuyou Xie
- Joint Research Centre for Disorders of Consciousness, Department of Rehabilitation Medicine, Zhujiang Hospital of Southern Medical University, Guangzhou 510631, China
| | - Chengwei Xu
- Joint Research Centre for Disorders of Consciousness, Department of Rehabilitation Medicine, Zhujiang Hospital of Southern Medical University, Guangzhou 510631, China
| | - Haiyun Huang
- School of Software, South China Normal University, Guangzhou 510631, China
- Pazhou Lab, Guangzhou 510631, China
| | - Jiahui Pan
- School of Software, South China Normal University, Guangzhou 510631, China
- Pazhou Lab, Guangzhou 510631, China
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22
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Functional Connectivity Increases in Response to High-Definition Transcranial Direct Current Stimulation in Patients with Chronic Disorder of Consciousness. Brain Sci 2022; 12:brainsci12081095. [PMID: 36009158 PMCID: PMC9405975 DOI: 10.3390/brainsci12081095] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2022] [Revised: 08/10/2022] [Accepted: 08/16/2022] [Indexed: 11/17/2022] Open
Abstract
Highlights Functional connectivity induced by HD-tDCS in DLPFC has different trends in CRS-R score improvers and non-improvers. An increase in theta PLV in the left frontal–parietooccipital region was significantly associated with CRS-R changes. DOC patients with increased PLV of the alpha band in the intra-bifrontal region have a better prognosis than those without.
Abstract High-definition transcranial direct current stimulation (HD-tDCS) has been shown to play an important role in improving consciousness in patients with disorders of consciousness (DOCs), but its neuroelectrophysiological evidence is still lacking. To better explain the electrophysiological mechanisms of the effects of HD-tDCS on patients with DOCs, 22 DOC patients underwent 10 anodal HD-tDCS sessions of the left dorsolateral prefrontal cortex (DLPFC). This study used the Coma Recovery Scale-Revised (CRS-R) to assess the level of consciousness in DOC patients. According to whether the CRS-R score increased before and after stimulation, DOC patients were divided into a responsive group and a non-responsive group. By comparing the differences in resting-state EEG functional connectivity between different frequency bands and brain regions, as well as the relationship between functional connectivity values and clinical scores, the electrophysiological mechanism of the clinical effects of HD-tDCS was further explored. The change of the phase locking value (PLV) on the theta frequency band in the left frontal–parietooccipital region was positively correlated with the change in the CRS-R scores. As the number of interventions increased, we observed that in the responsive group, the change in PLV showed an upward trend, and the increase in the PLV appeared in the left frontal–parietooccipital region at 4–8 Hz and in the intra-bifrontal region at 8–13 Hz. In the non-responsive group, although the CRS-R scores did not change after stimulation, the PLV showed a downward trend, and the decrease in the PLV appeared in the intra-bifrontal region at 8–13 Hz. In addition, at the three-month follow-up, patients with increased PLV in the intra-bifrontal region at 8–13 Hz after repeated HD-tDCS stimulation had better outcomes than those without. Repeated anodal stimulation of the left DLPFC with HD-tDCS resulted in improved consciousness in some patients with DOCs. The increase in functional connectivity in the brain regions may be associated with the improvement of related awareness after HD-tDCS and may be a predictor of better long-term outcomes.
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23
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Curley WH, Bodien YG, Zhou DW, Conte MM, Foulkes AS, Giacino JT, Victor JD, Schiff ND, Edlow BL. Electrophysiological correlates of thalamocortical function in acute severe traumatic brain injury. Cortex 2022; 152:136-152. [PMID: 35569326 PMCID: PMC9759728 DOI: 10.1016/j.cortex.2022.04.007] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2021] [Revised: 01/26/2022] [Accepted: 04/04/2022] [Indexed: 12/26/2022]
Abstract
Tools assaying the neural networks that modulate consciousness may facilitate tracking of recovery after acute severe brain injury. The ABCD framework classifies resting-state EEG into categories reflecting levels of thalamocortical network function that correlate with outcome in post-cardiac arrest coma. In this longitudinal cohort study, we applied the ABCD framework to 20 patients with acute severe traumatic brain injury requiring intensive care (12 of whom were also studied at ≥6-months post-injury) and 16 healthy controls. We tested four hypotheses: 1) EEG ABCD classifications are spatially heterogeneous and temporally variable; 2) ABCD classifications improve longitudinally, commensurate with the degree of behavioral recovery; 3) ABCD classifications correlate with behavioral level of consciousness; and 4) the Coma Recovery Scale-Revised arousal facilitation protocol yields improved ABCD classifications. Channel-level EEG power spectra were classified based on spectral peaks within pre-defined frequency bands: 'A' = no peaks above delta (<4 Hz) range (complete thalamocortical disruption); 'B' = theta (4-8 Hz) peak (severe thalamocortical disruption); 'C' = theta and beta (13-24 Hz) peaks (moderate thalamocortical disruption); or 'D' = alpha (8-13 Hz) and beta peaks (normal thalamocortical function). Acutely, 95% of patients demonstrated 'D' signals in at least one channel but exhibited within-session temporal variability and spatial heterogeneity in the proportion of different channel-level ABCD classifications. By contrast, healthy participants and patients at follow-up consistently demonstrated signals corresponding to intact thalamocortical network function. Patients demonstrated longitudinal improvement in ABCD classifications (p < .05) and ABCD classification distinguished patients with and without command-following in the subacute-to-chronic phase of recovery (p < .01). In patients studied acutely, ABCD classifications improved after the Coma Recovery Scale-Revised arousal facilitation protocol (p < .05) but did not correspond with behavioral level of consciousness. These findings support the use of the ABCD framework to characterize channel-level EEG dynamics and track fluctuations in functional thalamocortical network integrity in spatial detail.
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Affiliation(s)
- William H Curley
- Harvard Medical School, Boston, MA, USA; Center for Neurotechnology and Neurorecovery, Department of Neurology, Massachusetts General Hospital, Boston, MA, USA
| | - Yelena G Bodien
- Center for Neurotechnology and Neurorecovery, Department of Neurology, Massachusetts General Hospital, Boston, MA, USA; Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital and Harvard Medical School, Charlestown, MA, USA
| | - David W Zhou
- Center for Neurotechnology and Neurorecovery, Department of Neurology, Massachusetts General Hospital, Boston, MA, USA; Department of Brain and Cognitive Sciences, Massachusetts Institute of Technology, Cambridge, MA, USA
| | - Mary M Conte
- Feil Family Brain and Mind Research Institute, Weill Cornell Medical College, New York, NY, USA
| | - Andrea S Foulkes
- Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Joseph T Giacino
- Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital and Harvard Medical School, Charlestown, MA, USA; Department of Physical Medicine and Rehabilitation, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Jonathan D Victor
- Feil Family Brain and Mind Research Institute, Weill Cornell Medical College, New York, NY, USA; Department of Neurology, New York Presbyterian Hospital, New York, NY, USA
| | - Nicholas D Schiff
- Feil Family Brain and Mind Research Institute, Weill Cornell Medical College, New York, NY, USA; Department of Neurology, New York Presbyterian Hospital, New York, NY, USA
| | - Brian L Edlow
- Center for Neurotechnology and Neurorecovery, Department of Neurology, Massachusetts General Hospital, Boston, MA, USA; Athinoula A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital and Harvard Medical School, Charlestown, MA, USA.
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24
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Monti MM, Schnakers C. Flowchart for Implementing Advanced Imaging and Electrophysiology in Patients With Disorders of Consciousness: To fMRI or Not to fMRI? Neurology 2022; 98:452-459. [PMID: 35058337 DOI: 10.1212/wnl.0000000000200038] [Citation(s) in RCA: 24] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
The American Academy of Neurology and the European Academy of Neurology have recognized, for the first time, the value of advanced neuroimaging and electrophysiology techniques (AIEs) in the context of diagnosing patients with a disorder of consciousness (DOC). This recognition is part of an important agenda of promoting evidence-based competency in the management of patients with DOC. Nonetheless, considering that these techniques (and the required knowledge) are seldom available outside of advanced medical centers, it is important to provide physicians with a framework for balancing risks and benefits and deciding, on a single patient basis, whether AIEs are suitable. This issue is all the more urgent considering that family members are increasingly aware of the use of AIEs in patients with DOC, pressure for these assessments is likely to increase in the context of ethical and clinical imperatives to meet standards of care, and pathways for reimbursement for such assessments in DOC are yet to be established. The new guidelines, however, provide no guiding principle for physicians to decide when such assessments are appropriate, a limitation that impedes their wide adoption. We address this important gap by proposing an easy to use algorithmic flowchart that is based on the new guidelines and can be used to determine the appropriateness of AIEs for any given patient with DOC and ensure that evidence-based best practices are being followed. We also provide a brief context for understanding the main categories of AIEs available to clinicians, their advantages, and their limitations.
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Affiliation(s)
- Martin Max Monti
- From the Department of Psychology (M.M.M.) and Department of Neurosurgery, Brain Injury Research Center (C.S.), University of California Los Angeles; and Research Institute (C.S.), Casa Colina Hospitals and Centers for Healthcare, Pomona, CA.
| | - Caroline Schnakers
- From the Department of Psychology (M.M.M.) and Department of Neurosurgery, Brain Injury Research Center (C.S.), University of California Los Angeles; and Research Institute (C.S.), Casa Colina Hospitals and Centers for Healthcare, Pomona, CA
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25
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Goss AL, Creutzfeldt CJ. Prognostication, Ethical Issues, and Palliative Care in Disorders of Consciousness. Neurol Clin 2022; 40:59-75. [PMID: 34798975 PMCID: PMC8672806 DOI: 10.1016/j.ncl.2021.08.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Research advances in recent years have shown that some individuals with vegetative state or minimally conscious state can emerge to higher states of consciousness even years after injury. A minority of behaviorally unresponsive patients with vegetative state have also been shown to follow commands, or even communicate, using neuroimaging or electrophysiological techniques. These advances raise ethical questions that have important implications for clinical care. In this article, the authors argue that adopting a neuropalliative care approach can help clinicians provide ethical, compassionate care to these patients and their caregivers.
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Affiliation(s)
- Adeline L Goss
- Department of Neurology, University of California San Francisco, 505 Parnassus Avenue, Box 0114, San Francisco, CA 94143, USA.
| | - Claire J Creutzfeldt
- Department of Neurology, University of Washington, 325 Ninth Avenue, Seattle, WA 98104, USA
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26
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Young MJ, Bodien YG, Giacino JT, Fins JJ, Truog RD, Hochberg LR, Edlow BL. The neuroethics of disorders of consciousness: a brief history of evolving ideas. Brain 2021; 144:3291-3310. [PMID: 34347037 PMCID: PMC8883802 DOI: 10.1093/brain/awab290] [Citation(s) in RCA: 40] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2021] [Revised: 06/11/2021] [Accepted: 07/10/2021] [Indexed: 11/12/2022] Open
Abstract
Neuroethical questions raised by recent advances in the diagnosis and treatment of disorders of consciousness are rapidly expanding, increasingly relevant and yet underexplored. The aim of this thematic review is to provide a clinically applicable framework for understanding the current taxonomy of disorders of consciousness and to propose an approach to identifying and critically evaluating actionable neuroethical issues that are frequently encountered in research and clinical care for this vulnerable population. Increased awareness of these issues and clarity about opportunities for optimizing ethically responsible care in this domain are especially timely given recent surges in critically ill patients with prolonged disorders of consciousness associated with coronavirus disease 2019 around the world. We begin with an overview of the field of neuroethics: what it is, its history and evolution in the context of biomedical ethics at large. We then explore nomenclature used in disorders of consciousness, covering categories proposed by the American Academy of Neurology, the American Congress of Rehabilitation Medicine and the National Institute on Disability, Independent Living and Rehabilitation Research, including definitions of terms such as coma, the vegetative state, unresponsive wakefulness syndrome, minimally conscious state, covert consciousness and the confusional state. We discuss why these definitions matter, and why there has been such evolution in this nosology over the years, from Jennett and Plum in 1972 to the Multi-Society Task Force in 1994, the Aspen Working Group in 2002 and the 2018 American and 2020 European Disorders of Consciousness guidelines. We then move to a discussion of clinical aspects of disorders of consciousness, the natural history of recovery and ethical issues that arise within the context of caring for people with disorders of consciousness. We conclude with a discussion of key challenges associated with assessing residual consciousness in disorders of consciousness, potential solutions and future directions, including integration of crucial disability rights perspectives.
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Affiliation(s)
- Michael J Young
- Center for Neurotechnology and Neurorecovery,
Department of Neurology, Massachusetts General Hospital, Harvard Medical
School, Boston, MA 02114, USA
- Edmond J. Safra Center for Ethics, Harvard
University, Cambridge, MA 02138, USA
| | - Yelena G Bodien
- Center for Neurotechnology and Neurorecovery,
Department of Neurology, Massachusetts General Hospital, Harvard Medical
School, Boston, MA 02114, USA
- Department of Physical Medicine and Rehabilitation,
Spaulding Rehabilitation Hospital, Harvard Medical School, Charlestown, MA
02129, USA
| | - Joseph T Giacino
- Department of Physical Medicine and Rehabilitation,
Spaulding Rehabilitation Hospital, Harvard Medical School, Charlestown, MA
02129, USA
| | - Joseph J Fins
- Division of Medical Ethics, Weill Cornell Medical
College, New York, NY 10021, USA
- Yale Law School, New Haven,
Connecticut 06511, USA
| | - Robert D Truog
- Center for Bioethics, Harvard Medical
School, Boston, MA 02115, USA
| | - Leigh R Hochberg
- Center for Neurotechnology and Neurorecovery,
Department of Neurology, Massachusetts General Hospital, Harvard Medical
School, Boston, MA 02114, USA
- School of Engineering and Carney Institute for Brain
Science, Brown University, Providence, RI 02906, USA
- VA RR&D Center for Neurorestoration and
Neurotechnology, Department of Veterans Affairs Medical Center,
Providence, RI 02908, USA
| | - Brian L Edlow
- Center for Neurotechnology and Neurorecovery,
Department of Neurology, Massachusetts General Hospital, Harvard Medical
School, Boston, MA 02114, USA
- Athinoula A. Martinos Center for Biomedical Imaging,
Massachusetts General Hospital, Charlestown, MA 02129, USA
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27
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Abstract
Disorders of consciousness (DOC) continue to profoundly challenge both families and medical professionals. Once a brain-injured patient has been stabilized, questions turn to the prospect of recovery. However, what “recovery” means in the context of patients with prolonged DOC is not always clear. Failure to recognize potential differences of interpretation—and the assumptions about the relationship between health and well-being that underlie these differences—can inhibit communication between surrogate decisionmakers and a patient’s clinical team, and make it difficult to establish the goals of care. The authors examine the relationship between health and well-being as it pertains to patients with prolonged DOC. They argue that changes in awareness or other function should not be equated to changes in well-being, in the absence of a clear understanding of the constituents of well-being for that particular patient. The authors further maintain that a comprehensive conception of recovery for patients with prolonged DOC should incorporate aspects of both experienced well-being and evaluative well-being.
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28
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Bodien Y, Barra A, Temkin N, Barber J, Foreman B, Vassar M, Robertson CS, Taylor SR, Markowitz AJ, Manley GT, Giacino J, Edlow BL. Diagnosing Level of Consciousness: The Limits of the Glasgow Coma Scale Total Score. J Neurotrauma 2021; 38:3295-3305. [PMID: 34605668 DOI: 10.1089/neu.2021.0199] [Citation(s) in RCA: 65] [Impact Index Per Article: 21.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
Abstract
In nearly all clinical and research contexts, the initial severity of a traumatic brain injury (TBI) is measured using the Glasgow Coma Scale (GCS) total score. However, the GCS total score may not accurately reflect level of consciousness, a critical indicator of injury severity. We investigated the relationship between GCS total scores and level of consciousness in a consecutive sample of 2,455 adult subjects assessed with the GCS 69,487 times as part of the multi-center Transforming Research and Clinical Knowledge in TBI (TRACK-TBI) study. We assigned each GCS subscale score combination a level of consciousness rating based upon published criteria for the following disorders of consciousness (DoC) diagnoses: coma, vegetative state/unresponsive wakefulness syndrome, minimally conscious state, and post-traumatic confusional state, and present our findings using summary statistics and four illustrative cases. Participants had the following characteristics: mean (standard deviation) age 41.9 (17.6) years, 69% male, initial GCS 3-8=13%; 9-12=5%; 13-15=82%. All GCS total scores between 4-14 were associated with more than one DoC diagnosis; the greatest variability was observed for scores of 7-11. Furthermore, a wide range of total scores were associated with identical DoC diagnoses. Importantly, a diagnosis of coma was only possible with GCS total scores of 3-6. The GCS total score does not accurately reflect level of consciousness based on published DoC diagnostic criteria. To improve the classification of patients with TBI and to inform the design of future clinical trials, clinicians and investigators should consider individual subscale behaviors and more comprehensive assessments when evaluating TBI severity.
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Affiliation(s)
- Yelena Bodien
- Massachusetts General Hospital, 2348, Neurology, Boston, Massachusetts, United States.,Spaulding Rehabilitation Hospital, 24498, Physical Medicine and Rehabilitation, Charlestown, Massachusetts, United States;
| | | | - Nancy Temkin
- University of Washington, 7284, Departments of Neurological Surgery and Biostatistics, Seattle, Washington, United States;
| | - Jason Barber
- University of Washington, 7284, Seattle, Washington, United States;
| | - Brandon Foreman
- University of Cincinnati, Neurology, Cincinnati, Ohio, United States;
| | - Mary Vassar
- University of California San Francisco, 8785, San Francisco, California, United States;
| | - Claudia S Robertson
- Baylor College of Medicine, Neurosurgery, One Baylor Plaza, Houston, Texas, United States, 77030;
| | - Sabrina R Taylor
- University of California San Francisco Department of Neurological Surgery, 189227, San Francisco, California, United States;
| | - Amy J Markowitz
- University of California, San Francisco, Brain and Spinal Injury Center (BASIC), 1001 Potrero Ave, Bldg 1 Rm 101, San Francisco, California, United States, 94110;
| | - Geoffrey T Manley
- University of California San Francisco, Neurosurgery, San Francisco, California, United States.,UCSF Weill Institute for Neurosciences, San Francisco, California, United States;
| | - Joseph Giacino
- Spaulding Rehabilitation Hospital, 24498, PM&R, 300 1st Ave, Charlestown, Massachusetts, United States, 02129-3109;
| | - Brian L Edlow
- Harvard Medical School, 1811, 175 Cambridge Street - Suite 300, Boston, Massachusetts, United States, 02115.,Massachusetts General Hospital, 2348, Athinoula A. Martinos Center for Biomedical Imaging, Boston, Massachusetts, United States;
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29
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McCrea MA, Giacino JT, Barber J, Temkin NR, Nelson LD, Levin HS, Dikmen S, Stein M, Bodien YG, Boase K, Taylor SR, Vassar M, Mukherjee P, Robertson C, Diaz-Arrastia R, Okonkwo DO, Markowitz AJ, Manley GT, Adeoye O, Badjatia N, Bullock MR, Chesnut R, Corrigan JD, Crawford K, Duhaime AC, Ellenbogen R, Feeser VR, Ferguson AR, Foreman B, Gardner R, Gaudette E, Goldman D, Gonzalez L, Gopinath S, Gullapalli R, Hemphill JC, Hotz G, Jain S, Keene CD, Korley FK, Kramer J, Kreitzer N, Lindsell C, Machamer J, Madden C, Martin A, McAllister T, Merchant R, Ngwenya LB, Noel F, Nolan A, Palacios E, Perl D, Puccio A, Rabinowitz M, Rosand J, Sander A, Satris G, Schnyer D, Seabury S, Sherer M, Toga A, Valadka A, Wang K, Yue JK, Yuh E, Zafonte R. Functional Outcomes Over the First Year After Moderate to Severe Traumatic Brain Injury in the Prospective, Longitudinal TRACK-TBI Study. JAMA Neurol 2021; 78:982-992. [PMID: 34228047 DOI: 10.1001/jamaneurol.2021.2043] [Citation(s) in RCA: 114] [Impact Index Per Article: 38.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Importance Moderate to severe traumatic brain injury (msTBI) is a major cause of death and disability in the US and worldwide. Few studies have enabled prospective, longitudinal outcome data collection from the acute to chronic phases of recovery after msTBI. Objective To prospectively assess outcomes in major areas of life function at 2 weeks and 3, 6, and 12 months after msTBI. Design, Setting, and Participants This cohort study, as part of the Transforming Research and Clinical Knowledge in TBI (TRACK-TBI) study, was conducted at 18 level 1 trauma centers in the US from February 2014 to August 2018 and prospectively assessed longitudinal outcomes, with follow-up to 12 months postinjury. Participants were patients with msTBI (Glasgow Coma Scale scores 3-12) extracted from a larger group of patients with mild, moderate, or severe TBI who were enrolled in TRACK-TBI. Data analysis took place from October 2019 to April 2021. Exposures Moderate or severe TBI. Main Outcomes and Measures The Glasgow Outcome Scale-Extended (GOSE) and Disability Rating Scale (DRS) were used to assess global functional status 2 weeks and 3, 6, and 12 months postinjury. Scores on the GOSE were dichotomized to determine favorable (scores 4-8) vs unfavorable (scores 1-3) outcomes. Neurocognitive testing and patient reported outcomes at 12 months postinjury were analyzed. Results A total of 484 eligible patients were included from the 2679 individuals in the TRACK-TBI study. Participants with severe TBI (n = 362; 283 men [78.2%]; median [interquartile range] age, 35.5 [25-53] years) and moderate TBI (n = 122; 98 men [80.3%]; median [interquartile range] age, 38 [25-53] years) were comparable on demographic and premorbid variables. At 2 weeks postinjury, 36 of 290 participants with severe TBI (12.4%) and 38 of 93 participants with moderate TBI (41%) had favorable outcomes (GOSE scores 4-8); 301 of 322 in the severe TBI group (93.5%) and 81 of 103 in the moderate TBI group (78.6%) had moderate disability or worse on the DRS (total score ≥4). By 12 months postinjury, 142 of 271 with severe TBI (52.4%) and 54 of 72 with moderate TBI (75%) achieved favorable outcomes. Nearly 1 in 5 participants with severe TBI (52 of 270 [19.3%]) and 1 in 3 with moderate TBI (23 of 71 [32%]) reported no disability (DRS score 0) at 12 months. Among participants in a vegetative state at 2 weeks, 62 of 79 (78%) regained consciousness and 14 of 56 with available data (25%) regained orientation by 12 months. Conclusions and Relevance In this study, patients with msTBI frequently demonstrated major functional gains, including recovery of independence, between 2 weeks and 12 months postinjury. Severe impairment in the short term did not portend poor outcomes in a substantial minority of patients with msTBI. When discussing prognosis during the first 2 weeks after injury, clinicians should be particularly cautious about making early, definitive prognostic statements suggesting poor outcomes and withdrawal of life-sustaining treatment in patients with msTBI.
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Affiliation(s)
- Michael A McCrea
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee
| | - Joseph T Giacino
- Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Charlestown, Massachusetts.,Department of Physical Medicine and Rehabilitation, Massachusetts General Hospital, Boston.,Department of Physical Medicine and Rehabilitation, Harvard Medical School, Boston, Massachusetts
| | - Jason Barber
- Department of Neurological Surgery, University of Washington, Seattle
| | - Nancy R Temkin
- Department of Neurological Surgery, University of Washington, Seattle
| | - Lindsay D Nelson
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee
| | - Harvey S Levin
- Physical Medicine and Rehabilitation, Baylor College of Medicine, Houston, Texas
| | - Sureyya Dikmen
- Department of Neurological Surgery, University of Washington, Seattle
| | - Murray Stein
- Department of Family Medicine and Public Health, University of California, San Diego, San Diego
| | - Yelena G Bodien
- Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Charlestown, Massachusetts.,Department of Physical Medicine and Rehabilitation, Massachusetts General Hospital, Boston.,Department of Physical Medicine and Rehabilitation, Harvard Medical School, Boston, Massachusetts
| | - Kim Boase
- Department of Neurological Surgery, University of Washington, Seattle
| | - Sabrina R Taylor
- Neurological Surgery, University of California, San Francisco, San Francisco
| | - Mary Vassar
- Neurological Surgery, University of California, San Francisco, San Francisco
| | - Pratik Mukherjee
- Neurological Surgery, University of California, San Francisco, San Francisco
| | - Claudia Robertson
- Physical Medicine and Rehabilitation, Baylor College of Medicine, Houston, Texas
| | | | - David O Okonkwo
- Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Amy J Markowitz
- Neurological Surgery, University of California, San Francisco, San Francisco
| | - Geoffrey T Manley
- Neurological Surgery, University of California, San Francisco, San Francisco
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Sonia Jain
- University of California, San Diego, La Jolla
| | | | | | - Joel Kramer
- University of California, San Francisco, San Francisco
| | | | | | | | | | | | | | | | | | | | - Amber Nolan
- University of California, San Francisco, San Francisco
| | - Eva Palacios
- University of California, San Francisco, San Francisco
| | - Daniel Perl
- Uniformed Services University, Bethesda, Maryland
| | - Ava Puccio
- University of Pittsburgh, Pittsburgh, Pennsylvania
| | | | | | | | | | | | | | | | - Arthur Toga
- University of Southern California, Los Angeles
| | | | | | - John K Yue
- University of California, San Francisco, San Francisco
| | - Esther Yuh
- University of California, San Francisco, San Francisco
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Dopaminergic brainstem disconnection is common to pharmacological and pathological consciousness perturbation. Proc Natl Acad Sci U S A 2021; 118:2026289118. [PMID: 34301891 PMCID: PMC8325270 DOI: 10.1073/pnas.2026289118] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
Understanding the neural bases of consciousness is of basic scientific and clinical importance. Human neuroimaging has established that a network of interconnected brain regions known as the default mode network disintegrates in anesthesia and after brain damage that causes disorders of consciousness. However, the neurochemical underpinnings of this network change remain largely unknown. Motivated by preclinical animal work and clinical observations, we found that across pharmacological (sedation) and pathological (disorders of consciousness) consciousness perturbation, the dopaminergic source nucleus, the ventral tegmental area, disconnects from the main nodes of the default mode network. As the severity of this dopaminergic disconnection was associated with default mode network disintegration, we propose that dopaminergic modulation may be a central mechanism for consciousness maintenance. Clinical research into consciousness has long focused on cortical macroscopic networks and their disruption in pathological or pharmacological consciousness perturbation. Despite demonstrating diagnostic utility in disorders of consciousness (DoC) and monitoring anesthetic depth, these cortico-centric approaches have been unable to characterize which neurochemical systems may underpin consciousness alterations. Instead, preclinical experiments have long implicated the dopaminergic ventral tegmental area (VTA) in the brainstem. Despite dopaminergic agonist efficacy in DoC patients equally pointing to dopamine, the VTA has not been studied in human perturbed consciousness. To bridge this translational gap between preclinical subcortical and clinical cortico-centric perspectives, we assessed functional connectivity changes of a histologically characterized VTA using functional MRI recordings of pharmacologically (propofol sedation) and pathologically perturbed consciousness (DoC patients). Both cohorts demonstrated VTA disconnection from the precuneus and posterior cingulate (PCu/PCC), a main default mode network node widely implicated in consciousness. Strikingly, the stronger VTA–PCu/PCC connectivity was, the more the PCu/PCC functional connectome resembled its awake configuration, suggesting a possible neuromodulatory relationship. VTA-PCu/PCC connectivity increased toward healthy control levels only in DoC patients who behaviorally improved at follow-up assessment. To test whether VTA–PCu/PCC connectivity can be affected by a dopaminergic agonist, we demonstrated in a separate set of traumatic brain injury patients without DoC that methylphenidate significantly increased this connectivity. Together, our results characterize an in vivo dopaminergic connectivity deficit common to reversible and chronic consciousness perturbation. This noninvasive assessment of the dopaminergic system bridges preclinical and clinical work, associating dopaminergic VTA function with macroscopic network alterations, thereby elucidating a critical aspect of brainstem–cortical interplay for consciousness.
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Claassen J, Akbari Y, Alexander S, Bader MK, Bell K, Bleck TP, Boly M, Brown J, Chou SHY, Diringer MN, Edlow BL, Foreman B, Giacino JT, Gosseries O, Green T, Greer DM, Hanley DF, Hartings JA, Helbok R, Hemphill JC, Hinson HE, Hirsch K, Human T, James ML, Ko N, Kondziella D, Livesay S, Madden LK, Mainali S, Mayer SA, McCredie V, McNett MM, Meyfroidt G, Monti MM, Muehlschlegel S, Murthy S, Nyquist P, Olson DM, Provencio JJ, Rosenthal E, Sampaio Silva G, Sarasso S, Schiff ND, Sharshar T, Shutter L, Stevens RD, Vespa P, Videtta W, Wagner A, Ziai W, Whyte J, Zink E, Suarez JI. Proceedings of the First Curing Coma Campaign NIH Symposium: Challenging the Future of Research for Coma and Disorders of Consciousness. Neurocrit Care 2021; 35:4-23. [PMID: 34236619 PMCID: PMC8264966 DOI: 10.1007/s12028-021-01260-x] [Citation(s) in RCA: 40] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2021] [Accepted: 04/15/2021] [Indexed: 01/04/2023]
Abstract
Coma and disorders of consciousness (DoC) are highly prevalent and constitute a burden for patients, families, and society worldwide. As part of the Curing Coma Campaign, the Neurocritical Care Society partnered with the National Institutes of Health to organize a symposium bringing together experts from all over the world to develop research targets for DoC. The conference was structured along six domains: (1) defining endotype/phenotypes, (2) biomarkers, (3) proof-of-concept clinical trials, (4) neuroprognostication, (5) long-term recovery, and (6) large datasets. This proceedings paper presents actionable research targets based on the presentations and discussions that occurred at the conference. We summarize the background, main research gaps, overall goals, the panel discussion of the approach, limitations and challenges, and deliverables that were identified.
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Affiliation(s)
- Jan Claassen
- Department of Neurology, Columbia University and New York-Presbyterian Hospital, 177 Fort Washington Avenue, MHB 8 Center, Room 300, New York City, NY, 10032, USA.
| | - Yama Akbari
- Departments of Neurology, Neurological Surgery, and Anatomy & Neurobiology and Beckman Laser Institute and Medical Clinic, University of California, Irvine, Irvine, CA, USA
| | - Sheila Alexander
- Acute and Tertiary Care, School of Nursing and Critical Care Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | | | - Kathleen Bell
- Department of Physical Medicine and Rehabilitation, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Thomas P Bleck
- Davee Department of Neurology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Melanie Boly
- Department of Neurology, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, WI, USA
| | - Jeremy Brown
- Office of Emergency Care Research, Division of Clinical Research, National Institute of Neurological Disorders and Stroke, Bethesda, MD, USA
| | - Sherry H-Y Chou
- Departments of Critical Care Medicine, Neurology, and Neurosurgery, School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Michael N Diringer
- Department of Neurology, Washington University in St. Louis, St. Louis, MO, USA
| | - Brian L Edlow
- Department of Neurology, Center for Neurotechnology and Neurorecovery, Massachusetts General Hospital and Harvard Medical School, Harvard University, Boston, MA, USA
| | - Brandon Foreman
- Departments of Neurology and Rehabilitation Medicine, College of Medicine, University of Cincinnati, Cincinnati, OH, USA
| | - Joseph T Giacino
- Department of Physical Medicine and Rehabilitation, Harvard Medical School, Harvard University, Boston, MA, USA
| | - Olivia Gosseries
- GIGA Consciousness After Coma Science Group, University of Liege, Liege, Belgium
| | - Theresa Green
- School of Nursing, Queensland University of Technology, Kelvin Grove, QLD, Australia
| | - David M Greer
- Department of Neurology, School of Medicine, Boston University, Boston, MA, USA
| | - Daniel F Hanley
- Division of Brain Injury Outcomes, Department of Neurology, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Jed A Hartings
- Department of Neurosurgery, College of Medicine, University of Cincinnati, Cincinnati, OH, USA
| | - Raimund Helbok
- Neurocritical Care Unit, Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - J Claude Hemphill
- Department of Neurology, Weill Institute for Neurosciences, School of Medicine, University of California, San Francisco, San Francisco, CA, USA
| | - H E Hinson
- Department of Neurology, School of Medicine, Oregon Health & Science University, Portland, OR, USA
| | - Karen Hirsch
- Department of Neurology, Stanford University, Palo Alto, CA, USA
| | - Theresa Human
- Department of Pharmacy, Barnes Jewish Hospital, St. Louis, MO, USA
| | - Michael L James
- Departments of Anesthesiology and Neurology, Duke University, Durham, NC, USA
| | - Nerissa Ko
- Department of Neurology, Weill Institute for Neurosciences, School of Medicine, University of California, San Francisco, San Francisco, CA, USA
| | - Daniel Kondziella
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
- Department of Neurology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Sarah Livesay
- College of Nursing, Rush University, Chicago, IL, USA
| | - Lori K Madden
- Center for Nursing Science, University of California, Davis, Sacramento, CA, USA
| | - Shraddha Mainali
- Department of Neurology, The Ohio State University, Columbus, OH, USA
| | - Stephan A Mayer
- Department of Neurology, New York Medical College, Valhalla, NY, USA
| | - Victoria McCredie
- Interdepartmental Division of Critical Care, Department of Respirology, University of Toronto, Toronto, ON, Canada
| | - Molly M McNett
- College of Nursing, The Ohio State University, Columbus, OH, USA
| | - Geert Meyfroidt
- Department of Intensive Care Medicine, University Hospitals Leuven and University of Leuven, Leuven, Belgium
| | - Martin M Monti
- Departments of Neurosurgery and Psychology, Brain Injury Research Center, University of California, Los Angeles, Los Angeles, CA, USA
| | - Susanne Muehlschlegel
- Departments of Neurology, Anesthesiology/Critical Care, and Surgery, Medical School, University of Massachusetts, Worcester, MA, USA
| | - Santosh Murthy
- Department of Neurology, Weill Cornell Medical College, New York City, NY, USA
| | - Paul Nyquist
- Division of Neurosciences Critical Care, Departments of Anesthesiology and Critical Care Medicine, Neurology, and Neurosurgery, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - DaiWai M Olson
- Departments of Neurology and Neurosurgery, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - J Javier Provencio
- Departments of Neurology and Neuroscience, School of Medicine, University of Virginia, Charlottesville, VA, USA
| | - Eric Rosenthal
- Department of Neurology, Harvard Medical School, Harvard University, Boston, MA, USA
| | - Gisele Sampaio Silva
- Department of Neurology, Albert Einstein Israelite Hospital and Universidade Federal de São Paulo, São Paulo, Brazil
| | - Simone Sarasso
- Department of Biomedical and Clinical Sciences "L. Sacco", Università degli Studi di Milano, Milan, Italy
| | - Nicholas D Schiff
- Department of Neurology and Brain Mind Research Institute, Weill Cornell Medicine, Cornell University, New York City, NY, USA
| | - Tarek Sharshar
- Department of Intensive Care, Paris Descartes University, Paris, France
| | - Lori Shutter
- Departments of Critical Care Medicine, Neurology, and Neurosurgery, School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Robert D Stevens
- Division of Neurosciences Critical Care, Departments of Anesthesiology and Critical Care Medicine, Neurology, and Neurosurgery, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Paul Vespa
- Departments of Neurosurgery and Neurology, University of California, Los Angeles, Los Angeles, CA, USA
| | - Walter Videtta
- National Hospital Alejandro Posadas, Buenos Aires, Argentina
| | - Amy Wagner
- Department of Physical Medicine and Rehabilitation, School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Wendy Ziai
- Division of Neurosciences Critical Care, Departments of Anesthesiology and Critical Care Medicine, Neurology, and Neurosurgery, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - John Whyte
- Moss Rehabilitation Research Institute, Elkins Park, PA, USA
| | - Elizabeth Zink
- Division of Neurosciences Critical Care, Department of Neurology, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Jose I Suarez
- Division of Neurosciences Critical Care, Departments of Anesthesiology and Critical Care Medicine, Neurology, and Neurosurgery, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
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Giacino JT, Bodien YG, Zuckerman D, Henderson J, Schiff ND, Fins JJ. Empiricism and Rights Justify the Allocation of Health Care Resources to Persons with Disorders of Consciousness. AJOB Neurosci 2021; 12:169-171. [PMID: 33960891 DOI: 10.1080/21507740.2021.1904055] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Affiliation(s)
| | - Yelena G Bodien
- Harvard Medical School.,Spaulding Rehabilitation Hospital.,Massachusetts General Hospital
| | | | | | | | - Joseph J Fins
- Weill Cornell Medical College.,The Rockefeller University.,Yale Law School
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Edlow BL, Claassen J, Schiff ND, Greer DM. Recovery from disorders of consciousness: mechanisms, prognosis and emerging therapies. Nat Rev Neurol 2021; 17:135-156. [PMID: 33318675 PMCID: PMC7734616 DOI: 10.1038/s41582-020-00428-x] [Citation(s) in RCA: 280] [Impact Index Per Article: 93.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/23/2020] [Indexed: 12/16/2022]
Abstract
Substantial progress has been made over the past two decades in detecting, predicting and promoting recovery of consciousness in patients with disorders of consciousness (DoC) caused by severe brain injuries. Advanced neuroimaging and electrophysiological techniques have revealed new insights into the biological mechanisms underlying recovery of consciousness and have enabled the identification of preserved brain networks in patients who seem unresponsive, thus raising hope for more accurate diagnosis and prognosis. Emerging evidence suggests that covert consciousness, or cognitive motor dissociation (CMD), is present in up to 15-20% of patients with DoC and that detection of CMD in the intensive care unit can predict functional recovery at 1 year post injury. Although fundamental questions remain about which patients with DoC have the potential for recovery, novel pharmacological and electrophysiological therapies have shown the potential to reactivate injured neural networks and promote re-emergence of consciousness. In this Review, we focus on mechanisms of recovery from DoC in the acute and subacute-to-chronic stages, and we discuss recent progress in detecting and predicting recovery of consciousness. We also describe the developments in pharmacological and electrophysiological therapies that are creating new opportunities to improve the lives of patients with DoC.
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Affiliation(s)
- Brian L Edlow
- Center for Neurotechnology and Neurorecovery, Department of Neurology, Massachusetts General Hospital, Boston, MA, USA
- Athinoula A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital, Charlestown, MA, USA
| | - Jan Claassen
- Department of Neurology, Columbia University Medical Center, New York Presbyterian Hospital, New York, NY, USA
| | - Nicholas D Schiff
- Feil Family Brain Mind Research Institute, Weill Cornell Medical College, New York, NY, USA
| | - David M Greer
- Department of Neurology, Boston University School of Medicine, Boston, MA, USA.
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Rodgin S, Suskauer SJ, Chen J, Katz E, Davis KC, Slomine BS. Very Long-Term Outcomes in Children Admitted in a Disorder of Consciousness After Severe Traumatic Brain Injury. Arch Phys Med Rehabil 2021; 102:1507-1513. [PMID: 33609500 DOI: 10.1016/j.apmr.2021.01.084] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2020] [Revised: 01/17/2021] [Accepted: 01/22/2021] [Indexed: 11/17/2022]
Abstract
OBJECTIVES To investigate functional outcomes and state of consciousness at 1 year and ≥2 years postinjury in children who sustained a traumatic brain injury and were in a disorder of consciousness (DOC), either vegetative state (VS) or minimally conscious state (MCS), upon admission to inpatient rehabilitation. DESIGN Retrospective chart review. SETTING Pediatric inpatient rehabilitation unit. PARTICIPANTS Children aged 2-18 years (N=37) who were admitted to inpatient rehabilitation with admission scores <30 on the Cognitive and Linguistic Scale (CALS). INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES Glasgow Outcome Scale- Extended, Pediatric Revision (GOS-E Peds), and state of consciousness based on previously established guidelines. RESULTS At admission, 16 children were in VS (43.2%) and 21 (56.8%) were in MCS. Children admitted in VS had a significantly longer time from injury to inpatient rehabilitation admission, lower CALS admission scores, were more likely to be in a DOC ≥28 days, and had greater disability at both follow-up time points. At the 1-year follow-up, 3 patients were in VS, 7 were in MCS, and 27 had emerged from MCS. By the time of the most recent follow-up (≥2y), 2 more patients had emerged from MCS. Across the cohort, GOS-E Peds scores at 1 year ranged from VS (GOS-E Peds, 7) to upper moderate disability (GOS-E Peds, 3). Most patients were functioning in the lower severe disability category (GOS-E Peds, 6) at 1 year (43.2%) and at the time of the most recent follow-up (43.2%). Twenty-seven patients (73.0%) showed stable GOS-E Peds scores between the 2 time points, 6 (16.2%) improved, and 4 (10.8%) were deceased. CONCLUSIONS Although a majority of patients emerged from a DOC by 1 year postinjury, most continued to demonstrate notable functional impairment at the 1-year follow-up that persisted to the most recent follow-up. A small subset demonstrated important improvements between 1 year and the most recent follow-up (2 patients emerged, 6 patients showed improvement in GOS-E Peds scores).
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Affiliation(s)
- Sandra Rodgin
- Department of Neuropsychology, Kennedy Krieger Institute, Baltimore, MD; Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD.
| | - Stacy J Suskauer
- Department of Physical Medical and Rehabilitation, Johns Hopkins University School of Medicine, Baltimore, MD; Department of Pediatric Rehabilitation, Kennedy Krieger Institute, Baltimore, MD
| | - Julia Chen
- Department of Child and Adolescent Psychiatry and Behavioral Science, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Elana Katz
- Department of Pediatrics, Division of Rehabilitation Medicine, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Kimberly C Davis
- Department of Psychology, Texas Children's Hospital, Houston, TX; Department of Pediatrics, Baylor College of Medicine, Houston, TX
| | - Beth S Slomine
- Department of Neuropsychology, Kennedy Krieger Institute, Baltimore, MD; Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD; Department of Physical Medical and Rehabilitation, Johns Hopkins University School of Medicine, Baltimore, MD
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He R, Fan J, Wang H, Zhong Y, Ma J. Differentiating Responders and Non-responders to rTMS Treatment for Disorder of Consciousness Using EEG After-Effects. Front Neurol 2020; 11:583268. [PMID: 33329325 PMCID: PMC7714935 DOI: 10.3389/fneur.2020.583268] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Accepted: 10/26/2020] [Indexed: 12/17/2022] Open
Abstract
Background: It is controversial whether repetitive transcranial magnetic stimulation (rTMS) has potential benefits in improving the awareness of patients with disorder of consciousness (DOC). We hypothesized that rTMS could improve consciousness only in DOC patients who have measurable brain responses to rTMS. Objective: In this study, we aimed to investigate the EEG after-effects induced by rTMS in DOC patients and attempted to propose a prediction algorithm to discriminate between DOC patients who would respond to rTMS treatment from those who would not. Methods: Twenty-five DOC patients were enrolled in this study. Over 4 weeks, each patient received 20 sessions of 20 Hz rTMS that was applied over the left dorsolateral prefrontal cortex (DLPFC). For each patient, resting-state EEG was recorded before and immediately after one session of rTMS to assess the neurophysiologic modification induced by rTMS. The coma recovery scale revised (CRS-R) was used to define responders with improved consciousness. Results: Of the 25 DOC patients, 10 patients regained improved consciousness and were classified as responders. The responders were characterized by more preserved alpha power and a significant reduction of delta power induced by rTMS. The analysis of receiver operating characteristic (ROC) curves showed that the algorithm calculated from the relative alpha power and the relative delta power had a high accuracy in identifying DOC patients who were responders. Conclusions: DOC patients who had more preserved alpha power and a significant reduction in the delta band that was induced by rTMS are likely to regain improved consciousness, which provides a tool to identify DOC patients who may benefit in terms of therapeutic consciousness.
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Affiliation(s)
- Renhong He
- School of Biomedical Engineering, Southern Medical University, Guangzhou, China.,Department of Rehabilitation Medicine, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Jianzhong Fan
- Department of Rehabilitation Medicine, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Huijuan Wang
- Department of Rehabilitation Medicine, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Yuhua Zhong
- Department of Rehabilitation Medicine, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Jianhua Ma
- School of Biomedical Engineering, Southern Medical University, Guangzhou, China
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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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37
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Martens G, Bodien Y, Thomas A, Giacino J. Temporal Profile of Recovery of Communication in Patients With Disorders of Consciousness After Severe Brain Injury. Arch Phys Med Rehabil 2020; 101:1260-1264. [PMID: 32113971 DOI: 10.1016/j.apmr.2020.01.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2019] [Revised: 12/27/2019] [Accepted: 01/29/2020] [Indexed: 11/19/2022]
Abstract
OBJECTIVE Characterize the temporal profile of recovery of communication after severe brain injury. DESIGN Retrospective cohort study. SETTING Inpatient rehabilitation hospital. PARTICIPANTS Patients with severe acquired brain injury and no evidence of communication on the Coma Recovery Scale-Revised (CRS-R) (N=175). MAIN OUTCOME MEASURES Time from injury to recovery of intentional communication (IC, inconsistent yes/no responses) and functional communication (FC, consistent and accurate yes/no responses) on the CRS-R Communication subscale. RESULTS Patients (N=175) were included in the primary observation period of the first 8 weeks of inpatient rehabilitation (median [interquartile range, IQR]: 48 [27-61] years old, 105 men, 28 [21-38] days postinjury, 100 traumatic etiology). Fifty-four patients (31%) did not recover IC or FC. Thirty patients (17%) recovered IC only (median [IQR] days from injury to IC= 40 [34-54]), 72 patients (41%) recovered IC followed by FC (days from injury to FC=50 [42-61]), and 19 patients (11%) recovered FC without first recovering IC (43 [32-63]). The patients who recovered neither IC nor FC within 8 weeks of admission were admitted to rehabilitation later than those who recovered IC and/or FC (P<.01). Sixteen patients who did not recover communication within 8 weeks of admission to rehabilitation subsequently recovered FC prior to discharge. CONCLUSIONS In patients with severe brain injury receiving inpatient rehabilitation, discernible yes-no responses emerged approximately 6 weeks postinjury and became reliable 1 week later. Approximately 1 in 3 patients did not demonstrate IC or FC within 8 weeks of admission to rehabilitation, although 33% of these individuals recovered communication prior to discharge. In total, 61% of patients recovered FC prior to discharge from rehabilitation.
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Affiliation(s)
- Géraldine Martens
- Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Harvard Medical School, Boston, MA; Coma Science Group, GIGA Research, GIGA-Consciousness, University of Liège, Liège, Belgium; Centre du Cerveau(2), Centre intégré pluridisciplinaire de l'étude du cerveau, de la cognition et de la conscience, University Hospital of Liège, Liège, Belgium.
| | - Yelena Bodien
- Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Harvard Medical School, Boston, MA; Laboratory for Neuroimaging in Coma and Consciousness, Massachusetts General Hospital, Boston, MA
| | - Amber Thomas
- Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Harvard Medical School, Boston, MA
| | - Joseph Giacino
- Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Harvard Medical School, Boston, MA
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