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Jiang Y, Sleigh J. Consciousness and General Anesthesia: Challenges for Measuring the Depth of Anesthesia. Anesthesiology 2024; 140:313-328. [PMID: 38193734 DOI: 10.1097/aln.0000000000004830] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2024]
Abstract
The optimal consciousness level required for general anesthesia with surgery is unclear, but in existing practice, anesthetic oblivion, may be incomplete. This article discusses the concept of consciousness, how it is altered by anesthetics, the challenges for assessing consciousness, currently used technologies for assessing anesthesia levels, and future research directions. Wakefulness is marked by a subjective experience of existence (consciousness), perception of input from the body or the environment (connectedness), the ability for volitional responsiveness, and a sense of continuity in time. Anesthetic drugs may selectively impair some of these components without complete extinction of the subjective experience of existence. In agreement with Sanders et al. (2012), the authors propose that a state of disconnected consciousness is the optimal level of anesthesia, as it likely avoids both awareness and the possible dangers of oversedation. However, at present, there are no reliably tested indices that can discriminate between connected consciousness, disconnected consciousness, and complete unconsciousness.
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Affiliation(s)
- Yandong Jiang
- Department of Anesthesiology, Critical Care and Pain Medicine, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, Texas
| | - Jamie Sleigh
- Department of Anesthesiology, University of Auckland, Hamilton, New Zealand
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2
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The influence of induction speed on the frontal (processed) EEG. Sci Rep 2020; 10:19444. [PMID: 33173114 PMCID: PMC7655958 DOI: 10.1038/s41598-020-76323-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Accepted: 10/27/2020] [Indexed: 12/12/2022] Open
Abstract
The intravenous injection of the anaesthetic propofol is clinical routine to induce loss of responsiveness (LOR). However, there are only a few studies investigating the influence of the injection rate on the frontal electroencephalogram (EEG) during LOR. Therefore, we focused on changes of the frontal EEG especially during this period. We included 18 patients which were randomly assigned to a slow or fast induction group and recorded the frontal EEG. Based on this data, we calculated the power spectral density, the band powers and band ratios. To analyse the behaviour of processed EEG parameters we calculated the beta ratio, the spectral entropy, and the spectral edge frequency. Due to the prolonged induction period in the slow injection group we were able to distinguish loss of responsiveness to verbal command (LOvR) from loss of responsiveness to painful stimulus (LOpR) whereas in the fast induction group we could not. At LOpR, we observed a higher relative alpha and beta power in the slow induction group while the relative power in the delta range was lower than in the fast induction group. When concentrating on the slow induction group the increase in relative alpha power pre-LOpR and even before LOvR indicated that frontal EEG patterns, which have been suggested as an indicator of unconsciousness, can develop before LOR. Further, LOvR was best reflected by an increase of the alpha to delta ratio, and LOpR was indicated by a decrease of the beta to alpha ratio. These findings highlight the different spectral properties of the EEG at various levels of responsiveness and underline the influence of the propofol injection rate on the frontal EEG during induction of general anesthesia.
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Do Nicotinic Receptors Modulate High-Order Cognitive Processing? Trends Neurosci 2020; 43:550-564. [DOI: 10.1016/j.tins.2020.06.001] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2020] [Revised: 05/19/2020] [Accepted: 06/01/2020] [Indexed: 12/19/2022]
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Mashour GA, Roelfsema P, Changeux JP, Dehaene S. Conscious Processing and the Global Neuronal Workspace Hypothesis. Neuron 2020; 105:776-798. [PMID: 32135090 PMCID: PMC8770991 DOI: 10.1016/j.neuron.2020.01.026] [Citation(s) in RCA: 394] [Impact Index Per Article: 98.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2019] [Revised: 10/31/2019] [Accepted: 01/22/2020] [Indexed: 10/24/2022]
Abstract
We review the central tenets and neuroanatomical basis of the global neuronal workspace (GNW) hypothesis, which attempts to account for the main scientific observations regarding the elementary mechanisms of conscious processing in the human brain. The GNW hypothesis proposes that, in the conscious state, a non-linear network ignition associated with recurrent processing amplifies and sustains a neural representation, allowing the corresponding information to be globally accessed by local processors. We examine this hypothesis in light of recent data that contrast brain activity evoked by either conscious or non-conscious contents, as well as during conscious or non-conscious states, particularly general anesthesia. We also discuss the relationship between the intertwined concepts of conscious processing, attention, and working memory.
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Affiliation(s)
- George A Mashour
- Center for Consciousness Science, Neuroscience Graduate Program, and Department of Anesthesiology, University of Michigan, Ann Arbor, MI, USA
| | - Pieter Roelfsema
- Department of Vision & Cognition, Netherlands Institute for Neuroscience, Meibergdreef 47, 1105 BA, Amsterdam, the Netherlands; Department of Integrative Neurophysiology, Center for Neurogenomics and Cognitive Research, VU University, Amsterdam, the Netherlands; Department of Psychiatry, Academic Medical Center, Amsterdam, the Netherlands
| | - Jean-Pierre Changeux
- CNRS UMR 3571, Institut Pasteur, 75724 Paris, France; Collège de France, 11 Place Marcelin Berthelot, 75005 Paris, France; Kavli Institute for Brain & Mind, University of California, San Diego, La Jolla, CA, USA.
| | - Stanislas Dehaene
- Collège de France, 11 Place Marcelin Berthelot, 75005 Paris, France; Cognitive Neuroimaging Unit, CEA, INSERM, Université Paris-Sud, Université Paris-Saclay, NeuroSpin Center, 91191 Gif/Yvette, France.
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Sanders RD, Banks MI, Darracq M, Moran R, Sleigh J, Gosseries O, Bonhomme V, Brichant JF, Rosanova M, Raz A, Tononi G, Massimini M, Laureys S, Boly M. Propofol-induced unresponsiveness is associated with impaired feedforward connectivity in cortical hierarchy. Br J Anaesth 2018; 121:1084-1096. [PMID: 30336853 DOI: 10.1016/j.bja.2018.07.006] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2017] [Revised: 07/02/2018] [Accepted: 07/11/2018] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Impaired consciousness has been associated with impaired cortical signal propagation after transcranial magnetic stimulation (TMS). We hypothesised that the reduced current propagation under propofol-induced unresponsiveness is associated with changes in both feedforward and feedback connectivity across the cortical hierarchy. METHODS Eight subjects underwent left occipital TMS coupled with high-density EEG recordings during wakefulness and propofol-induced unconsciousness. Spectral analysis was applied to responses recorded from sensors overlying six hierarchical cortical sources involved in visual processing. Dynamic causal modelling (DCM) of induced time-frequency responses and evoked response potentials were used to investigate propofol's effects on connectivity between regions. RESULTS Sensor space analysis demonstrated that propofol reduced both induced and evoked power after TMS in occipital, parietal, and frontal electrodes. Bayesian model selection supported a DCM with hierarchical feedforward and feedback connections. DCM of induced EEG responses revealed that the primary effect of propofol was impaired feedforward responses in cross-frequency theta/alpha-gamma coupling and within frequency theta coupling (F contrast, family-wise error corrected P<0.05). An exploratory analysis (thresholded at uncorrected P<0.001) also suggested that propofol impaired feedforward and feedback beta band coupling. Post hoc analyses showed impairments in all feedforward connections and one feedback connection from parietal to occipital cortex. DCM of the evoked response potential showed impaired feedforward connectivity between left-sided occipital and parietal cortex (T contrast P=0.004, Bonferroni corrected). CONCLUSIONS Propofol-induced loss of consciousness is associated with impaired hierarchical feedforward connectivity assessed by EEG after occipital TMS.
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Affiliation(s)
- R D Sanders
- Department of Anesthesiology, University of Wisconsin, Madison, WI, USA.
| | - M I Banks
- Department of Anesthesiology, University of Wisconsin, Madison, WI, USA
| | - M Darracq
- Department of Anesthesiology, University of Wisconsin, Madison, WI, USA
| | - R Moran
- Faculty of Engineering, University of Bristol, Bristol, UK
| | - J Sleigh
- Department of Anaesthesia, Waikato Hospital, Hamilton, New Zealand
| | - O Gosseries
- Coma Science Group, GIGA-consciousness, University of Liège, Liège, Belgium
| | - V Bonhomme
- Anesthesia and Intensive Care Laboratory, GIGA-Consciousness, University of Liège, Liège, Belgium; Department of Anestheisa and ICM, CHU Liège, Liège, Belgium; University Department of Anesthesia and ICM, CHR Citadelle, Liège, Belgium
| | - J F Brichant
- Department of Anestheisa and ICM, CHU Liège, Liège, Belgium
| | - M Rosanova
- Department of Biomedical and Clinical Sciences, University of Milan, Milan, Italy
| | - A Raz
- Department of Anesthesiology, University of Wisconsin, Madison, WI, USA; Rambam Healthcare Campus, Haifa, Israel
| | - G Tononi
- Department of Psychiatry, University of Wisconsin, Madison, WI, USA
| | - M Massimini
- Department of Biomedical and Clinical Sciences, University of Milan, Milan, Italy
| | - S Laureys
- Coma Science Group, GIGA-consciousness, University of Liège, Liège, Belgium; Department of Neurology, CHU Liège, Liège, Belgium
| | - M Boly
- Department of Psychiatry, University of Wisconsin, Madison, WI, USA; Department of Neurology, University of Wisconsin, Madison, WI, USA
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Scheinin H, Alkire EC, Scheinin A, Alkire MT, Kantonen O, Långsjö J. Using Positron Emission Tomography in Revealing the Mystery of General Anesthesia: Study Design Challenges and Opportunities. Methods Enzymol 2018; 603:279-303. [PMID: 29673531 DOI: 10.1016/bs.mie.2018.01.025] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
Functional neuroimaging with positron emission tomography (PET) is one of the cornerstones for studying the central nervous system effects of general anesthetics and anesthesia mechanisms. General anesthesia offers a unique and safe way to directly manipulate consciousness, and can thus be used as a powerful research tool to study the neurobiology of human consciousness. In this chapter, we will address the possibilities of PET imaging in revealing the mysteries of general anesthesia and anesthetic induced unconsciousness and summarize some of the recent advancements in the field. Importantly, we will discuss possible ways to separate brain activity changes associated with the changing level of consciousness from the concentration or dose-dependent direct or indirect drug effects on the brain. We will try to demonstrate how state-of-the-art clinical pharmacology, use of specific anesthetic drugs, and innovative study design solutions could be utilized.
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Affiliation(s)
- Harry Scheinin
- Turku PET Centre, University of Turku and the Hospital District of Southwest Finland, Turku, Finland; Turku University Hospital, Turku, Finland; Integrative Physiology and Pharmacology, Institute of Biomedicine, University of Turku, Turku, Finland.
| | - Emilee C Alkire
- The Center for the Neurobiology of Learning and Memory, University of California, Irvine, Irvine, CA, United States
| | - Annalotta Scheinin
- Turku PET Centre, University of Turku and the Hospital District of Southwest Finland, Turku, Finland; Turku University Hospital, Turku, Finland
| | - Michael T Alkire
- The Center for the Neurobiology of Learning and Memory, University of California, Irvine, Irvine, CA, United States; VA Long Beach Healthcare System, Long Beach, CA, United States
| | - Oskari Kantonen
- Turku University Hospital, Turku, Finland; The Center for the Neurobiology of Learning and Memory, University of California, Irvine, Irvine, CA, United States
| | - Jaakko Långsjö
- Turku PET Centre, University of Turku and the Hospital District of Southwest Finland, Turku, Finland; Tampere University Hospital, Tampere, Finland
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Sanders RD, Mostert N, Lindroth H, Tononi G, Sleigh J. Is consciousness frontal? Two perioperative case reports that challenge that concept. Br J Anaesth 2018; 121:330-332. [PMID: 29935590 DOI: 10.1016/j.bja.2018.01.010] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2017] [Revised: 01/09/2018] [Accepted: 01/10/2018] [Indexed: 11/19/2022] Open
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Network Properties in Transitions of Consciousness during Propofol-induced Sedation. Sci Rep 2017; 7:16791. [PMID: 29196672 PMCID: PMC5711919 DOI: 10.1038/s41598-017-15082-5] [Citation(s) in RCA: 64] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2017] [Accepted: 10/20/2017] [Indexed: 01/10/2023] Open
Abstract
Reliable electroencephalography (EEG) signatures of transitions between consciousness and unconsciousness under anaesthesia have not yet been identified. Herein we examined network changes using graph theoretical analysis of high-density EEG during patient-titrated propofol-induced sedation. Responsiveness was used as a surrogate for consciousness. We divided the data into five states: baseline, transition into unresponsiveness, unresponsiveness, transition into responsiveness, and recovery. Power spectral analysis showed that delta power increased from responsiveness to unresponsiveness. In unresponsiveness, delta waves propagated from frontal to parietal regions as a traveling wave. Local increases in delta connectivity were evident in parietal but not frontal regions. Graph theory analysis showed that increased local efficiency could differentiate the levels of responsiveness. Interestingly, during transitions of responsive states, increased beta connectivity was noted relative to consciousness and unconsciousness, again with increased local efficiency. Abrupt network changes are evident in the transitions in responsiveness, with increased beta band power/connectivity marking transitions between responsive states, while the delta power/connectivity changes were consistent with the fading of consciousness using its surrogate responsiveness. These results provide novel insights into the neural correlates of these behavioural transitions and EEG signatures for monitoring the levels of consciousness under sedation.
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Banks M, Murphy C, Sanders R. Correlational studies of unconsciousness under anaesthesia: how far can preclinical studies take us? Br J Anaesth 2017; 119:1079-1081. [DOI: 10.1093/bja/aex391] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Demertzi A, Sitt JD, Sarasso S, Pinxten W. Measuring states of pathological (un)consciousness: research dimensions, clinical applications, and ethics. Neurosci Conscious 2017; 2017:nix010. [PMID: 30042843 PMCID: PMC6007135 DOI: 10.1093/nc/nix010] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2016] [Revised: 02/02/2017] [Accepted: 04/18/2017] [Indexed: 12/26/2022] Open
Abstract
Consciousness is a multidimensional construct with no widely accepted definition. Especially in pathological conditions, it is less clear what exactly is meant by (un)consciousness, how it can be reliably observed or measured. Here, we aim at (i) bringing together state of the art approaches to classification of single patients suffering from disorders of consciousness by means of motor-independent assessment of consciousness states with electrophysiology and functional neuroimaging, (ii) showing how each proposed metric translates into clinical practice and (iii) raising a discussion on the ethical aspects of consciousness measurements. We realize that when dealing with patients some issues commonly pertain to each methodology discussed here, such as the overall clinical condition, clinical heterogeneity, and diagnostic uncertainty. When predicting patients' diagnosis, though, each method adopts a different approach to determine (a) a "gold standard" of the benchmark population upon which the metric is computed and (b) the generalization and replicability in the attempt to avoid overfitting. From an applied ethics perspective, the focus is, hence, on knowing what one is measuring and on the validity of measurements. We conclude that, when searching for consciousness in pathological conditions, confident diagnosis can be based on the use of probabilistic predictions as well as on accumulative evidence stemming from multiple non-overlapping assessments with different modalities. A framework which will regulate the application order of these techniques (balancing their availability, sensitivity, and specificity, based on underlying clinical assumptions about a patient's conscious state), is expected to ameliorate clinical management and further inform on the critical patterns of (un)consciousness.
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Affiliation(s)
- Athena Demertzi
- Brain and Spine Institute- Institut du Cerveau et de la Moelle épinière (ICM), Hôpital Pitié-Salpêtrière, 47, bd de l'Hôpital - 75013 Paris, France
- Coma Science Group, GIGA Research, CHU Sart Tilman B34-Quartier Hôpital, Avenue de l'Hôpital, 11 4000 Liège, Belgium
| | - Jacobo Diego Sitt
- Brain and Spine Institute- Institut du Cerveau et de la Moelle épinière (ICM), Hôpital Pitié-Salpêtrière, 47, bd de l'Hôpital - 75013 Paris, France
- INSERM, U 1127, F-75013, Paris, France
| | - Simone Sarasso
- Department of Biomedical and Clinical Sciences “L. Sacco”, University of Milan, Via G.B. Grassi, 74. 20157, Milano, Italy
| | - Wim Pinxten
- Faculty of Medicine and Life Sciences, Hasselt University, Martelarenlaan 42, 3500 Hasselt, Belgium
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Rowley P, Boncyk C, Gaskell A, Absalom A, Bonhomme V, Coburn M, Raz A, Sleigh J, Sanders R. What do people expect of general anaesthesia? Br J Anaesth 2017; 118:486-488. [DOI: 10.1093/bja/aex040] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
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Incidence of Connected Consciousness after Tracheal Intubation: A Prospective, International, Multicenter Cohort Study of the Isolated Forearm Technique. Anesthesiology 2016; 126:214-222. [PMID: 27984262 DOI: 10.1097/aln.0000000000001479] [Citation(s) in RCA: 72] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
BACKGROUND The isolated forearm technique allows assessment of consciousness of the external world (connected consciousness) through a verbal command to move the hand (of a tourniquet-isolated arm) during intended general anesthesia. Previous isolated forearm technique data suggest that the incidence of connected consciousness may approach 37% after a noxious stimulus. The authors conducted an international, multicenter, pragmatic study to establish the incidence of isolated forearm technique responsiveness after intubation in routine practice. METHODS Two hundred sixty adult patients were recruited at six sites into a prospective cohort study of the isolated forearm technique after intubation. Demographic, anesthetic, and intubation data, plus postoperative questionnaires, were collected. Univariate statistics, followed by bivariate logistic regression models for age plus variable, were conducted. RESULTS The incidence of isolated forearm technique responsiveness after intubation was 4.6% (12/260); 5 of 12 responders reported pain through a second hand squeeze. Responders were younger than nonresponders (39 ± 17 vs. 51 ± 16 yr old; P = 0.01) with more frequent signs of sympathetic activation (50% vs. 2.4%; P = 0.03). No participant had explicit recall of intraoperative events when questioned after surgery (n = 253). Across groups, depth of anesthesia monitoring values showed a wide range; however, values were higher for responders before (54 ± 20 vs. 42 ± 14; P = 0.02) and after (52 ± 16 vs. 43 ± 16; P = 0.02) intubation. In patients not receiving total intravenous anesthesia, exposure to volatile anesthetics before intubation reduced the odds of responding (odds ratio, 0.2 [0.1 to 0.8]; P = 0.02) after adjustment for age. CONCLUSIONS Intraoperative connected consciousness occurred frequently, although the rate is up to 10-times lower than anticipated. This should be considered a conservative estimate of intraoperative connected consciousness.
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Casarotto S, Comanducci A, Rosanova M, Sarasso S, Fecchio M, Napolitani M, Pigorini A, G Casali A, Trimarchi PD, Boly M, Gosseries O, Bodart O, Curto F, Landi C, Mariotti M, Devalle G, Laureys S, Tononi G, Massimini M. Stratification of unresponsive patients by an independently validated index of brain complexity. Ann Neurol 2016; 80:718-729. [PMID: 27717082 PMCID: PMC5132045 DOI: 10.1002/ana.24779] [Citation(s) in RCA: 241] [Impact Index Per Article: 30.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2016] [Revised: 09/12/2016] [Accepted: 09/13/2016] [Indexed: 12/19/2022]
Abstract
Objective Validating objective, brain‐based indices of consciousness in behaviorally unresponsive patients represents a challenge due to the impossibility of obtaining independent evidence through subjective reports. Here we address this problem by first validating a promising metric of consciousness—the Perturbational Complexity Index (PCI)—in a benchmark population who could confirm the presence or absence of consciousness through subjective reports, and then applying the same index to patients with disorders of consciousness (DOCs). Methods The benchmark population encompassed 150 healthy controls and communicative brain‐injured subjects in various states of conscious wakefulness, disconnected consciousness, and unconsciousness. Receiver operating characteristic curve analysis was performed to define an optimal cutoff for discriminating between the conscious and unconscious conditions. This cutoff was then applied to a cohort of noncommunicative DOC patients (38 in a minimally conscious state [MCS] and 43 in a vegetative state [VS]). Results We found an empirical cutoff that discriminated with 100% sensitivity and specificity between the conscious and the unconscious conditions in the benchmark population. This cutoff resulted in a sensitivity of 94.7% in detecting MCS and allowed the identification of a number of unresponsive VS patients (9 of 43) with high values of PCI, overlapping with the distribution of the benchmark conscious condition. Interpretation Given its high sensitivity and specificity in the benchmark and MCS population, PCI offers a reliable, independently validated stratification of unresponsive patients that has important physiopathological and therapeutic implications. In particular, the high‐PCI subgroup of VS patients may retain a capacity for consciousness that is not expressed in behavior. Ann Neurol 2016;80:718–729
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Affiliation(s)
- Silvia Casarotto
- Department of Biomedical and Clinical Sciences "L. Sacco", University of Milan, Milan, Italy
| | - Angela Comanducci
- Department of Biomedical and Clinical Sciences "L. Sacco", University of Milan, Milan, Italy
| | - Mario Rosanova
- Department of Biomedical and Clinical Sciences "L. Sacco", University of Milan, Milan, Italy.,Fondazione Europea per la Ricerca Biomedica, Milan, Italy
| | - Simone Sarasso
- Department of Biomedical and Clinical Sciences "L. Sacco", University of Milan, Milan, Italy
| | - Matteo Fecchio
- Department of Biomedical and Clinical Sciences "L. Sacco", University of Milan, Milan, Italy
| | - Martino Napolitani
- Department of Health Science, School of Medicine and Surgery, University of Milan-Bicocca, Monza, Italy
| | - Andrea Pigorini
- Department of Biomedical and Clinical Sciences "L. Sacco", University of Milan, Milan, Italy
| | - Adenauer G Casali
- Institute of Science and Technology, Federal University of São Paulo, São José dos Campos, Brazil
| | - Pietro D Trimarchi
- Istituto di Ricovero e Cura a Carattere Scientifico, Fondazione Don Gnocchi Onlus, Milan, Italy
| | - Melanie Boly
- Department of Psychiatry, University of Wisconsin, Madison, WI, USA.,Department of Neurology, University of Wisconsin, Madison, WI, USA
| | - Olivia Gosseries
- Department of Psychiatry, University of Wisconsin, Madison, WI, USA.,Coma Science Group, GIGA, University of Liège, Liège, Belgium
| | - Olivier Bodart
- Coma Science Group, GIGA, University of Liège, Liège, Belgium.,Department of Neurology, University of Liège and University Hospital of Liège, Liège, Belgium
| | - Francesco Curto
- Neurocritical Care Unit, Department of Neuroscience, Azienda Socio-Sanitaria Territoriale, Grande Ospedale Metropolitano Niguarda Cà Granda, Milan, Italy
| | - Cristina Landi
- Fondazione Europea per la Ricerca Biomedica, Milan, Italy
| | - Maurizio Mariotti
- Department of Biomedical and Clinical Sciences "L. Sacco", University of Milan, Milan, Italy
| | - Guya Devalle
- Istituto di Ricovero e Cura a Carattere Scientifico, Fondazione Don Gnocchi Onlus, Milan, Italy
| | - Steven Laureys
- Coma Science Group, GIGA, University of Liège, Liège, Belgium
| | - Giulio Tononi
- Department of Psychiatry, University of Wisconsin, Madison, WI, USA
| | - Marcello Massimini
- Department of Biomedical and Clinical Sciences "L. Sacco", University of Milan, Milan, Italy.,Istituto di Ricovero e Cura a Carattere Scientifico, Fondazione Don Gnocchi Onlus, Milan, Italy
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Russell I, Sanders R. Monitoring consciousness under anaesthesia: the 21st century isolated forearm technique. Br J Anaesth 2016; 116:738-40. [DOI: 10.1093/bja/aew112] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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