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Luo Y, Wang L, Yang Y, Jiang X, Zheng K, Xi Y, Wang M, Wang L, Xu Y, Li J, Xie Y, Wang Y. Exploration of resting-state brain functional connectivity as preclinical markers for arousal prediction in prolonged disorders of consciousness: A pilot study based on functional near-infrared spectroscopy. Brain Behav 2024; 14:e70002. [PMID: 39183500 PMCID: PMC11345494 DOI: 10.1002/brb3.70002] [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: 11/10/2023] [Revised: 06/04/2024] [Accepted: 07/24/2024] [Indexed: 08/27/2024] Open
Abstract
BACKGROUND There is no diagnostic assessment procedure with moderate or strong evidence of use, and evidence for current means of treating prolonged disorders of consciousness (pDOC) is sparse. This may be related to the fact that the mechanisms of pDOC have not been studied deeply enough and are not clear enough. Therefore, the aim of this study was to explore the mechanism of pDOC using functional near-infrared spectroscopy (fNIRS) to provide a basis for the treatment of pDOC, as well as to explore preclinical markers for determining the arousal of pDOC patients. METHODS Five minutes resting-state data were collected from 10 pDOC patients and 13healthy adults using fNIRS. Based on the concentrations of oxyhemoglobin (HbO) and deoxyhemoglobin (HbR) in the time series, the resting-state cortical brain functional connectivity strengths of the two groups were calculated, and the functional connectivity strengths of homologous and heterologous brain networks were compared at the sensorimotor network (SEN), dorsal attention network (DAN), ventral attention network (VAN), default mode network (DMN), frontoparietal network (FPN), and visual network (VIS) levels. Univariate binary logistic regression analyses were performed on brain networks with statistically significant differences to identify brain networks associated with arousal in pDOC patients. The receiver operating characteristic (ROC) curves were further analyzed to determine the cut-off value of the relevant brain networks to provide clinical biomarkers for the prediction of arousal in pDOC patients. RESULTS The results showed that the functional connectivity strengths of oxyhemoglobin (HbO)-based SEN∼SEN, VIS∼VIS, DAN∼DAN, DMN∼DMN, SEN∼VIS, SEN∼FPN, SEN∼DAN, SEN∼DMN, VIS∼FPN, VIS∼DAN, VIS∼DMN, HbR-based SEN∼SEN, and SEN∼DAN were significantly reduced in the pDOC group and were factors that could reflect the participants' state of consciousness. The cut-off value of resting-state functional connectivity strength calculated by ROC curve analysis can be used as a potential preclinical marker for predicting the arousal state of subjects. CONCLUSION Resting-state functional connectivity strength of cortical networks is significantly reduced in pDOC patients. The cut-off values of resting-state functional connectivity strength are potential preclinical markers for predicting arousal in pDOC patients.
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Affiliation(s)
- Yaomin Luo
- Department of Rehabilitation MedicineAffiliated Hospital of North Sichuan Medical CollegeNanchongChina
| | - Lingling Wang
- Department of Rehabilitation MedicineWest China Second Hospital of Sichuan UniversityChenduChina
| | - Yuxuan Yang
- Department of Rehabilitation MedicineWest China Second Hospital of Sichuan UniversityChenduChina
| | - Xin Jiang
- Department of Respiratory MedicineGaoping District People's HospitalNanchongChina
| | - Kaiyuan Zheng
- Department of Rehabilitation MedicineAffiliated Hospital of North Sichuan Medical CollegeNanchongChina
| | - Yu Xi
- Department of Operating RoomNanchong Hospital of Traditional Chinese MedicineNanchongChina
| | - Min Wang
- Department of Paediatric SurgeryNanchong Central Hospital, The Second Clinical College, North Sichuan Medical CollegeNanchongChina
| | - Li Wang
- Department of Rehabilitation MedicineAffiliated Hospital of North Sichuan Medical CollegeNanchongChina
| | - Yanlin Xu
- Sports Rehabilitation, North Sichuan Medical CollegeNanchongChina
| | - Jun Li
- Sports Rehabilitation, North Sichuan Medical CollegeNanchongChina
| | - Yulei Xie
- Department of Rehabilitation MedicineAffiliated Hospital of North Sichuan Medical CollegeNanchongChina
- School of RehabilitationCapital Medical UniversityBeijingChina
| | - Yinxu Wang
- Department of Rehabilitation MedicineAffiliated Hospital of North Sichuan Medical CollegeNanchongChina
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Vaz A, Wathen C, Miranda S, Thomas R, Darlington T, Jabarkheel R, Tomlinson S, Arena J, Bond K, Salwi S, Ajmera S, Bachschmid-Romano L, Gugger J, Sandsmark D, Diaz-Arrastia R, Schuster J, Ramayya AG, Cajigas I, Pesaran B, Chen HI, Petrov D. Return of intracranial beta oscillations and traveling waves with recovery from traumatic brain injury. BIORXIV : THE PREPRINT SERVER FOR BIOLOGY 2024:2024.07.19.604293. [PMID: 39091808 PMCID: PMC11291083 DOI: 10.1101/2024.07.19.604293] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 08/04/2024]
Abstract
Traumatic brain injury (TBI) remains a pervasive clinical problem associated with significant morbidity and mortality. However, TBI remains clinically and biophysically ill-defined, and prognosis remains difficult even with the standardization of clinical guidelines and advent of multimodality monitoring. Here we leverage a unique data set from TBI patients implanted with either intracranial strip electrodes during craniotomy or quad-lumen intracranial bolts with depth electrodes as part of routine clinical practice. By extracting spectral profiles of this data, we found that the presence of narrow-band oscillatory activity in the beta band (12-30 Hz) closely corresponds with the neurological exam as quantified with the standard Glasgow Coma Scale (GCS). Further, beta oscillations were distributed over the cortical surface as traveling waves, and the evolution of these waves corresponded to recovery from coma, consistent with the putative role of waves in perception and cognitive activity. We consequently propose that beta oscillations and traveling waves are potential biomarkers of recovery from TBI. In a broader sense, our findings suggest that emergence from coma results from recovery of thalamo-cortical interactions that coordinate cortical beta rhythms.
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Affiliation(s)
- Alex Vaz
- Department of Neurosurgery, University of Pennsylvania, Philadelphia, PA, 19104, USA
- Surgical Neurology Branch, NINDS, National Institutes of Health, Bethesda, MD 20892, USA
| | - Connor Wathen
- Department of Neurosurgery, University of Pennsylvania, Philadelphia, PA, 19104, USA
| | - Stephen Miranda
- Department of Neurosurgery, University of Pennsylvania, Philadelphia, PA, 19104, USA
| | - Rachel Thomas
- Department of Neurology, University of Pennsylvania, Philadelphia, PA, 19104, USA
| | - Timothy Darlington
- Department of Neurosurgery, University of Pennsylvania, Philadelphia, PA, 19104, USA
| | - Rashad Jabarkheel
- Department of Neurosurgery, University of Pennsylvania, Philadelphia, PA, 19104, USA
| | - Samuel Tomlinson
- Department of Neurosurgery, University of Pennsylvania, Philadelphia, PA, 19104, USA
| | - John Arena
- Department of Neurosurgery, University of Pennsylvania, Philadelphia, PA, 19104, USA
| | - Kamila Bond
- Department of Neurosurgery, University of Pennsylvania, Philadelphia, PA, 19104, USA
| | - Sanjana Salwi
- Department of Neurosurgery, University of Pennsylvania, Philadelphia, PA, 19104, USA
| | - Sonia Ajmera
- Department of Neurosurgery, University of Pennsylvania, Philadelphia, PA, 19104, USA
| | | | - James Gugger
- Department of Neurology, University of Pennsylvania, Philadelphia, PA, 19104, USA
| | - Danielle Sandsmark
- Department of Neurology, University of Pennsylvania, Philadelphia, PA, 19104, USA
| | - Ramon Diaz-Arrastia
- Department of Neurology, University of Pennsylvania, Philadelphia, PA, 19104, USA
| | - James Schuster
- Department of Neurosurgery, University of Pennsylvania, Philadelphia, PA, 19104, USA
| | - Ashwin G Ramayya
- Department of Neurosurgery, Stanford University, Palo Alto, CA, 94305, USA
| | - Iahn Cajigas
- Department of Neurosurgery, University of Pennsylvania, Philadelphia, PA, 19104, USA
| | - Bijan Pesaran
- Department of Neurosurgery, University of Pennsylvania, Philadelphia, PA, 19104, USA
| | - H Isaac Chen
- Department of Neurosurgery, University of Pennsylvania, Philadelphia, PA, 19104, USA
- Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, PA 19104, USA
| | - Dmitriy Petrov
- Department of Neurosurgery, University of Pennsylvania, Philadelphia, PA, 19104, USA
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Spaccavento S, Carraturo G, Brattico E, Matarrelli B, Rivolta D, Montenegro F, Picciola E, Haumann NT, Jespersen KV, Vuust P, Losavio E. Musical and electrical stimulation as intervention in disorder of consciousness (DOC) patients: A randomised cross-over trial. PLoS One 2024; 19:e0304642. [PMID: 38820520 PMCID: PMC11142721 DOI: 10.1371/journal.pone.0304642] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Accepted: 05/14/2024] [Indexed: 06/02/2024] Open
Abstract
BACKGROUND Disorders of consciousness (DOC), i.e., unresponsive wakefulness syndrome (UWS) or vegetative state (VS) and minimally conscious state (MCS), are conditions that can arise from severe brain injury, inducing widespread functional changes. Given the damaging implications resulting from these conditions, there is an increasing need for rehabilitation treatments aimed at enhancing the level of consciousness, the quality of life, and creating new recovery perspectives for the patients. Music may represent an additional rehabilitative tool in contexts where cognition and language are severely compromised, such as among DOC patients. A further type of rehabilitation strategies for DOC patients consists of Non-Invasive Brain Stimulation techniques (NIBS), including transcranial electrical stimulation (tES), affecting neural excitability and promoting brain plasticity. OBJECTIVE We here propose a novel rehabilitation protocol for DOC patients that combines music-based intervention and NIBS in neurological patients. The main objectives are (i) to assess the residual neuroplastic processes in DOC patients exposed to music, (ii) to determine the putative neural modulation and the clinical outcome in DOC patients of non-pharmacological strategies, i.e., tES(control condition), and music stimulation, and (iii) to evaluate the putative positive impact of this intervention on caregiver's burden and psychological distress. METHODS This is a randomised cross-over trial in which a total of 30 participants will be randomly allocated to one of three different combinations of conditions: (i) Music only, (ii) tES only (control condition), (iii) Music + tES. The music intervention will consist of listening to an individually tailored playlist including familiar and self-relevant music together with fixed songs; concerning NIBS, tES will be applied for 20 minutes every day, 5 times a week, for two weeks. After these stimulations two weeks of placebo treatments will follow, with sham stimulation combined with noise for other two weeks. The primary outcomes will be clinical, i.e., based on the differences in the scores obtained on the neuropsychological tests, such as Coma Recovery Scale-Revised, and neurophysiological measures as EEG, collected pre-intervention, post-intervention and post-placebo. DISCUSSION This study proposes a novel rehabilitation protocol for patients with DOC including a combined intervention of music and NIBS. Considering the need for rigorous longitudinal randomised controlled trials for people with severe brain injury disease, the results of this study will be highly informative for highlighting and implementing the putative beneficial role of music and NIBS in rehabilitation treatments. TRIAL REGISTRATION ClinicalTrials.gov identifier: NCT05706831, registered on January 30, 2023.
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Affiliation(s)
- Simona Spaccavento
- Istituti Clinici Scientifici Maugeri IRCCS, Institute of Bari, Bari, Italy
| | - Giulio Carraturo
- Department of Education, Psychology, Communication, University of Bari Aldo Moro, Bari, Italy
| | - Elvira Brattico
- Department of Education, Psychology, Communication, University of Bari Aldo Moro, Bari, Italy
- Center for Music in the Brain, Department of Clinical Medicine, Aarhus University & Royal Academy of Aarhus/Aalborg, Aarhus, Denmark
| | - Benedetta Matarrelli
- Department of Education, Psychology, Communication, University of Bari Aldo Moro, Bari, Italy
| | - Davide Rivolta
- Department of Education, Psychology, Communication, University of Bari Aldo Moro, Bari, Italy
| | - Fabiana Montenegro
- Istituti Clinici Scientifici Maugeri IRCCS, Institute of Bari, Bari, Italy
| | - Emilia Picciola
- Istituti Clinici Scientifici Maugeri IRCCS, Institute of Bari, Bari, Italy
| | - Niels Trusbak Haumann
- Center for Music in the Brain, Department of Clinical Medicine, Aarhus University & Royal Academy of Aarhus/Aalborg, Aarhus, Denmark
| | - Kira Vibe Jespersen
- Center for Music in the Brain, Department of Clinical Medicine, Aarhus University & Royal Academy of Aarhus/Aalborg, Aarhus, Denmark
| | - Peter Vuust
- Center for Music in the Brain, Department of Clinical Medicine, Aarhus University & Royal Academy of Aarhus/Aalborg, Aarhus, Denmark
| | - Ernesto Losavio
- Istituti Clinici Scientifici Maugeri IRCCS, Institute of Bari, Bari, Italy
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Calderone A, Cardile D, Gangemi A, De Luca R, Quartarone A, Corallo F, Calabrò RS. Traumatic Brain Injury and Neuromodulation Techniques in Rehabilitation: A Scoping Review. Biomedicines 2024; 12:438. [PMID: 38398040 PMCID: PMC10886871 DOI: 10.3390/biomedicines12020438] [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: 01/09/2024] [Revised: 02/08/2024] [Accepted: 02/13/2024] [Indexed: 02/25/2024] Open
Abstract
BACKGROUND AND OBJECTIVES Traumatic Brain Injury (TBI) is a condition in which an external force, usually a violent blow to the head, causes functional impairment in the brain. Neuromodulation techniques are thought to restore altered function in the brain, resulting in improved function and reduced symptoms. Brain stimulation can alter the firing of neurons, boost synaptic strength, alter neurotransmitters and excitotoxicity, and modify the connections in their neural networks. All these are potential effects on brain activity. Accordingly, this is a promising therapy for TBI. These techniques are flexible because they can target different brain areas and vary in frequency and amplitude. This review aims to investigate the recent literature about neuromodulation techniques used in the rehabilitation of TBI patients. MATERIALS AND METHODS The identification of studies was made possible by conducting online searches on PubMed, Web of Science, Cochrane, Embase, and Scopus databases. Studies published between 2013 and 2023 were selected. This review has been registered on OSF (JEP3S). RESULTS We have found that neuromodulation techniques can improve the rehabilitation process for TBI patients in several ways. Transcranial Magnetic Stimulation (TMS) can improve cognitive functions such as recall ability, neural substrates, and overall improved performance on neuropsychological tests. Repetitive TMS has the potential to increase neural connections in many TBI patients but not in all patients, such as those with chronic diffuse axonal damage. CONCLUSIONS This review has demonstrated that neuromodulation techniques are promising instruments in the rehabilitation field, including those affected by TBI. The efficacy of neuromodulation can have a significant impact on their lives and improve functional outcomes for TBI patients.
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Affiliation(s)
| | - Davide Cardile
- IRCCS Centro Neurolesi Bonino-Pulejo, S.S. 113 Via Palermo, C. da Casazza; 98124 Messina, Italy; (A.C.); (A.G.); (R.D.L.); (A.Q.); (F.C.); (R.S.C.)
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Guo B, Han Q, Ni J, Yan Z. Research hotspots and frontiers of neuromodulation techniques in disorders of consciousness: a bibliometric analysis. Front Neurosci 2024; 17:1343471. [PMID: 38260028 PMCID: PMC10800698 DOI: 10.3389/fnins.2023.1343471] [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: 11/23/2023] [Accepted: 12/26/2023] [Indexed: 01/24/2024] Open
Abstract
Background The characteristics of disorders of consciousness (DOC) are changes in arousal and/or awareness caused by severe brain injuries. To date, the management of DOC patients remains a complex and challenging task, and neuromodulation techniques offer a promising solution. However, a bibliometric analysis focusing on neuromodulation techniques in DOC is currently absent. The aim of this study is to provide a bibliometric visualization analysis to investigate the research hotspots and frontiers in the field of neuromodulation techniques in DOC from 2012 to 2022. Methods The publications were collected and retrieved from the Web of Science (WoS) from 2012 to 2022. CiteSpace and Microsoft Excel were utilized perform the first global bibliographic analysis of the literature related to neuromodulation techniques for DOC. Results The analysis included a total of 338 publications. From 2012 to 2022, a consistent yet irregular increase in the number of articles published on neuromodulation techniques in DOC was observed. Frontiers in Neurology published the highest number of papers (n = 16). Neurosciences represented the main research hotspot category (n = 170). The most prolific country, institution, and author were the USA (n = 105), the University of Liege (n = 41), and Laureys Steven (n = 38), respectively. An analysis of keywords revealed that UWS/VS, MCS, and TMS constituted the primary research trends and focal points within this domain. Conclusion This bibliometric study sheds light on the current progress and emerging trends of neuromodulation techniques in DOC from 2012 to 2022. The focal topics in this domain encompass the precise diagnosis of consciousness levels in patients suffering from DOC and the pursuit of efficacious neuromodulation-based evaluation and treatment protocols for such patients.
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Affiliation(s)
- Bilian Guo
- Department of Rehabilitation Medicine, First Affiliated Hospital of Fujian Medical University, Fuzhou, China
- Department of Rehabilitation Medicine, National Regional Medical Center, Binhai Campus of the First Affiliated Hospital, Fujian Medical University, Fuzhou, China
| | - Qiong Han
- Department of Rehabilitation Medicine, First Affiliated Hospital of Fujian Medical University, Fuzhou, China
- Department of Rehabilitation Medicine, National Regional Medical Center, Binhai Campus of the First Affiliated Hospital, Fujian Medical University, Fuzhou, China
| | - Jun Ni
- Department of Rehabilitation Medicine, First Affiliated Hospital of Fujian Medical University, Fuzhou, China
- Department of Rehabilitation Medicine, National Regional Medical Center, Binhai Campus of the First Affiliated Hospital, Fujian Medical University, Fuzhou, China
| | - Zhipeng Yan
- Department of Rehabilitation Medicine, First Affiliated Hospital of Fujian Medical University, Fuzhou, China
- Department of Rehabilitation Medicine, National Regional Medical Center, Binhai Campus of the First Affiliated Hospital, Fujian Medical University, Fuzhou, China
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Piedade GS, Assumpcao de Monaco B, Guest JD, Cordeiro JG. Review of spinal cord stimulation for disorders of consciousness. Curr Opin Neurol 2023; 36:507-515. [PMID: 37889524 DOI: 10.1097/wco.0000000000001222] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2023]
Abstract
PURPOSE OF REVIEW High-cervical spinal cord stimulation can alter cortical activity and cerebral metabolism. These effects are potentially beneficial for disorders of consciousness. A better understanding of the effects of clinical application of stimulation is needed. We aimed to evaluate the existing literature to determine the state of available knowledge. We performed a literature review of clinical studies assessing cervical spinal cord epidural stimulation for disorders of consciousness. Only peer-reviewed articles reporting preoperative and postoperative clinical status were included. RECENT FINDINGS Nineteen studies were included. A total of 532 cases were reported, and 255 patients were considered responsive (47.9%). Considering only studies published after the definition of minimally conscious state (MCS) as an entity, 402 individuals in unresponsive wakefulness syndrome (UWS) and 113 in MCS were reported. Responsiveness to SCS was reported in 170 UWS patients (42.3%) and in 78 MCS cases (69.0%), although the criteria for responsiveness and outcome measures varied among publications. SUMMARY Cervical SCS yielded encouraging results in patients with disorders of consciousness and seems to be more effective in MCS. More extensive investigation is needed to understand its potential role in clinical practice.
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Affiliation(s)
| | | | - James D Guest
- Department of Neurosurgery, Jackson Memorial Hospital, University of Miami Miller School of Medicine, Miami
- The Miami Project to Cure Paralysis, Miller School of Medicine, Miami, Florida, USA
| | - Joacir Graciolli Cordeiro
- Department of Neurosurgery, Jackson Memorial Hospital, University of Miami Miller School of Medicine, Miami
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De Luca R, Lauria P, Bonanno M, Corallo F, Rifici C, Castorina MV, Trifirò S, Gangemi A, Lombardo C, Quartarone A, De Cola MC, Calabrò RS. Neurophysiological and Psychometric Outcomes in Minimal Consciousness State after Advanced Audio-Video Emotional Stimulation: A Retrospective Study. Brain Sci 2023; 13:1619. [PMID: 38137067 PMCID: PMC10741433 DOI: 10.3390/brainsci13121619] [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: 10/21/2023] [Revised: 11/19/2023] [Accepted: 11/21/2023] [Indexed: 12/24/2023] Open
Abstract
In the last ten years, technological innovations have led to the development of new, advanced sensory stimulation (SS) tools, such as PC-based rehabilitative programs or virtual reality training. These are meant to stimulate residual cognitive abilities and, at the same time, assess cognition and awareness, also in patients with a minimally conscious state (MCS). Our purpose was to evaluate the clinical and neurophysiological effects of multi-sensory and emotional stimulation provided by Neurowave in patients with MCS, as compared to a conventional SS treatment. The psychological status of their caregivers was also monitored. In this retrospective study, we have included forty-two MCS patients and their caregivers. Each MCS subject was included in either the control group (CG), receiving a conventional SS, or the experimental group (EG), who was submitted to the experimental training with the Neurowave. They were assessed before (T0) and after the training (T1) through a specific clinical battery, including both motor and cognitive outcomes. Moreover, in the EG, we also monitored the brain electrophysiological activity (EEG and P300). In both study groups (EG and CG), the psychological caregiver's aspects, including anxiety levels, were measured using the Zung Self-Rating Anxiety Scale (SAS). The intra-group analysis (T0-T1) of the EG showed statistical significances in all patients' outcome measures, while in the CG, we found statistical significances in consciousness and awareness outcomes. The inter-group analysis between the EG and the CG showed no statistical differences, except for global communication skills. In conclusion, the multi-sensory stimulation approach through Neurowave was found to be an innovative rehabilitation treatment, also allowing the registration of brain activity during treatment.
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Affiliation(s)
| | | | - Mirjam Bonanno
- IRCCS Centro Neurolesi Bonino Pulejo, 98124 Messina, Italy; (R.D.L.); (P.L.); (F.C.); (C.R.); (M.V.C.); (S.T.); (A.G.); (C.L.); (A.Q.); (M.C.D.C.); (R.S.C.)
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Yang Y, He Q, Dang Y, Xia X, Xu X, Chen X, Zhao J, He J. Long-term functional outcomes improved with deep brain stimulation in patients with disorders of consciousness. Stroke Vasc Neurol 2023; 8:368-378. [PMID: 36882201 PMCID: PMC10647871 DOI: 10.1136/svn-2022-001998] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2022] [Accepted: 01/26/2023] [Indexed: 03/09/2023] Open
Abstract
BACKGROUND Deep brain stimulation (DBS) has been preliminarily applied to treat patients with disorders of consciousness (DoCs). The study aimed to determine whether DBS was effective for treating patients with DoC and identify factors related to patients' outcomes. METHODS Data from 365 patients with DoCs who were consecutively admitted from 15 July 2011 to 31 December 2021 were retrospectively analysed. Multivariate regression and subgroup analysis were performed to adjust for potential confounders. The primary outcome was improvement in consciousness at 1 year. RESULTS An overall improvement in consciousness at 1 year was achieved in 32.4% (12/37) of the DBS group compared with 4.3% (14/328) of the conservative group. After full adjustment, DBS significantly improved consciousness at 1 year (adjusted OR 11.90, 95% CI 3.65-38.46, p<0.001). There was a significant treatment×follow up interaction (H=14.99, p<0.001). DBS had significantly better effects in patients with minimally conscious state (MCS) compared with patients with vegetative state/unresponsive wakefulness syndrome (p for interaction <0.001). A nomogram based on age, state of consciousness, pathogeny and duration of DoCs indicated excellent predictive performance (c-index=0.882). CONCLUSIONS DBS was associated with better outcomes in patients with DoC, and the effect was likely to be significantly greater in patients with MCS. DBS should be cautiously evaluated by nomogram preoperatively, and randomised controlled trials are still needed.
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Affiliation(s)
- Yi Yang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- Translational Medicine Center, Chinese Institute for Brain Research, Beijing, China
- Beijing Institute of Brain Disorders, Capital Medical University, Beijing, China
| | - Qiheng He
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yuanyuan Dang
- Department of Neurosurgery, PLA General Hospital, Beijing, China
| | - Xiaoyu Xia
- Department of Neurosurgery, PLA General Hospital, Beijing, China
| | - Xin Xu
- Department of Neurosurgery, PLA General Hospital, Beijing, China
| | - Xueling Chen
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Jizong Zhao
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- Academician Office, China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Jianghong He
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
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McNerney MW, Gurkoff GG, Beard C, Berryhill ME. The Rehabilitation Potential of Neurostimulation for Mild Traumatic Brain Injury in Animal and Human Studies. Brain Sci 2023; 13:1402. [PMID: 37891771 PMCID: PMC10605899 DOI: 10.3390/brainsci13101402] [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: 08/14/2023] [Revised: 09/25/2023] [Accepted: 09/28/2023] [Indexed: 10/29/2023] Open
Abstract
Neurostimulation carries high therapeutic potential, accompanied by an excellent safety profile. In this review, we argue that an arena in which these tools could provide breakthrough benefits is traumatic brain injury (TBI). TBI is a major health problem worldwide, with the majority of cases identified as mild TBI (mTBI). MTBI is of concern because it is a modifiable risk factor for dementia. A major challenge in studying mTBI is its inherent heterogeneity across a large feature space (e.g., etiology, age of injury, sex, treatment, initial health status, etc.). Parallel lines of research in human and rodent mTBI can be collated to take advantage of the full suite of neuroscience tools, from neuroimaging (electroencephalography: EEG; functional magnetic resonance imaging: fMRI; diffusion tensor imaging: DTI) to biochemical assays. Despite these attractive components and the need for effective treatments, there are at least two major challenges to implementation. First, there is insufficient understanding of how neurostimulation alters neural mechanisms. Second, there is insufficient understanding of how mTBI alters neural function. The goal of this review is to assemble interrelated but disparate areas of research to identify important gaps in knowledge impeding the implementation of neurostimulation.
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Affiliation(s)
- M. Windy McNerney
- Mental Illness Research Education and Clinical Center (MIRECC), Veterans Affairs Palo Alto Health Care System, Palo Alto, CA 94304, USA; (M.W.M.); (C.B.)
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, CA 94305, USA
| | - Gene G. Gurkoff
- Department of Neurological Surgery, and Center for Neuroscience, University of California, Davis, Sacramento, CA 95817, USA;
- Department of Veterans Affairs, VA Northern California Health Care System, Martinez, CA 94553, USA
| | - Charlotte Beard
- Mental Illness Research Education and Clinical Center (MIRECC), Veterans Affairs Palo Alto Health Care System, Palo Alto, CA 94304, USA; (M.W.M.); (C.B.)
- Program in Neuroscience and Behavioral Biology, Emory University, Atlanta, GA 30322, USA
| | - Marian E. Berryhill
- Programs in Cognitive and Brain Sciences, and Integrative Neuroscience, Department of Psychology, University of Nevada, Reno, NV 89557, USA
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He J, Zhang H, Dang Y, Zhuang Y, Ge Q, Yang Y, Xu L, Xia X, Laureys S, Yu S, Zhang W. Electrophysiological characteristics of CM-pf in diagnosis and outcome of patients with disorders of consciousness. Brain Stimul 2023; 16:1522-1532. [PMID: 37778457 DOI: 10.1016/j.brs.2023.09.021] [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: 01/11/2023] [Revised: 09/07/2023] [Accepted: 09/20/2023] [Indexed: 10/03/2023] Open
Abstract
BACKGROUND Deep brain stimulation (DBS) in the centromedian-parafascicular complex (CM-pf) has been reported as a potential therapeutic option for disorders of consciousness (DoC). However, the lack of understanding of its electrophysiological characteristics limits the improvement of therapeutic effect. OBJECTIVE To investigate the CM-pf electrophysiological characteristics underlying disorders of consciousness (DoC) and its recovery. METHODS We collected the CM-pf electrophysiological signals from 23 DoC patients who underwent central thalamus DBS (CT-DBS) surgery. Five typical electrophysiological features were extracted, including neuronal firing properties, multiunit activity (MUA) properties, signal stability, spike-MUA synchronization strength (syncMUA), and the background noise level. Their correlations with the consciousness level, the outcome, and the primary clinical factors of DoC were analyzed. RESULTS 11 out of 23 patients (0/2 chronic coma, 5/13 unresponsive wakefulness syndrome/vegetative state (UWS/VS), 6/8 minimally conscious state minus (MCS-)) exhibited an improvement in the level of consciousness after CT-DBS. In CM-pf, significantly stronger gamma band syncMUA strength and alpha band normalized MUA power were found in MCS- patients. In addition, higher firing rates, stronger high-gamma band MUA power and alpha band normalized power, and more stable theta oscillation were correlated with better outcomes. Besides, we also identified electrophysiological properties that are correlated with clinical factors, including etiologies, age, and duration of DoC. CONCLUSION We provide comprehensive analyses of the electrophysiological characteristics of CM-pf in DoC patients. Our results support the 'mesocircuit' hypothesis, one proposed mechanism of DoC recovery, and reveal CM-pf electrophysiological features that are crucial for understanding the pathogenesis of DoC, predicting its recovery, and explaining the effect of clinical factors on DoC.
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Affiliation(s)
- Jianghong He
- Neurosurgery Center, The National Key Clinical Specialty, The Engineering Technology Research Center of Education Ministry of China on Diagnosis and Treatment of Cerebrovascular Disease, Guangdong Provincial Key Laboratory on Brain Function Repair and Regeneration, The Neurosurgery Institute of Guangdong Province, Zhujiang Hospital, Southern Medical University, China; Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, 100070, China
| | - Haoran Zhang
- Laboratory of Brain Atlas and Brain-inspired Intelligence, Institute of Automation, Chinese Academy of Sciences, Beijing, 100190, China; School of Future Technology, University of Chinese Academy of Sciences, Beijing, 100049, China
| | - Yuanyuan Dang
- Department of Neurosurgery, The First Medical Center of Chinese PLA General Hospital, Beijing, 100853, China
| | - Yutong Zhuang
- Department of Neurosurgery, The Second School of Clinical Medicine, Southern Medical University, Guangzhou, China
| | - Qianqian Ge
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, 100070, China
| | - Yi Yang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, 100070, China
| | - Long Xu
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, 100070, China
| | - Xiaoyu Xia
- Department of Neurosurgery, The Seventh Medical Center of PLA General Hospital, Beijing, 100700, China
| | - Steven Laureys
- CERVO Brain Research Centre, Laval University, Canada; Coma Science Group, GIGA Consciousness Research Unit, Liège University Hospital, Belgium; International Consciousness Science Institute, Hangzhou Normal University, Hangzhou, Zhejiang, China
| | - Shan Yu
- Laboratory of Brain Atlas and Brain-inspired Intelligence, Institute of Automation, Chinese Academy of Sciences, Beijing, 100190, China; School of Future Technology, University of Chinese Academy of Sciences, Beijing, 100049, China.
| | - Wangming Zhang
- Neurosurgery Center, The National Key Clinical Specialty, The Engineering Technology Research Center of Education Ministry of China on Diagnosis and Treatment of Cerebrovascular Disease, Guangdong Provincial Key Laboratory on Brain Function Repair and Regeneration, The Neurosurgery Institute of Guangdong Province, Zhujiang Hospital, Southern Medical University, China.
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Schiff ND. Mesocircuit mechanisms in the diagnosis and treatment of disorders of consciousness. Presse Med 2023; 52:104161. [PMID: 36563999 DOI: 10.1016/j.lpm.2022.104161] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2022] [Revised: 11/14/2022] [Accepted: 12/13/2022] [Indexed: 12/24/2022] Open
Abstract
The 'mesocircuit hypothesis' proposes mechanisms underlying the recovery of consciousness following severe brain injuries. The model builds up from a single premise that multifocal brain injuries resulting in coma and subsequent disorders of consciousness produce widespread neuronal death and dysfunction. Considering the general properties of cortical, thalamic, and striatal neurons, a lawful and specific circuit-level mechanism is constructed based on these known anatomical and physiological specializations of neuronal subtypes. The mesocircuit model generates many testable predictions at the mesocircuit, local circuit, and cellular level across multiple cerebral structures to correlate diagnostic measurements and interpret therapeutic interventions. The anterior forebrain mesocircuit is integrally related to the frontal-parietal network, another network demonstrated to show strong correlation with levels of recovery in disorders of consciousness. A further extension known as the "ABCD" model has been used to examine interaction of these models in recovery of consciousness using electrophysiological data types. Many studies have examined predictions of the mesocircuit model; here we first present the model and review the accumulated evidence for several predictions of model across multiple stages of recovery function in human subjects. Recent studies linking the mesocircuit model, the ABCD model, and interactions with the frontoparietal network are reviewed. Finally, theoretical implications of the mesocircuit model at the neuronal level are considered to interpret recent studies of deep brain stimulation in the central lateral thalamus in patients recovering from coma and in new experimental models in the context of emerging understanding of neuronal and local circuit mechanisms underlying conscious brain states.
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Affiliation(s)
- Nicholas D Schiff
- Jerold B. Katz Professor of Neurology and Neuroscience, Feil Family Brain and Mind Research Institute, Weill Cornell Medical College, United States.
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12
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Yang Y, He Q, He J. Short-term spinal cord stimulation in treating disorders of consciousness monitored by resting-state fMRI and qEEG: The first case report. Front Neurol 2022; 13:968932. [PMID: 36388222 PMCID: PMC9640422 DOI: 10.3389/fneur.2022.968932] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2022] [Accepted: 09/20/2022] [Indexed: 10/28/2023] Open
Abstract
Disorders of consciousness (DOC) are one of the most frequent complications in patients after severe brain injury, mainly caused by trauma, stroke, and anoxia. With the development of neuromodulation techniques, novel therapies including deep brain stimulation (DBS) and spinal cord stimulation (SCS) have been employed to treat DOC. Here, we report the case of a DOC patient receiving short-term SCS (st-SCS) treatment and showing improvement monitored by resting-state fMRI (rs-fMRI) and quantitative EEG (qEEG). A 35-year-old male with severe traumatic brain injury remained comatose for 3 months. The patient was evaluated using JFK coma recovery scale-revised (CRS-R) and showed no improvement within 1 month. He received st-SCS surgery 93 days after the injury and the stimulation was applied the day after surgery. He regained communication according to instructions on day 21 after surgery and improved from a vegetative state/unwakefulness syndrome to an emergence from a minimally conscious state. To our knowledge, this report is the first published case of st-SCS in a patient with DOC. These results shed light that st-SCS may be effective in treating certain patients with DOC, which may reduce patients' suffering during treatment and lessen financial burden.
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Affiliation(s)
- Yi Yang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- Joint Laboratory, Chinese Institute for Brain Research, Beijing, China
- Center of Stroke, Beijing Institute of Brain Disorders, Beijing, China
- Department of Neurosurgery, China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Qiheng He
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- Department of Neurosurgery, China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Jianghong He
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- Department of Neurosurgery, China National Clinical Research Center for Neurological Diseases, Beijing, China
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Pérez-Santos I, Palomero-Gallagher N, Zilles K, Cavada C. Distribution of the Noradrenaline Innervation and Adrenoceptors in the Macaque Monkey Thalamus. Cereb Cortex 2021; 31:4115-4139. [PMID: 34003210 PMCID: PMC8328208 DOI: 10.1093/cercor/bhab073] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Revised: 02/18/2021] [Accepted: 03/03/2021] [Indexed: 11/14/2022] Open
Abstract
Noradrenaline (NA) in the thalamus has important roles in physiological, pharmacological, and pathological neuromodulation. In this work, a complete characterization of NA axons and Alpha adrenoceptors distributions is provided. NA axons, revealed by immunohistochemistry against the synthesizing enzyme and the NA transporter, are present in all thalamic nuclei. The most densely innervated ones are the midline nuclei, intralaminar nuclei (paracentral and parafascicular), and the medial sector of the mediodorsal nucleus (MDm). The ventral motor nuclei and most somatosensory relay nuclei receive a moderate NA innervation. The pulvinar complex receives a heterogeneous innervation. The lateral geniculate nucleus (GL) has the lowest NA innervation. Alpha adrenoceptors were analyzed by in vitro quantitative autoradiography. Alpha-1 receptor densities are higher than Alpha-2 densities. Overall, axonal densities and Alpha adrenoceptor densities coincide; although some mismatches were identified. The nuclei with the highest Alpha-1 values are MDm, the parvocellular part of the ventral posterior medial nucleus, medial pulvinar, and midline nuclei. The nucleus with the lowest Alpha-1 receptor density is GL. Alpha-2 receptor densities are highest in the lateral dorsal, centromedian, medial and inferior pulvinar, and midline nuclei. These results suggest a role for NA in modulating thalamic involvement in consciousness, limbic, cognitive, and executive functions.
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Affiliation(s)
- Isabel Pérez-Santos
- Departamento de Anatomía, Histología y Neurociencia, Facultad de Medicina, Universidad Autónoma de Madrid (UAM), Calle Arzobispo Morcillo 4, 28029 Madrid, Spain
| | - Nicola Palomero-Gallagher
- Institute of Neuroscience and Medicine (INM-1), Research Centre Jülich, 52425 Jülich, Germany.,Department of Psychiatry, Psychotherapy and Psychosomatics, Medical Faculty, RWTH Aachen University, 52074 Aachen, Germany.,C. & O. Vogt Institute for Brain Research, Heinrich-Heine-University, 40225 Düsseldorf, Germany
| | - Karl Zilles
- Institute of Neuroscience and Medicine (INM-1), Research Centre Jülich, 52425 Jülich, Germany.,C. & O. Vogt Institute for Brain Research, Heinrich-Heine-University, 40225 Düsseldorf, Germany.,JARA-BRAIN, Jülich-Aachen Research Alliance, 52425 Jülich, Germany
| | - Carmen Cavada
- Departamento de Anatomía, Histología y Neurociencia, Facultad de Medicina, Universidad Autónoma de Madrid (UAM), Calle Arzobispo Morcillo 4, 28029 Madrid, Spain
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14
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Machado C. Jahi McMath, a New Disorder of Consciousness. REVISTA LATINOAMERICANA DE BIOÉTICA 2021. [DOI: 10.18359/rlbi.5635] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
In this paper, I review the case of Jahi McMath, who was diagnosed with brain death (BD). Nonetheless, ancillary tests performed nine months after the initial brain insult showed conservation of intracranial structures, EEG activity, and autonomic reactivity to the “Mother Talks” stimulus. She was clinically in an unarousable and unresponsive state, without evidence of self-awareness or awareness of the environment. However, the total absence of brainstem reflexes and partial responsiveness rejected the possibility of a coma. Jahi did not have uws because she was not in a wakefulness state and showed partial responsiveness. She could not be classified as a LIS patient either because LIS patients are wakeful and aware, and although quadriplegic, they fully or partially preserve brainstem reflexes, vertical eye movements or blinking, and respire on their own. She was not in an MCS because she did not preserve arousal and preserved awareness only partially. The CRS-R resulted in a very low score, incompatible with MCS patients. mcs patients fully or partially preserve brainstem reflexes and usually breathe on their own. MCS has always been described as a transitional state between a coma and UWS but never reported in a patient with all clinical BD findings. This case does not contradict the concept of BD but brings again the need to use ancillary tests in BD up for discussion. I concluded that Jahi represented a new disorder of consciousness, non-previously described, which I have termed “reponsive unawakefulness syndrome” (RUS).
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16
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Pain Perception in Disorder of Consciousness: A Scoping Review on Current Knowledge, Clinical Applications, and Future Perspective. Brain Sci 2021; 11:brainsci11050665. [PMID: 34065349 PMCID: PMC8161058 DOI: 10.3390/brainsci11050665] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2021] [Revised: 05/05/2021] [Accepted: 05/19/2021] [Indexed: 01/18/2023] Open
Abstract
Pain perception in individuals with prolonged disorders of consciousness (PDOC) is still a matter of debate. Advanced neuroimaging studies suggest some cortical activations even in patients with unresponsive wakefulness syndrome (UWS) compared to those with a minimally conscious state (MCS). Therefore, pain perception has to be considered even in individuals with UWS. However, advanced neuroimaging assessment can be challenging to conduct, and its findings are sometimes difficult to be interpreted. Conversely, multichannel electroencephalography (EEG) and laser-evoked potentials (LEPs) can be carried out quickly and are more adaptable to the clinical needs. In this scoping review, we dealt with the neurophysiological basis underpinning pain in PDOC, pointing out how pain perception assessment in these individuals might help in reducing the misdiagnosis rate. The available literature data suggest that patients with UWS show a more severe functional connectivity breakdown among the pain-related brain areas compared to individuals in MCS, pointing out that pain perception increases with the level of consciousness. However, there are noteworthy exceptions, because some UWS patients show pain-related cortical activations that partially overlap those observed in MCS individuals. This suggests that some patients with UWS may have residual brain functional connectivity supporting the somatosensory, affective, and cognitive aspects of pain processing (i.e., a conscious experience of the unpleasantness of pain), rather than only being able to show autonomic responses to potentially harmful stimuli. Therefore, the significance of the neurophysiological approach to pain perception in PDOC seems to be clear, and despite some methodological caveats (including intensity of stimulation, multimodal paradigms, and active vs. passive stimulation protocols), remain to be solved. To summarize, an accurate clinical and neurophysiological assessment should always be performed for a better understanding of pain perception neurophysiological underpinnings, a more precise differential diagnosis at the level of individual cases as well as group comparisons, and patient-tailored management.
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Cover KK, Mathur BN. Rostral Intralaminar Thalamus Engagement in Cognition and Behavior. Front Behav Neurosci 2021; 15:652764. [PMID: 33935663 PMCID: PMC8082140 DOI: 10.3389/fnbeh.2021.652764] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2021] [Accepted: 03/22/2021] [Indexed: 11/25/2022] Open
Abstract
The thalamic rostral intralaminar nuclei (rILN) are a contiguous band of neurons that include the central medial, paracentral, and central lateral nuclei. The rILN differ from both thalamic relay nuclei, such as the lateral geniculate nucleus, and caudal intralaminar nuclei, such as the parafascicular nucleus, in afferent and efferent connectivity as well as physiological and synaptic properties. rILN activity is associated with a range of neural functions and behaviors, including arousal, pain, executive function, and action control. Here, we review this evidence supporting a role for the rILN in integrating arousal, executive and motor feedback information. In light of rILN projections out to the striatum, amygdala, and sensory as well as executive cortices, we propose that such a function enables the rILN to modulate cognitive and motor resources to meet task-dependent behavioral engagement demands.
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Affiliation(s)
- Kara K Cover
- Department of Pharmacology, University of Maryland School of Medicine, Baltimore, MD, United States
| | - Brian N Mathur
- Department of Pharmacology, University of Maryland School of Medicine, Baltimore, MD, United States
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He RH, Wang HJ, Zhou Z, Fan JZ, Zhang SQ, Zhong YH. The influence of high-frequency repetitive transcranial magnetic stimulation on endogenous estrogen in patients with disorders of consciousness. Brain Stimul 2021; 14:461-466. [PMID: 33677157 DOI: 10.1016/j.brs.2021.02.014] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2020] [Revised: 02/15/2021] [Accepted: 02/21/2021] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Repetitive transcranial magnetic stimulation (rTMS) has been proposed as a promising therapeutic intervention for neurological disorders. However, the precise mechanisms of rTMS in neural excitability remains poorly understood. Estradiol is known to have strong influence on cortical excitability. This study aimed to determine whether high-frequency (HF) rTMS influences endogenous estradiol in male patients with disorders of consciousness (DOC). METHODS A randomized controlled trial was conducted with a total of 57 male patients with DOC. Eventually, 50 patients completed the study. Twenty-five patients underwent real rTMS, and 25 patients underwent sham rTMS, which were delivered over the dorsolateral prefrontal cortex. The primary outcome measure was the change in serum estradiol from baseline to after 10 sessions of HF-rTMS. The improvement in the total score of the JFK Coma Recovery Scale-Revised (CRS-R) was also assessed. RESULTS Changes in estradiol levels and CRS-R scores from pre-to post-treatment were significantly different between the active rTMS and sham stimulation conditions. A significant enhancement of CRS-R scores in the patients receiving rTMS stimulation was observed compared to the sham group. Serum estradiol levels in patients following HF-rTMS were significantly higher than their baseline levels, whereas no significant changes were found in the sham group from pre-to post-stimulation. The rise in estradiol levels was greater in responders than in non-responders. The changes in estradiol levels were significantly positively correlated with the improvement in CRS-R scores. CONCLUSION These preliminary findings indicate that serum estradiol levels are affected by HF-rTMS and positively related to clinical responses in male patients with DOC. The elevation of estradiol levels may lay a physiological foundation for successful rTMS treatment for DOC patients by increasing cortical excitability.
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Affiliation(s)
- Ren Hong He
- Department of Rehabilitation Medicine, Nanfang Hospital, Southern Medical University, P.R. China
| | - Hui Juan Wang
- Department of Rehabilitation Medicine, Nanfang Hospital, Southern Medical University, P.R. China
| | - Zhou Zhou
- Department of Rehabilitation Medicine, Nanfang Hospital, Southern Medical University, P.R. China
| | - Jian Zhong Fan
- Department of Rehabilitation Medicine, Nanfang Hospital, Southern Medical University, P.R. China
| | - Sheng Quan Zhang
- Department of Rehabilitation Medicine, Nanfang Hospital, Southern Medical University, P.R. China
| | - Yu Hua Zhong
- Department of Rehabilitation Medicine, Nanfang Hospital, Southern Medical University, P.R. China.
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Abstract
Background: Reviving patients with prolonged disorders of consciousness (DOCs) has always been focused and challenging in medical research. Owing to the limited effectiveness of available medicine, recent research has increasingly turned towards neuromodulatory therapies, involving the stimulation of neural circuits. We summarised the progression of research regarding neuromodulatory therapies in the field of DOCs, compared the differences among different studies, in an attempt to explore optimal stimulation patterns and parameters, and analyzed the major limitations of the relevant studies to facilitate future research. Methods: We performed a search in the PubMed database, using the concepts of DOCs and neuromodulation. Inclusion criteria were: articles in English, published after 2002, and reporting clinical trials of neuromodulatory therapies in human patients with DOCs. Results: Overall, 187 published articles met the search criteria, and 60 articles met the inclusion criteria. There are differences among these studies regarding the clinical efficacies of neurostimulation techniques for patients with DOCs, and large-sample studies are still lacking. Conclusions: Neuromodulatory techniques were used as trial therapies for DOCs wherein their curative effects were controversial. The difficulties in detecting residual consciousness, the confounding effect between the natural course of the disease and therapeutic effect, and the heterogeneity across patients are the major limitations. Large-sample, well-designed studies, and innovations for both treatment and assessment are anticipated in future research.
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Transcranial magnetic stimulation-evoked connectivity reveals modulation effects of repetitive transcranial magnetic stimulation on patients with disorders of consciousness. Neuroreport 2020; 30:1307-1315. [PMID: 31714484 DOI: 10.1097/wnr.0000000000001362] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Several studies have investigated possible role of repetitive transcranial magnetic stimulation (rTMS) in patients with disorder of consciousness (DOC). But the details of patients' brain responses to the rTMS are yet to be disclosed. The aim of the study is to explore the neural electrical responses of DOC patients to rTMS modulation. DOC Patients [14 vegetative state, seven minimally conscious state (MCS)] and healthy subjects were enrolled and received one session of rTMS. The TMS-electroencephalogram was recorded at before and immediately after rTMS stimulation. TMS-evoked potentials as well as TMS-evoked connectivity were proposed to capture the effective connectivity alteration induced by rTMS. Significant changes of TMS-evoked potential were found in the healthy group but not in DOC patients. TMS-evoked connectivity was significantly enhanced by the rTMS in healthy and MCS groups. In addition, the enhancement was positively correlated with patients' Coma Recovery Scale-Revised scores. Global synchrony of the TMS-evoked connectivity matrix significantly enhanced by rTMS in the control and MCS groups but not in vegetative state patients. Furthermore, after rTMS stimulation, the similarity of TMS-evoked connectivity patterns between pairwise patients was significantly raised in MCS patients. But no significant changes were found in vegetative state patients. TMS-evoked connectivity reveals that rTMS can effectively modulate effective connectivity of MCS patients, but no evidence of changes in vegetative state patients.
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Sensory stimulation to improve arousal in comatose patients after traumatic brain injury: a systematic review of the literature. Neurol Sci 2020; 41:2367-2376. [PMID: 32323082 DOI: 10.1007/s10072-020-04410-9] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2019] [Accepted: 04/11/2020] [Indexed: 01/14/2023]
Abstract
BACKGROUND No standard rehabilitative treatment for coma arousal after traumatic brain injury (TBI) exists. Based on our clinical experience, we hypothesized that sensory stimulation (SS) is a promising protocol to improve outcomes in these patients. METHODS We performed a literature review on the progress of sensory stimulation to enhance coma arousal after traumatic brain injury. We searched the databases on Medline, Embase, and Cochrane to gain access to relevant publications using the key words "traumatic brain injury," "disorders of consciousness," "sensory stimulation," and "coma scale." RESULTS We included all original studies published in English with patients presenting severe disorders of consciousness due to traumatic brain injury who had received SS and whose behavioral/neural responses had been measured. We compared data on ten selected studies and analyzed the SS effects in comatose patient outcomes after TBI. Our review outlines the role of SS in patients with TBI and provides guidance for its implementation in the clinical practice. CONCLUSIONS The literature suggests the SS program improves coma arousal after TBI. However, high-quality clinical trials are needed to establish standard SS protocols.
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Yang Y, Xu L, Xie R, Dang Y, Xia X, He J, Zhao J. A meta-analysis on the efficiency of the time window of hyperbaric oxygen treatment on disorders of consciousness in China. JOURNAL OF NEURORESTORATOLOGY 2020. [DOI: 10.26599/jnr.2020.9040025] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
Objective To investigate the clinical effects of time window on hyperbaric oxygen treatment (HBOT) in patients with disorders of consciousness (DOC). Methods All the clinical research literature regarding HBOT for DOC published between January 2000 and November 2020 were retrieved from China National Knowledge Infrastructure (CNKI), Wanfang Standards Database (WFSD) and VIP Database using Chinese key words disorders of consciousness, the vegetable state, minimally conscious state, or hyperbaric oxygen followed by a comprehensive meta-analysis. Results The query gave rise to 348 results, in which 21 articles were eventually selected for meta-analysis. Among the selected 21 articles, 18 articles involved a time window comparison. All the patients were classified into < 60- (718 patients) and ≥ 60- (374 patients) day groups depending on the number of days from HBOT initiation. The Jadad scores for the included datasets were relatively low in general with 2 points as the highest score. Comparable baseline data were demonstrated in all of the articles. Datasets from different sources were pooled and analyzed, and the results suggested that the clinical curative effect rate in the treatment group was significantly higher compared with that in the control group (curative effect rate: 69.86% versus 42.30%; Z = 11.28, P = 0.000, odds ratio = 3.80, 95% CI = 3.02-4.80). Additionally, the adverse reaction rate of the < 60-day group was found to be significantly lower compared with that of the ≥ 60-day group (Z = 10.01, P = 0.000, odds ratio = 4.82, 95% CI = 3.54-6.56). The funnel diagram in articles related to curative effect analysis and time window evaluation is inverted and symmetrical, indicating that publication bias was not significant. Conclusions The clinical curative effect of the HBOT group is higher compared with that of the control group. However, the conclusions based on meta-analysis are limited because of the methodological problems of some studies. Therefore, the clinical efficacy needs to be further tested using carefully designed large sample trials (multicenter, randomized, controlled, and double-blind).
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Abstract
Throughout evolution the frontal lobes have progressively acquired a central role in most aspects of cognition and behavior. In humans, frontal lobe functions are conditional on the development of an intricate set of short- and long-range connections that guarantee direct access to sensory information and control over regions dedicated to planning and motor execution. Here the frontal cortical anatomy and the major connections that constitute the local and extended frontal connectivity are reviewed in the context of diffusion tractography studies, contemporary models of frontal lobe functions, and clinical syndromes. A particular focus of this chapter is the use of comparative anatomy and neurodevelopmental data to address the question of how frontal networks evolved and what this signified for unique human abilities.
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Affiliation(s)
- Marco Catani
- NatBrainLab, Department of Forensic and Neurodevelopmental Sciences, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, United Kingdom.
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Napier S. The Minimally Conscious State, the Disability Bias, and the Moral Authority of Advance Directives. INTERNATIONAL JOURNAL OF LAW AND PSYCHIATRY 2019; 65:101333. [PMID: 29661479 DOI: 10.1016/j.ijlp.2018.03.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/20/2018] [Revised: 03/16/2018] [Accepted: 03/20/2018] [Indexed: 06/08/2023]
Affiliation(s)
- Stephen Napier
- SAC 108, Philosophy Department, 800 Lancaster Ave., Villanova, PA 19085, USA.
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Rezaei Haddad A, Lythe V, Green AL. Deep Brain Stimulation for Recovery of Consciousness in Minimally Conscious Patients After Traumatic Brain Injury: A Systematic Review. Neuromodulation 2019; 22:373-379. [DOI: 10.1111/ner.12944] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2018] [Revised: 01/05/2019] [Accepted: 02/06/2019] [Indexed: 10/27/2022]
Affiliation(s)
- Ali Rezaei Haddad
- Medical Sciences Divisional Office University of Oxford, John Radcliffe Hospital Oxford UK
- Neurosurgical Department Oxford University Hospitals Oxford UK
| | - Vanessa Lythe
- Green Templeton College, University of Oxford Oxford UK
| | - Alexander L. Green
- Neurosurgical Department Oxford University Hospitals Oxford UK
- Nuffield Department of Surgical Sciences University of Oxford Oxford UK
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Dunn TL, Gaspar C, Risko EF. Cue awareness in avoiding effortful control. Neuropsychologia 2019; 123:77-91. [PMID: 29772220 DOI: 10.1016/j.neuropsychologia.2018.05.011] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2017] [Revised: 05/07/2018] [Accepted: 05/11/2018] [Indexed: 12/20/2022]
Abstract
Based on a recent metacognitive account, cognitive effort is the result of an inferential evaluation made over explicitly available cues. Following from this account, we present here a pre-registered experiment that tested the specific hypothesis that explicit awareness of cues that are aligned with cognitive demand is a prerequisite in avoiding effortful lines of action. We attempted to modulate levels of effort avoidance behavior by introducing an incentive (between-subjects) to monitor two lines of action that, unbeknownst to individuals, varied in the probability of a task switch. Importantly, previous research has demonstrated that the difference in these probabilities is relatively opaque to individuals. We did not find strong evidence for our incentive manipulation having an effect on demand avoidance as indexed by individuals' choices in a block of the task where avoiding effort was instructed. However, we do find that being aware of the task-switching cue appears to increase the likelihood of demand avoidance. We consider these results within the context of the metacognition of cognitive effort.
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Affiliation(s)
- Timothy L Dunn
- Leeds School of Business, University of Colorado Boulder, Boulder, CO, United States.
| | - Connor Gaspar
- Department of Psychology, University of Waterloo, Canada
| | - Evan F Risko
- Department of Psychology, University of Waterloo, Canada
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Gottshall JL, Adams ZM, Forgacs PB, Schiff ND. Daytime Central Thalamic Deep Brain Stimulation Modulates Sleep Dynamics in the Severely Injured Brain: Mechanistic Insights and a Novel Framework for Alpha-Delta Sleep Generation. Front Neurol 2019; 10:20. [PMID: 30778326 PMCID: PMC6369150 DOI: 10.3389/fneur.2019.00020] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2018] [Accepted: 01/08/2019] [Indexed: 12/17/2022] Open
Abstract
Loss of organized sleep electrophysiology is a characteristic finding following severe brain injury. The return of structured elements of sleep architecture has been associated with positive prognosis across injury etiologies, suggesting a role for sleep dynamics as biomarkers of wakeful neuronal circuit function. In a continuing study of one minimally conscious state patient studied over the course of ~8½ years, we sought to investigate whether changes in daytime brain activation induced by central thalamic deep brain stimulation (CT-DBS) influenced sleep electrophysiology. In this patient subject, we previously reported significant improvements in sleep electrophysiology during 5½ years of CT-DBS treatment, including increased sleep spindle frequency and SWS delta power. We now present novel findings that many of these improvements in sleep electrophysiology regress following CT-DBS discontinuation; these regressions in sleep features correlate with a significant decrease in behavioral responsiveness. We also observe the re-emergence of alpha-delta sleep, which had been previously suppressed by daytime CT-DBS in this patient subject. Importantly, CT-DBS was only active during the daytime and has been proposed to mediate recovery of consciousness by driving synaptic activity across frontostriatal systems through the enhancement of thalamocortical output. Accordingly, the improvement of sleep dynamics during daytime CT-DBS and their subsequent regression following CT-DBS discontinuation implicates wakeful synaptic activity as a robust modulator of sleep electrophysiology. We interpret these findings in the context of the “synaptic homeostasis hypothesis,” whereby we propose that daytime upregulation of thalamocortical output in the severely injured brain may facilitate organized frontocortical circuit activation and yield net synaptic potentiation during wakefulness, providing a homeostatic drive that reconstitutes sleep dynamics over time. Furthermore, we consider common large-scale network dynamics across several neuropsychiatric disorders in which alpha-delta sleep has been documented, allowing us to formulate a novel mechanistic framework for alpha-delta sleep generation. We conclude that the bi-directional modulation of sleep electrophysiology by daytime thalamocortical activity in the severely injured brain: (1) emphasizes the cyclical carry-over effects of state-dependent circuit activation on large-scale brain dynamics, and (2) further implicates sleep electrophysiology as a sensitive indicator of wakeful brain activation and covert functional recovery in the severely injured brain.
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Affiliation(s)
- Jackie L Gottshall
- Feil Family Brain and Mind Research Institute, Weill Cornell Medicine, New York, NY, United States
| | - Zoe M Adams
- Department of Neurology, Weill Cornell Medicine, New York, NY, United States
| | - Peter B Forgacs
- Feil Family Brain and Mind Research Institute, Weill Cornell Medicine, New York, NY, United States.,Department of Neurology, Weill Cornell Medicine, New York, NY, United States.,Rockefeller University Hospital, New York, NY, United States
| | - Nicholas D Schiff
- Feil Family Brain and Mind Research Institute, Weill Cornell Medicine, New York, NY, United States.,Department of Neurology, Weill Cornell Medicine, New York, NY, United States.,Rockefeller University Hospital, New York, NY, United States
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Abstract
With the development of modern international medicine, the subject of disorders of consciousness (DOCs) has begun to be raised in mainland China. Much progress has been made to date in several specialties related to the management of chronic DOC patients in China. In this article, we briefly review the present status of DOC studies in China, specifically concerning diagnosis, prognosis, therapy, and rehabilitation. The development of DOC-related scientific organizations and activities in China are introduced. Some weaknesses that need improvement are also noted. The current program provides a good foundation for future development.
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Affiliation(s)
- Jizong Zhao
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, 100050, China.
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29
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Wathen CA, Frizon LA, Maiti TK, Baker KB, Machado AG. Deep brain stimulation of the cerebellum for poststroke motor rehabilitation: from laboratory to clinical trial. Neurosurg Focus 2018; 45:E13. [PMID: 30064319 DOI: 10.3171/2018.5.focus18164] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Ischemic stroke is a leading cause of disability worldwide, with profound economic costs. Poststroke motor impairment is the most commonly encountered deficit resulting in significant disability and is the primary driver of stroke-associated healthcare expenditures. Although many patients derive some degree of benefit from physical rehabilitation, a significant proportion continue to suffer from persistent motor impairment. Noninvasive brain stimulation, vagal nerve stimulation, epidural cortical stimulation, and deep brain stimulation (DBS) have all been studied as potential modalities to improve upon the benefits derived from physical therapy alone. These neuromodulatory therapies aim primarily to augment neuroplasticity and drive functional reorganization of the surviving perilesional cortex. The authors have proposed a novel and emerging therapeutic approach based on cerebellar DBS targeted at the dentate nucleus. Their rationale is based on the extensive reciprocal connectivity between the dentate nucleus and wide swaths of cerebral cortex via the dentatothalamocortical and corticopontocerebellar tracts, as well as the known limitations to motor rehabilitation imposed by crossed cerebellar diaschisis. Preclinical studies in rodent models of ischemic stroke have shown that cerebellar DBS promotes functional recovery in a frequency-dependent manner, with the most substantial benefits of the therapy noted at 30-Hz stimulation. The improvements in motor function are paralleled by increased expression of markers of synaptic plasticity, synaptogenesis, and neurogenesis in the perilesional cortex. Given the findings of preclinical studies, a first-in-human trial, Electrical Stimulation of the Dentate Nucleus Area (EDEN) for Improvement of Upper Extremity Hemiparesis Due to Ischemic Stroke: A Safety and Feasibility Study, commenced in 2016. Although the existing preclinical evidence is promising, the results of this Phase I trial and subsequent clinical trials will be necessary to determine the future applicability of this therapy.
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Affiliation(s)
| | - Leonardo A Frizon
- 2Center for Neurological Restoration, Neurological Institute, Cleveland Clinic
| | - Tanmoy K Maiti
- 3Department of Neurosurgery, Neurological Institute, Cleveland Clinic; and
| | - Kenneth B Baker
- 4Department of Neurosciences, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio
| | - Andre G Machado
- 3Department of Neurosurgery, Neurological Institute, Cleveland Clinic; and
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Xia X, Yang Y, Guo Y, Bai Y, Dang Y, Xu R, He J. Current Status of Neuromodulatory Therapies for Disorders of Consciousness. Neurosci Bull 2018; 34:615-625. [PMID: 29916112 DOI: 10.1007/s12264-018-0244-4] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2018] [Accepted: 04/25/2018] [Indexed: 11/26/2022] Open
Abstract
Treatment for disorders of consciousness (DOCs) is still a Gordian knot. Evidence-based guidelines on the treatment of DOC patients are not currently available, while neuromodulation techniques are seen as a potential treatment. Multiple neuromodulation therapies have been applied. This article reviews the most relevant studies in the literature in order to describe a clear picture of the current state of neuromodulation therapies that could be used to treat DOC patients. Both invasive and non-invasive brain stimulation is discussed. Significant behavioral improvements in prolonged DOCs under neuromodulation therapies are rare. The efficacy of various such therapies remains a matter of debate. Further clinical investigations of existing techniques in larger samples properly controlling for spontaneous recovery are needed, and new approaches are awaited.
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Affiliation(s)
- Xiaoyu Xia
- Department of Neurosurgery, PLA Army General Hospital, Beijing, 100700, China
| | - Yi Yang
- Department of Neurosurgery, PLA Army General Hospital, Beijing, 100700, China
| | - Yongkun Guo
- Department of Neurosurgery, Zhengzhou Central Hospital Affiliated to Zhengzhou University, Zhengzhou, 450007, China
| | - Yang Bai
- International Vegetative State and Consciousness Science Institute, Hangzhou Normal University, Hangzhou, 311121, China
| | - Yuanyuan Dang
- Department of Neurosurgery, PLA Army General Hospital, Beijing, 100700, China
| | - Ruxiang Xu
- Department of Neurosurgery, PLA Army General Hospital, Beijing, 100700, China
| | - Jianghong He
- Department of Neurosurgery, PLA Army General Hospital, Beijing, 100700, China.
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Effects of 20 Hz Repetitive Transcranial Magnetic Stimulation on Disorders of Consciousness: A Resting-State Electroencephalography Study. Neural Plast 2018; 2018:5036184. [PMID: 29770146 PMCID: PMC5889874 DOI: 10.1155/2018/5036184] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2017] [Accepted: 12/14/2017] [Indexed: 12/28/2022] Open
Abstract
Repetitive transcranial magnetic stimulation (rTMS) has been proposed as an experimental approach for the treatment of disorders of consciousness (DOC). To date, there has been little research into the use of rTMS in DOC and the therapeutic effects have been variously documented. This study aimed to examine the effects of 20 Hz rTMS on the electroencephalography (EEG) reactivity and clinical response in patients with DOC and to explore the neuromodulatory effects of high-frequency rTMS. In this randomized, sham-controlled, crossover study, real or sham 20 Hz rTMS was applied to the left primary motor cortex (M1) of patients with DOC for 5 consecutive days. Evaluations were blindly performed at the baseline (T0), immediately after the end of the 5 days of treatment (T1) and 1 week after the treatment (T2) using the JFK coma recovery scale-revised (CRS-R) and resting-state EEG. Only one patient, with a history of 2 months of traumatic brain injury, showed long-lasting (T1, T2) behavioral and neurophysiological modifications after the real rTMS stimulation. The 5 remaining patients presented brain reactivity localized at several electrodes, and the EEG modification was not significant. rTMS stimulation may improve awareness and arousal of DOC. Additionally, EEG represents a potential biomarker for the therapeutic efficacy of rTMS. This trial is registered with (NCT03385278).
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32
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Overbeek BUH, Eilander HJ, Lavrijsen JCM, Koopmans RTCM. Are visual functions diagnostic signs of the minimally conscious state? an integrative review. J Neurol 2018; 265:1957-1975. [PMID: 29492651 PMCID: PMC6132665 DOI: 10.1007/s00415-018-8788-9] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2017] [Revised: 02/04/2018] [Accepted: 02/05/2018] [Indexed: 12/22/2022]
Abstract
Visual pursuit (VP) and visual fixation (VF) have been recognized as the first signs of emerging consciousness and, therefore, are considered indicative of the minimally conscious state (MCS). However, debate exists about their status as they are considered either conscious reactions or reflexes. The aim of this study is to review the evidence of the definition, operationalization, and assessment of VP and VF in unconscious patients. PubMed and EMBASE were searched for relevant papers between May 26, 1994 and October 1, 2016. In addition, an internet search was done to identify other relevant papers, reports and manuals of assessment methods. Papers were included if the definition, operationalization, or assessment method of VP and VF was discussed in patients with disorders of consciousness. We identified 2364 articles, of which 38 were included. No uniform definitions of VP and VF were found. VP and VF were operationalized differently, depending on which scale was used. The Coma Recovery Scale-revised and the Sensory Tool to Assess Responsiveness were the only diagnostic scales found; the other scales were developed to monitor DOC patients. The use of a mirror was the most sensitive method for detecting VP and VF. The literature about the importance VP and VF in relation with consciousness is controversial. This integrative review shows a lack of consensus regarding the definition, operationalization, and assessment of VP and VF. International consensus development about the definition, operationalization, and assessment of VP and VF is recommended.
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Affiliation(s)
- Berno U H Overbeek
- Department of Primary and Community Care, Centre of Family Medicine, Geriatric Care and Public Health, Radboud University Medical Centre, Nijmegen, PO Box 9101, 6500 HB, Nijmegen, The Netherlands. .,Azora, PO Box 30, 7060 AA, Terborg, The Netherlands. .,Kalorama, PO Box 85, 6573 ZH, Beek, The Netherlands.
| | - Henk J Eilander
- Department of Primary and Community Care, Centre of Family Medicine, Geriatric Care and Public Health, Radboud University Medical Centre, Nijmegen, PO Box 9101, 6500 HB, Nijmegen, The Netherlands
| | - Jan C M Lavrijsen
- Department of Primary and Community Care, Centre of Family Medicine, Geriatric Care and Public Health, Radboud University Medical Centre, Nijmegen, PO Box 9101, 6500 HB, Nijmegen, The Netherlands
| | - Raymond T C M Koopmans
- Department of Primary and Community Care, Centre of Family Medicine, Geriatric Care and Public Health, Radboud University Medical Centre, Nijmegen, PO Box 9101, 6500 HB, Nijmegen, The Netherlands
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Ramirez-Zamora A, Giordano JJ, Gunduz A, Brown P, Sanchez JC, Foote KD, Almeida L, Starr PA, Bronte-Stewart HM, Hu W, McIntyre C, Goodman W, Kumsa D, Grill WM, Walker HC, Johnson MD, Vitek JL, Greene D, Rizzuto DS, Song D, Berger TW, Hampson RE, Deadwyler SA, Hochberg LR, Schiff ND, Stypulkowski P, Worrell G, Tiruvadi V, Mayberg HS, Jimenez-Shahed J, Nanda P, Sheth SA, Gross RE, Lempka SF, Li L, Deeb W, Okun MS. Evolving Applications, Technological Challenges and Future Opportunities in Neuromodulation: Proceedings of the Fifth Annual Deep Brain Stimulation Think Tank. Front Neurosci 2018; 11:734. [PMID: 29416498 PMCID: PMC5787550 DOI: 10.3389/fnins.2017.00734] [Citation(s) in RCA: 51] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2017] [Accepted: 12/15/2017] [Indexed: 12/21/2022] Open
Abstract
The annual Deep Brain Stimulation (DBS) Think Tank provides a focal opportunity for a multidisciplinary ensemble of experts in the field of neuromodulation to discuss advancements and forthcoming opportunities and challenges in the field. The proceedings of the fifth Think Tank summarize progress in neuromodulation neurotechnology and techniques for the treatment of a range of neuropsychiatric conditions including Parkinson's disease, dystonia, essential tremor, Tourette syndrome, obsessive compulsive disorder, epilepsy and cognitive, and motor disorders. Each section of this overview of the meeting provides insight to the critical elements of discussion, current challenges, and identified future directions of scientific and technological development and application. The report addresses key issues in developing, and emphasizes major innovations that have occurred during the past year. Specifically, this year's meeting focused on technical developments in DBS, design considerations for DBS electrodes, improved sensors, neuronal signal processing, advancements in development and uses of responsive DBS (closed-loop systems), updates on National Institutes of Health and DARPA DBS programs of the BRAIN initiative, and neuroethical and policy issues arising in and from DBS research and applications in practice.
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Affiliation(s)
- Adolfo Ramirez-Zamora
- Department of Neurology, Center for Movement Disorders and Neurorestoration, University of Florida, Gainesville, FL, United States,*Correspondence: Adolfo Ramirez-Zamora
| | - James J. Giordano
- Department of Neurology, Pellegrino Center for Clinical Bioethics, Georgetown University Medical Center, Washington, DC, United States
| | - Aysegul Gunduz
- J. Crayton Pruitt Family Department of Biomedical Engineering, Center for Movement Disorders and Neurorestoration, University of Florida, Gainesville, FL, United States
| | - Peter Brown
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, United Kingdom
| | - Justin C. Sanchez
- Biological Technologies Office, Defense Advanced Research Projects Agency, Arlington, VA, United States
| | - Kelly D. Foote
- Department of Neurosurgery, Center for Movement Disorders and Neurorestoration, University of Florida, Gainesville, FL, United States
| | - Leonardo Almeida
- Department of Neurology, Center for Movement Disorders and Neurorestoration, University of Florida, Gainesville, FL, United States
| | - Philip A. Starr
- Department of Neurological Surgery, Kavli Institute for Fundamental Neuroscience, University of California, San Francisco, San Francisco, CA, United States
| | - Helen M. Bronte-Stewart
- Departments of Neurology and Neurological Sciences and Neurosurgery, Stanford University, Stanford, CA, United States
| | - Wei Hu
- Department of Neurology, Center for Movement Disorders and Neurorestoration, University of Florida, Gainesville, FL, United States
| | - Cameron McIntyre
- Department of Biomedical Engineering, Case Western Reserve University, Cleveland, OH, United States
| | - Wayne Goodman
- Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, NY, United States,Department of Neuroscience, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Doe Kumsa
- Division of Biomedical Physics, Office of Science and Engineering Laboratories, Center for Devices and Radiological Health, United States Food and Drug Administration, White Oak Federal Research Center, Silver Spring, MD, United States
| | - Warren M. Grill
- Department of Biomedical Engineering, Duke University, Durham, NC, United States
| | - Harrison C. Walker
- Division of Movement Disorders, Department of Neurology, University of Alabama at Birmingham, Birmingham, AL, United States,Department of Biomedical Engineering, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Matthew D. Johnson
- Department of Biomedical Engineering, University of Minnesota, Minneapolis, MN, United States
| | - Jerrold L. Vitek
- Department of Neurology, University of Minnesota, Minneapolis, MN, United States
| | - David Greene
- NeuroPace, Inc., Mountain View, CA, United States
| | - Daniel S. Rizzuto
- Department of Psychology, University of Pennsylvania, Philadelphia, PA, United States
| | - Dong Song
- Department of Biomedical Engineering, University of Southern California, Los Angeles, CA, United States
| | - Theodore W. Berger
- Department of Biomedical Engineering, University of Southern California, Los Angeles, CA, United States
| | - Robert E. Hampson
- Physiology and Pharmacology, Wake Forest University School of Medicine, Wake Forest University, Winston-Salem, NC, United States
| | - Sam A. Deadwyler
- Physiology and Pharmacology, Wake Forest University School of Medicine, Wake Forest University, Winston-Salem, NC, United States
| | - Leigh R. Hochberg
- Department of Neurology, Center for Neurotechnology and Neurorecovery, Massachusetts General Hospital, Harvard Medical School, Harvard University, Boston, MA, United States,Center for Neurorestoration and Neurotechnology, Rehabilitation R and D Service, Veterans Affairs Medical Center, Providence, RI, United States,School of Engineering and Brown Institute for Brain Science, Brown University, Providence, RI, United States
| | - Nicholas D. Schiff
- Laboratory of Cognitive Neuromodulation, Feil Family Brain Mind Research Institute, Weill Cornell Medicine, New York, NY, United States
| | | | - Greg Worrell
- Department of Neurology, Mayo Clinic, Rochester, MN, United States
| | - Vineet Tiruvadi
- Department of Biomedical Engineering, Georgia Institute of Technology, Emory University School of Medicine, Emory University, Atlanta, GA, United States
| | - Helen S. Mayberg
- Departments of Psychiatry, Neurology, and Radiology, Emory University School of Medicine, Emory University, Atlanta, GA, United States
| | - Joohi Jimenez-Shahed
- Parkinson's Disease Center and Movement Disorders Clinic, Department of Neurology, Baylor College of Medicine, Houston, TX, United States
| | - Pranav Nanda
- Department of Neurological Surgery, The Neurological Institute, Columbia University Herbert and Florence Irving Medical Center, Colombia University, New York, NY, United States
| | - Sameer A. Sheth
- Department of Neurological Surgery, The Neurological Institute, Columbia University Herbert and Florence Irving Medical Center, Colombia University, New York, NY, United States
| | - Robert E. Gross
- Department of Neurosurgery, Emory University, Atlanta, GA, United States
| | - Scott F. Lempka
- Department of Biomedical Engineering, University of Michigan, Ann Arbor, MI, United States
| | - Luming Li
- National Engineering Laboratory for Neuromodulation, School of Aerospace Engineering, Tsinghua University, Beijing, China,Precision Medicine and Healthcare Research Center, Tsinghua-Berkeley Shenzhen Institute, Tsinghua University, Beijing, China,Center of Epilepsy, Beijing Institute for Brain Disorders, Beijing, China
| | - Wissam Deeb
- Department of Neurology, Center for Movement Disorders and Neurorestoration, University of Florida, Gainesville, FL, United States
| | - Michael S. Okun
- Department of Neurology, Center for Movement Disorders and Neurorestoration, University of Florida, Gainesville, FL, United States
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The Therapeutic “Mis”conception: An Examination of its Normative Assumptions and a Call for its Revision. Camb Q Healthc Ethics 2017; 27:154-162. [DOI: 10.1017/s0963180117000482] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Dissecting Bioethics, edited by Tuija Takala and Matti Hayry, welcomes contributions on the conceptual and theoretical dimensions of bioethics. The department is dedicated to the idea that words defined by bioethicists and others should not be allowed to imprison people’s actual concerns, emotions, and thoughts. Papers that expose the many meanings of a concept, describe the different readings of a moral doctrine, or provide an alternative angle to seemingly self-evident issues are particularly appreciated. To submit a paper or to discuss a suitable topic, contact Tuija Takala at tuija.takala@helsinki.fi.
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Abstract
In the 2015 David Kopf Lecture on Neuroethics of the Society for Neuroscience, Dr. Joseph Fins presents his work on neuroethics and disorders of consciousness through the experience of Maggie and Nancy Worthen, a young woman who sustained a severe brain injury and her mother who cared for her. The central protagonists in his book, Rights Come to Mind: Brain Injury, Ethics and the Struggle for Consciousness (Cambridge University Press, 2015), their experience is emblematic of the challenges faced by families touched by severe brain injury and the possibility for improved diagnosis and treatment offered by progress in neuroscience. By telling their story, and those of other families interviewed as part of the research for Rights Come to Mind, Fins calls for improved care for this population arguing that this is both an access to care issue and a civil and disability rights issue worthy of greater societal attention.
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36
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Zhang Y, Song W. Transcranial direct current stimulation in disorders of consciousness: a review. Int J Neurosci 2017; 128:255-261. [PMID: 28918680 DOI: 10.1080/00207454.2017.1381094] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Affiliation(s)
- Ye Zhang
- Department of Rehabilitation Medicine, Xuan Wu Hospital, Capital Medical University, Beijing, China
| | - Weiqun Song
- Department of Rehabilitation Medicine, Xuan Wu Hospital, Capital Medical University, Beijing, China
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37
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Ragazzoni A, Cincotta M, Giovannelli F, Cruse D, Young GB, Miniussi C, Rossi S. Clinical neurophysiology of prolonged disorders of consciousness: From diagnostic stimulation to therapeutic neuromodulation. Clin Neurophysiol 2017; 128:1629-1646. [DOI: 10.1016/j.clinph.2017.06.037] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2017] [Revised: 05/17/2017] [Accepted: 06/15/2017] [Indexed: 10/19/2022]
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Vanhoecke J, Hariz M. Deep brain stimulation for disorders of consciousness: Systematic review of cases and ethics. Brain Stimul 2017; 10:1013-1023. [PMID: 28966051 DOI: 10.1016/j.brs.2017.08.006] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2017] [Revised: 07/24/2017] [Accepted: 08/21/2017] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND A treatment for patients suffering from prolonged severely altered consciousness is not available. The success of Deep Brain Stimulation (DBS) in diseases such as Parkinson's, dystonia and essential tremor provided a renewed impetus for its application in Disorders of Consciousness (DoC). OBJECTIVE To evaluate the rationale for DBS in patients with DoC, through systematic review of literature containing clinical data and ethical considerations. METHODS Articles from PubMed, Embase, Medline and Web of Science were systematically reviewed. RESULTS The outcomes of 78 individual patients reported in 19 articles from 1968 onwards were pooled and elements of ethical discussions were compared. There is no clear clinical evidence that DBS is a treatment for DoC that can restore both consciousness and the ability to communicate. In patients who benefitted, the outcome of DBS is often confounded by the time frame of spontaneous recovery from DoC. Difficult ethical considerations remain, such as the risk of increasing self-awareness of own limitations, without improving overall wellbeing, and the issues of proxy consent. CONCLUSION DBS is far from being evident as a possible future therapeutic avenue for patients with DoC. Double-blind studies are lacking, and many clinical and ethical issues have to be addressed. In the rare cases when DBS for patients with DoC is considered, this needs to be evaluated meticulously on a case by case basis, with comprehensive overall outcome measures including psychological and quality-of-life assessments, and with the guidance of an ethical and interdisciplinary panel, especially in relation to proxy consent.
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Affiliation(s)
- Jonathan Vanhoecke
- Unit of Functional Neurosurgery, Institute of Neurology, University College London, Queen Square, WC1N 3BG, London, UK.
| | - Marwan Hariz
- Unit of Functional Neurosurgery, Institute of Neurology, University College London, Queen Square, WC1N 3BG, London, UK; Department of Clinical Neuroscience, Umeå University, SE-901 87, Umeå, Sweden.
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39
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Xie Q, Ni X, Yu R, Li Y, Huang R. Chronic disorders of consciousness. Exp Ther Med 2017; 14:1277-1283. [PMID: 28810588 DOI: 10.3892/etm.2017.4639] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2015] [Accepted: 02/17/2017] [Indexed: 01/19/2023] Open
Abstract
Over the last 20 years, studies have provided greater insight into disorders of consciousness (DOC), also known as altered state of consciousness. Increased brain residual functions have been identified in patients with DOC due to the successful application of novel next-generation imaging technologies. Many unconscious patients have now been confirmed to retain considerable cognitive functions. It is hoped that greater insight regarding the psychological state of patients may be achieved through the use of functional magnetic resonance imaging and brain-computer interfaces. However, issues surrounding the research and treatment of DOC remain problematic. These include differing opinions on the definition of consciousness, difficulties in diagnosis, assessment, prognosis and/or treatment, and newly emerging ethical, legal and social issues. To overcome these, appropriate care must be offered to patients with DOC by clinicians and families, as DOC patients may now be considered to live in more than just a vegetative state. The present article reviews the controversy surrounding the definition of consciousness and the reliability of novel technologies, prognostic prediction, communication with DOC patients and treatment methods. The ethical and social issues surrounding the treatment of DOC and future perspectives are also considered.
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Affiliation(s)
- Qiuyou Xie
- Coma Research Group, Center for Hyperbaric Oxygen and Neurorehabilitation, Neuroscience Institute, Guangzhou General Hospital of Guangzhou Command, Guangzhou, Guangdong 510010, P.R. China
| | - Xiaoxiao Ni
- Coma Research Group, Center for Hyperbaric Oxygen and Neurorehabilitation, Neuroscience Institute, Guangzhou General Hospital of Guangzhou Command, Guangzhou, Guangdong 510010, P.R. China
| | - Ronghao Yu
- Coma Research Group, Center for Hyperbaric Oxygen and Neurorehabilitation, Neuroscience Institute, Guangzhou General Hospital of Guangzhou Command, Guangzhou, Guangdong 510010, P.R. China
| | - Yuanqing Li
- Center for Brain Computer Interfaces and Brain Information Processing, South China University of Technology, Guangzhou, Guangdong 510641, P.R. China
| | - Ruiwang Huang
- Centre for Studies of Psychological Application, Guangdong Key Laboratory of Mental Health and Cognitive Science, School of Psychology, South China Normal University, Guangzhou, Guangdong 510631, P.R. China
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Xia X, Bai Y, Zhou Y, Yang Y, Xu R, Gao X, Li X, He J. Effects of 10 Hz Repetitive Transcranial Magnetic Stimulation of the Left Dorsolateral Prefrontal Cortex in Disorders of Consciousness. Front Neurol 2017; 8:182. [PMID: 28515709 PMCID: PMC5413493 DOI: 10.3389/fneur.2017.00182] [Citation(s) in RCA: 57] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2016] [Accepted: 04/18/2017] [Indexed: 11/13/2022] Open
Abstract
Background While repetitive transcranial magnetic stimulation (rTMS) has been applied in treatment of patients with disorders of consciousness (DOC), a standardized stimulation protocol has not been proposed, and its therapeutic effects are inconsistently documented. Objectives To assess the efficacy of rTMS in improving consciousness in patients with persistent minimally conscious state (MCS) or unresponsive wakefulness syndrome (UWS), previously known as vegetative state (VS). Method A prospective single-blinded study, with selected subjects, was carried out. In total, 16 patients (5 MCS and 11 VS/UWS) with chronic DOC were included. All patients received active 10 Hz rTMS at the left dorsolateral prefrontal cortex (DLPFC), at one session per day, for 20 consecutive days. A single daily session of stimulation consisted of 1,000 pulses (10 s of 10 Hz trains; repeated 10 times with an inter-train interval of 60 s; and 11 min and 40 s for total session). The main outcome measures were changes in the total score on the JFK Coma Recovery Scale-Revised (CRS-R) scale. Additional measures were the impressions of caregivers after the conclusion of the interventions, which were assessed using the Clinical Global Impression-Improvement (CGI-I) scale. Results The CRS-R scores were increased in all 5 MCS patients and 4 of 11 VS/UWS patients, while a significant enhancement of CRS-R scores was observed compared to the baseline in all participants (p = 0.007). However, the improvement was more notable in MCS patients (p = 0.042) than their VS/UWS counterparts (p = 0.066). Based on the CGI-I scores, two patients improved considerably, two improved, six minimally improved, six experienced no change, and none deteriorated. Good concordance was seen between the CGI-I result and the increases in CRS-R scores. Conclusion Treatment of 10 Hz multisession rTMS applied to the left DLPFC is promising for the rehabilitation of DOC patients, especially those in MCS. Further validation with a cohort of a larger sample size is required.
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Affiliation(s)
- Xiaoyu Xia
- School of Medicine, Tsinghua University, Beijing, China.,Department of Neurosurgery, PLA Army General Hospital, Beijing, China
| | - Yang Bai
- Institute of Electrical Engineering, Yanshan University, Qinhuangdao, China
| | | | - Yi Yang
- Department of Neurosurgery, PLA Army General Hospital, Beijing, China
| | - Ruxiang Xu
- Department of Neurosurgery, PLA Army General Hospital, Beijing, China
| | - Xiaorong Gao
- School of Medicine, Tsinghua University, Beijing, China
| | - Xiaoli Li
- State Key Laboratory of Cognitive Neuroscience and Learning, IDG/McGovern Institute for Brain Research, Beijing Normal University, Beijing, China
| | - Jianghong He
- Department of Neurosurgery, PLA Army General Hospital, Beijing, China
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Estraneo A, Pascarella A, Moretta P, Masotta O, Fiorenza S, Chirico G, Crispino E, Loreto V, Trojano L. Repeated transcranial direct current stimulation in prolonged disorders of consciousness: A double-blind cross-over study. J Neurol Sci 2017; 375:464-470. [PMID: 28320187 DOI: 10.1016/j.jns.2017.02.036] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2016] [Revised: 01/15/2017] [Accepted: 02/15/2017] [Indexed: 10/20/2022]
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Abstract
Disorder of consciousness (DOC) is a state of prolonged altered consciousness, which can be categorized into coma, vegetative state, or minimally conscious state based on neurobehavioral function. The pathophysiology of DOC is poorly understood but recent advances in neuroimaging and advanced electrophysiological techniques may provide an improved understanding for the neural network involved with consciousness. The primary aim of DOC rehabilitation programs is to promote arousal while preventing secondary medical complications while providing education and training to families. Treatment interventions include both pharmacologic and nonpharmacologic programs, but there are currently no consensus treatment guidelines for individuals with DOC.
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Affiliation(s)
- Blessen C Eapen
- Polytrauma Rehabilitation Center, South Texas Veterans Healthcare System, 7400 Merton Minter, San Antonio, TX 78229, USA.
| | - Jason Georgekutty
- Kessler Institute for Rehabilitation, 201 Pleasant Hill Road, Chester, NJ 07830, USA
| | - Bruno Subbarao
- Polytrauma Rehabilitation Center, South Texas Veterans Healthcare System, 7400 Merton Minter, San Antonio, TX 78229, USA
| | - Sheital Bavishi
- Traumatic Brain Injury Rehabilitation Program, Department of Physical Medicine and Rehabilitation, Ohio State University Wexner Medical Center, 480 Medical Center Drive, Columbus, OH 43210, USA
| | - David X Cifu
- Department of PM&R, Virginia Commonwealth University, US Department of Veterans Affairs, VA/DoD Chronic Effects of NeuroTrauma Consortium, 1223 E. Marshall Street, P.O. Box 980677, Richmond, Virginia 23284-0667, USA
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Kundishora AJ, Gummadavelli A, Ma C, Liu M, McCafferty C, Schiff ND, Willie JT, Gross RE, Gerrard J, Blumenfeld H. Restoring Conscious Arousal During Focal Limbic Seizures with Deep Brain Stimulation. Cereb Cortex 2017; 27:1964-1975. [PMID: 26941379 PMCID: PMC5964488 DOI: 10.1093/cercor/bhw035] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
Impaired consciousness occurs suddenly and unpredictably in people with epilepsy, markedly worsening quality of life and increasing risk of mortality. Focal seizures with impaired consciousness are the most common form of epilepsy and are refractory to all current medical and surgical therapies in about one-sixth of cases. Restoring consciousness during and following seizures would be potentially transformative for these individuals. Here, we investigate deep brain stimulation to improve level of conscious arousal in a rat model of focal limbic seizures. We found that dual-site stimulation of the central lateral nucleus of the intralaminar thalamus (CL) and the pontine nucleus oralis (PnO) bilaterally during focal limbic seizures restored normal-appearing cortical electrophysiology and markedly improved behavioral arousal. In contrast, single-site bilateral stimulation of CL or PnO alone was insufficient to achieve the same result. These findings support the "network inhibition hypothesis" that focal limbic seizures impair consciousness through widespread inhibition of subcortical arousal. Driving subcortical arousal function would be a novel therapeutic approach to some forms of refractory epilepsy and may be compatible with devices already in use for responsive neurostimulation. Multisite deep brain stimulation of subcortical arousal structures may benefit not only patients with epilepsy but also those with other disorders of consciousness.
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Affiliation(s)
| | - Abhijeet Gummadavelli
- Department of Neurosurgery, Yale University School of Medicine, New Haven, CT 06520, USA
| | | | | | | | - Nicholas D. Schiff
- Department of Neurology, Weill-Cornell Medical College, New York, NY 10021, USA
| | | | - Robert E. Gross
- Department of Neurological Surgery
- Department of Neurology, Emory School of Medicine, Atlanta, GA 30322, USA
| | - Jason Gerrard
- Department of Neurosurgery, Yale University School of Medicine, New Haven, CT 06520, USA
| | - Hal Blumenfeld
- Department of Neurology
- Department of Neuroscience
- Department of Neurosurgery, Yale University School of Medicine, New Haven, CT 06520, USA
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Bai Y, Xia X, Kang J, Yang Y, He J, Li X. TDCS modulates cortical excitability in patients with disorders of consciousness. NEUROIMAGE-CLINICAL 2017; 15:702-709. [PMID: 28702347 PMCID: PMC5487253 DOI: 10.1016/j.nicl.2017.01.025] [Citation(s) in RCA: 61] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/30/2016] [Revised: 12/27/2016] [Accepted: 01/23/2017] [Indexed: 12/16/2022]
Abstract
Transcranial direct current stimulation (tDCS)1 has been reported to be a promising technique for consciousness improvement for patients with disorders of consciousness (DOC).2 However, there has been no direct electrophysiological evidence to demonstrate the efficacy of tDCS on patients with DOC. Therefore, we aim to measure the cortical excitability changes induced by tDCS in patients with DOC, to find electrophysiological evidence supporting the therapeutic efficacy of tDCS on patients with DOC. In this study, we enrolled sixteen patients with DOC, including nine vegetative state (VS)3 and seven minimally conscious state (MCS)4 (six females and ten males). TMS-EEG was applied to assess cortical excitability changes after twenty minutes of anodal tDCS of the left dorsolateral prefrontal cortex. Global cerebral excitability were calculated to quantify cortical excitability in the temporal domain: four time intervals (0–100, 100–200, 200–300, 300-400 ms). Then local cerebral excitability in the significantly altered time windows were investigated (frontal, left/right hemispheres, central, and posterior). Compared to baseline and sham stimulation, we found that global cerebral excitability increased in early time windows (0–100 and 100-200 ms) for patients with MCS; for the patients with VS, global cerebral excitability increased in the 0-100 ms interval but decreased in the 300-400 ms interval. The local cerebral excitability was significantly different between MCS and VS. The results indicated that tDCS can effectively modulate the cortical excitability of patients with DOC; and the changes in excitability in temporal and spatial domains are different between patients with MCS and those with VS. TDCS was used to alter cerebral excitability in patients of DOC. TMS-EEG was used to evaluate cortical excitability changes in patients of DOC. TDCS could induce significant cortical excitability changes in patients of DOC. TDCS induced different temporal-spatial excitability changes between MCS and VS.
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Affiliation(s)
- Yang Bai
- Institute of Electrical Engineering, Yanshan University, Qinhuangdao 066004, China
| | - Xiaoyu Xia
- Department of Neurosurgery, PLA Army General Hospital, Beijing 100700, China; Department of Biomedical Engineering, Medical school, Tsinghua University, China
| | - Jiannan Kang
- Institute of Electronic Information Engineering, Hebei University, Baoding 071002, China
| | - Yi Yang
- Department of Neurosurgery, PLA Army General Hospital, Beijing 100700, China
| | - Jianghong He
- Department of Neurosurgery, PLA Army General Hospital, Beijing 100700, China.
| | - Xiaoli Li
- State Key Laboratory of Cognitive Neuroscience and Learning & IDG/McGovern Institute for Brain Research, Beijing Normal University, Beijing 100875, China; Center for Collaboration and Innovation in Brain and Learning Sciences, Beijing Normal University, Beijing 100875, China.
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Disorders of Consciousness: Painless or Painful Conditions?-Evidence from Neuroimaging Studies. Brain Sci 2016; 6:brainsci6040047. [PMID: 27740600 PMCID: PMC5187561 DOI: 10.3390/brainsci6040047] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2016] [Revised: 09/26/2016] [Accepted: 09/28/2016] [Indexed: 01/18/2023] Open
Abstract
The experience of pain in disorders of consciousness is still debated. Neuroimaging studies, using functional Magnetic Resonance Imaging (fMRI), Positron Emission Tomography (PET), multichannel electroencephalography (EEG) and laser-evoked potentials, suggest that the perception of pain increases with the level of consciousness. Brain activation in response to noxious stimuli has been observed in patients with unresponsive wakefulness syndrome (UWS), which is also referred to as a vegetative state (VS), as well as those in a minimally conscious state (MCS). However, all of these techniques suggest that pain-related brain activation patterns of patients in MCS more closely resemble those of healthy subjects. This is further supported by fMRI findings showing a much greater functional connectivity within the structures of the so-called pain matrix in MCS as compared to UWS/VS patients. Nonetheless, when interpreting the results, a distinction is necessary between autonomic responses to potentially harmful stimuli and conscious experience of the unpleasantness of pain. Even more so if we consider that the degree of residual functioning and cortical connectivity necessary for the somatosensory, affective and cognitive-evaluative components of pain processing are not yet clear. Although procedurally challenging, the particular value of the aforementioned techniques in the assessment of pain in disorders of consciousness has been clearly demonstrated. The study of pain-related brain activation and functioning can contribute to a better understanding of the networks underlying pain perception while addressing clinical and ethical questions concerning patient care. Further development of technology and methods should aim to increase the availability of neuroimaging, objective assessment of functional connectivity and analysis at the level of individual cases as well as group comparisons. This will enable neuroimaging to truly become a clinical tool to reliably investigate pain in severely brain-injured patients as well as an asset for research.
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Adams ZM, Forgacs PB, Conte MM, Nauvel TJ, Drover JD, Schiff ND. Late and progressive alterations of sleep dynamics following central thalamic deep brain stimulation (CT-DBS) in chronic minimally conscious state. Clin Neurophysiol 2016; 127:3086-3092. [PMID: 27472544 PMCID: PMC5582539 DOI: 10.1016/j.clinph.2016.06.028] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2016] [Accepted: 06/24/2016] [Indexed: 02/03/2023]
Affiliation(s)
- Zoe M Adams
- Feil Family Brain and Mind Research Institute, Weill Cornell Medical College, 1300 York Avenue, New York, NY, USA
| | - Peter B Forgacs
- Feil Family Brain and Mind Research Institute, Weill Cornell Medical College, 1300 York Avenue, New York, NY, USA; The Rockefeller University, 1230 York Avenue, New York, NY, USA
| | - Mary M Conte
- Feil Family Brain and Mind Research Institute, Weill Cornell Medical College, 1300 York Avenue, New York, NY, USA
| | - Tanya J Nauvel
- Feil Family Brain and Mind Research Institute, Weill Cornell Medical College, 1300 York Avenue, New York, NY, USA
| | - Jonathan D Drover
- Feil Family Brain and Mind Research Institute, Weill Cornell Medical College, 1300 York Avenue, New York, NY, USA
| | - Nicholas D Schiff
- Feil Family Brain and Mind Research Institute, Weill Cornell Medical College, 1300 York Avenue, New York, NY, USA; The Rockefeller University, 1230 York Avenue, New York, NY, USA.
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47
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Lancioni GE, Singh NN, O'Reilly MF, Sigafoos J, D'Amico F, Buonocunto F, Navarro J, Lanzilotti C, Fiore P, Megna M, Damiani S. Assistive technology to help persons in a minimally conscious state develop responding and stimulation control: Performance assessment and social rating. NeuroRehabilitation 2016; 37:393-403. [PMID: 26518532 DOI: 10.3233/nre-151269] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
BACKGROUND Post-coma persons in a minimally conscious state (MCS) and with extensive motor impairment and lack of speech tend to be passive and isolated. OBJECTIVE This study aimed to (a) further assess a technology-aided approach for fostering MCS participants' responding and stimulation control and (b) carry out a social validation check about the approach. METHODS Eight MCS participants were exposed to the aforementioned approach according to an ABAB design. The technology included optic, pressure or touch microswitches to monitor eyelid, hand or finger responses and a computer system that allowed those responses to produce brief periods of positive stimulation during the B (intervention) phases of the study. Eighty-four university psychology students and 42 care and health professionals were involved in the social validation check. RESULTS The MCS participants showed clear increases in their response frequencies, thus producing increases in their levels of environmental stimulation input, during the B phases of the study. The students and care and health professionals involved in the social validation check rated the technology-aided approach more positively than a control condition in which stimulation was automatically presented to the participants. CONCLUSIONS A technology-aided approach to foster responding and stimulation control in MCS persons may be effective and socially desirable.
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Affiliation(s)
| | - Nirbhay N Singh
- Medical College of Georgia, Georgia Regents University, Augusta, GA, USA
| | | | | | | | | | - Jorge Navarro
- S. Raffaele Rehabilitation Center, Ceglie Messapica, Italy
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48
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A Narrative Review of Pharmacologic and Non-pharmacologic Interventions for Disorders of Consciousness Following Brain Injury in the Pediatric Population. CURRENT PHYSICAL MEDICINE AND REHABILITATION REPORTS 2016; 4:56-70. [PMID: 27280064 DOI: 10.1007/s40141-016-0108-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Traumatic brain injury (TBI) is the most common cause of long-term disability in the United States. A significant proportion of children who experience a TBI will have moderate or severe injuries, which includes a period of decreased responsiveness. Both pharmacological and non-pharmacological modalities are used for treating disorders of consciousness after TBI in children. However, the evidence supporting the use of potential therapies is relatively scant, even in adults, and overall, there is a paucity of study in pediatrics. The goal of this review is to describe the state of the science for use of pharmacologic and non-pharmacologic interventions for disorders of consciousness in the pediatric population.
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Gosseries O, Pistoia F, Charland-Verville V, Carolei A, Sacco S, Laureys S. The Role of Neuroimaging Techniques in Establishing Diagnosis, Prognosis and Therapy in Disorders of Consciousness. Open Neuroimag J 2016; 10:52-68. [PMID: 27347265 PMCID: PMC4894918 DOI: 10.2174/1874440001610010052] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2016] [Revised: 04/06/2016] [Accepted: 04/11/2016] [Indexed: 12/30/2022] Open
Abstract
Non-communicative brain damaged patients raise important clinical and scientific issues. Here, we review three major pathological disorders of consciousness: coma, the unresponsive wakefulness syndrome and the minimally conscious state. A number of clinical studies highlight the difficulty in making a correct diagnosis in patients with disorders of consciousness based only on behavioral examinations. The increasing use of neuroimaging techniques allows improving clinical characterization of these patients. Recent neuroimaging studies using positron emission tomography, functional magnetic resonance imaging, electroencephalography and transcranial magnetic stimulation can help assess diagnosis, prognosis, and therapeutic treatment. These techniques, using resting state, passive and active paradigms, also highlight possible dissociations between consciousness and responsiveness, and are facilitating a more accurate understanding of brain function in this challenging population.
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Affiliation(s)
- Olivia Gosseries
- Coma Science Group, GIGA, University of Liege, Liege, Belgium; Department of Psychology and Psychiatry, University of Wisconsin, Madison, WI, United-States
| | - Francesca Pistoia
- Department of Biotechnological and Applied Clinical Sciences, Neurological Institute, University of L'Aquila, L'Aquila, Italy
| | | | - Antonio Carolei
- Department of Biotechnological and Applied Clinical Sciences, Neurological Institute, University of L'Aquila, L'Aquila, Italy
| | - Simona Sacco
- Department of Biotechnological and Applied Clinical Sciences, Neurological Institute, University of L'Aquila, L'Aquila, Italy
| | - Steven Laureys
- Coma Science Group, GIGA, University of Liege, Liege, Belgium
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Central thalamic deep brain stimulation to support anterior forebrain mesocircuit function in the severely injured brain. J Neural Transm (Vienna) 2016; 123:797-806. [PMID: 27113938 DOI: 10.1007/s00702-016-1547-0] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2016] [Accepted: 04/02/2016] [Indexed: 10/21/2022]
Abstract
This integrative review frames a general rationale for the use of central thalamic deep brain stimulation (CT-DBS) to support arousal regulation mechanisms in the severely injured brain. The organizing role of the anterior forebrain mesocircuit in recovery mechanisms following widespread deafferentation produced by multi-focal structural brain injuries is emphasized. The mesocircuit model provides the conceptual foundation for the key role of the central thalamus as a privileged node for neuromodulation to support forebrain arousal regulation. In this context, cellular mechanisms arising at the neocortical, striatal, and thalamic population level are considered in the assessment of an individual patient's capacity for harboring underlying reserve that could be recruited for further recovery. Recent preclinical studies and pilot clinical results are compared to frame the detailed rationale for CT-DBS. Application of CT-DBS across the range of outcomes following severe-to-moderate brain injuries is discussed with the aim of improving consciousness and cognition in patients with non-progressive brain injuries.
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