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Woodward MR, Wells CL, Arnold S, Dorman F, Ahmed Z, Morris NA, Ciryam P, Podell JE, Chang WTW, Zimmerman WD, Motta M, Butt B, Pergakis MB, Labib M, Wang TI, Edlow BL, Badjatia N, Braun R, Parikh GY. Behavioral Assessment With the Coma Recovery Scale-Revised Is Safe and Feasible in Critically Ill Patients With Disorders of Consciousness. Crit Care Explor 2024; 6:e1101. [PMID: 38912722 PMCID: PMC11199005 DOI: 10.1097/cce.0000000000001101] [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: 06/25/2024] Open
Abstract
OBJECTIVES Accurate classification of disorders of consciousness (DoC) is key in developing rehabilitation plans after brain injury. The Coma Recovery Scale-Revised (CRS-R) is a sensitive measure of consciousness validated in the rehabilitation phase of care. We tested the feasibility, safety, and impact of CRS-R-guided rehabilitation in the ICU for patients with DoC after acute hemorrhagic stroke. DESIGN Retrospective cohort study. SETTING This single-center study was conducted in the neurocritical care unit at the University of Maryland Medical Center. PATIENTS We analyzed records from consecutive patients with subarachnoid hemorrhage (SAH) or intracerebral hemorrhage (ICH), who underwent serial CRS-R assessments during ICU admission from April 1, 2018, to December 31, 2021, where CRS-R less than 8 is vegetative state/unresponsive wakefulness syndrome (VS/UWS); CRS-R greater than or equal to 8 is a minimally conscious state (MCS). INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Outcomes included adverse events during CRS-R evaluations and associations between CRS-R and discharge disposition, therapy-based function, and mobility. We examined the utility of CRS-R compared with other therapist clinical assessment tools in predicting discharge disposition. Seventy-six patients (22 SAH, 54 ICH, median age = 59, 50% female) underwent 276 CRS-R sessions without adverse events. Discharge to acute rehabilitation occurred in 4.4% versus 41.9% of patients with a final CRS-R less than 8 and CRS-R greater than or equal to 8, respectively (odds ratio [OR] 13.4; 95% CI, 2.7-66.1; p < 0.001). Patients with MCS on final CRS-R completed more therapy sessions during hospitalization and had improved mobility and functional performance. Compared with other therapy assessment tools, the CRS-R had the best performance in predicting discharge disposition (area under the curve: 0.83; 95% CI, 0.72-0.94; p < 0.0001). CONCLUSIONS Early neurorehabilitation guided by CRS-R appears to be feasible and safe in the ICU following hemorrhagic stroke complicated by DoC and may enhance access to inpatient rehabilitation, with the potential for lasting benefit on recovery. Further research is needed to assess generalizability and understand the impact on long-term outcomes.
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Affiliation(s)
| | - Chris L. Wells
- Department of Rehabilitation Medicine, University of Maryland School of Medicine, Baltimore, MD
| | - Shannon Arnold
- Department of Neurology, University of Maryland School of Medicine, Baltimore, MD
| | - Farra Dorman
- Department of Rehabilitation Medicine, University of Maryland School of Medicine, Baltimore, MD
| | - Zaka Ahmed
- Department of Neurology, University of Maryland School of Medicine, Baltimore, MD
| | - Nicholas A. Morris
- Program in Trauma, R Adams Cowley Shock Trauma Center, Baltimore, MD
- Department of Neurology, University of Maryland School of Medicine, Baltimore, MD
| | - Prajwal Ciryam
- Program in Trauma, R Adams Cowley Shock Trauma Center, Baltimore, MD
- Department of Neurology, University of Maryland School of Medicine, Baltimore, MD
| | - Jamie E. Podell
- Program in Trauma, R Adams Cowley Shock Trauma Center, Baltimore, MD
- Department of Neurology, University of Maryland School of Medicine, Baltimore, MD
| | - Wan-Tsu W. Chang
- Program in Trauma, R Adams Cowley Shock Trauma Center, Baltimore, MD
- Department of Neurology, University of Maryland School of Medicine, Baltimore, MD
- Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, MD
| | - W. Denney Zimmerman
- Program in Trauma, R Adams Cowley Shock Trauma Center, Baltimore, MD
- Department of Neurology, University of Maryland School of Medicine, Baltimore, MD
| | - Melissa Motta
- Program in Trauma, R Adams Cowley Shock Trauma Center, Baltimore, MD
- Department of Neurology, University of Maryland School of Medicine, Baltimore, MD
| | - Bilal Butt
- Program in Trauma, R Adams Cowley Shock Trauma Center, Baltimore, MD
- Department of Neurology, University of Maryland School of Medicine, Baltimore, MD
| | - Melissa B. Pergakis
- Program in Trauma, R Adams Cowley Shock Trauma Center, Baltimore, MD
- Department of Neurology, University of Maryland School of Medicine, Baltimore, MD
| | - Mohamed Labib
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, MD
| | - Ting I. Wang
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, MD
| | - Brian L. Edlow
- Department of Neurology, Massachusetts General Hospital, Boston, MA
| | - Neeraj Badjatia
- Program in Trauma, R Adams Cowley Shock Trauma Center, Baltimore, MD
- Department of Neurology, University of Maryland School of Medicine, Baltimore, MD
| | - Robynne Braun
- Department of Rehabilitation Medicine, University of Maryland School of Medicine, Baltimore, MD
- Department of Neurology, University of Maryland School of Medicine, Baltimore, MD
| | - Gunjan Y. Parikh
- Program in Trauma, R Adams Cowley Shock Trauma Center, Baltimore, MD
- Department of Neurology, University of Maryland School of Medicine, Baltimore, MD
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Fins JJ, Shulman KS. Neuroethics, Covert Consciousness, and Disability Rights: What Happens When Artificial Intelligence Meets Cognitive Motor Dissociation? J Cogn Neurosci 2024; 36:1667-1674. [PMID: 38579252 DOI: 10.1162/jocn_a_02157] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/07/2024]
Abstract
In this article, we consider the intersection of cognitive motor dissociation (CMD) and artificial intelligence (AI), hence when CMD meets AI. In covert consciousness, there is a discordance between the observed behavior, the traditional bedside mode of assessment, and the response to volitional commands as depicted by neuroimaging or EEG studies. This alphabet soup of acronyms represents both the promise and peril of nascent technology in covert consciousness. On the diagnostic side, there is the complexity and uncertainty of identifying the discordance between cognitive activity and overt behavior. On the therapeutic side, when AI is used to generate speech, there is the possibility of misrepresenting the thoughts and intentions of those who are otherwise voiceless. This concordance of factors makes the application of AI to CMD worthy of deeper consideration. We offer this analysis in the spirit of anticipatory governance, a prudential process by which one plans to prevent or mitigate unintended consequences of novel technology. We first consider the normative challenges posed by CMD for clinical practice, neuroethics, and the law. We then explore the history of covert consciousness and the relationship of severe brain injury to the right-to-die movement, before introducing three biographies of brain injury that highlight the potential impact of disability bias or ableism in clinical practice, assistive technology, and translational research. Subsequently, we explore how AI might give voice to conscious individuals who are unable to communicate and the ethical challenges that this technology must overcome to promote human flourishing drawing upon what Nussbaum and Sen have described as a "capabilities approach" to promote normative reasoning.
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Yan Y, Li M, Annen J, Huang W, Cai T, Wang X, Hu X, Laureys S, Di H. Perception of diagnosis by family caregivers in severe brain injury patients in China. BMC Palliat Care 2024; 23:148. [PMID: 38872186 PMCID: PMC11170822 DOI: 10.1186/s12904-024-01482-8] [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] [Received: 06/24/2023] [Accepted: 06/05/2024] [Indexed: 06/15/2024] Open
Abstract
OBJECTIVES Surrogate decision-making by family caregivers for patients with severe brain injury is influenced by the availability and understanding of relevant information and expectations for future rehabilitation. We aimed to compare the consistency of family caregivers' perceptions with clinical diagnoses and to inform their expectation of prognosis in the future. METHODS The Coma Recovery Scale-Revised was used to assess the diagnosis of inpatients with severe brain injury between February 2019 and February 2020. A main family caregiver was included per patient. The family caregiver's perception of the patient's consciousness and expectations of future recovery were collected through questionnaires and compared consistently with the clinical diagnosis. RESULTS The final sample included 101 main family caregivers of patients (57 UWS, unresponsive wakefulness syndrome, 37 MCS, minimally conscious state, 7 EMCS, emergence from MCS) with severe brain injury. Only 57 family caregivers correctly assessed the level of consciousness as indicated by the CRS-R, showing weak consistency (Kappa = 0.217, P = 0.002). Family caregivers' demographic characteristics and CRS-R diagnosis influenced the consistency between perception and clinical diagnosis. Family caregivers who provided hands-on care to patients showed higher levels of consistent perception (AOR = 12.24, 95% CI = 2.06-73.00, P = 0.006). Compared to UWS, the family caregivers of MCS patients were more likely to have a correct perception (OR = 7.68, 95% CI = 1.34-44.06). Family caregivers had positive expectations for patients' recovery in terms of both communication and returning to normal life. CONCLUSION Nearly half of family caregivers have inadequate understanding of their relative's level of consciousness, and most of them report overly optimistic expectations that do not align with clinical diagnosis. Providing more medical information to family caregivers to support their surrogate decision-making process is essential.
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Affiliation(s)
- Yifan Yan
- International Unresponsive Wakefulness Syndrome and Consciousness Science Institute, Hangzhou Normal University, Hangzhou, 310036, China
- School of Public Health, Zhejiang University, Hangzhou, China
| | - Meiqi Li
- International Unresponsive Wakefulness Syndrome and Consciousness Science Institute, Hangzhou Normal University, Hangzhou, 310036, China
- Department of Nursing, Hangzhou First People's Hospital, Hangzhou, China
| | - Jitka Annen
- Coma Science Group, GIGA-Consciousness, University of Liège, Liège, Belgium
- Centre du Cerveau2, University Hospital of Liège, Liège, Belgium
| | - Wangshan Huang
- International Unresponsive Wakefulness Syndrome and Consciousness Science Institute, Hangzhou Normal University, Hangzhou, 310036, China
| | - Tiantian Cai
- Department of Endocrinology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Xueying Wang
- International Unresponsive Wakefulness Syndrome and Consciousness Science Institute, Hangzhou Normal University, Hangzhou, 310036, China
| | - Xiaohua Hu
- Department of Rehabilitation, Hospital of Zhejiang People's Armed Polic, Hangzhou, China
| | - Steven Laureys
- Coma Science Group, GIGA-Consciousness, University of Liège, Liège, Belgium
- Centre du Cerveau2, University Hospital of Liège, Liège, Belgium
- CERVO Brain Research Centre, Laval University, Québec, Canada
| | - Haibo Di
- International Unresponsive Wakefulness Syndrome and Consciousness Science Institute, Hangzhou Normal University, Hangzhou, 310036, China.
- School of Basic Medicine, Hangzhou Normal University, Hangzhou, China.
- Department of radiology of Affiliated Hospital, Hangzhou Normal University, Hangzhou, China.
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Leskinen S, Singha S, Mehta NH, Quelle M, Shah HA, D'Amico RS. Applications of Functional Magnetic Resonance Imaging to the Study of Functional Connectivity and Activation in Neurological Disease: A Scoping Review of the Literature. World Neurosurg 2024; 189:185-192. [PMID: 38843969 DOI: 10.1016/j.wneu.2024.06.003] [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: 05/13/2024] [Accepted: 06/02/2024] [Indexed: 07/09/2024]
Abstract
BACKGROUND Functional magnetic resonance imaging (fMRI) has transformed our understanding of brain's functional architecture, providing critical insights into neurological diseases. This scoping review synthesizes the current landscape of fMRI applications across various neurological domains, elucidating the evolving role of both task-based and resting-state fMRI in different settings. METHODS We conducted a comprehensive scoping review following the Preferred Reporting Items for Systematic Review and Meta-Analyses Extension for Scoping Reviews guidelines. Extensive searches in Medline/PubMed, Embase, and Web of Science were performed, focusing on studies published between 2003 and 2023 that utilized fMRI to explore functional connectivity and regional activation in adult patients with neurological conditions. Studies were selected based on predefined inclusion and exclusion criteria, with data extracted. RESULTS We identified 211 studies, covering a broad spectrum of neurological disorders including mental health, movement disorders, epilepsy, neurodegeneration, traumatic brain injury, cerebrovascular accidents, vascular abnormalities, neurorehabilitation, neuro-critical care, and brain tumors. The majority of studies utilized resting-state fMRI, underscoring its prominence in identifying disease-specific connectivity patterns. Results highlight the potential of fMRI to reveal the underlying pathophysiological mechanisms of various neurological conditions, facilitate diagnostic processes, and potentially guide therapeutic interventions. CONCLUSIONS fMRI serves as a powerful tool for elucidating complex neural dynamics and pathologies associated with neurological diseases. Despite the breadth of applications, further research is required to standardize fMRI protocols, improve interpretative methodologies, and enhance the translation of imaging findings to clinical practice. Advances in fMRI technology and analytics hold promise for improving the precision of neurological assessments and interventions.
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Affiliation(s)
- Sandra Leskinen
- State University of New York Downstate Medical Center, New York, USA
| | - Souvik Singha
- Department of Neurological Surgery, Lenox Hill Hospital/Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, New York, NY, USA.
| | - Neel H Mehta
- Department of Neurosurgery, Massachusetts General Hospital/Harvard Medical School, Boston, MA, USA
| | | | - Harshal A Shah
- Department of Neurological Surgery, Lenox Hill Hospital/Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, New York, NY, USA
| | - Randy S D'Amico
- Department of Neurological Surgery, Lenox Hill Hospital/Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, New York, NY, USA
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Kim KS, Polizzotto L, Suarez JI, Olson DM, Hemphill JC, Mainali S. An Update on Curing Coma Campaign. Semin Neurol 2024; 44:389-397. [PMID: 38631382 DOI: 10.1055/s-0044-1785478] [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: 04/19/2024]
Abstract
The Curing Coma Campaign (CCC) and its contributing collaborators identified multiple key areas of knowledge and research gaps in coma and disorders of consciousness (DoC). This step was a crucial effort and essential to prioritize future educational and research efforts. These key areas include defining categories of DoC, assessing DoC using multimodal approach (e.g., behavioral assessment tools, advanced neuroimaging studies), discussing optimal clinical trials' design and exploring computational models to conduct clinical trials in patients with DoC, and establishing common data elements to standardize data collection. Other key areas focused on creating coma care registry and educating clinicians and patients and promoting awareness of DoC to improve care in patients with DoC. The ongoing efforts in these key areas are discussed.
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Affiliation(s)
- Keri S Kim
- Department of Pharmacy Practice, University of Illinois Chicago, Chicago, Illinois
| | - Leonard Polizzotto
- Department of Biomedical Engineering, Worcester Polytechnic Institute, Worcester, Massachusetts
| | - Jose I Suarez
- Division of Neurosciences Critical Care, Departments of Anesthesiology and Critical Care Medicine, Neurology, and Neurosurgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - DaiWai M Olson
- Department of Neurology, University of Texas Southwestern, Dallas, Texas
| | - J Claude Hemphill
- Department of Neurology, University of California, San Francisco, California
| | - Shraddha Mainali
- Department of Neurology, Virginia Commonwealth University School of Medicine, Richmond, Virginia
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Lejeune N, Fritz P, Cardone P, Szymkowicz E, Vitello MM, Martial C, Thibaut A, Gosseries O. Exploring the Significance of Cognitive Motor Dissociation on Patient Outcome in Acute Disorders of Consciousness. Semin Neurol 2024; 44:271-280. [PMID: 38604229 DOI: 10.1055/s-0044-1785507] [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: 04/13/2024]
Abstract
Cognitive motor dissociation (CMD) is characterized by a dissociation between volitional brain responses and motor control, detectable only through techniques such as electroencephalography (EEG) and functional magnetic resonance imaging. Hence, it has recently emerged as a major challenge in the assessment of patients with disorders of consciousness. Specifically, this review focuses on the prognostic implications of CMD detection during the acute stage of brain injury. CMD patients were identified in each diagnostic category (coma, unresponsive wakefulness syndrome/vegetative state, minimally conscious state minus) with a relatively similar prevalence of around 20%. Current knowledge tends to indicate that the diagnosis of CMD in the acute phase often predicts a more favorable clinical outcome compared with other unresponsive non-CMD patients. Nevertheless, the review underscores the limited research in this domain, probably at least partially explained by its nascent nature and the lack of uniformity in the nomenclature for CMD-related disorders, hindering the impact of the literature in the field.
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Affiliation(s)
- Nicolas Lejeune
- Coma Science Group, GIGA-Consciousness, University of Liège, Liège, Belgium
- Centre du Cerveau, University Hospital of Liège, Liège, Belgium
- DoC Care Unit, Centre Hospitalier Neurologique William Lennox, Ottignies-Louvain-la-Neuve, Belgium
- Institute of NeuroScience, UCLouvain, Brussels, Belgium
| | - Pauline Fritz
- Coma Science Group, GIGA-Consciousness, University of Liège, Liège, Belgium
- Centre du Cerveau, University Hospital of Liège, Liège, Belgium
| | - Paolo Cardone
- Coma Science Group, GIGA-Consciousness, University of Liège, Liège, Belgium
- Centre du Cerveau, University Hospital of Liège, Liège, Belgium
| | - Emilie Szymkowicz
- Coma Science Group, GIGA-Consciousness, University of Liège, Liège, Belgium
- Centre du Cerveau, University Hospital of Liège, Liège, Belgium
| | - Marie M Vitello
- Coma Science Group, GIGA-Consciousness, University of Liège, Liège, Belgium
- Centre du Cerveau, University Hospital of Liège, Liège, Belgium
| | - Charlotte Martial
- Coma Science Group, GIGA-Consciousness, University of Liège, Liège, Belgium
- Centre du Cerveau, University Hospital of Liège, Liège, Belgium
| | - Aurore Thibaut
- Coma Science Group, GIGA-Consciousness, University of Liège, Liège, Belgium
- Centre du Cerveau, University Hospital of Liège, Liège, Belgium
| | - Olivia Gosseries
- Coma Science Group, GIGA-Consciousness, University of Liège, Liège, Belgium
- Centre du Cerveau, University Hospital of Liège, Liège, Belgium
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7
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Podell JE, Morris NA. Traumatic Brain Injury and Traumatic Spinal Cord Injury. Continuum (Minneap Minn) 2024; 30:721-756. [PMID: 38830069 DOI: 10.1212/con.0000000000001423] [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: 06/05/2024]
Abstract
OBJECTIVE This article reviews the mechanisms of primary traumatic injury to the brain and spinal cord, with an emphasis on grading severity, identifying surgical indications, anticipating complications, and managing secondary injury. LATEST DEVELOPMENTS Serum biomarkers have emerged for clinical decision making and prognosis after traumatic injury. Cortical spreading depolarization has been identified as a potentially modifiable mechanism of secondary injury after traumatic brain injury. Innovative methods to detect covert consciousness may inform prognosis and enrich future studies of coma recovery. The time-sensitive nature of spinal decompression is being elucidated. ESSENTIAL POINTS Proven management strategies for patients with severe neurotrauma in the intensive care unit include surgical decompression when appropriate, the optimization of perfusion, and the anticipation and treatment of complications. Despite validated models, predicting outcomes after traumatic brain injury remains challenging, requiring prognostic humility and a model of shared decision making with surrogate decision makers to establish care goals. Penetrating injuries, especially gunshot wounds, are often devastating and require public health and policy approaches that target prevention.
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8
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Young MJ, Kazazian K, Fischer D, Lissak IA, Bodien YG, Edlow BL. Disclosing Results of Tests for Covert Consciousness: A Framework for Ethical Translation. Neurocrit Care 2024; 40:865-878. [PMID: 38243150 PMCID: PMC11147696 DOI: 10.1007/s12028-023-01899-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Accepted: 11/22/2023] [Indexed: 01/21/2024]
Abstract
The advent of neurotechnologies including advanced functional magnetic resonance imaging and electroencephalography to detect states of awareness not detectable by traditional bedside neurobehavioral techniques (i.e., covert consciousness) promises to transform neuroscience research and clinical practice for patients with brain injury. As these interventions progress from research tools into actionable, guideline-endorsed clinical tests, ethical guidance for clinicians on how to responsibly communicate the sensitive results they yield is crucial yet remains underdeveloped. Drawing on insights from empirical and theoretical neuroethics research and our clinical experience with advanced neurotechnologies to detect consciousness in behaviorally unresponsive patients, we critically evaluate ethical promises and perils associated with disclosing the results of clinical covert consciousness assessments and describe a semistructured approach to responsible data sharing to mitigate potential risks.
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Affiliation(s)
- Michael J Young
- Center for Neurotechnology and Neurorecovery, Department of Neurology, Massachusetts General Hospital and Harvard Medical School, 101 Merrimac Street, Suite 310, Boston, MA, 02114, USA.
| | - Karnig Kazazian
- Center for Neurotechnology and Neurorecovery, Department of Neurology, Massachusetts General Hospital and Harvard Medical School, 101 Merrimac Street, Suite 310, Boston, MA, 02114, USA
- Western Institute of Neuroscience, Western University, London, ON, Canada
| | - David Fischer
- University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - India A Lissak
- Center for Neurotechnology and Neurorecovery, Department of Neurology, Massachusetts General Hospital and Harvard Medical School, 101 Merrimac Street, Suite 310, Boston, MA, 02114, USA
| | - Yelena G Bodien
- Center for Neurotechnology and Neurorecovery, Department of Neurology, Massachusetts General Hospital and Harvard Medical School, 101 Merrimac Street, Suite 310, Boston, MA, 02114, USA
| | - Brian L Edlow
- Center for Neurotechnology and Neurorecovery, Department of Neurology, Massachusetts General Hospital and Harvard Medical School, 101 Merrimac Street, Suite 310, Boston, MA, 02114, USA
- Athinoula A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital and Harvard Medical School, Charlestown, MA, USA
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Lo CCH, Woo PYM, Cheung VCK. Task-based EEG and fMRI paradigms in a multimodal clinical diagnostic framework for disorders of consciousness. Rev Neurosci 2024; 0:revneuro-2023-0159. [PMID: 38804042 DOI: 10.1515/revneuro-2023-0159] [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: 12/20/2023] [Accepted: 05/09/2024] [Indexed: 05/29/2024]
Abstract
Disorders of consciousness (DoC) are generally diagnosed by clinical assessment, which is a predominantly motor-driven process and accounts for up to 40 % of non-communication being misdiagnosed as unresponsive wakefulness syndrome (UWS) (previously known as prolonged/persistent vegetative state). Given the consequences of misdiagnosis, a more reliable and objective multimodal protocol to diagnosing DoC is needed, but has not been produced due to concerns regarding their interpretation and reliability. Of the techniques commonly used to detect consciousness in DoC, task-based paradigms (active paradigms) produce the most unequivocal result when findings are positive. It is well-established that command following (CF) reliably reflects preserved consciousness. Task-based electroencephalography (EEG) and functional magnetic resonance imaging (fMRI) can detect motor-independent CF and reveal preserved covert consciousness in up to 14 % of UWS patients. Accordingly, to improve the diagnostic accuracy of DoC, we propose a practical multimodal clinical decision framework centered on task-based EEG and fMRI, and complemented by measures like transcranial magnetic stimulation (TMS-EEG).
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Affiliation(s)
- Chris Chun Hei Lo
- School of Biomedical Sciences, and Gerald Choa Neuroscience Institute, The Chinese University of Hong Kong, Shatin, New Territories, Hong Kong, China
| | - Peter Yat Ming Woo
- Division of Neurosurgery, Department of Surgery, Faculty of Medicine, The Chinese University of Hong Kong, Shatin, New Territories, Hong Kong, China
| | - Vincent C K Cheung
- School of Biomedical Sciences, and Gerald Choa Neuroscience Institute, The Chinese University of Hong Kong, Shatin, New Territories, Hong Kong, China
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Yang H, Wu H, Kong L, Luo W, Xie Q, Pan J, Quan W, Hu L, Li D, Wu X, Liang H, Qin P. Precise detection of awareness in disorders of consciousness using deep learning framework. Neuroimage 2024; 290:120580. [PMID: 38508294 DOI: 10.1016/j.neuroimage.2024.120580] [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: 01/19/2024] [Revised: 03/14/2024] [Accepted: 03/16/2024] [Indexed: 03/22/2024] Open
Abstract
Diagnosis of disorders of consciousness (DOC) remains a formidable challenge. Deep learning methods have been widely applied in general neurological and psychiatry disorders, while limited in DOC domain. Considering the successful use of resting-state functional MRI (rs-fMRI) for evaluating patients with DOC, this study seeks to explore the conjunction of deep learning techniques and rs-fMRI in precisely detecting awareness in DOC. We initiated our research with a benchmark dataset comprising 140 participants, including 76 unresponsive wakefulness syndrome (UWS), 25 minimally conscious state (MCS), and 39 Controls, from three independent sites. We developed a cascade 3D EfficientNet-B3-based deep learning framework tailored for discriminating MCS from UWS patients, referred to as "DeepDOC", and compared its performance against five state-of-the-art machine learning models. We also included an independent dataset consists of 11 DOC patients to test whether our model could identify patients with cognitive motor dissociation (CMD), in which DOC patients were behaviorally diagnosed unconscious but could be detected conscious by brain computer interface (BCI) method. Our results demonstrate that DeepDOC outperforms the five machine learning models, achieving an area under curve (AUC) value of 0.927 and accuracy of 0.861 for distinguishing MCS from UWS patients. More importantly, DeepDOC excels in CMD identification, achieving an AUC of 1 and accuracy of 0.909. Using gradient-weighted class activation mapping algorithm, we found that the posterior cortex, encompassing the visual cortex, posterior middle temporal gyrus, posterior cingulate cortex, precuneus, and cerebellum, as making a more substantial contribution to classification compared to other brain regions. This research offers a convenient and accurate method for detecting covert awareness in patients with MCS and CMD using rs-fMRI data.
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Affiliation(s)
- Huan Yang
- Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou 510080, China; Medical Big Data Center, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou 510080, China; Guangdong Provincial Key Laboratory of Artificial Intelligence in Medical Image Analysis and Application, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Guangzhou 510080, China
| | - Hang Wu
- Key Laboratory of Brain, Cognition and Education Sciences, Ministry of Education; Institute for Brain Research and Rehabilitation, and Guangdong Key Laboratory of Mental Health and Cognitive Science, South China Normal University, Guangzhou 510631, China
| | - Lingcong Kong
- Medical Big Data Center, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou 510080, China; Guangdong Provincial Key Laboratory of Artificial Intelligence in Medical Image Analysis and Application, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Guangzhou 510080, China
| | - Wen Luo
- The First Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou 528199, China
| | - Qiuyou Xie
- Joint Research Center for disorders of consciousness, Department of Rehabilitation, Zhujiang Hospital, School of Rehabilitation Sciences, Southern Medical University, Guangzhou 510220, China
| | - Jiahui Pan
- School of Software, South China Normal University, Foshan 528225, China; Pazhou Lab, Guangzhou 510330, China
| | - Wuxiu Quan
- Medical Big Data Center, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou 510080, China; Guangdong Provincial Key Laboratory of Artificial Intelligence in Medical Image Analysis and Application, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Guangzhou 510080, China
| | - Lianting Hu
- Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou 510080, China; Medical Big Data Center, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou 510080, China; Guangdong Provincial Key Laboratory of Artificial Intelligence in Medical Image Analysis and Application, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Guangzhou 510080, China
| | - Dantong Li
- Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou 510080, China; Medical Big Data Center, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou 510080, China; Guangdong Provincial Key Laboratory of Artificial Intelligence in Medical Image Analysis and Application, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Guangzhou 510080, China
| | - Xuehai Wu
- Pazhou Lab, Guangzhou 510330, China; Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai 200433, China; Shanghai Clinical Medical Center of Neurosurgery, Shanghai Key laboratory of Brain Function Restoration and Neural Regeneration, Neurosurgical Institute of Fudan University, Shanghai 200433, China; State Key Laboratory of Medical Neurobiology and MOE Frontiers Center for Brain Science, School of Basic Medical Sciences and Institutes of Brain Science, Fudan University, Shanghai 200433, China
| | - Huiying Liang
- Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou 510080, China; Medical Big Data Center, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou 510080, China; Guangdong Provincial Key Laboratory of Artificial Intelligence in Medical Image Analysis and Application, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Guangzhou 510080, China.
| | - Pengmin Qin
- Pazhou Lab, Guangzhou 510330, China; Key Laboratory of Brain, Cognition and Education Sciences, Ministry of Education; School of Psychology, Center for Studies of Psychological Application, and Guangdong Key Laboratory of Mental Health and Cognitive Science, South China Normal University, Guangzhou 510631, China.
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11
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Amiri M, Raimondo F, Fisher PM, Cacic Hribljan M, Sidaros A, Othman MH, Zibrandtsen I, Bergdal O, Fabritius ML, Hansen AE, Hassager C, Højgaard JLS, Jensen HR, Knudsen NV, Laursen EL, Møller JE, Nersesjan V, Nicolic M, Sigurdsson ST, Sitt JD, Sølling C, Welling KL, Willumsen LM, Hauerberg J, Larsen VA, Fabricius ME, Knudsen GM, Kjærgaard J, Møller K, Kondziella D. Multimodal Prediction of 3- and 12-Month Outcomes in ICU Patients with Acute Disorders of Consciousness. Neurocrit Care 2024; 40:718-733. [PMID: 37697124 PMCID: PMC10959792 DOI: 10.1007/s12028-023-01816-z] [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] [Received: 05/10/2023] [Accepted: 07/21/2023] [Indexed: 09/13/2023]
Abstract
BACKGROUND In intensive care unit (ICU) patients with coma and other disorders of consciousness (DoC), outcome prediction is key to decision-making regarding prognostication, neurorehabilitation, and management of family expectations. Current prediction algorithms are largely based on chronic DoC, whereas multimodal data from acute DoC are scarce. Therefore, the Consciousness in Neurocritical Care Cohort Study Using Electroencephalography and Functional Magnetic Resonance Imaging (i.e. CONNECT-ME; ClinicalTrials.gov identifier: NCT02644265) investigates ICU patients with acute DoC due to traumatic and nontraumatic brain injuries, using electroencephalography (EEG) (resting-state and passive paradigms), functional magnetic resonance imaging (fMRI) (resting-state) and systematic clinical examinations. METHODS We previously presented results for a subset of patients (n = 87) concerning prediction of consciousness levels in the ICU. Now we report 3- and 12-month outcomes in an extended cohort (n = 123). Favorable outcome was defined as a modified Rankin Scale score ≤ 3, a cerebral performance category score ≤ 2, and a Glasgow Outcome Scale Extended score ≥ 4. EEG features included visual grading, automated spectral categorization, and support vector machine consciousness classifier. fMRI features included functional connectivity measures from six resting-state networks. Random forest and support vector machine were applied to EEG and fMRI features to predict outcomes. Here, random forest results are presented as areas under the curve (AUC) of receiver operating characteristic curves or accuracy. Cox proportional regression with in-hospital death as a competing risk was used to assess independent clinical predictors of time to favorable outcome. RESULTS Between April 2016 and July 2021, we enrolled 123 patients (mean age 51 years, 42% women). Of 82 (66%) ICU survivors, 3- and 12-month outcomes were available for 79 (96%) and 77 (94%), respectively. EEG features predicted both 3-month (AUC 0.79 [95% confidence interval (CI) 0.77-0.82]) and 12-month (AUC 0.74 [95% CI 0.71-0.77]) outcomes. fMRI features appeared to predict 3-month outcome (accuracy 0.69-0.78) both alone and when combined with some EEG features (accuracies 0.73-0.84) but not 12-month outcome (larger sample sizes needed). Independent clinical predictors of time to favorable outcome were younger age (hazard ratio [HR] 1.04 [95% CI 1.02-1.06]), traumatic brain injury (HR 1.94 [95% CI 1.04-3.61]), command-following abilities at admission (HR 2.70 [95% CI 1.40-5.23]), initial brain imaging without severe pathological findings (HR 2.42 [95% CI 1.12-5.22]), improving consciousness in the ICU (HR 5.76 [95% CI 2.41-15.51]), and favorable visual-graded EEG (HR 2.47 [95% CI 1.46-4.19]). CONCLUSIONS Our results indicate that EEG and fMRI features and readily available clinical data predict short-term outcome of patients with acute DoC and that EEG also predicts 12-month outcome after ICU discharge.
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Affiliation(s)
- Moshgan Amiri
- Department of Neurology, Copenhagen University Hospital - Rigshospitalet, Blegdamsvej 9, 2100, Copenhagen, Denmark
| | - Federico Raimondo
- Brain and Behaviour, Institute of Neuroscience and Medicine, Research Center Jülich, Jülich, Germany
- Institute of Systems Neuroscience, Medical Faculty, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Patrick M Fisher
- Neurobiology Research Unit, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
- Department of Drug Design and Pharmacology, University of Copenhagen, Copenhagen, Denmark
| | - Melita Cacic Hribljan
- Department of Neurophysiology, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Annette Sidaros
- Department of Neurology, Copenhagen University Hospital - Rigshospitalet, Blegdamsvej 9, 2100, Copenhagen, Denmark
- Department of Neurophysiology, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Marwan H Othman
- Department of Neurology, Copenhagen University Hospital - Rigshospitalet, Blegdamsvej 9, 2100, Copenhagen, Denmark
| | - Ivan Zibrandtsen
- Department of Neurology, Copenhagen University Hospital - Rigshospitalet, Blegdamsvej 9, 2100, Copenhagen, Denmark
- Department of Neurophysiology, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Ove Bergdal
- Department of Neurosurgery, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Maria Louise Fabritius
- Department of Neuroanaesthesiology, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Adam Espe Hansen
- Department of Radiology, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Christian Hassager
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
- Department of Cardiology, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Joan Lilja S Højgaard
- Department of Neurology, Copenhagen University Hospital - Rigshospitalet, Blegdamsvej 9, 2100, Copenhagen, Denmark
| | - Helene Ravnholt Jensen
- Department of Neuroanaesthesiology, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Niels Vendelbo Knudsen
- Department of Neuroanaesthesiology, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Emilie Lund Laursen
- Department of Neurology, Copenhagen University Hospital - Rigshospitalet, Blegdamsvej 9, 2100, Copenhagen, Denmark
| | - Jacob E Møller
- Department of Cardiology, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Vardan Nersesjan
- Biological and Precision Psychiatry, Copenhagen Research Center for Mental Health, Copenhagen University Hospital, Copenhagen, Denmark
| | - Miki Nicolic
- Department of Neurophysiology, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Sigurdur Thor Sigurdsson
- Department of Neuroanaesthesiology, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Jacobo D Sitt
- Institut du Cerveau - Paris Brain Institute, Inserm, Centre nationl de la recherche scientifique, Assistance Publique - Hôpitaux de Paris, Sorbonne Université, Hôpital de La Pitié Salpêtrière, Paris, France
| | - Christine Sølling
- Department of Neuroanaesthesiology, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Karen Lise Welling
- Department of Neuroanaesthesiology, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Lisette M Willumsen
- Department of Neurosurgery, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - John Hauerberg
- Department of Neurosurgery, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Vibeke Andrée Larsen
- Department of Radiology, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Martin Ejler Fabricius
- Department of Neurophysiology, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Gitte Moos Knudsen
- Neurobiology Research Unit, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Jesper Kjærgaard
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
- Department of Cardiology, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Kirsten Møller
- Department of Neuroanaesthesiology, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Daniel Kondziella
- Department of Neurology, Copenhagen University Hospital - Rigshospitalet, Blegdamsvej 9, 2100, Copenhagen, Denmark.
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark.
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12
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Cai W, Han X, Tang X, Cao Z, Yu Z, Sun Z, Wu J, Wu Y, Xie H. Uncovering sympathetic nervous system dysfunction in disorders of consciousness via heart rate variability during head-up tilt test. Physiol Rep 2024; 12:e16000. [PMID: 38584117 PMCID: PMC10999365 DOI: 10.14814/phy2.16000] [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] [Received: 10/02/2023] [Revised: 03/20/2024] [Accepted: 03/22/2024] [Indexed: 04/09/2024] Open
Abstract
Few standardized tools are available for evaluation of disorders of consciousness (DOC). The potential of heart rate variability (HRV) during head-up tilt (HUT) test was investigated as a complementary evaluation tool. Twenty-one DOC patients and 21 healthy participants were enrolled in this study comparing clinical characteristics and HRV time- and frequency-domain outcomes and temporal changes during HUT test. During the 1st-5th min of the HUT, DOC group showed a significant increase and decrease in log low frequency (LF) (p = 0.045) and log normalized high frequency (nHF) (p = 0.02), respectively, compared to the supine position and had lower log normalized LF (nLF) (p = 0.004) and log ratio of low-to-high frequency (LF/HF) (p = 0.001) compared to healthy controls. As the HUT continued from the 6th to the 20th min, DOC group exhibited a significant increase in log LF/HF (16th-20th min) (p < 0.05), along with a decrease in log nHF (6th-10th and 16th-20th min) (p < 0.05) and maintained lower log LF, log nLF, and log LF/HF than controls (p < 0.05). 1st-10th min after returning to the supine position, DOC group demonstrated a significant decrease in log nHF (p < 0.01) and increases in log LF/HF (p < 0.01) and had lower log LF (p < 0.01) and log nLF (p < 0.05) compared to controls. In contrast, the control group exhibited a significant decrease in log nHF (p < 0.05) and increase in log LF/HF (p < 0.05) throughout the entire HUT test. Notably, no significant differences were observed when comparing time-domain outcomes reflecting parasympathetic nervous system between the two groups. HRV during HUT test indicated a delayed and attenuated autonomic response, particularly in the sympathetic nervous system, in DOC patients compared with healthy individuals.
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Affiliation(s)
- Weiqiang Cai
- Department of Rehabilitation Medicine, Huashan HospitalFudan UniversityShanghaiChina
| | - Xu Han
- Department of Rehabilitation Medicine, Huashan HospitalFudan UniversityShanghaiChina
| | - Xinwei Tang
- Department of Rehabilitation Medicine, Huashan HospitalFudan UniversityShanghaiChina
| | - Zuojun Cao
- Department of Rehabilitation Medicine, Huashan HospitalFudan UniversityShanghaiChina
| | - Zi Yu
- Department of Rehabilitation Medicine, Huashan HospitalFudan UniversityShanghaiChina
| | - Zuowen Sun
- Department of Rehabilitation Medicine, Huashan HospitalFudan UniversityShanghaiChina
| | - Junfa Wu
- Department of Rehabilitation Medicine, Huashan HospitalFudan UniversityShanghaiChina
| | - Yi Wu
- Department of Rehabilitation Medicine, Huashan HospitalFudan UniversityShanghaiChina
| | - Hongyu Xie
- Department of Rehabilitation Medicine, Huashan HospitalFudan UniversityShanghaiChina
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13
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Edlow BL, Claassen J, Suarez JI. Common data elements for disorders of consciousness. Neurocrit Care 2024; 40:715-717. [PMID: 38291278 DOI: 10.1007/s12028-023-01931-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2024]
Affiliation(s)
- Brian L Edlow
- Center for Neurotechnology and Neurorecovery, Department of Neurology, Massachusetts General Hospital and Harvard Medical School, 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, NY, USA
- NewYork-Presbyterian Hospital, New York, NY, USA
| | - Jose I Suarez
- Division of Neurosciences Critical Care, Departments of Neurology, Neurosurgery, and Anesthesiology and Critical Care Medicine, The Johns Hopkins University and The Johns Hopkins Hospital, Baltimore, MD, USA
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14
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Fischer D, Edlow BL. Coma Prognostication After Acute Brain Injury: A Review. JAMA Neurol 2024:2815829. [PMID: 38436946 DOI: 10.1001/jamaneurol.2023.5634] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/05/2024]
Abstract
Importance Among the most impactful neurologic assessments is that of neuroprognostication, defined here as the prediction of neurologic recovery from disorders of consciousness caused by severe, acute brain injury. Across a range of brain injury etiologies, these determinations often dictate whether life-sustaining treatment is continued or withdrawn; thus, they have major implications for morbidity, mortality, and health care costs. Neuroprognostication relies on a diverse array of tests, including behavioral, radiologic, physiological, and serologic markers, that evaluate the brain's functional and structural integrity. Observations Prognostic markers, such as the neurologic examination, electroencephalography, and conventional computed tomography and magnetic resonance imaging (MRI), have been foundational in assessing a patient's current level of consciousness and capacity for recovery. Emerging techniques, such as functional MRI, diffusion MRI, and advanced forms of electroencephalography, provide new ways of evaluating the brain, leading to evolving schemes for characterizing neurologic function and novel methods for predicting recovery. Conclusions and Relevance Neuroprognostic markers are rapidly evolving as new ways of assessing the brain's structural and functional integrity after brain injury are discovered. Many of these techniques remain in development, and further research is needed to optimize their prognostic utility. However, even as such efforts are underway, a series of promising findings coupled with the imperfect predictive value of conventional prognostic markers and the high stakes of these assessments have prompted clinical guidelines to endorse emerging techniques for neuroprognostication. Thus, clinicians have been thrust into an uncertain predicament in which emerging techniques are not yet perfected but too promising to ignore. This review illustrates the current, and likely future, landscapes of prognostic markers. No matter how much prognostic markers evolve and improve, these assessments must be approached with humility and individualized to reflect each patient's values.
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Affiliation(s)
- David Fischer
- Division of Neurocritical Care, Department of Neurology, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Brian L Edlow
- Center for Neurotechnology and Neurorecovery, Department of Neurology, Massachusetts General Hospital and Harvard Medical School, Boston
- Athinoula A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital and Harvard Medical School, Charlestown
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15
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Gallucci A, Varoli E, Del Mauro L, Hassan G, Rovida M, Comanducci A, Casarotto S, Lo Re V, Romero Lauro LJ. Multimodal approaches supporting the diagnosis, prognosis and investigation of neural correlates of disorders of consciousness: A systematic review. Eur J Neurosci 2024; 59:874-933. [PMID: 38140883 DOI: 10.1111/ejn.16149] [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] [Received: 12/12/2022] [Revised: 08/30/2023] [Accepted: 09/11/2023] [Indexed: 12/24/2023]
Abstract
The limits of the standard, behaviour-based clinical assessment of patients with disorders of consciousness (DoC) prompted the employment of functional neuroimaging, neurometabolic, neurophysiological and neurostimulation techniques, to detect brain-based covert markers of awareness. However, uni-modal approaches, consisting in employing just one of those techniques, are usually not sufficient to provide an exhaustive exploration of the neural underpinnings of residual awareness. This systematic review aimed at collecting the evidence from studies employing a multimodal approach, that is, combining more instruments to complement DoC diagnosis, prognosis and better investigating their neural correlates. Following the PRISMA guidelines, records from PubMed, EMBASE and Scopus were screened to select peer-review original articles in which a multi-modal approach was used for the assessment of adult patients with a diagnosis of DoC. Ninety-two observational studies and 32 case reports or case series met the inclusion criteria. Results highlighted a diagnostic and prognostic advantage of multi-modal approaches that involve electroencephalography-based (EEG-based) measurements together with neuroimaging or neurometabolic data or with neurostimulation. Multimodal assessment deepened the knowledge on the neural networks underlying consciousness, by showing correlations between the integrity of the default mode network and the different clinical diagnosis of DoC. However, except for studies using transcranial magnetic stimulation combined with electroencephalography, the integration of more than one technique in most of the cases occurs without an a priori-designed multi-modal diagnostic approach. Our review supports the feasibility and underlines the advantages of a multimodal approach for the diagnosis, prognosis and for the investigation of neural correlates of DoCs.
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Affiliation(s)
- Alessia Gallucci
- Ph.D. Program in Neuroscience, School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
- NeuroMi (Neuroscience Center), University of Milano-Bicocca, Milan, Italy
| | - Erica Varoli
- Neurology Service, Department of Diagnostic and Therapeutic Services, Istituto di Ricovero e Cura a Carattere Scientifico-Istituto Mediterraneo per i Trapianti e Terapie ad Alta Specializzazione (IRCCS ISMETT), Palermo, Italy
| | - Lilia Del Mauro
- Department of Psychology, University of Milano-Bicocca, Milan, Italy
| | - Gabriel Hassan
- Department of Biomedical and Clinical Sciences, University of Milan, Italy
| | - Margherita Rovida
- Department of Psychology, University of Milano-Bicocca, Milan, Italy
| | - Angela Comanducci
- IRCSS Fondazione Don Carlo Gnocchi ONLUS, Milan, Italy
- Università Campus Bio-Medico di Roma, Rome, Italy
| | - Silvia Casarotto
- Department of Biomedical and Clinical Sciences, University of Milan, Italy
- IRCCS Fondazione Don Carlo Gnocchi, Milan, Italy
| | - Vincenzina Lo Re
- Neurology Service, Department of Diagnostic and Therapeutic Services, Istituto di Ricovero e Cura a Carattere Scientifico-Istituto Mediterraneo per i Trapianti e Terapie ad Alta Specializzazione (IRCCS ISMETT), Palermo, Italy
| | - Leonor J Romero Lauro
- NeuroMi (Neuroscience Center), University of Milano-Bicocca, Milan, Italy
- Department of Psychology, University of Milano-Bicocca, Milan, Italy
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16
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Young MJ, Fecchio M, Bodien YG, Edlow BL. Covert cortical processing: a diagnosis in search of a definition. Neurosci Conscious 2024; 2024:niad026. [PMID: 38327828 PMCID: PMC10849751 DOI: 10.1093/nc/niad026] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2023] [Revised: 10/22/2023] [Accepted: 12/10/2023] [Indexed: 02/09/2024] Open
Abstract
Historically, clinical evaluation of unresponsive patients following brain injury has relied principally on serial behavioral examination to search for emerging signs of consciousness and track recovery. Advances in neuroimaging and electrophysiologic techniques now enable clinicians to peer into residual brain functions even in the absence of overt behavioral signs. These advances have expanded clinicians' ability to sub-stratify behaviorally unresponsive and seemingly unaware patients following brain injury by querying and classifying covert brain activity made evident through active or passive neuroimaging or electrophysiologic techniques, including functional MRI, electroencephalography (EEG), transcranial magnetic stimulation-EEG, and positron emission tomography. Clinical research has thus reciprocally influenced clinical practice, giving rise to new diagnostic categories including cognitive-motor dissociation (i.e. 'covert consciousness') and covert cortical processing (CCP). While covert consciousness has received extensive attention and study, CCP is relatively less understood. We describe that CCP is an emerging and clinically relevant state of consciousness marked by the presence of intact association cortex responses to environmental stimuli in the absence of behavioral evidence of stimulus processing. CCP is not a monotonic state but rather encapsulates a spectrum of possible association cortex responses from rudimentary to complex and to a range of possible stimuli. In constructing a roadmap for this evolving field, we emphasize that efforts to inform clinicians, philosophers, and researchers of this condition are crucial. Along with strategies to sensitize diagnostic criteria and disorders of consciousness nosology to these vital discoveries, democratizing access to the resources necessary for clinical identification of CCP is an emerging clinical and ethical imperative.
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Affiliation(s)
- Michael J Young
- Center for Neurotechnology and Neurorecovery, Department of Neurology, Massachusetts General Hospital and Harvard Medical School, 101 Merrimac Street, Suite 310, Boston, MA 02114, USA
| | - Matteo Fecchio
- Center for Neurotechnology and Neurorecovery, Department of Neurology, Massachusetts General Hospital and Harvard Medical School, 101 Merrimac Street, Suite 310, Boston, MA 02114, USA
| | - Yelena G Bodien
- Center for Neurotechnology and Neurorecovery, Department of Neurology, Massachusetts General Hospital and Harvard Medical School, 101 Merrimac Street, Suite 310, Boston, MA 02114, USA
- Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Harvard Medical School, 300 1st Ave, Charlestown, Boston, MA 02129, USA
| | - Brian L Edlow
- Center for Neurotechnology and Neurorecovery, Department of Neurology, Massachusetts General Hospital and Harvard Medical School, 101 Merrimac Street, Suite 310, Boston, MA 02114, USA
- Athinoula A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital and Harvard Medical School, 149 13th St, Charlestown, Charlestown, MA 02129, USA
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17
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Murtaugh B, Fager S, Sorenson T. Emergence from Disorders of Consciousness: Optimizing Self-Agency Through Communication. Phys Med Rehabil Clin N Am 2024; 35:175-191. [PMID: 37993188 PMCID: PMC11216683 DOI: 10.1016/j.pmr.2023.07.002] [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: 11/24/2023]
Abstract
Language and communication deficits are intrinsic to disorders of consciousness. This article will provide an overview of language and communication deficits that can significantly confound the accuracy of diagnostic assessment in these patients. Authors will also discuss interventions to promote early communication using assistive technology and augmentative communication rehabilitation strategies. Finally, this article will discuss the importance of family education as well as ethical considerations connected to the recovery of communication and adaptive strategies to support patient autonomy and enhance self-agency.
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Affiliation(s)
- Brooke Murtaugh
- Department of Rehabilitation Programs, Madonna Rehabilitation Hospitals, 5401 South Street, Lincoln, NE 68506, USA.
| | - Susan Fager
- Research Institute, Madonna Rehabilitation Hospitals, 5401 South Street, Lincoln, NE 68506, USA
| | - Tabatha Sorenson
- Department of Occupational Therapy, Madonna Rehabilitation Hospitals, 5401 South Street, Lincoln, NE 68506, USA
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18
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Claassen J, Kondziella D, Alkhachroum A, Diringer M, Edlow BL, Fins JJ, Gosseries O, Hannawi Y, Rohaut B, Schnakers C, Stevens RD, Thibaut A, Monti M. Cognitive Motor Dissociation: Gap Analysis and Future Directions. Neurocrit Care 2024; 40:81-98. [PMID: 37349602 DOI: 10.1007/s12028-023-01769-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Accepted: 05/26/2023] [Indexed: 06/24/2023]
Abstract
BACKGROUND Patients with disorders of consciousness who are behaviorally unresponsive may demonstrate volitional brain responses to motor imagery or motor commands detectable on functional magnetic resonance imaging or electroencephalography. This state of cognitive motor dissociation (CMD) may have prognostic significance. METHODS The Neurocritical Care Society's Curing Coma Campaign identified an international group of experts who convened in a series of monthly online meetings between September 2021 and April 2023 to examine the science of CMD and identify key knowledge gaps and unmet needs. RESULTS The group identified major knowledge gaps in CMD research: (1) lack of information about patient experiences and caregiver accounts of CMD, (2) limited epidemiological data on CMD, (3) uncertainty about underlying mechanisms of CMD, (4) methodological variability that limits testing of CMD as a biomarker for prognostication and treatment trials, (5) educational gaps for health care personnel about the incidence and potential prognostic relevance of CMD, and (6) challenges related to identification of patients with CMD who may be able to communicate using brain-computer interfaces. CONCLUSIONS To improve the management of patients with disorders of consciousness, research efforts should address these mechanistic, epidemiological, bioengineering, and educational gaps to enable large-scale implementation of CMD assessment in clinical practice.
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Affiliation(s)
- Jan Claassen
- Department of Neurology, Neurological Institute, Columbia University Irving Medical Center, NewYork Presbyterian Hospital, 177 Fort Washington Avenue, MHB 8 Center, Room 300, New York, NY, 10032, USA.
| | - Daniel Kondziella
- Department of Neurology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | | | - Michael Diringer
- Department of Neurology, Washington University, St. Louis, MO, USA
| | - Brian L Edlow
- Department of Neurology, Center for Neurotechnology and Neurorecovery, Massachusetts General Hospital, Boston, MA, 02114, USA
| | - Joseph J Fins
- Division of Medical Ethics, Department of Medicine, Weill Cornell Medical College, NewYork Presbyterian Hospital, New York, NY, 10032, USA
| | - Olivia Gosseries
- Coma Science Group, GIGA Consciousness, University of Liege, Liege, Belgium
- Centre du Cerveau, University Hospital of Liege, Liege, Belgium
| | - Yousef Hannawi
- Division of Cerebrovascular Diseases and Neurocritical Care, Department of Neurology, The Ohio State University, Columbus, OH, USA
| | - Benjamin Rohaut
- Sorbonne Université, Assistance Publique-Hôpitaux de Paris (AP-HP) - Pitié Salpêtrière, Paris, France
| | | | - Robert D Stevens
- Department of Anesthesiology and Critical Care Medicine, Neurology, and Radiology, School of Medicine, Secondary Appointment in Biomedical Engineering, Whiting School of Engineering, Johns Hopkins University, Baltimore, MD, USA
| | - Aurore Thibaut
- Coma Science Group, GIGA Consciousness, University of Liege, Liege, Belgium
- Centre du Cerveau, University Hospital of Liege, Liege, Belgium
| | - Martin Monti
- Department of Psychology, University of California Los Angeles, Los Angeles, CA, USA
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19
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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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20
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Young MJ. Disorders of Consciousness Rehabilitation: Ethical Dimensions and Epistemic Dilemmas. Phys Med Rehabil Clin N Am 2024; 35:209-221. [PMID: 37993190 DOI: 10.1016/j.pmr.2023.06.016] [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] [Indexed: 11/24/2023]
Abstract
Patients with disorders of consciousness who survive to discharge following severe acute brain injury may face profoundly complex medical, ethical, and psychosocial challenges during their courses of recovery and rehabilitation. Although issues encountered in caring for such patients during acute hospitalization have received substantial attention, ethical challenges that may arise in subacute and chronic phases have been underexplored. Shedding light on these issues, this article explores the landscape of normative issues in the course of treating and facilitating access to care for persons with disorders of consciousness during rehabilitation and examines potential implications for patients, clinicians, family members, and society.
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Affiliation(s)
- Michael J Young
- Department of Neurology, Massachusetts General Hospital, Center for Neurotechnology and Neurorecovery, 101 Merrimac Street, Suite 310, Boston, MA 02114, USA.
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21
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Xu LB, Hampton S, Fischer D. Neuroimaging in Disorders of Consciousness and Recovery. Phys Med Rehabil Clin N Am 2024; 35:51-64. [PMID: 37993193 DOI: 10.1016/j.pmr.2023.06.017] [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: 11/24/2023]
Abstract
There is a clinical need for more accurate diagnosis and prognostication in patients with disorders of consciousness (DoC). There are several neuroimaging modalities that enable detailed, quantitative assessment of structural and functional brain injury, with demonstrated diagnostic and prognostic value. Additionally, longitudinal neuroimaging studies have hinted at quantifiable structural and functional neuroimaging biomarkers of recovery, with potential implications for the management of DoC.
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Affiliation(s)
- Linda B Xu
- Department of Neurology, University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA 19104, USA.
| | - Stephen Hampton
- Department of Physical Medicine and Rehabilitation, University of Pennsylvania, 1800 Lombard Street, Philadelphia, PA 19146, USA
| | - David Fischer
- Department of Neurology, University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA 19104, USA.
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Abstract
Covert consciousness is a state of residual awareness following severe brain injury or neurological disorder that evades routine bedside behavioral detection. Patients with covert consciousness have preserved awareness but are incapable of self-expression through ordinary means of behavior or communication. Growing recognition of the limitations of bedside neurobehavioral examination in reliably detecting consciousness, along with advances in neurotechnologies capable of detecting brain states or subtle signs indicative of consciousness not discernible by routine examination, carry promise to transform approaches to classifying, diagnosing, prognosticating and treating disorders of consciousness. Here we describe and critically evaluate the evolving clinical category of covert consciousness, including approaches to its diagnosis through neuroimaging, electrophysiology, and novel behavioral tools, its prognostic relevance, and open questions pertaining to optimal clinical management of patients with covert consciousness recovering from severe brain injury.
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Affiliation(s)
- Michael J. Young
- Department of Neurology, Center for Neurotechnology and Neurorecovery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Brian L. Edlow
- Department of Neurology, Center for Neurotechnology and Neurorecovery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
- Athinoula A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital, Charlestown, MA, USA
| | - Yelena G. Bodien
- Department of Neurology, Center for Neurotechnology and Neurorecovery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
- Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Harvard Medical School, Boston, MA, USA
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23
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Dhakal K, Rosenthal ES, Kulpanowski AM, Dodelson JA, Wang Z, Cudemus-Deseda G, Villien M, Edlow BL, Presciutti AM, Januzzi JL, Ning M, Taylor Kimberly W, Amorim E, Brandon Westover M, Copen WA, Schaefer PW, Giacino JT, Greer DM, Wu O. Increased task-relevant fMRI responsiveness in comatose cardiac arrest patients is associated with improved neurologic outcomes. J Cereb Blood Flow Metab 2024; 44:50-65. [PMID: 37728641 PMCID: PMC10905635 DOI: 10.1177/0271678x231197392] [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: 04/14/2023] [Revised: 06/27/2023] [Accepted: 06/29/2023] [Indexed: 09/21/2023]
Abstract
Early prediction of the recovery of consciousness in comatose cardiac arrest patients remains challenging. We prospectively studied task-relevant fMRI responses in 19 comatose cardiac arrest patients and five healthy controls to assess the fMRI's utility for neuroprognostication. Tasks involved instrumental music listening, forward and backward language listening, and motor imagery. Task-specific reference images were created from group-level fMRI responses from the healthy controls. Dice scores measured the overlap of individual subject-level fMRI responses with the reference images. Task-relevant responsiveness index (Rindex) was calculated as the maximum Dice score across the four tasks. Correlation analyses showed that increased Dice scores were significantly associated with arousal recovery (P < 0.05) and emergence from the minimally conscious state (EMCS) by one year (P < 0.001) for all tasks except motor imagery. Greater Rindex was significantly correlated with improved arousal recovery (P = 0.002) and consciousness (P = 0.001). For patients who survived to discharge (n = 6), the Rindex's sensitivity was 75% for predicting EMCS (n = 4). Task-based fMRI holds promise for detecting covert consciousness in comatose cardiac arrest patients, but further studies are needed to confirm these findings. Caution is necessary when interpreting the absence of task-relevant fMRI responses as a surrogate for inevitable poor neurological prognosis.
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Affiliation(s)
- Kiran Dhakal
- Athinoula A. Martinos Center for Biomedical Imaging, Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Charlestown, MA, USA
| | - Eric S Rosenthal
- Department of Neurology, Massachusetts General Hospital, Boston, MA, USA
| | - Annelise M Kulpanowski
- Athinoula A. Martinos Center for Biomedical Imaging, Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Charlestown, MA, USA
| | - Jacob A Dodelson
- Athinoula A. Martinos Center for Biomedical Imaging, Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Charlestown, MA, USA
| | - Zihao Wang
- Athinoula A. Martinos Center for Biomedical Imaging, Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Charlestown, MA, USA
| | - Gaston Cudemus-Deseda
- Department of Cardiac Anesthesiology and Critical Care Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Marjorie Villien
- Athinoula A. Martinos Center for Biomedical Imaging, Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Charlestown, MA, USA
| | - Brian L Edlow
- Athinoula A. Martinos Center for Biomedical Imaging, Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Charlestown, MA, USA
- Department of Neurology, Massachusetts General Hospital, Boston, MA, USA
| | - Alexander M Presciutti
- Department of Psychiatry, Center for Health Outcomes and Interdisciplinary Research, Massachusetts General Hospital, Boston, MA, USA
| | - James L Januzzi
- Department of Medicine, Cardiology Division, Massachusetts General Hospital and Baim Institute for Clinical Research, Boston, MA, USA
| | - MingMing Ning
- Department of Neurology, Massachusetts General Hospital, Boston, MA, USA
| | - W Taylor Kimberly
- Department of Neurology, Massachusetts General Hospital, Boston, MA, USA
| | - Edilberto Amorim
- Department of Neurology, Massachusetts General Hospital, Boston, MA, USA
| | | | - William A Copen
- Department of Radiology, Neuroradiology Division, Massachusetts General Hospital, Boston, MA, USA
| | - Pamela W Schaefer
- Department of Radiology, Neuroradiology Division, Massachusetts General Hospital, Boston, MA, USA
| | - Joseph T Giacino
- Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Harvard Medical School, Charlestown, MA, USA
| | - David M Greer
- Department of Neurology, Boston University School of Medicine, Boston Medical Center, Boston, MA, USA
| | - Ona Wu
- Athinoula A. Martinos Center for Biomedical Imaging, Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Charlestown, MA, USA
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24
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Robbins NM, Bernat JL. Ethical issues of nosology in disorders of consciousness. NeuroRehabilitation 2024; 54:3-9. [PMID: 38277312 DOI: 10.3233/nre-230120] [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: 01/28/2024]
Abstract
The current classification scheme for severe disorders of consciousness (DoC) has several shortcomings. First, there is no consensus on how to incorporate patients with covert consciousness. Second, there is a mismatch between the definitions of severe DoC, based on consciousness, and the diagnosis of these same DoC, which is based on observable motoric responsiveness. Third, current categories are grouped into large heterogeneous syndromes which share phenotype, but do not incorporate underlying pathophysiology. Here we discuss several ethical issues pertaining to the current nosology of severe DoC. We conclude by proposing a revised nosology which addresses these shortcomings.
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Affiliation(s)
- Nathaniel M Robbins
- Geisel School of Medicine at Dartmouth, Hanover, NH, USA
- Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
| | - James L Bernat
- Geisel School of Medicine at Dartmouth, Hanover, NH, USA
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25
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Russell ME, Hammond FM, Murtaugh B. Prognosis and enhancement of recovery in disorders of consciousness. NeuroRehabilitation 2024; 54:43-59. [PMID: 38277313 DOI: 10.3233/nre-230148] [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: 01/28/2024]
Abstract
Disorders of consciousness after severe brain injury encompass conditions of coma, vegetative state/unresponsive wakefulness syndrome, and minimally conscious state. DoC clinical presentation pose perplexing challenges to medical professionals, researchers, and families alike. The outcome is uncertain in the first weeks to months after a brain injury, with families and medical providers often making important decisions that require certainty. Prognostication for individuals with these conditions has been the subject of intense scientific investigation that continues to strive for valid prognostic indicators and algorithms for predicting recovery of consciousness. This manuscript aims to provide an overview of the current clinical landscape surrounding prognosis and optimizing recovery in DoC and the current and future research that could improve prognostic accuracy after severe brain injury. Improved understanding of these factors will aid healthcare professionals in providing optimal care, fostering hope, and advocating for ethical practices in the management of individuals with DoC.
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Affiliation(s)
- Mary E Russell
- Department of Physical Medicine and Rehabilitation, University of Texas McGovern Medical School, Houston, TX, USA
- TIRR Memorial Hermann - The Woodlands, Shenandoah, TX, USA
| | - Flora M Hammond
- Department of Physical Medicine and Rehabilitation, Indiana University School of Medicine, Indianapolis, IN, USA
- Rehabilitation Hospital of Indiana, Indianapolis, IN, USA
| | - Brooke Murtaugh
- Department of Rehabilitation Programs, Madonna Rehabilitation Hospitals, Lincoln, NE, USA
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26
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Snider SB, Temkin NR, Barber J, Edlow BL, Giacino JT, Hammond FM, Izzy S, Kowalski RG, Markowitz AJ, Rovito CA, Shih SL, Zafonte RD, Manley GT, Bodien YG. Predicting Functional Dependency in Patients with Disorders of Consciousness: A TBI-Model Systems and TRACK-TBI Study. Ann Neurol 2023; 94:1008-1023. [PMID: 37470289 PMCID: PMC10799195 DOI: 10.1002/ana.26741] [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] [Received: 03/28/2023] [Revised: 06/27/2023] [Accepted: 06/29/2023] [Indexed: 07/21/2023]
Abstract
OBJECTIVE It is not currently possible to predict long-term functional dependency in patients with disorders of consciousness (DoC) after traumatic brain injury (TBI). Our objective was to fit and externally validate a prediction model for 1-year dependency in patients with DoC ≥ 2 weeks after TBI. METHODS We included adults with TBI enrolled in TBI Model Systems (TBI-MS) or Transforming Research and Clinical Knowledge in TBI (TRACK-TBI) studies who were not following commands at rehabilitation admission or 2 weeks post-injury, respectively. We fit a logistic regression model in TBI-MS and validated it in TRACK-TBI. The primary outcome was death or dependency at 1 year post-injury, defined using the Disability Rating Scale. RESULTS In the TBI-MS Discovery Sample, 1,960 participants (mean age 40 [18] years, 76% male, 68% white) met inclusion criteria, and 406 (27%) were dependent 1 year post-injury. In a TBI-MS held out cohort, the dependency prediction model's area under the receiver operating characteristic curve was 0.79 (95% CI 0.74-0.85), positive predictive value was 53% and negative predictive value was 86%. In the TRACK-TBI external validation (n = 124, age 40 [16] years, 77% male, 81% white), the area under the receiver operating characteristic curve was 0.66 (0.53, 0.79), equivalent to the standard IMPACTcore + CT score (p = 0.8). INTERPRETATION We developed a 1-year dependency prediction model using the largest existing cohort of patients with DoC after TBI. The sensitivity and negative predictive values were greater than specificity and positive predictive values. Accuracy was diminished in an external sample, but equivalent to the IMPACT model. Further research is needed to improve dependency prediction in patients with DoC after TBI. ANN NEUROL 2023;94:1008-1023.
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Affiliation(s)
- Samuel B. Snider
- Division of Neurocritical Care, Department of Neurology, Brigham and Women’s Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Nancy R. Temkin
- Department of Neurological Surgery, University of Washington, Seattle, Washington, USA
- Department of Biostatistics, University of Washington, Seattle, Washington, USA
| | - Jason Barber
- Department of Neurological Surgery, University of Washington, Seattle, Washington, USA
| | - Brian L. Edlow
- Harvard Medical School, Boston, MA, USA
- Center for Neurotechnology and Neurorecovery and Department of Neurology, Massachusetts General Hospital, Boston, MA, USA
- Athinoula A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital, Charlestown, MA, USA
| | - Joseph T. Giacino
- Harvard Medical School, Boston, MA, USA
- Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Boston, MA USA
| | - Flora M. Hammond
- Department of Physical Medicine and Rehabilitation, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Saef Izzy
- Division of Neurocritical Care, Department of Neurology, Brigham and Women’s Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Robert G. Kowalski
- Departments of Neurosurgery and Neurology, University of Colorado School of Medicine, Aurora CO, USA
| | | | - Craig A. Rovito
- Harvard Medical School, Boston, MA, USA
- Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Boston, MA USA
| | - Shirley L. Shih
- Harvard Medical School, Boston, MA, USA
- Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Boston, MA USA
| | - Ross D. Zafonte
- Harvard Medical School, Boston, MA, USA
- Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Boston, MA USA
| | - Geoffrey T. Manley
- Department of Neurological Surgery, UCSF, San Francisco, CA USA
- Brain and Spinal Cord Injury Center, Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, CA USA
| | - Yelena G. Bodien
- Harvard Medical School, Boston, MA, USA
- Center for Neurotechnology and Neurorecovery and Department of Neurology, Massachusetts General Hospital, Boston, MA, USA
- Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Boston, MA USA
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27
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Edlow BL, Boerwinkle VL, Annen J, Boly M, Gosseries O, Laureys S, Mukherjee P, Puybasset L, Stevens RD, Threlkeld ZD, Newcombe VFJ, Fernandez-Espejo D. Common Data Elements for Disorders of Consciousness: Recommendations from the Working Group on Neuroimaging. Neurocrit Care 2023; 39:611-617. [PMID: 37552410 DOI: 10.1007/s12028-023-01794-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2023] [Accepted: 06/22/2023] [Indexed: 08/09/2023]
Abstract
BACKGROUND Over the past 5 decades, advances in neuroimaging have yielded insights into the pathophysiologic mechanisms that cause disorders of consciousness (DoC) in patients with severe brain injuries. Structural, functional, metabolic, and perfusion imaging studies have revealed specific neuroanatomic regions, such as the brainstem tegmentum, thalamus, posterior cingulate cortex, medial prefrontal cortex, and occipital cortex, where lesions correlate with the current or future state of consciousness. Advanced imaging modalities, such as diffusion tensor imaging, resting-state functional magnetic resonance imaging (fMRI), and task-based fMRI, have been used to improve the accuracy of diagnosis and long-term prognosis, culminating in the endorsement of fMRI for the clinical evaluation of patients with DoC in the 2018 US (task-based fMRI) and 2020 European (task-based and resting-state fMRI) guidelines. As diverse neuroimaging techniques are increasingly used for patients with DoC in research and clinical settings, the need for a standardized approach to reporting results is clear. The success of future multicenter collaborations and international trials fundamentally depends on the implementation of a shared nomenclature and infrastructure. METHODS To address this need, the Neurocritical Care Society's Curing Coma Campaign convened an international panel of DoC neuroimaging experts to propose common data elements (CDEs) for data collection and reporting in this field. RESULTS We report the recommendations of this CDE development panel and disseminate CDEs to be used in neuroimaging studies of patients with DoC. CONCLUSIONS These CDEs will support progress in the field of DoC neuroimaging and facilitate international collaboration.
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Affiliation(s)
- Brian L Edlow
- Center for Neurotechnology and Neurorecovery, Department of Neurology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA.
- Athinoula A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital, Charlestown, MA, USA.
| | - Varina L Boerwinkle
- Clinical Resting-State Functional Magnetic Resonance Imaging Laboratory and Service, Department of Neurology, University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | - Jitka Annen
- Coma Science Group, GIGA Consciousness, University of Liège, Liège, Belgium
- Centre de Cerveau2, University Hospital of Liège, Liège, Belgium
| | - Melanie Boly
- Department of Neurology, University of Wisconsin, Madison, WI, USA
- Department of Psychiatry, Wisconsin Institute for Sleep and Consciousness, University of Wisconsin, Madison, WI, USA
| | - Olivia Gosseries
- Coma Science Group, GIGA Consciousness, University of Liège, Liège, Belgium
- Centre de Cerveau2, University Hospital of Liège, Liège, Belgium
| | - Steven Laureys
- Coma Science Group, GIGA Consciousness, University of Liège, Liège, Belgium
- Centre de Cerveau2, University Hospital of Liège, Liège, Belgium
- CERVO Research Institute, Laval University, Quebec, Canada
| | - Pratik Mukherjee
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, San Francisco, CA, USA
| | - Louis Puybasset
- Department of Anesthesiology and Intensive Care, Groupe Hospitalier Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Robert D Stevens
- Departments of Anesthesiology and Critical Care Medicine, Neurology, Radiology, and Biomedical Engineering, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Zachary D Threlkeld
- Department of Neurology, Stanford University School of Medicine, Stanford, CA, USA
| | | | - Davinia Fernandez-Espejo
- School of Psychology and Centre for Human Brain Health, University of Birmingham, Birmingham, UK
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28
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Lewis A, Young MJ, Rohaut B, Jox RJ, Claassen J, Creutzfeldt CJ, Illes J, Kirschen M, Trevick S, Fins JJ. Ethics Along the Continuum of Research Involving Persons with Disorders of Consciousness. Neurocrit Care 2023; 39:565-577. [PMID: 36977963 PMCID: PMC11023737 DOI: 10.1007/s12028-023-01708-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2022] [Accepted: 02/23/2023] [Indexed: 03/30/2023]
Abstract
Interest in disorders of consciousness (DoC) has grown substantially over the past decade and has illuminated the importance of improving understanding of DoC biology; care needs (use of monitoring, performance of interventions, and provision of emotional support); treatment options to promote recovery; and outcome prediction. Exploration of these topics requires awareness of numerous ethics considerations related to rights and resources. The Curing Coma Campaign Ethics Working Group used its expertise in neurocritical care, neuropalliative care, neuroethics, neuroscience, philosophy, and research to formulate an informal review of ethics considerations along the continuum of research involving persons with DoC related to the following: (1) study design; (2) comparison of risks versus benefits; (3) selection of inclusion and exclusion criteria; (4) screening, recruitment, and enrollment; (5) consent; (6) data protection; (7) disclosure of results to surrogates and/or legally authorized representatives; (8) translation of research into practice; (9) identification and management of conflicts of interest; (10) equity and resource availability; and (11) inclusion of minors with DoC in research. Awareness of these ethics considerations when planning and performing research involving persons with DoC will ensure that the participant rights are respected while maximizing the impact and meaningfulness of the research, interpretation of outcomes, and communication of results.
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Affiliation(s)
- Ariane Lewis
- NYU Langone Medical Center, 530 First Avenue, Skirball-7R, New York, NY, 10016, USA.
| | - Michael J Young
- Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Benjamin Rohaut
- Inserm, CNRS, APHP - Hôpital de la Pitié Salpêtrière, Paris Brain Institute - ICM, DMU Neuroscience, Sorbonne University, Paris, France
| | - Ralf J Jox
- Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Jan Claassen
- New York Presbyterian Hospital, Columbia University, New York, NY, USA
| | - Claire J Creutzfeldt
- Harborview Medical Center, Seattle, WA, USA
- University of Washington, Seattle, WA, USA
- Cambia Palliative Care Center of Excellence, Seattle, WA, USA
| | - Judy Illes
- University of British Columbia, Vancouver, BC, Canada
| | | | | | - Joseph J Fins
- Weill Cornell Medical College, New York, NY, USA
- Yale Law School, New Haven, CT, USA
- Rockefeller University, New York, NY, USA
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29
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Kolisnyk M, Kazazian K, Rego K, Novi SL, Wild CJ, Gofton TE, Debicki DB, Owen AM, Norton L. Predicting neurologic recovery after severe acute brain injury using resting-state networks. J Neurol 2023; 270:6071-6080. [PMID: 37665382 DOI: 10.1007/s00415-023-11941-6] [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] [Received: 07/06/2023] [Revised: 08/13/2023] [Accepted: 08/14/2023] [Indexed: 09/05/2023]
Abstract
OBJECTIVE There is a lack of reliable tools used to predict functional recovery in unresponsive patients following a severe brain injury. The objective of the study is to evaluate the prognostic utility of resting-state functional magnetic resonance imaging for predicting good neurologic recovery in unresponsive patients with severe brain injury in the intensive-care unit. METHODS Each patient underwent a 5.5-min resting-state scan and ten resting-state networks were extracted via independent component analysis. The Glasgow Outcome Scale was used to classify patients into good and poor outcome groups. The Nearest Centroid classifier used each patient's ten resting-state network values to predict best neurologic outcome within 6 months post-injury. RESULTS Of the 25 patients enrolled (mean age = 43.68, range = [19-69]; GCS ≤ 9; 6 females), 10 had good and 15 had poor outcome. The classifier correctly and confidently predicted 8/10 patients with good and 12/15 patients with poor outcome (mean = 0.793, CI = [0.700, 0.886], Z = 2.843, p = 0.002). The prediction performance was largely determined by three visual (medial: Z = 3.11, p = 0.002; occipital pole: Z = 2.44, p = 0.015; lateral: Z = 2.85, p = 0.004) and the left frontoparietal network (Z = 2.179, p = 0.029). DISCUSSION Our approach correctly identified good functional outcome with higher sensitivity (80%) than traditional prognostic measures. By revealing preserved networks in the absence of discernible behavioral signs, functional connectivity may aid in the prognostic process and affect the outcome of discussions surrounding withdrawal of life-sustaining measures.
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Affiliation(s)
- Matthew Kolisnyk
- Western Institute of Neuroscience, Western Interdisciplinary Research Building, Western University, 1151 Richmond Street, London, ON, N6A 3K7, Canada
| | - Karnig Kazazian
- Western Institute of Neuroscience, Western Interdisciplinary Research Building, Western University, 1151 Richmond Street, London, ON, N6A 3K7, Canada.
| | - Karina Rego
- Temerty Faculty of Medicine, University of Toronto, Toronto, Canada
| | - Sergio L Novi
- Western Institute of Neuroscience, Western Interdisciplinary Research Building, Western University, 1151 Richmond Street, London, ON, N6A 3K7, Canada
- Department of Physiology and Pharmacology, Schulich School of Medicine and Dentistry, Western University, London, Canada
| | - Conor J Wild
- Western Institute of Neuroscience, Western Interdisciplinary Research Building, Western University, 1151 Richmond Street, London, ON, N6A 3K7, Canada
| | - Teneille E Gofton
- Department of Clinical Neurological Sciences, Schulich School of Medicine and Dentistry, Western University, London, Canada
| | - Derek B Debicki
- Department of Clinical Neurological Sciences, Schulich School of Medicine and Dentistry, Western University, London, Canada
| | - Adrian M Owen
- Western Institute of Neuroscience, Western Interdisciplinary Research Building, Western University, 1151 Richmond Street, London, ON, N6A 3K7, Canada
- Department of Physiology and Pharmacology, Schulich School of Medicine and Dentistry, Western University, London, Canada
- Department of Psychology, Western University, London, Canada
| | - Loretta Norton
- Western Institute of Neuroscience, Western Interdisciplinary Research Building, Western University, 1151 Richmond Street, London, ON, N6A 3K7, Canada
- Department of Psychology, King's University College at Western University, London, Canada
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30
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Choi WJ, Young MJ. Disambiguating Consciousness in Clinical Settings. Neurology 2023; 101:896-900. [PMID: 37748883 PMCID: PMC10662996 DOI: 10.1212/wnl.0000000000207765] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2023] [Accepted: 07/26/2023] [Indexed: 09/27/2023] Open
Affiliation(s)
- William J Choi
- From the Warren Alpert Medical School (W.J.C.), Brown University, Providence, RI; and Department of Neurology (M.J.Y.), Massachusetts General Hospital, Boston.
| | - Michael J Young
- From the Warren Alpert Medical School (W.J.C.), Brown University, Providence, RI; and Department of Neurology (M.J.Y.), Massachusetts General Hospital, Boston
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31
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Sarma AK, Popli G, Anzalone A, Contillo N, Cornell C, Nunn AM, Rowland JA, Godwin DW, Flashman LA, Couture D, Stapleton-Kotloski JR. Use of magnetic source imaging to assess recovery after severe traumatic brain injury-an MEG pilot study. Front Neurol 2023; 14:1257886. [PMID: 38020602 PMCID: PMC10656620 DOI: 10.3389/fneur.2023.1257886] [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: 07/14/2023] [Accepted: 10/13/2023] [Indexed: 12/01/2023] Open
Abstract
Rationale Severe TBI (sTBI) is a devastating neurological injury that comprises a significant global trauma burden. Early comprehensive neurocritical care and rehabilitation improve outcomes for such patients, although better diagnostic and prognostic tools are necessary to guide personalized treatment plans. Methods In this study, we explored the feasibility of conducting resting state magnetoencephalography (MEG) in a case series of sTBI patients acutely after injury (~7 days), and then about 1.5 and 8 months after injury. Synthetic aperture magnetometry (SAM) was utilized to localize source power in the canonical frequency bands of delta, theta, alpha, beta, and gamma, as well as DC-80 Hz. Results At the first scan, SAM source maps revealed zones of hypofunction, islands of preserved activity, and hemispheric asymmetry across bandwidths, with markedly reduced power on the side of injury for each patient. GCS scores improved at scan 2 and by scan 3 the patients were ambulatory. The SAM maps for scans 2 and 3 varied, with most patients showing increasing power over time, especially in gamma, but a continued reduction in power in damaged areas and hemispheric asymmetry and/or relative diminishment in power at the site of injury. At the group level for scan 1, there was a large excess of neural generators operating within the delta band relative to control participants, while the number of neural generators for beta and gamma were significantly reduced. At scan 2 there was increased beta power relative to controls. At scan 3 there was increased group-wise delta power in comparison to controls. Conclusion In summary, this pilot study shows that MEG can be safely used to monitor and track the recovery of brain function in patients with severe TBI as well as to identify patient-specific regions of decreased or altered brain function. Such MEG maps of brain function may be used in the future to tailor patient-specific rehabilitation plans to target regions of altered spectral power with neurostimulation and other treatments.
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Affiliation(s)
- Anand Karthik Sarma
- Department of Neurology, Wake Forest University School of Medicine, Winston-Salem, NC, United States
- Neurocritical Care, Piedmont Atlanta Hospital, Atlanta, GA, United States
| | - Gautam Popli
- Department of Neurology, Wake Forest University School of Medicine, Winston-Salem, NC, United States
| | - Anthony Anzalone
- Wake Forest University School of Medicine, Winston-Salem, NC, United States
- Department of Neurosurgery, Henry Ford Health System, Detroit, MI, United States
| | - Nicholas Contillo
- Wake Forest University School of Medicine, Winston-Salem, NC, United States
| | - Cassandra Cornell
- Department of Neurology, Wake Forest University School of Medicine, Winston-Salem, NC, United States
| | - Andrew M. Nunn
- Department of Surgery, Wake Forest University School of Medicine, Winston-Salem, NC, United States
| | - Jared A. Rowland
- Department of Neurobiology and Anatomy, Wake Forest University School of Medicine, Winston-Salem, NC, United States
- Research and Education Department, W.G. (Bill) Hefner VA Healthcare System, Salisbury, NC, United States
| | - Dwayne W. Godwin
- Department of Neurology, Wake Forest University School of Medicine, Winston-Salem, NC, United States
- Department of Neurobiology and Anatomy, Wake Forest University School of Medicine, Winston-Salem, NC, United States
- Research and Education Department, W.G. (Bill) Hefner VA Healthcare System, Salisbury, NC, United States
| | - Laura A. Flashman
- Department of Neurology, Wake Forest University School of Medicine, Winston-Salem, NC, United States
| | - Daniel Couture
- Department of Neurosurgery, Wake Forest University School of Medicine, Winston-Salem, NC, United States
| | - Jennifer R. Stapleton-Kotloski
- Department of Neurology, Wake Forest University School of Medicine, Winston-Salem, NC, United States
- Department of Neurobiology and Anatomy, Wake Forest University School of Medicine, Winston-Salem, NC, United States
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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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Thibaut A, Fregni F, Estraneo A, Fiorenza S, Noe E, Llorens R, Ferri J, Formisano R, Morone G, Bender A, Rosenfelder M, Lamberti G, Kodratyeva E, Kondratyev S, Legostaeva L, Suponeva N, Krewer C, Müller F, Dardenne N, Jedidi H, Laureys S, Gosseries O, Lejeune N, Martens G. Sham-controlled randomized multicentre trial of transcranial direct current stimulation for prolonged disorders of consciousness. Eur J Neurol 2023; 30:3016-3031. [PMID: 37515394 DOI: 10.1111/ene.15974] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2022] [Revised: 06/01/2023] [Accepted: 07/04/2023] [Indexed: 07/30/2023]
Abstract
BACKGROUND AND PURPOSE Transcranial direct current stimulation (tDCS) has been shown to improve signs of consciousness in a subset of patients with disorders of consciousness (DoC). However, no multicentre study confirmed its efficacy when applied during rehabilitation. In this randomized controlled double-blind study, the effects of tDCS whilst patients were in rehabilitation were tested at the group level and according to their diagnosis and aetiology to better target DoC patients who might repond to tDCS. METHODS Patients received 2 mA tDCS or sham applied over the left prefrontal cortex for 4 weeks. Behavioural assessments were performed weekly and up to 3 months' follow-up. Analyses were conducted at the group and subgroup levels based on the diagnosis (minimally conscious state [MCS] and unresponsive wakefulness syndrome) and the aetiology (traumatic or non-traumatic). Interim analyses were planned to continue or stop the trial. RESULTS The trial was stopped for futility when 62 patients from 10 centres were enrolled (44 ± 14 years, 37 ± 24.5 weeks post-injury, 18 women, 32 MCS, 39 non-traumatic). Whilst, at the group level, no treatment effect was found, the subgroup analyses at 3 months' follow-up revealed a significant improvement for patients in MCS and with traumatic aetiology. CONCLUSIONS Transcranial direct current stimulation during rehabilitation does not seem to enhance patients' recovery. However, diagnosis and aetiology appear to be important factors leading to a response to the treatment. These findings bring novel insights into possible cortical plasticity changes in DoC patients given these differential results according to the subgroups of patients.
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Affiliation(s)
- Aurore Thibaut
- Coma Science Group, GIGA-Consciousness, Centre du Cerveau2, University and University Hospital of Liège, Liège, Belgium
| | - Felipe Fregni
- Neuromodulation Lab, Spaulding Rehabilitation Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Anna Estraneo
- Neurorehabilitation Department, Scientific Institute for Research and Health Care, Don Carlo Gnocchi Foundation, Sant'Angelo dei Lombardi, Florence, Italy
| | - Salvatore Fiorenza
- Neurorehabilitation Department, Scientific Institute for Research and Health Care, Don Carlo Gnocchi Foundation, Sant'Angelo dei Lombardi, Florence, Italy
| | - Enrique Noe
- IRENEA Instituto de Rehabilitación Neurológica, Fundación Hospitales Vithas, Valéncia, Spain
| | - Roberto Llorens
- IRENEA Instituto de Rehabilitación Neurológica, Fundación Hospitales Vithas, Valéncia, Spain
- Neurorehabilitation and Brain Research Group, Instituto Universitario de Investigación en Tecnología Centrada en el Ser Humano, Universitat Politècnica de València, Valencia, Spain
| | - Joan Ferri
- IRENEA Instituto de Rehabilitación Neurológica, Fundación Hospitales Vithas, Valéncia, Spain
| | - Rita Formisano
- Santa Lucia Foundation, Neurorehabilitation and Scientific Institute for Research, Rome, Italy
| | - Giovanni Morone
- Santa Lucia Foundation, Neurorehabilitation and Scientific Institute for Research, Rome, Italy
| | - Andreas Bender
- Therapiezentrum Burgau, Burgau, Germany
- Department of Neurology, Ludwig-Maximilians University of Munich, Munich, Germany
| | - Martin Rosenfelder
- Therapiezentrum Burgau, Burgau, Germany
- Clinical and Biological Psychology, Institute of Psychology and Education, Ulm University, Ulm, Germany
| | - Gianfranco Lamberti
- Neurorehabilitation Department AUSL Piacenza - University of Parma, Piacenza, Italy
| | | | | | | | | | - Carmen Krewer
- Department for Neurology, Research Group, Schoen Clinic Bad Aibling, Bad Aibling, Germany
- Chair of Human Movement Science, Department of Sports and Health Sciences, Technical University of Munich, Munich, Germany
| | - Friedemann Müller
- Department for Neurology, Research Group, Schoen Clinic Bad Aibling, Bad Aibling, Germany
| | - Nadia Dardenne
- University and Hospital Biostatistics Center (B-STAT), Faculty of Medicine, University of Liège, Liège, Belgium
| | | | - Steven Laureys
- Coma Science Group, GIGA-Consciousness, Centre du Cerveau2, University and University Hospital of Liège, Liège, Belgium
- Joint International Research Unit on Consciousness, CERVO Brain Research Centre, CIUSS, University Laval, Quebec, Canada
| | - Olivia Gosseries
- Coma Science Group, GIGA-Consciousness, Centre du Cerveau2, University and University Hospital of Liège, Liège, Belgium
| | - Nicolas Lejeune
- Coma Science Group, GIGA-Consciousness, Centre du Cerveau2, University and University Hospital of Liège, Liège, Belgium
- Centre Hospitalier Neurologique William Lennox, Ottignies-Louvain-la-Neuve, Belgium
| | - Géraldine Martens
- Coma Science Group, GIGA-Consciousness, Centre du Cerveau2, University and University Hospital of Liège, Liège, Belgium
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Boerwinkle VL, Gillette K, Rubinos CA, Broman-Fulks J, Aseem F, DeHoff GK, Arhin M, Cediel E, Strohm T. Functional MRI for Acute Covert Consciousness: Emerging Data and Implementation Case Series. Semin Neurol 2023; 43:712-734. [PMID: 37788679 DOI: 10.1055/s-0043-1775845] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/05/2023]
Abstract
Although research studies have begun to demonstrate relationships between disorders of consciousness and brain network biomarkers, there are limited data on the practical aspects of obtaining such network biomarkers to potentially guide care. As the state of knowledge continues to evolve, guidelines from professional societies such as the American and European Academies of Neurology and many experts have advocated that the risk-benefit ratio for the assessment of network biomarkers has begun to favor their application toward potentially detecting covert consciousness. Given the lack of detailed operationalization guidance and the context of the ethical implications, herein we offer a roadmap based on local institutional experience with the implementation of functional MRI in the neonatal, pediatric, and adult intensive care units of our local government-supported health system. We provide a case-based demonstrative approach intended to review the current literature and to assist with the initiation of such services at other facilities.
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Affiliation(s)
- Varina L Boerwinkle
- Division of Child Neurology, University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - Kirsten Gillette
- Division of Child Neurology, University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - Clio A Rubinos
- Division of Neurocritical Care, University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - Jordan Broman-Fulks
- Division of Child Neurology, University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - Fazila Aseem
- Division of Neurocritical Care, University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - Grace K DeHoff
- Division of Neurocritical Care, University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - Martin Arhin
- Division of Child Neurology, University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - Emilio Cediel
- Division of Child Neurology, University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - Tamara Strohm
- Division of Neurocritical Care, University of North Carolina School of Medicine, Chapel Hill, North Carolina
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35
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Alwood JS, Mulavara AP, Iyer J, Mhatre SD, Rosi S, Shelhamer M, Davis C, Jones CW, Mao XW, Desai RI, Whitmire AM, Williams TJ. Circuits and Biomarkers of the Central Nervous System Relating to Astronaut Performance: Summary Report for a NASA-Sponsored Technical Interchange Meeting. Life (Basel) 2023; 13:1852. [PMID: 37763256 PMCID: PMC10532466 DOI: 10.3390/life13091852] [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: 06/15/2023] [Revised: 08/24/2023] [Accepted: 08/25/2023] [Indexed: 09/29/2023] Open
Abstract
Biomarkers, ranging from molecules to behavior, can be used to identify thresholds beyond which performance of mission tasks may be compromised and could potentially trigger the activation of countermeasures. Identification of homologous brain regions and/or neural circuits related to operational performance may allow for translational studies between species. Three discussion groups were directed to use operationally relevant performance tasks as a driver when identifying biomarkers and brain regions or circuits for selected constructs. Here we summarize small-group discussions in tables of circuits and biomarkers categorized by (a) sensorimotor, (b) behavioral medicine and (c) integrated approaches (e.g., physiological responses). In total, hundreds of biomarkers have been identified and are summarized herein by the respective group leads. We hope the meeting proceedings become a rich resource for NASA's Human Research Program (HRP) and the community of researchers.
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Affiliation(s)
| | | | - Janani Iyer
- Universities Space Research Association (USRA), Moffett Field, CA 94035, USA
| | | | - Susanna Rosi
- Department of Physical Therapy & Rehabilitation Science, University of California, San Francisco, CA 94110, USA
- Department of Neurological Surgery, University of California, San Francisco, CA 94110, USA
| | - Mark Shelhamer
- Department of Otolaryngology–Head and Neck Surgery, Johns Hopkins University, Baltimore, MD 21205, USA
| | - Catherine Davis
- Department of Pharmacology and Molecular Therapeutics, Uniformed Services University of the Health Sciences (USUHS), Bethesda, MD 20814, USA
| | - Christopher W. Jones
- Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Xiao Wen Mao
- Department of Basic Sciences, Division of Biomedical Engineering Sciences (BMES), Loma Linda University Health, Loma Linda, CA 92354, USA
| | - Rajeev I. Desai
- Integrative Neurochemistry Laboratory, Behavioral Biology Program, McLean Hospital-Harvard Medical School, Belmont, MA 02478, USA
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36
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Liuzzi P, Hakiki B, Scarpino M, Burali R, Maiorelli A, Draghi F, Romoli AM, Grippo A, Cecchi F, Mannini A. Neural coding of autonomic functions in different states of consciousness. J Neuroeng Rehabil 2023; 20:96. [PMID: 37491259 PMCID: PMC10369699 DOI: 10.1186/s12984-023-01216-6] [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] [Received: 03/17/2023] [Accepted: 07/10/2023] [Indexed: 07/27/2023] Open
Abstract
Detecting signs of residual neural activity in patients with altered states of consciousness is a crucial issue for the customization of neurorehabilitation treatments and clinical decision-making. With this large observational prospective study, we propose an innovative approach to detect residual signs of consciousness via the assessment of the amount of autonomic information coded within the brain. The latter was estimated by computing the mutual information (MI) between preprocessed EEG and ECG signals, to be then compared across consciousness groups, together with the absolute power and an international qualitative labeling. One-hundred seventy-four patients (73 females, 42%) were included in the study (median age of 65 years [IQR = 20], MCS +: 29, MCS -: 23, UWS: 29). Electroencephalography (EEG) information content was found to be mostly related to the coding of electrocardiography (ECG) activity, i.e., with higher MI (p < 0.05), in Unresponsive Wakefulness Syndrome and Minimally Consciousness State minus (MCS -). EEG-ECG MI, besides clearly discriminating patients in an MCS - and +, significantly differed between lesioned areas (sides) in a subgroup of unilateral hemorrhagic patients. Crucially, such an accessible and non-invasive measure of residual consciousness signs was robust across electrodes and patient groups. Consequently, exiting from a strictly neuro-centric consciousness detection approach may be the key to provide complementary insights for the objective assessment of patients' consciousness levels and for the patient-specific planning of rehabilitative interventions.
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Affiliation(s)
- Piergiuseppe Liuzzi
- Sant’Anna School of Advanced Studies, The BioRobotics Institute, Viale Rinaldo Piaggio 69, 56025 Pontedera, PI Italy
- IRCSS Fondazione Don Carlo Gnocchi ONLUS, Via di Scandicci 269, FI 50143 Florence, Italy
| | - Bahia Hakiki
- IRCSS Fondazione Don Carlo Gnocchi ONLUS, Via di Scandicci 269, FI 50143 Florence, Italy
| | - Maenia Scarpino
- IRCSS Fondazione Don Carlo Gnocchi ONLUS, Via di Scandicci 269, FI 50143 Florence, Italy
| | - Rachele Burali
- IRCSS Fondazione Don Carlo Gnocchi ONLUS, Via di Scandicci 269, FI 50143 Florence, Italy
| | - Antonio Maiorelli
- IRCSS Fondazione Don Carlo Gnocchi ONLUS, Via di Scandicci 269, FI 50143 Florence, Italy
| | - Francesca Draghi
- IRCSS Fondazione Don Carlo Gnocchi ONLUS, Via di Scandicci 269, FI 50143 Florence, Italy
| | - Anna Maria Romoli
- IRCSS Fondazione Don Carlo Gnocchi ONLUS, Via di Scandicci 269, FI 50143 Florence, Italy
| | - Antonello Grippo
- IRCSS Fondazione Don Carlo Gnocchi ONLUS, Via di Scandicci 269, FI 50143 Florence, Italy
| | - Francesca Cecchi
- IRCSS Fondazione Don Carlo Gnocchi ONLUS, Via di Scandicci 269, FI 50143 Florence, Italy
- Department of Experimental and Clinical Medicine, University of Florence, Largo Brambilla 3, 50143 Florence, FI Italy
| | - Andrea Mannini
- IRCSS Fondazione Don Carlo Gnocchi ONLUS, Via di Scandicci 269, FI 50143 Florence, Italy
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Murtaugh B, Shapiro Rosenbaum A. Clinical application of recommendations for neurobehavioral assessment in disorders of consciousness: an interdisciplinary approach. Front Hum Neurosci 2023; 17:1129466. [PMID: 37502093 PMCID: PMC10368884 DOI: 10.3389/fnhum.2023.1129466] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Accepted: 06/05/2023] [Indexed: 07/29/2023] Open
Abstract
Accurate diagnosis, prognosis, and subsequent rehabilitation care planning for persons with Disorders of Consciousness (DoC) has historically posed a challenge for neurological care professionals. Evidence suggests rates of misdiagnosis may be as high as 40% when informal beside evaluations are used to determine level of consciousness. The presence of myriad medical, neurological, functional (motor, sensory, cognitive) and environmental confounds germane to these conditions complicates behavioral assessment. Achieving diagnostic certainty is elusive but critical to inform care planning, clinical decision making, and prognostication. Standardized neurobehavioral rating scales has been shown to improve accuracy in distinguishing between coma, unresponsive wakefulness syndrome/vegetative state and minimally consciousness state as compared to informal assessment methods. Thus, these scales are currently recommended for use as the informal "gold standard" for diagnostic assessment in DoC. The following paper will present an evidence-based approach to neurobehavioral assessment for use in clinical practice. Strategies for optimizing assessment and aiding in identification and management of confounds that can limit diagnostic accuracy will be provided. Finally, clinical application of an interdisciplinary approach to identifying and managing confounds will be discussed and how assessment results can be used to identify trends in performance and guide prognostic counseling with families.
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Affiliation(s)
- Brooke Murtaugh
- Department of Rehabilitation Programs, Madonna Rehabilitation Hospitals, Lincoln, NE, United States
| | - Amy Shapiro Rosenbaum
- Department of Brain Injury Rehabilitation, Park Terrace Care Center, Queens, NY, United States
- TBI Model System, Icahn School of Medicine at Mount Sinai, New York, NY, United States
- Brainmatters Neuropsychological Services, PLLC, Plainview, NY, United States
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38
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Friedman G, Turk KW, Budson AE. The Current of Consciousness: Neural Correlates and Clinical Aspects. Curr Neurol Neurosci Rep 2023; 23:345-352. [PMID: 37303019 PMCID: PMC10287796 DOI: 10.1007/s11910-023-01276-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/29/2023] [Indexed: 06/13/2023]
Abstract
PURPOSE OF REVIEW In this review, we summarize the current understanding of consciousness including its neuroanatomic basis. We discuss major theories of consciousness, physical exam-based and electroencephalographic metrics used to stratify levels of consciousness, and tools used to shed light on the neural correlates of the conscious experience. Lastly, we review an expanded category of 'disorders of consciousness,' which includes disorders that impact either the level or experience of consciousness. RECENT FINDINGS Recent studies have revealed many of the requisite EEG, ERP, and fMRI signals to predict aspects of the conscious experience. Neurological disorders that disrupt the reticular activating system can affect the level of consciousness, whereas cortical disorders from seizures and migraines to strokes and dementia may disrupt phenomenal consciousness. The recently introduced memory theory of consciousness provides a new explanation of phenomenal consciousness that may explain better than prior theories both experimental studies and the neurologist's clinical experience. Although the complete neurobiological basis of consciousness remains a mystery, recent advances have improved our understanding of the physiology underlying level of consciousness and phenomenal consciousness.
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Affiliation(s)
- Garrett Friedman
- Center for Translational Cognitive Neuroscience, VA Boston Healthcare System, 150 S. Huntington Ave., Jamaica Plain, Boston, MA, 02130, USA
| | - Katherine W Turk
- Center for Translational Cognitive Neuroscience, VA Boston Healthcare System, 150 S. Huntington Ave., Jamaica Plain, Boston, MA, 02130, USA
- Department of Neurology, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA
| | - Andrew E Budson
- Center for Translational Cognitive Neuroscience, VA Boston Healthcare System, 150 S. Huntington Ave., Jamaica Plain, Boston, MA, 02130, USA.
- Department of Neurology, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA.
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Sanz LR, Laureys S, Gosseries O. Towards modern post-coma care based on neuroscientific evidence. Int J Clin Health Psychol 2023; 23:100370. [PMID: 36817874 PMCID: PMC9932483 DOI: 10.1016/j.ijchp.2023.100370] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2022] [Accepted: 01/12/2023] [Indexed: 02/05/2023] Open
Abstract
Background Understanding the mechanisms underlying human consciousness is pivotal to improve the prognostication and treatment of severely brain-injured patients. Consciousness remains an elusive concept and the identification of its neural correlates is an active subject of research, however recent neuroscientific advances have allowed scientists to better characterize disorders of consciousness. These breakthroughs question the historical nomenclature and our current management of post-comatose patients. Method This review examines the contribution of consciousness neurosciences to the current clinical management of severe brain injury. It investigates the major impact of consciousness disorders on healthcare systems, the scientific frameworks employed to identify their neural correlates and how evidence-based data from neuroimaging research have reshaped the landscape of post-coma care in recent years. Results Our increased ability to detect behavioral and neurophysiological signatures of consciousness has led to significant changes in taxonomy and clinical practice. We advocate for a multimodal framework for the management of severely brain-injured patients based on precision medicine and evidence-based decisions, integrating epidemiology, health economics and neuroethics. Conclusions Major progress in brain imaging and clinical assessment have opened the door to a new era of post-coma care based on standardized neuroscientific evidence. We highlight its implications in clinical applications and call for improved collaborations between researchers and clinicians to better translate findings to the bedside.
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Affiliation(s)
- Leandro R.D. Sanz
- Coma Science Group, GIGA Consciousness, University of Liège, Liège, Belgium
- Centre du Cerveau, University Hospital of Liège, Liège, Belgium
| | - Steven Laureys
- Coma Science Group, GIGA Consciousness, University of Liège, Liège, Belgium
- Centre du Cerveau, University Hospital of Liège, Liège, Belgium
- Joint International Research Unit on Consciousness, CERVO Brain Research Centre, CIUSS, Laval University, Québec, Canada
| | - Olivia Gosseries
- Coma Science Group, GIGA Consciousness, University of Liège, Liège, Belgium
- Centre du Cerveau, University Hospital of Liège, Liège, Belgium
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Onami S, Tran D, Koh-Pham C, Shih W, Chi B, Peng J, Shavlik D, Singh P, Giacino J. Coma Recovery Scale-Revised Predicts Disability Rating Scale in Acute Rehabilitation of Severe Traumatic Brain Injury. Arch Phys Med Rehabil 2023; 104:1054-1061. [PMID: 36736600 PMCID: PMC10404472 DOI: 10.1016/j.apmr.2023.01.007] [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] [Received: 05/26/2022] [Revised: 12/19/2022] [Accepted: 01/04/2023] [Indexed: 02/03/2023]
Abstract
OBJECTIVE To explore the prognostic value of the Coma Recovery Scale-Revised (CRS-R) in predicting disability outcomes in patients with severe traumatic brain injury using the Disability Rating Scale (DRS). DESIGN Secondary analysis including linear and logistic regressions were performed. SETTING Data were collected in a previous clinical trial. PARTICIPANTS One hundred eighty-four participants across 3 countries (N=184). MAIN OUTCOME MEASURES Disability Rating Scales. RESULTS Analyses showed an inverse relation between CRS-R scores obtained at baseline and change in DRS scores at 6 weeks. Similarly, changes in CRS-R scores between baseline and 4 weeks were also found to have an inverse relation to change in DRS scores at 6 weeks. CONCLUSIONS This study generates a tool that can be used to predict the probability that a patient with severe traumatic brain injury lands in 1 of 3 disability categories. The CRS-R may be useful in prognostication of disability in patients with severe traumatic brain injury.
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Affiliation(s)
- Susan Onami
- Physical Medicine & Rehabilitation, Loma Linda University, Loma Linda, CA
| | - Duc Tran
- Physical Medicine & Rehabilitation, Loma Linda University, Loma Linda, CA
| | - Christine Koh-Pham
- Physical Medicine & Rehabilitation, Loma Linda University, Loma Linda, CA.
| | - Wendy Shih
- Research Consulting Group, Loma Linda University School of Public Health, Loma Linda, CA
| | - Bradley Chi
- Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY
| | - Jiahao Peng
- Research Consulting Group, Loma Linda University School of Public Health, Loma Linda, CA
| | - David Shavlik
- Research Consulting Group, Loma Linda University School of Public Health, Loma Linda, CA
| | - Pramil Singh
- Research Consulting Group, Loma Linda University School of Public Health, Loma Linda, CA
| | - Joseph Giacino
- Physical Medicine & Rehabilitation, Spaulding Rehabilitation Hospital, Charleston, MA
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Elwell C. Functional Neuroimaging in Patients With Disorders of Consciousness: Caution Advised. J Neurosurg Anesthesiol 2023; 35:257-259. [PMID: 37217437 PMCID: PMC10249596 DOI: 10.1097/ana.0000000000000920] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2023] [Accepted: 04/06/2023] [Indexed: 05/24/2023]
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Alnagger N, Cardone P, Martial C, Laureys S, Annen J, Gosseries O. The current and future contribution of neuroimaging to the understanding of disorders of consciousness. Presse Med 2023; 52:104163. [PMID: 36796250 DOI: 10.1016/j.lpm.2022.104163] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Revised: 11/21/2022] [Accepted: 12/13/2022] [Indexed: 02/16/2023] Open
Abstract
Patients with disorders of consciousness (DoC) represent a group of severely brain-injured patients with varying capacities for consciousness in terms of both wakefulness and awareness. The current state-of-the-art for assessing these patients is through standardised behavioural examinations, but inaccuracies are commonplace. Neuroimaging and electrophysiological techniques have revealed vast insights into the relationships between neural alterations, andcognitive and behavioural features of consciousness in patients with DoC. This has led to the establishment of neuroimaging paradigms for the clinical assessment of DoC patients. Here, we review selected neuroimaging findings on the DoC population, outlining key findings of the dysfunction underlying DoC and presenting the current clinical utility of neuroimaging tools. We discuss that whilst individual brain areas play instrumental roles in generating and supporting consciousness, activation of these areas alone is not sufficient for conscious experience. Instead, for consciousness to arise, we need preserved thalamo-cortical circuits, in addition to sufficient connectivity between distinctly differentiated brain networks, underlined by connectivity both within, and between such brain networks. Finally, we present recent advances and future perspectives in computational methodologies applied to DoC, supporting the notion that progress in the science of DoC will be driven by a symbiosis of these data-driven analyses, and theory-driven research. Both perspectives will work in tandem to provide mechanistic insights contextualised within theoretical frameworks which ultimately inform the practice of clinical neurology.
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Affiliation(s)
- Naji Alnagger
- Coma Science Group, GIGA-Consciousness, University of Liège, Liège, Belgium; Centre du Cerveau(2), University Hospital of Liège, Liège, Belgium
| | - Paolo Cardone
- Coma Science Group, GIGA-Consciousness, University of Liège, Liège, Belgium; Centre du Cerveau(2), University Hospital of Liège, Liège, Belgium
| | - Charlotte Martial
- Coma Science Group, GIGA-Consciousness, University of Liège, Liège, Belgium; Centre du Cerveau(2), University Hospital of Liège, Liège, Belgium
| | - Steven Laureys
- Coma Science Group, GIGA-Consciousness, University of Liège, Liège, Belgium; Centre du Cerveau(2), University Hospital of Liège, Liège, Belgium; CERVO Research Center, Laval University, Quebec, Canada
| | - Jitka Annen
- Coma Science Group, GIGA-Consciousness, University of Liège, Liège, Belgium; Centre du Cerveau(2), University Hospital of Liège, Liège, Belgium
| | - Olivia Gosseries
- Coma Science Group, GIGA-Consciousness, University of Liège, Liège, Belgium; Centre du Cerveau(2), University Hospital of Liège, Liège, Belgium.
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Egawa S, Ader J, Shen Q, Nakagawa S, Fujimoto Y, Fujii S, Masuda K, Shirota A, Ota M, Yoshino Y, Amai H, Miyao S, Nakamoto H, Kuroda Y, Doyle K, Grobois L, Vrosgou A, Carmona JC, Velazquez A, Ghoshal S, Roh D, Agarwal S, Park S, Claassen J. Long-Term Outcomes of Patients with Stroke Predicted by Clinicians to have no Chance of Meaningful Recovery: A Japanese Cohort Study. Neurocrit Care 2023; 38:733-740. [PMID: 36450972 PMCID: PMC10227183 DOI: 10.1007/s12028-022-01644-7] [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] [Received: 08/04/2022] [Accepted: 11/08/2022] [Indexed: 12/03/2022]
Abstract
BACKGROUND Little is known about the natural history of comatose patients with brain injury, as in many countries most of these patients die in the context of withdrawal of life-sustaining therapies (WLSTs). The accuracy of predicting recovery that is used to guide goals-of-care decisions is uncertain. We examined long-term outcomes of patients with ischemic or hemorrhagic stroke predicted by experienced clinicians to have no chance of meaningful recovery in Japan, where WLST in patients with isolated neurological disease is uncommon. METHODS We retrospectively reviewed the medical records of all patients admitted with acute ischemic stroke, intracerebral hemorrhage, or nontraumatic subarachnoid hemorrhage between January 2018 and December 2020 to a neurocritical care unit at Toda Medical Group Asaka Medical Center in Saitama, Japan. We screened for patients who were predicted by the attending physician on postinjury day 1-4 to have no chance of meaningful recovery. Primary outcome measures were disposition at hospital discharge and the ability to follow commands and functional outcomes measured by the Glasgow Outcome Scale-Extended (GOS-E), which was assessed 6 months after injury. RESULTS From 860 screened patients, we identified 40 patients (14 with acute ischemic stroke, 19 with intracerebral hemorrhage, and 7 with subarachnoid hemorrhage) who were predicted to have no chance of meaningful recovery. Median age was 77 years (interquartile range 64-85), 53% (n = 21) were women, and 80% (n = 32) had no functional deficits prior to hospitalization. Six months after injury, 17 patients were dead, 14 lived in a long-term care hospital, 3 lived at home, 2 lived in a rehabilitation center, and 2 lived in a nursing home. Three patients reliably followed commands, two were in a vegetative state (GOS-E 2), four fully depended on others and required constant assistance (GOS-E 3), one could be left alone independently for 8 h per day but remained dependent (GOS-E 4), and one was independent and able to return to work-like activities (GOS-E 5). CONCLUSIONS In the absence of WLST, almost half of the patients predicted shortly after the injury to have no chance of meaningful recovery were dead 6 months after the injury. A small minority of patients had good functional recovery, highlighting the need for more accurate neurological prognostication.
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Affiliation(s)
- Satoshi Egawa
- Department of Neurology, Columbia University Medical Center, New York-Presbyterian Hospital, 177 Fort Washington Avenue, MHB 8 Center, Room 300, New York, NY, 10032, USA
- Department of Neurointensive Care, Toda Medical Group Asaka Medical Center, Saitama, Japan
- Department of Neurosurgery, Stroke and Epilepsy Center, Toda Medical Group Asaka Medical Center, Saitama, Japan
| | - Jeremy Ader
- Department of Neurology, Columbia University Medical Center, New York-Presbyterian Hospital, 177 Fort Washington Avenue, MHB 8 Center, Room 300, New York, NY, 10032, USA
| | - Qi Shen
- Department of Neurology, Columbia University Medical Center, New York-Presbyterian Hospital, 177 Fort Washington Avenue, MHB 8 Center, Room 300, New York, NY, 10032, USA
| | - Shun Nakagawa
- Department of Neurointensive Care, Toda Medical Group Asaka Medical Center, Saitama, Japan
| | - Yoshihisa Fujimoto
- Department of Neurointensive Care, Toda Medical Group Asaka Medical Center, Saitama, Japan
| | - Shuichi Fujii
- Department of Neurointensive Care, Toda Medical Group Asaka Medical Center, Saitama, Japan
| | - Kenta Masuda
- Department of Rehabilitation, Toda Medical Group Asaka Medical Center, Saitama, Japan
| | - Akira Shirota
- Department of Rehabilitation, Toda Medical Group Asaka Medical Center, Saitama, Japan
| | - Masafumi Ota
- Department of Rehabilitation, Toda Medical Group Asaka Medical Center, Saitama, Japan
| | - Yuji Yoshino
- Department of Rehabilitation, Toda Medical Group Asaka Medical Center, Saitama, Japan
| | - Hitomi Amai
- Department of Social Work, Toda Medical Group Asaka Medical Center, Saitama, Japan
| | - Satoru Miyao
- Department of Neurosurgery, Stroke and Epilepsy Center, Toda Medical Group Asaka Medical Center, Saitama, Japan
| | - Hidetoshi Nakamoto
- Department of Neurosurgery, Stroke and Epilepsy Center, Toda Medical Group Asaka Medical Center, Saitama, Japan
| | - Yasuhiro Kuroda
- Emergency Medical Center, Kagawa University Hospital, Kagawa, Japan
| | - Kevin Doyle
- Department of Neurology, Columbia University Medical Center, New York-Presbyterian Hospital, 177 Fort Washington Avenue, MHB 8 Center, Room 300, New York, NY, 10032, USA
| | - Lauren Grobois
- Department of Neurology, Columbia University Medical Center, New York-Presbyterian Hospital, 177 Fort Washington Avenue, MHB 8 Center, Room 300, New York, NY, 10032, USA
| | - Athina Vrosgou
- Department of Neurology, Columbia University Medical Center, New York-Presbyterian Hospital, 177 Fort Washington Avenue, MHB 8 Center, Room 300, New York, NY, 10032, USA
| | - Jerina C Carmona
- Department of Neurology, Columbia University Medical Center, New York-Presbyterian Hospital, 177 Fort Washington Avenue, MHB 8 Center, Room 300, New York, NY, 10032, USA
| | - Angela Velazquez
- Department of Neurology, Columbia University Medical Center, New York-Presbyterian Hospital, 177 Fort Washington Avenue, MHB 8 Center, Room 300, New York, NY, 10032, USA
| | - Shivani Ghoshal
- Department of Neurology, Columbia University Medical Center, New York-Presbyterian Hospital, 177 Fort Washington Avenue, MHB 8 Center, Room 300, New York, NY, 10032, USA
| | - David Roh
- Department of Neurology, Columbia University Medical Center, New York-Presbyterian Hospital, 177 Fort Washington Avenue, MHB 8 Center, Room 300, New York, NY, 10032, USA
| | - Sachin Agarwal
- Department of Neurology, Columbia University Medical Center, New York-Presbyterian Hospital, 177 Fort Washington Avenue, MHB 8 Center, Room 300, New York, NY, 10032, USA
| | - Soojin Park
- Department of Neurology, Columbia University Medical Center, New York-Presbyterian Hospital, 177 Fort Washington Avenue, MHB 8 Center, Room 300, New York, NY, 10032, USA
- Department of Biomedical Informatics, 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, 177 Fort Washington Avenue, MHB 8 Center, Room 300, New York, NY, 10032, USA.
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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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Edlow BL, Fecchio M, Bodien YG, Comanducci A, Rosanova M, Casarotto S, Young MJ, Li J, Dougherty DD, Koch C, Tononi G, Massimini M, Boly M. Measuring Consciousness in the Intensive Care Unit. Neurocrit Care 2023; 38:584-590. [PMID: 37029315 DOI: 10.1007/s12028-023-01706-4] [Citation(s) in RCA: 15] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Accepted: 02/23/2023] [Indexed: 04/09/2023]
Abstract
Early reemergence of consciousness predicts long-term functional recovery for patients with severe brain injury. However, tools to reliably detect consciousness in the intensive care unit are lacking. Transcranial magnetic stimulation electroencephalography has the potential to detect consciousness in the intensive care unit, predict recovery, and prevent premature withdrawal of life-sustaining therapy.
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Affiliation(s)
- Brian L Edlow
- Center for Neurotechnology and Neurorecovery, Department of Neurology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA.
- Athinoula A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital, Charlestown, MA, USA.
| | - Matteo Fecchio
- Center for Neurotechnology and Neurorecovery, Department of Neurology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Yelena G Bodien
- Center for Neurotechnology and Neurorecovery, Department of Neurology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
- Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital and Harvard Medical School, Charlestown, MA, USA
| | - Angela Comanducci
- IRCCS Fondazione Don Carlo Gnocchi Onlus, Milan, Italy
- Università Campus Bio-Medico di Roma, Rome, Italy
| | - Mario Rosanova
- Department of Biomedical and Clinical Sciences, University of Milan, Milan, Italy
| | - Silvia Casarotto
- IRCCS Fondazione Don Carlo Gnocchi Onlus, Milan, Italy
- Department of Biomedical and Clinical Sciences, University of Milan, Milan, Italy
| | - Michael J Young
- Center for Neurotechnology and Neurorecovery, Department of Neurology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Jian Li
- Center for Neurotechnology and Neurorecovery, Department of Neurology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
- Athinoula A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital, Charlestown, MA, USA
| | - Darin D Dougherty
- Athinoula A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital, Charlestown, MA, USA
- Department of Psychiatry, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Christof Koch
- MindScope Program, Allen Institute, Seattle, WA, USA
- Tiny Blue Dot Foundation, Santa Monica, CA, USA
| | - Giulio Tononi
- Department of Psychiatry, University of Wisconsin-Madison, Madison, WI, USA
| | - Marcello Massimini
- IRCCS Fondazione Don Carlo Gnocchi Onlus, Milan, Italy
- Department of Biomedical and Clinical Sciences, University of Milan, Milan, Italy
| | - Melanie Boly
- Department of Neurology, University of Wisconsin-Madison, Madison, WI, USA
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La Framboise NF, Rochat E, Diserens K. A Biopsychosocial Evaluation of Post-Acute Outcome of Patients with Severe Brain Lesions Recovering from Coma: An Exploratory Study. J Clin Med 2023; 12:jcm12103572. [PMID: 37240678 DOI: 10.3390/jcm12103572] [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: 03/29/2023] [Revised: 05/09/2023] [Accepted: 05/17/2023] [Indexed: 05/28/2023] Open
Abstract
Currently, very little is known about the holistic outcome of patients recovering from coma. The aim of this retrospective exploratory study was to evaluate the outcomes of patients recovering from coma after care in an acute neurorehabilitation unit with particular focus on their biopsychosocial and spiritual needs in the post-acute phase of recovery. We included 12 patients and evaluated clinical outcome evolution by comparing standard neurobehavioral scores from patient files measured in the acute and post-acute phases. We assessed patient needs using the Quality of Life after Brain Injury scale (QOLIBRI) and classified self-reported complaints mentioned in patient files according to the International Classification of Functioning, Disability and Health framework (ICF). Mean patient evolution was a Level of Cognitive Functioning Scale (LCF)-r increase of 3.33 levels (range = 2); a Disability Rating Scale score (DRS) of -3.27 points (SD = 3.78); a Functional Ambulation Classification (FAC) scale score of 1.83 (range = 5); and a Glasgow Outcome Scale (GOS) median = 0 (Interquartile range = 1). Main patient complaints concerned mental functioning (n = 7), sensory functioning and pain (n = 6), neuromusculoskeletal and movement problems (n = 5), and major life areas (n = 5). To conclude, a significant handicap that affects their daily life was present in the post-acute phase in most patients. Complaints involved biopsychosocial and spiritual elements. The neurobehavioral scale results do not necessarily correlate with the subjective representations patients had of their condition.
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Affiliation(s)
- Noah F La Framboise
- Faculty of Biology and Medicine (FBM), Lausanne University, 1005 Lausanne, Switzerland
| | - Etienne Rochat
- Institute of Humanities in Medicine, Faculty of Biology and Medicine (FBM), Lausanne University, 1007 Lausanne, Switzerland
| | - Karin Diserens
- Department of Clinical Neurosciences, Lausanne University Hospital (CHUV), 1011 Lausanne, Switzerland
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Jakobsen EW, Nersesjan V, Albrechtsen SS, Othman MH, Amiri M, Knudsen NV, Larson MD, Hassager C, Møller K, Kjaergaard J, Kondziella D. Brimonidine eye drops reveal diminished sympathetic pupillary tone in comatose patients with brain injury. Acta Neurochir (Wien) 2023; 165:1483-1494. [PMID: 37014450 DOI: 10.1007/s00701-023-05569-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2022] [Accepted: 02/20/2023] [Indexed: 04/05/2023]
Abstract
BACKGROUND There is an urgent need for easy-to-perform bedside measures to detect residual consciousness in clinically unresponsive patients with acute brain injury. Interestingly, the sympathetic control of pupil size is thought to be lost in states of unconsciousness. We therefore hypothesized that administration of brimonidine (an alpha-2-adrenergic agonist) eye drops into one eye should produce a pharmacologic Horner's syndrome if the clinically unresponsive patient is conscious, but not if the patient is unconscious. Here, in a first step to explore this hypothesis, we investigated the potential of brimonidine eye drops to distinguish preserved sympathetic pupillary function in awake volunteers from impairment of sympathetic tone in patients in a coma. METHODS We enrolled comatose patients admitted for acute brain injury to one of the intensive care units (ICU) of a tertiary referral center, in whom EEG and/or neuroimaging for all practical purposes had ruled out residual consciousness. Exclusion criteria were deep sedation, medications with known drug interactions with brimonidine, and a history of eye disease. Age- and sex-matched healthy and awake volunteers served as controls. We measured pupils of both eyes, under scotopic conditions, at baseline and five times 5-120 min after administering brimonidine into the right eye, using automated pupillometry. Primary outcomes were miosis and anisocoria at the individual and group levels. RESULTS We included 15 comatose ICU patients (seven women, mean age 59 ± 13.8 years) and 15 controls (seven women, mean age 55 ± 16.3 years). At 30 min, miosis and anisocoria were seen in all 15 controls (mean difference between the brimonidine-treated pupil and the control pupil: - 1.31 mm, 95% CI [- 1.51; - 1.11], p < 0.001), but in none (p < 0.001) of the 15 ICU patients (mean difference: 0.09 mm, 95% CI [- 0.12;0.30], p > 0.99). This effect was unchanged after 120 min and remained robust in sensitivity analyses correcting for baseline pupil size, age, and room illuminance. CONCLUSION In this proof-of-principle study, brimonidine eye drops produced anisocoria in awake volunteers but not in comatose patients with brain injury. This suggests that automated pupillometry after administration of brimonidine can distinguish between the extremes of the spectrum of consciousness (i.e., fully conscious vs. deeply comatose). A larger study testing the "intermediate zone" of disorders of consciousness in the ICU seems warranted.
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Affiliation(s)
- Elisabeth Waldemar Jakobsen
- Department of Neurology, Rigshospitalet, Copenhagen University Hospital, Blegdamsvej 9, DK-2100, Copenhagen, Denmark
| | - Vardan Nersesjan
- Department of Neurology, Rigshospitalet, Copenhagen University Hospital, Blegdamsvej 9, DK-2100, Copenhagen, Denmark
| | - Simon Sander Albrechtsen
- Department of Neurology, Rigshospitalet, Copenhagen University Hospital, Blegdamsvej 9, DK-2100, Copenhagen, Denmark
| | - Marwan H Othman
- Department of Neurology, Rigshospitalet, Copenhagen University Hospital, Blegdamsvej 9, DK-2100, Copenhagen, Denmark
| | - Moshgan Amiri
- Department of Neurology, Rigshospitalet, Copenhagen University Hospital, Blegdamsvej 9, DK-2100, Copenhagen, Denmark
| | - Niels Vendelbo Knudsen
- Department of Neuroanesthesiology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Merlin D Larson
- Department of Anesthesiology, University of California San Francisco, San Francisco, CA, USA
| | - Christian Hassager
- Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Kirsten Møller
- Department of Neuroanesthesiology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Jesper Kjaergaard
- Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Daniel Kondziella
- Department of Neurology, Rigshospitalet, Copenhagen University Hospital, Blegdamsvej 9, DK-2100, Copenhagen, Denmark.
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark.
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48
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Maundrell R. Brain Death: Still A Puzzle After All These Years. NEUROETHICS-NETH 2023. [DOI: 10.1007/s12152-022-09513-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
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Xu C, Zheng R, Zhou L, Feng D. Alteration in ventral tegmental area and default mode network interplay and prediction of coma recovery in patients with sTBI. Heliyon 2023; 9:e15279. [PMID: 37128308 PMCID: PMC10148103 DOI: 10.1016/j.heliyon.2023.e15279] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2022] [Revised: 03/19/2023] [Accepted: 03/31/2023] [Indexed: 05/03/2023] Open
Abstract
Purpose To investigate the role of VTA and DMN in modulating human consciousness in patient with sTBI. Methods We mapped an atlas of VTA in the brainstem and a total of 19 region of interests in the ventral and dorsal DMN onto functional magnetic resonance imaging in 28 patients with sTBI and 28 healthy controls. We assessed the functional connectivity alteration in subcortical VTA and cortical DMN nodes in patients of coma. We evaluated the spatially distribution of FC alteration in VTA and DMN nodes after sTBI and evaluated their predictive value for coma recovery. Results There was a decrease in FC between VTA and DMN in patients compared to controls. After decomposition, the FC between VTA and 10 DMN nodes were decreased whereas the FC within 2 DMN nodes were increased in patients with acute coma. The FC alteration in DMN nodes provided useful information for the early prediction of 6-month coma recovery in patients with sTBI. Conclusions We provide initial evidence for the decreased FC between VTA and massive DMN nodes in patients with coma in acute phase of sTBI. We found that the FC alteration within DMN is more useful than the FC alteration between VTA and DMN for predicting coma recovery in patients with sTBI. VTA and DMN connectivity mapping provides an opportunity to advance the cortical-subcortical mechanism of human consciousness.
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Affiliation(s)
- Canxin Xu
- Department of Neurosurgery, Southern Medical University Affiliated Fengxian Hospital, Shanghai, China
- Department of Neurosurgery, Ruijin Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - RuiZhe Zheng
- Institute of Traumatic Medicine, Shanghai Jiao Tong University School of Medicine, Shanghai, PR China
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China
| | - LaiYang Zhou
- Institute of Wannan Medical College, Wuhu, PR China
| | - DongFu Feng
- Department of Neurosurgery, Southern Medical University Affiliated Fengxian Hospital, Shanghai, China
- Institute of Traumatic Medicine, Shanghai Jiao Tong University School of Medicine, Shanghai, PR China
- Corresponding author. Department of Neurosurgery, Southern Medical University Affiliated Fengxian Hospital, Shanghai,201499, China.
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50
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Norton L, Graham M, Kazazian K, Gofton T, Weijer C, Debicki D, Fernandez-Espejo D, Thenayan EA, Owen AM. Use of functional magnetic resonance imaging to assess cognition and consciousness in severe Guillain-Barré syndrome. Int J Clin Health Psychol 2023; 23:100347. [DOI: 10.1016/j.ijchp.2022.100347] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2022] [Accepted: 10/08/2022] [Indexed: 11/13/2022] Open
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