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Wan X, Zhang Y, Li Y, Song W. Effects of parietal repetitive transcranial magnetic stimulation in prolonged disorders of consciousness: A pilot study. Heliyon 2024; 10:e30192. [PMID: 38707352 PMCID: PMC11066627 DOI: 10.1016/j.heliyon.2024.e30192] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2023] [Revised: 04/21/2024] [Accepted: 04/22/2024] [Indexed: 05/07/2024] Open
Abstract
Objective Although the parietal cortex is related to consciousness, the dorsolateral prefrontal and primary motor cortices are the usual targets for repetitive transcranial magnetic stimulation (rTMS) for prolonged disorders of consciousness (pDoC). Herein, we applied parietal rTMS to patients with pDoC, to verify its neurobehavioral effects and explore a new potential rTMS target. Materials and methods Twenty-six patients with pDoC were assigned to a rTMS or sham group. The rTMS group received 10 sessions of parietal rTMS; the sham group received 10 sessions of sham stimulation. The Coma Recovery Scale-Revised (CRS-R) and event-related potential (ERP) were collected before and after the 10 sessions or sham sessions. Results After the 10 sessions, the rTMS group showed: a significant CRS-R score increase; ERP appearance of a P300 waveform and significantly increased Fz amplitudes; increased potentials on topographic mapping, especially in the left prefrontal cortex; and an increase in delta and theta band powers at Fz, Cz, and Pz. The sham group did not show such changes in CRS-R score or ERP results statistically. Conclusion Parietal rTMS shows promise as a novel intervention in the recovery of consciousness in pDoC. It showed neurobehavioral enhancement of residual brain function and may promote frontal activity by enhancing frontal-parietal connections. The parietal cortex may thus be an alternative for rTMS therapy protocols.
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Affiliation(s)
- Xiaoping Wan
- Department of Rehabilitation Medicine, Xuan Wu Hospital, Capital Medical University, No. 45 Chang Chun Street, Beijing, 100053, China
| | - Ye Zhang
- Department of Rehabilitation Medicine, Xuan Wu Hospital, Capital Medical University, No. 45 Chang Chun Street, Beijing, 100053, China
| | - Yanhua Li
- Department of Rehabilitation Medicine, Xuan Wu Hospital, Capital Medical University, No. 45 Chang Chun Street, Beijing, 100053, China
| | - Weiqun Song
- Department of Rehabilitation Medicine, Xuan Wu Hospital, Capital Medical University, No. 45 Chang Chun Street, Beijing, 100053, China
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Wan X, Zhang Y, Li Y, Song W. An update on noninvasive neuromodulation in the treatment of patients with prolonged disorders of consciousness. CNS Neurosci Ther 2024; 30:e14757. [PMID: 38747078 PMCID: PMC11094579 DOI: 10.1111/cns.14757] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Revised: 04/16/2024] [Accepted: 04/28/2024] [Indexed: 05/18/2024] Open
Abstract
BACKGROUND With the improvement of emergency techniques, the survival rate of patients with severe brain injury has increased. However, this has also led to an annual increase in the number of patients with prolonged disorders of consciousness (pDoC). Hence, recovery of consciousness is an important part of treatment. With advancing techniques, noninvasive neuromodulation seems a promising intervention. The objective of this review was to summarize the latest techniques and provide the basis for protocols of noninvasive neuromodulations in pDoC. METHODS This review summarized the advances in noninvasive neuromodulation in the treatment of pDoC in the last 5 years. RESULTS Variable techniques of neuromodulation are used in pDoC. Transcranial ultrasonic stimulation (TUS) and transcutaneous auricular vagus nerve stimulation (taVNS) are very new techniques, while transcranial direct current stimulation (tDCS) and transcranial magnetic stimulation (TMS) are still the hotspots in pDoC. Median nerve electrical stimulation (MNS) has received little attention in the last 5 years. CONCLUSIONS Noninvasive neuromodulation is a valuable and promising technique to treat pDoC. Further studies are needed to determine a unified stimulus protocol to achieve optimal effects as well as safety.
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Affiliation(s)
- Xiaoping Wan
- Department of Rehabilitation Medicine, Xuan Wu Hospital, Capital Medical University, Beijing, China
| | - Ye Zhang
- Department of Rehabilitation Medicine, Xuan Wu Hospital, Capital Medical University, Beijing, China
| | - Yanhua Li
- 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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Yan J, Zha F, Zhou J, Zhou J, Zhao J, Zhang Q, Long J, Hou D, Song Z, Wang Y. Combining HD-tDCS with music stimulation for patients with prolonged disorders of consciousness: Study protocol for an RCT trial. NeuroRehabilitation 2024; 54:495-504. [PMID: 38457160 PMCID: PMC11091638 DOI: 10.3233/nre-230282] [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: 11/06/2023] [Accepted: 01/27/2024] [Indexed: 03/09/2024]
Abstract
BACKGROUND Patients with prolonged disorders of consciousness (pDOC) pose significant challenges to healthcare workers due to their severe motor impairments and limited interaction with the environment. Non-invasive brain stimulation such as high-definition transcranial direct current stimulation (HD-tDCS) and music stimulation show promise in awakening this population. OBJECTIVE In this study, we present a protocol aiming at investigating the efficacy of combined HD-tDCS and music stimulation in awakening patients with pDOC through a single-blind, randomized controlled trial. METHODS Ninety patients with pDOC will be randomly divided into three groups: active HD-tDCS with music stimulation, active HD-tDCS, and sham HD-tDCS. All participants will receive 20 treatment sessions over a period of 10 days and the Coma Recovery Scale-Revised, Glasgow Outcome Scale and electroencephalogram will be used as assessment measures to evaluate their level of consciousness throughout the study. Adverse events and complications will be recorded during treatment. Within-group pre-post comparisons and between-group efficacy comparisons will be conducted to identify the most effective intervention approach. Statistical analysis will be performed using SPSS software with a significance level set at P < 0.05. CONCLUSION The pursuit of awakening therapy for patients with pDOC remains a clinical research challenge. This study protocol is designed with the aim of introducing an innovative non-pharmacological approach which combined HD-tDCS and music stimulation to facilitate the reinstatement of consciousness in patients with pDOC.
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Affiliation(s)
- Jie Yan
- Department of Rehabilitation, The First Affiliated Hospital of Shenzhen University, Shenzhen Second People’s Hospital, Shenzhen, China
- Department of Rehabilitation Medicine, Shandong University of Traditional Chinese Medicine, Jinan, China
| | - Fubing Zha
- Department of Rehabilitation, The First Affiliated Hospital of Shenzhen University, Shenzhen Second People’s Hospital, Shenzhen, China
| | - Juan Zhou
- Department of Rehabilitation, The First Affiliated Hospital of Shenzhen University, Shenzhen Second People’s Hospital, Shenzhen, China
| | - Jing Zhou
- Department of Rehabilitation, The First Affiliated Hospital of Shenzhen University, Shenzhen Second People’s Hospital, Shenzhen, China
| | - Jingpu Zhao
- Department of Rehabilitation, The First Affiliated Hospital of Shenzhen University, Shenzhen Second People’s Hospital, Shenzhen, China
| | - Qingfang Zhang
- Department of Rehabilitation, The First Affiliated Hospital of Shenzhen University, Shenzhen Second People’s Hospital, Shenzhen, China
- Department of Rehabilitation Medicine, Shandong University of Traditional Chinese Medicine, Jinan, China
| | - Jianjun Long
- Department of Rehabilitation, The First Affiliated Hospital of Shenzhen University, Shenzhen Second People’s Hospital, Shenzhen, China
| | - Dianrui Hou
- Department of Rehabilitation, Nan’ao People’s Hospital of Shenzhen, Dapeng New District, Shenzhen, China
| | - Zhenhua Song
- Department of Rehabilitation Medicine, Haikou Hospital Affiliated to Xiangya Medical College of Central South University, Haikou, China
| | - Yulong Wang
- Department of Rehabilitation, The First Affiliated Hospital of Shenzhen University, Shenzhen Second People’s Hospital, Shenzhen, China
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Gunduz ME, Bucak B, Keser Z. Advances in Stroke Neurorehabilitation. J Clin Med 2023; 12:6734. [PMID: 37959200 PMCID: PMC10650295 DOI: 10.3390/jcm12216734] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2023] [Revised: 10/20/2023] [Accepted: 10/23/2023] [Indexed: 11/15/2023] Open
Abstract
Stroke is one of the leading causes of disability worldwide despite recent advances in hyperacute interventions to lessen the initial impact of stroke. Stroke recovery therapies are crucial in reducing the long-term disability burden after stroke. Stroke recovery treatment options have rapidly expanded within the last decade, and we are in the dawn of an exciting era of multimodal therapeutic approaches to improve post-stroke recovery. In this narrative review, we highlighted various promising advances in treatment and technologies targeting stroke rehabilitation, including activity-based therapies, non-invasive and minimally invasive brain stimulation techniques, robotics-assisted therapies, brain-computer interfaces, pharmacological treatments, and cognitive therapies. These new therapies are targeted to enhance neural plasticity as well as provide an adequate dose of rehabilitation and improve adherence and participation. Novel activity-based therapies and telerehabilitation are promising tools to improve accessibility and provide adequate dosing. Multidisciplinary treatment models are crucial for post-stroke neurorehabilitation, and further adjuvant treatments with brain stimulation techniques and pharmacological agents should be considered to maximize the recovery. Among many challenges in the field, the heterogeneity of patients included in the study and the mixed methodologies and results across small-scale studies are the cardinal ones. Biomarker-driven individualized approaches will move the field forward, and so will large-scale clinical trials with a well-targeted patient population.
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Affiliation(s)
- Muhammed Enes Gunduz
- Department of Neurology, University of Massachusetts Chan Medical School, Worcester, MA 01655, USA
| | - Bilal Bucak
- Department of Neurology, Mayo Clinic, Rochester, MN 55905, USA; (B.B.); (Z.K.)
| | - Zafer Keser
- Department of Neurology, Mayo Clinic, Rochester, MN 55905, USA; (B.B.); (Z.K.)
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Yang Z, Yue T, Zschorlich VR, Li D, Wang D, Qi F. Behavioral Effects of Repetitive Transcranial Magnetic Stimulation in Disorders of Consciousness: A Systematic Review and Meta-Analysis. Brain Sci 2023; 13:1362. [PMID: 37891731 PMCID: PMC10605911 DOI: 10.3390/brainsci13101362] [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: 08/08/2023] [Revised: 09/12/2023] [Accepted: 09/20/2023] [Indexed: 10/29/2023] Open
Abstract
Traumatic brain injury, cardiac arrest, intracerebral hemorrhage, and ischemic stroke may cause disorders of consciousness (DoC). Repetitive transcranial magnetic stimulation (rTMS) has been used to promote the recovery of disorders of consciousness (DoC) patients. In this meta-analysis, we examined whether rTMS can relieve DoC patient symptoms. We searched through journal articles indexed in PubMed, the Web of Science, Embase, Scopus, and the Cochrane Library until 20 April 2023. We assessed whether studies used rTMS as an intervention and reported the pre- and post-rTMS coma recovery scale-revised (CRS-R) scores. A total of 207 patients from seven trials were included. rTMS significantly improved the recovery degree of patients; the weighted mean difference (WMD) of the change in the CRS-R score was 1.89 (95% confidence interval (CI): 1.39-2.39; p < 0.00001) in comparison with controls. The subgroup analysis showed a significant improvement in CRS-R scores in rTMS over the dorsolateral prefrontal cortex (WMD = 2.24; 95% CI: 1.55-2.92; p < 0.00001; I2 = 31%) and the primary motor cortex (WMD = 1.63; 95% CI: 0.69-2.57; p = 0.0007; I2 = 14%). Twenty-hertz rTMS significantly improved CRS-R scores in patients with DoC (WMD = 1.61; 95% CI: 0.39-2.83; p = 0.010; I2 = 31%). Furthermore, CRS-R scores in rTMS over 20 sessions significantly improved (WMD = 1.75; 95% CI: 0.95-2.55; p < 0.0001; I2 = 12%). rTMS improved the symptoms of DoC patients; however, the available evidence remains limited and inadequate.
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Affiliation(s)
- Zihan Yang
- School of Sports Medicine and Rehabilitation, Beijing Sport University, Beijing 100084, China
| | - Tian Yue
- School of Sports Medicine and Rehabilitation, Beijing Sport University, Beijing 100084, China
| | - Volker R. Zschorlich
- Institute of Sport Science, Carl von Ossietzky Universität Oldenburg, 26129 Oldenburg, Germany
| | - Dai Li
- Department of Sports Medicine, Peking University Third Hospital, Institute of Sports Medicine of Peking University, Beijing 100191, China
- Beijing Key Laboratory of Sports Injuries, Beijing 100191, China
- Engineering Research Center of Sports Trauma Treatment Technology and Devices, Ministry of Education, Beijing 100191, China
| | - Duanwei Wang
- Shandong Mental Health Center, Shandong University, Jinan 250012, China
| | - Fengxue Qi
- Sports, Exercise and Brain Sciences Laboratory, Beijing Sport University, Beijing 100084, China
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Vitello MM, Rosenfelder MJ, Cardone P, Niimi M, Willacker L, Thibaut A, Lejeune N, Laureys S, Bender A, Gosseries O. A protocol for a multicenter randomized and personalized controlled trial using rTMS in patients with disorders of consciousness. Front Neurol 2023; 14:1216468. [PMID: 37545735 PMCID: PMC10401598 DOI: 10.3389/fneur.2023.1216468] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2023] [Accepted: 07/06/2023] [Indexed: 08/08/2023] Open
Abstract
Background Improving the functional recovery of patients with DoC remains one of the greatest challenges of the field. Different theories exist about the role of the anterior (prefrontal areas) versus posterior (parietal areas) parts of the brain as hotspots for the recovery of consciousness. Repetitive transcranial magnetic stimulation (rTMS) is a powerful non-invasive brain stimulation technique for the treatment of DoC. However, a direct comparison of the effect of TMS treatment on the front versus the back of the brain has yet to be performed. In this study, we aim to assess the short- and long-term effects of frontal and parietal rTMS on DoC recovery and characterize responders phenotypically. Methods/design Ninety patients with subacute and prolonged DoC will be included in a two-part multicenter prospective study. In the first phase (randomized controlled trial, RCT), patients will undergo four rTMS sessions in a crossover design over 10 days, targeting (i) the left dorsolateral prefrontal cortex (DLPFC) and (ii) the left angular gyrus (AG), as well as (iii & iv) their sham alternatives. In the second phase (longitudinal personalized trial), patients will receive personalized stimulations for 20 working days targeting the brain area that showed the best results in the RCT and will be randomly assigned to either active or sham intervention. The effects of rTMS on neurobehavioral and neurophysiological functioning in patients with DoC will be evaluated using clinical biomarkers of responsiveness (i.e., the Coma Recovery Scale-Revised; CRS-R), and electrophysiological biomarkers (e.g., power spectra, functional and effective connectivity, perturbational complexity index before and after intervention). Functional long-term outcomes will be assessed at 3 and 6 months post-intervention. Adverse events will be recorded during the treatment phase. Discussion This study seeks to identify which brain region (front or back) is best to stimulate for the treatment of patients with DoC using rTMS, and to characterize the neural correlates of its action regarding recovery of consciousness and functional outcome. In addition, we will define the responders' profile based on patients' characteristics and functional impairments; and develop biomarkers of responsiveness using EEG analysis according to the clinical responsiveness to the treatment. Clinical Trial Registration https://clinicaltrials.gov/ct2/show/NCT04401319, Clinicaltrials.gov, n° NCT04401319.
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Affiliation(s)
- Marie M. Vitello
- Coma Science Group, GIGA Consciousness, University of Liège, Liège, Belgium
- Centre du Cerveau, University Hospital of Liège, Liège, Belgium
| | - Martin J. Rosenfelder
- Department of Neurology, Therapiezentrum Burgau, Burgau, Germany
- Clinical and Biological Psychology, Institute of Psychology and Education, Ulm University, Ulm, Germany
| | - Paolo Cardone
- Coma Science Group, GIGA Consciousness, University of Liège, Liège, Belgium
- Centre du Cerveau, University Hospital of Liège, Liège, Belgium
| | - Masachika Niimi
- Coma Science Group, GIGA Consciousness, University of Liège, Liège, Belgium
- Centre du Cerveau, University Hospital of Liège, Liège, Belgium
- Department of Rehabilitation Medicine, Nihon University School of Medicine, Tokyo, Japan
| | - Lina Willacker
- Department of Neurology, Ludwig-Maximilians University Hospital of Munich, University of Munich, Munich, Germany
| | - Aurore Thibaut
- Coma Science Group, GIGA Consciousness, University of Liège, Liège, Belgium
- Centre du Cerveau, University Hospital of Liège, Liège, Belgium
| | - Nicolas Lejeune
- Coma Science Group, GIGA Consciousness, University of Liège, Liège, Belgium
- Centre du Cerveau, University Hospital of Liège, Liège, Belgium
- William Lennox Neurological Hospital, Ottignies-Louvain-la-Neuve, Belgium
| | - Steven Laureys
- Coma Science Group, GIGA Consciousness, University of Liège, Liège, Belgium
- Centre du Cerveau, University Hospital of Liège, Liège, Belgium
- CERVO Research Center, Laval University, Québec, QC, Canada
| | - Andreas Bender
- Department of Neurology, Therapiezentrum Burgau, Burgau, Germany
- Department of Neurology, Ludwig-Maximilians University Hospital of Munich, University of Munich, Munich, Germany
| | - Olivia Gosseries
- Coma Science Group, GIGA Consciousness, University of Liège, Liège, Belgium
- Centre du Cerveau, University Hospital of Liège, Liège, Belgium
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Dong L, Li H, Dang H, Zhang X, Yue S, Zhang H. Efficacy of non-invasive brain stimulation for disorders of consciousness: a systematic review and meta-analysis. Front Neurosci 2023; 17:1219043. [PMID: 37496734 PMCID: PMC10366382 DOI: 10.3389/fnins.2023.1219043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2023] [Accepted: 06/26/2023] [Indexed: 07/28/2023] Open
Abstract
Objective The aim of this study is to evaluate the efficacy of non-invasive brain stimulation (NIBS) in patients with disorders of consciousness (DoC) and compare differences in efficacy between different stimulation modalities. Methods We searched the PubMed, Cochrane Library, Web of Science, and EMBASE databases for all studies published in English from inception to April 2023. Literature screening and quality assessment were performed independently by two investigators. Weighted mean differences (WMDs) and 95% confidence intervals (CIs) were used to evaluate the therapeutic effects of NIBS. The Cochrane Q test and I2 statistic were used to evaluate heterogeneity between studies. Subgroup analysis was performed to identify the source of heterogeneity, and differences in efficacy between different stimulation modalities were compared by Bayesian analysis. Results A total of 17 studies with 377 DoC patients were included. NIBS significantly improved the state of consciousness in DoC patients when compared to sham stimulation (WMD: 0.81; 95% CI: 0.46, 1.17; I2 = 78.2%, p = 0.000). When divided into subgroups according to stimulation modalities, the heterogeneity of each subgroup was significantly lower than before (I2: 0.00-30.4%, p >0.05); different stimulation modalities may be the main source of such heterogeneity. Bayesian analysis, based on different stimulation modalities, indicated that a patient's state of consciousness improved most significantly after repetitive transcranial magnetic stimulation (rTMS) of the left dorsolateral prefrontal cortex (DLPFC). Diagnosis-based subgroup analysis showed that NIBS significantly improved the state of consciousness in patients with a minimal consciousness state (WMD: 1.11; 95% CI: 0.37, 1.86) but not in patients with unresponsive wakefulness syndrome or a vegetative state (WMD: 0.31; 95% CI: -0.09, 0.71). Subgroup analysis based on observation time showed that single treatment did not improve the state of consciousness in DoC patients (WMD: 0.28; 95% CI: -0.27, 0.82) while multiple treatments could (WMD: 1.05; 95% CI: 0.49, 1.61). Furthermore, NIBS had long-term effects on DoC patients (WMD: 0.79; 95% CI: 0.08-1.49). Conclusion Available evidence suggests that the use of NIBS on patients with DoC is more effective than sham stimulation, and that rTMS of the left DLPFC may be the most prominent stimulation modality.
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Affiliation(s)
- Linghui Dong
- Shandong University, Jinan, Shandong, China
- China Rehabilitation Research Center, Beijing, China
- University of Health and Rehabilitation Sciences, Qingdao, Shandong, China
| | - Hui Li
- Shandong University, Jinan, Shandong, China
- China Rehabilitation Research Center, Beijing, China
- University of Health and Rehabilitation Sciences, Qingdao, Shandong, China
| | - Hui Dang
- Shandong University, Jinan, Shandong, China
- China Rehabilitation Research Center, Beijing, China
- University of Health and Rehabilitation Sciences, Qingdao, Shandong, China
| | | | - Shouwei Yue
- Shandong University, Jinan, Shandong, China
- University of Health and Rehabilitation Sciences, Qingdao, Shandong, China
| | - Hao Zhang
- Shandong University, Jinan, Shandong, China
- China Rehabilitation Research Center, Beijing, China
- University of Health and Rehabilitation Sciences, Qingdao, Shandong, China
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Liu Z, Zhang X, Yu B, Wang J, Lu X. Effectiveness on level of consciousness of non-invasive neuromodulation therapy in patients with disorders of consciousness: a systematic review and meta-analysis. Front Hum Neurosci 2023; 17:1129254. [PMID: 37292582 PMCID: PMC10246452 DOI: 10.3389/fnhum.2023.1129254] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Accepted: 05/02/2023] [Indexed: 06/10/2023] Open
Abstract
Background Disorders of consciousness (DoC) commonly occurs secondary to severe neurological injury. A considerable volume of research has explored the effectiveness of different non-invasive neuromodulation therapy (NINT) on awaking therapy, however, equivocal findings were reported. Objective The aim of this study was to systematically investigate the effectiveness on level of consciousness of different NINT in patients with DoC and explore optimal stimulation parameters and characteristics of patients. Methods PubMed, Embase, Web of Science, Scopus, and Cochrane central register of controlled trials were searched from their inception through November 2022. Randomized controlled trials, that investigated effectiveness on level of consciousness of NINT, were included. Mean difference (MD) with 95% confidence interval (CI) was evaluated as effect size. Risk of bias was assessed with revised Cochrane risk-of-bias tool. Results A total of 15 randomized controlled trials with 345 patients were included. Meta-analysis was performed on 13 out of 15 reviewed trials indicating that transcranial Direct Current Stimulation (tDCS), Transcranial Magnetic Stimulation (TMS), and median nerve stimulation (MNS) all had a small but significant effect (MD 0.71 [95% CI 0.28, 1.13]; MD 1.51 [95% CI 0.87, 2.15]; MD 3.20 [95%CI: 1.45, 4.96]) on level of consciousness. Subgroup analyses revealed that patients with traumatic brain injury, higher initial level of consciousness (minimally conscious state), and shorter duration of prolonged DoC (subacute phase of DoC) reserved better awaking ability after tDCS. TMS also showed encouraging awaking effect when stimulation was applied on dorsolateral prefrontal cortex in patients with prolonged DoC. Conclusion tDCS and TMS appear to be effective interventions for improving level of consciousness of patients with prolonged DoC. Subgroup analyses identified the key parameters required to enhance the effects of tDCS and TMS on level of consciousness. Etiology of DoC, initial level of consciousness, and phase of DoC could act as significant characteristics of patients related to the effectiveness of tDCS. Stimulation site could act as significant stimulation parameter related to the effectiveness of TMS. There is insufficient evidence to support the use of MNS in clinical practice to improve level of consciousness in patients with coma. Systematic review registration https://www.crd.york.ac.uk/PROSPERO/display_record.php?RecordID=337780, identifier: CRD42022337780.
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Affiliation(s)
| | | | | | | | - Xiao Lu
- Department of Rehabilitation Medicine, The First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu, China
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Weaver JA, Watters K, Cogan AM. Interventions Facilitating Recovery of Consciousness Following Traumatic Brain Injury: A Systematic Review. OTJR-OCCUPATION PARTICIPATION AND HEALTH 2023; 43:322-336. [PMID: 36047664 DOI: 10.1177/15394492221117779] [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: 11/17/2022]
Abstract
People who experience disorders of consciousness (DoC) following a severe traumatic brain injury (TBI) have complex rehabilitation needs addressed by occupational therapy. To examine the effectiveness of interventions to improve arousal and awareness of people with DoC following a TBI. For this systematic review, we followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We searched six databases in collaboration with a research librarian. Twenty-seven studies were included and grouped thematically. Multimodal sensory stimulation, familiar voices telling structured stories, and transcranial direct current stimulation had a moderate level of evidence. Multimodal sensory stimulation had the strongest evidence in support of its use in clinical practice. Occupational therapy practitioners should administer multimodal stimuli frequently as studies reported administering these interventions at least twice daily. Occupational therapy practitioners should incorporate personally relevant, meaningful, salient stimuli into interventions when treating patients with DoC.
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Affiliation(s)
| | | | - Alison M Cogan
- VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA
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Xu C, Zhu Z, Wu W, Zheng X, Zhong H, Huang X, Xie Q, Qian X. Effects of 10 Hz individualized repetitive transcranial magnetic stimulation on patients with disorders of consciousness: a study protocol for an exploratory double-blind crossover randomized sham-controlled trial. Trials 2023; 24:249. [PMID: 37005647 PMCID: PMC10067296 DOI: 10.1186/s13063-023-07122-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2022] [Accepted: 01/28/2023] [Indexed: 04/04/2023] Open
Abstract
BACKGROUND Repetitive transcranial magnetic stimulation (rTMS), as a non-invasive brain stimulation technique, has shown potentials for consciousness recovery of patients with disorders of consciousness (DoC), as, to a certain extent, it is effective in regulating the excitability of central nervous system. However, it is difficult to achieve satisfactory effect with "one size fits all" rTMS treatment due to different clinical conditions of patients. There is an urgent need to develop individualized strategy to improve the effectiveness of rTMS on patients with DoC. METHODS Our protocol is a randomized double-blind sham-controlled crossover trial that includes 30 DoC patients. Each patient will received 20 sessions, in which 10 sessions will be rTMS-active stimulus, and the other 10 sessions will be sham stimulus, separated by no less than 10 days' washout period. The rTMS-active will include 10 Hz rTMS over the individualized-targeted selection area for each patient according to the different insult regions of the brain. Coma Recovery Scale-Revised (CRS-R) will be used as primary outcome at baseline, after the first stage of stimulation, at the end of the washout period, and after the second stage of stimulation. Secondary outcomes will be measured at the same time, including efficiency, relative spectral power, and functional connectivity of high-density electroencephalograph (EEG). Adverse events will be recorded during the study. DISCUSSION rTMS has obtained grade A evidence in treating patients with several central nervous system diseases, and there has been some evidence showing partial improvement on level of consciousness in DoC patients. However, the effectiveness of rTMS in DoC is only 30~36%, mostly due to the non-specific target selection. In this protocol, we present a double-blind crossover randomized sham-controlled trial based on the individualized-targeted selection strategy that aims to study the effectiveness of rTMS therapy for DoC, and the result may provide new insights to non-invasive brain stimulation. TRIAL REGISTRATION ClinicalTrials.gov : NCT05187000. Registered on January 10, 2022.
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Affiliation(s)
- Chengwei Xu
- Department of Rehabilitation Medicine, Zhujiang Hospital of Southern Medical University, Guangzhou, Guangdong Province, 510280, People's Republic of China
| | - Zhaohua Zhu
- Clinical Research Center, Zhujiang Hospital of Southern Medical University, Guangzhou, Guangdong Province, 510280, People's Republic of China
| | - Wanchun Wu
- Department of Rehabilitation Medicine, Zhujiang Hospital of Southern Medical University, Guangzhou, Guangdong Province, 510280, People's Republic of China
| | - Xiaochun Zheng
- Department of Rehabilitation Medicine, Zhujiang Hospital of Southern Medical University, Guangzhou, Guangdong Province, 510280, People's Republic of China
| | - Haili Zhong
- Department of Rehabilitation Medicine, Zhujiang Hospital of Southern Medical University, Guangzhou, Guangdong Province, 510280, People's Republic of China
| | - Xiyan Huang
- Department of Rehabilitation Medicine, Zhujiang Hospital of Southern Medical University, Guangzhou, Guangdong Province, 510280, People's Republic of China.
| | - Qiuyou Xie
- Department of Rehabilitation Medicine, Zhujiang Hospital of Southern Medical University, Guangzhou, Guangdong Province, 510280, People's Republic of China.
| | - Xinyi Qian
- School of Rehabilitation Medicine, Gannan Medical University, Ganzhou, Jiangxi province, 341000, People's Republic of China
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Shen L, Huang Y, Liao Y, Yin X, Huang Y, Ou J, Ouyang H, Chen Z, Long J. Effect of high-frequency repetitive transcranial magnetic stimulation over M1 for consciousness recovery after traumatic brain injury. Brain Behav 2023; 13:e2971. [PMID: 36977194 PMCID: PMC10176007 DOI: 10.1002/brb3.2971] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Revised: 02/26/2023] [Accepted: 03/03/2023] [Indexed: 03/30/2023] Open
Abstract
BACKGROUND The brain area stimulated during repetitive transcranial magnetic stimulation (rTMS) treatment is important in altered states of consciousness. However, the functional contribution of the M1 region during the treatment of high-frequency rTMS remains unclear. OBJECTIVE The aim of this study was to examine the clinical [the Glasgow coma scale (GCS) and the coma recovery scale-revised (CRS-R)] and neurophysiological (EEG reactivity and SSEP) responses in vegetative state (VS) patients following traumatic brain injury (TBI) before and after a protocol of high-frequency rTMS over the M1 region. METHODS Ninety-nine patients in a VS following TBI were recruited so that their clinical and neurophysiological responses could be evaluated in this study. These patients were randomly allocated into three experimental groups: rTMS over the M1 region (test group; n = 33), rTMS over the left dorsolateral prefrontal cortex (DLPFC) (control group; n = 33) and placebo rTMS over the M1 region (placebo group; n = 33). Each rTMS treatment lasted 20 min and was carried out once a day. The duration of this protocol was a month with 20 treatments (5 times per week) occurring with that time. RESULTS We found that the clinical and neurophysiological responses improved after treatment in the test, control, and placebo groups; the improvement was highest in the test group compared to that in the control and placebo groups. CONCLUSIONS Our results demonstrate an effective method of high-frequency rTMS over the M1 region for consciousness recovery after severe brain injury.
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Affiliation(s)
- Longbin Shen
- Department of Rehabilitation Medicine, The First Affiliated Hospital of Jinan University, Guangzhou, Guangdong, China
| | - Yixuan Huang
- Graduate School, Gimcheon University, Gimcheon, South Korea
| | - Yujun Liao
- Department of Rehabilitation Medicine, The Fifth Affiliated Hospital of Guangzhou Medical University, Guangzhou, Guangdong, China
| | - Xiaona Yin
- Department of Rehabilitation, Shenzhen Longhua Maternity & Child Healthcare Hospital, Shenzhen, Guangdong, China
| | - Yulin Huang
- Department of Rehabilitation Medicine, The First Affiliated Hospital of Jinan University, Guangzhou, Guangdong, China
| | - Jianlin Ou
- Department of Rehabilitation Medicine, The First Affiliated Hospital of Jinan University, Guangzhou, Guangdong, China
| | - Hui Ouyang
- Department of Rehabilitation Medicine, The First Affiliated Hospital of Jinan University, Guangzhou, Guangdong, China
| | - Zhuoming Chen
- Department of Rehabilitation Medicine, The First Affiliated Hospital of Jinan University, Guangzhou, Guangdong, China
| | - Jinyi Long
- College of Information Science and Technology, Jinan University, Guangzhou, Guangdong, China
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12
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Li Y, Li L, Huang H. Effect of non-invasive brain stimulation on conscious disorder in patients after brain injury: a network meta-analysis. Neurol Sci 2023:10.1007/s10072-023-06743-7. [PMID: 36943589 DOI: 10.1007/s10072-023-06743-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2023] [Accepted: 03/09/2023] [Indexed: 03/23/2023]
Abstract
OBJECTIVE To systematically evaluate the rehabilitation effect of non-invasive brain stimulation (NIBS) on disorder of consciousness (DOC) after brain injury and compare the effects of different NIBSs. METHODS Randomized controlled trials (RCTs) on the effect of NIBS on DOC after brain injury were retrieved from the PubMed, Cochrane Library, Web of Science, CNKI, VIP, Wanfang Data, and CBM databases from inception to October 2022. The risk of bias and quality of the trials were assessed following the Cochrane Handbook of Systematic Reviews and the physiotherapy evidence database Jadad Scale. Statistical analysis was conducted with RevMan 5.4 and R Studio. This study was registered on PROSPERO (No. CRD42022371334). RESULTS A total of 28 articles were included involving 1118 patients. Meta-analysis showed that NIBS combined with routine rehabilitation had the highest effect than the routine rehabilitation and the sham NIBS combined with routine rehabilitation. The cumulative probability ranking results showed that the rTMS was best. The order of network meta-analysis with GCS (Glasgow Coma Scale) as the outcome index is rTMS combined with routine rehabilitation > tDCS combined with routine rehabilitation > routine rehabilitation > NIBS sham stimulation combined with routine rehabilitation. The order of network meta-analysis with CRS-R (Coma Recovery Scale-Revised) as the outcome index is rTMS combined with routine rehabilitation > tDCS combined with routine rehabilitation > NIBS sham stimulation combined with routine rehabilitation > routine rehabilitation. For patients with different conditions of DOC, the subgroup analysis results showed that rTMS improved the effect of patients with severe DOC better than those with unclear conditions of DOC, but the overall results of the two groups were not significantly different. On the contrary, the effect of tDCS on patients with DOC whose condition was not clear was better than that on patients with severe DOC, and the effect on patients with severe DOC was not significant (P > 0.05). In terms of safety, only 9 articles mentioned ADRs in the included literature, including 8 articles without ADRs, and 1 article with ADRs. CONCLUSION Based on the research results of various indicators, NIBS can improve DOC after brain injury, and the rTMS is the best. Limited by the number and the quality of literature, the above conclusions need more high-quality research to verify.
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Affiliation(s)
- Yaning Li
- College of Rehabilitation Medicine, Shandong University of Traditional Chinese Medicine, Jinan, 250355, Shandong, China
| | - Lingling Li
- College of Rehabilitation Medicine, Shandong University of Traditional Chinese Medicine, Jinan, 250355, Shandong, China
| | - Hailiang Huang
- College of Rehabilitation Medicine, Shandong University of Traditional Chinese Medicine, Jinan, 250355, Shandong, China.
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Wang X, Gao H, Song J, Jing P, Wang C, Yu N, Wu S, Zhu J, Gao Z. How somatosensory evoked potentials improve the diagnosis of the disturbance of consciousness: A retrospective analysis. NETWORK (BRISTOL, ENGLAND) 2023; 34:392-407. [PMID: 37855276 DOI: 10.1080/0954898x.2023.2269263] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Accepted: 10/06/2023] [Indexed: 10/20/2023]
Abstract
The interpeak latency is a crucial characteristic of upper limb somatosensory evoked potentials (USEPs). However, the existing research on the correlation between interpeak latency and consciousness disorders is currently limited. We aimed to investigate how USEPs can contribute to the diagnosis of consciousness disorders. A retrospective analysis was conducted on 10 patients who underwent repetitive transcranial magnetic stimulation (rTMS) for consciousness disorders. The interpeak latency N13-N20, Glasgow coma scale (GCS), and Chinese Nanjing persistent vegetative state scale (CNPVSS) were evaluated before and after rTMS treatment, and the linear correlation between N13-N20, GCS, and CNPVSS was analysed. The scores of CNPVSS and GCS significantly increased in the first, second, and third months after rTMS. The N13-N20 was shorter in the second and third months after rTMS compared to before treatment. rTMS was found to shorten the N13-N20 latency, and there was a negative correlation between N13-N20 and the score of consciousness disorders. N13-N20 can serve as an objective index for evaluating consciousness disorders. This research provides potential insights for doctors in diagnosing patients with consciousness disorders.
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Affiliation(s)
- Xinwei Wang
- Nanjing Zijin Hospital, Nanjing, Jiangsu, China
| | | | - Jiulong Song
- The Fourth Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China
| | - Peng Jing
- Nanjing Zijin Hospital, Nanjing, Jiangsu, China
| | - Chao Wang
- Nanjing Zijin Hospital, Nanjing, Jiangsu, China
| | - Nuanxin Yu
- Nanjing Zijin Hospital, Nanjing, Jiangsu, China
| | - Shanshan Wu
- Nanjing Zijin Hospital, Nanjing, Jiangsu, China
| | - Jianxiong Zhu
- School of Mechanical Engineering, Southeast University, Nanjing, P. R. China
- Guangxi Key Laboratory of Automatic Detecting Technology and Instruments, Guilin University of Electronic Technology, Guilin, P. R. China
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Xiong Q, Le K, Tang Y, Ye W, Wang Y, Zhong Y, Zhou Y, Feng Z. Effect of single and combined median nerve stimulation and repetitive transcranial magnetic stimulation in patients with prolonged disorders of consciousness: a prospective, randomized, single-blinded, controlled trial. Front Aging Neurosci 2023; 15:1112768. [PMID: 37168716 PMCID: PMC10164991 DOI: 10.3389/fnagi.2023.1112768] [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: 11/30/2022] [Accepted: 02/23/2023] [Indexed: 05/13/2023] Open
Abstract
Objective To investigate the efficacy of median nerve stimulation (MNS) combined with repetitive transcranial magnetic stimulation (rTMS), MNS alone, and rTMS alone in elevating the level of consciousness in patients with prolonged disorders of consciousness (pDOC). Participants and methods We enrolled 75 eligible inpatients suffering from pDOC as a result of traumatic or non-traumatic brain injury. Participants were randomly assigned to one of the following three treatment groups: (1) rTMS+sham-MNS; (2) MNS + sham-rTMS; or (3) MNS + rTMS. The rTMS protocol involved stimulation above the left dorsolateral prefrontal cortex at a 10 Hz frequency and 90% resting motor threshold. The MNS protocol involved the delivery of a 15-20 mA current at the median nerve point 2 cm from the wrist crease of the right distal forearm. The primary outcome was the change from baseline of the Coma Recovery Scale-Revised (CRS-R) score after treatment. Secondary outcomes included post-treatment changes from baseline of the Glasgow Coma Scale (GCS) score, awaken ratio, electroencephalography (EEG) scores, and the latency and amplitude of N20 on somatosensory evoked potentials. Results Before the intervention, there were no significant differences between groups in the CRS-R, GCS scores, age, duration of pDOC, clinical diagnosis, EEG scores, latency and amplitude of N20, sex, job, marital status, education level, or disease etiology. Within the three groups, the total CRS-R, GCS scores and amplitude of N20 on both side significantly increased and latency of N20 on poor side significantly decreased post-intervention. Significantly greater improvement in CRS-R, GCS total scores, amplitude of N20 on both side and latency of N20 on the poor side were observed in the MNS + TMS group compared to those of the groups receiving rTMS alone or MNS alone. The patients receiving TMS and MNS intervention showed a greater EEG activity improvement, and the EEG activity improved ratio significantly differ between groups, while there were no significant differences in the awakening ratios between the three groups. Conclusion The combination of MNS + rTMS was more efficacious in improving the level of consciousness than MNS alone or rTMS alone in patients with pDOC.
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Xu C, Wu W, Zheng X, Liang Q, Huang X, Zhong H, Xiao Q, Lan Y, Bai Y, Xie Q. Repetitive transcranial magnetic stimulation over the posterior parietal cortex improves functional recovery in nonresponsive patients: A crossover, randomized, double-blind, sham-controlled study. Front Neurol 2023; 14:1059789. [PMID: 36873436 PMCID: PMC9978157 DOI: 10.3389/fneur.2023.1059789] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2022] [Accepted: 01/18/2023] [Indexed: 02/19/2023] Open
Abstract
Background Recent studies have shown that patients with disorders of consciousness (DoC) can benefit from repetitive transcranial magnetic stimulation (rTMS) therapy. The posterior parietal cortex (PPC) is becoming increasingly important in neuroscience research and clinical treatment for DoC as it plays a crucial role in the formation of human consciousness. However, the effect of rTMS on the PPC in improving consciousness recovery remains to be studied. Method We conducted a crossover, randomized, double-blind, sham-controlled clinical study to assess the efficacy and safety of 10 Hz rTMS over the left PPC in unresponsive patients. Twenty patients with unresponsive wakefulness syndrome were recruited. The participants were randomly divided into two groups: one group received active rTMS treatment for 10 consecutive days (n = 10) and the other group received sham treatment for the same period (n = 10). After a 10-day washout period, the groups crossed over and received the opposite treatment. The rTMS protocol involved the delivery of 2000 pulses/day at a frequency of 10 Hz, targeting the left PPC (P3 electrode sites) at 90% of the resting motor threshold. The primary outcome measure was the JFK Coma Recovery Scele-Revised (CRS-R), and evaluations were conducted blindly. EEG power spectrum assessments were also conducted simultaneously before and after each stage of the intervention. Result rTMS-active treatment resulted in a significant improvement in the CRS-R total score (F = 8.443, p = 0.009) and the relative alpha power (F = 11.166, p = 0.004) compared to sham treatment. Furthermore, 8 out of 20 patients classified as rTMS responders showed improvement and evolved to a minimally conscious state (MCS) as a result of active rTMS. The relative alpha power also significantly improved in responders (F = 26.372, p = 0.002) but not in non-responders (F = 0.704, p = 0.421). No adverse effects related to rTMS were reported in the study. Conclusions This study suggests that 10 Hz rTMS over the left PPC can significantly improve functional recovery in unresponsive patients with DoC, with no reported side effects. Clinical trial registration www.ClinicalTrials.gov, identifier: NCT05187000.
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Affiliation(s)
- Chengwei Xu
- Department of Rehabilitation Medicine, Joint Research Centre for Disorders of Consciousness, Zhujiang Hospital of Southern Medical University, Guangzhou, China
| | - Wanchun Wu
- Department of Rehabilitation Medicine, Joint Research Centre for Disorders of Consciousness, Zhujiang Hospital of Southern Medical University, Guangzhou, China
| | - Xiaochun Zheng
- Department of Rehabilitation Medicine, Joint Research Centre for Disorders of Consciousness, Zhujiang Hospital of Southern Medical University, Guangzhou, China
| | - Qimei Liang
- Department of Rehabilitation Medicine, Joint Research Centre for Disorders of Consciousness, Zhujiang Hospital of Southern Medical University, Guangzhou, China
| | - Xiyan Huang
- Department of Rehabilitation Medicine, Joint Research Centre for Disorders of Consciousness, Zhujiang Hospital of Southern Medical University, Guangzhou, China
| | - Haili Zhong
- Department of Rehabilitation Medicine, Joint Research Centre for Disorders of Consciousness, Zhujiang Hospital of Southern Medical University, Guangzhou, China
| | - Qiuyi Xiao
- Department of Rehabilitation Medicine, Joint Research Centre for Disorders of Consciousness, Zhujiang Hospital of Southern Medical University, Guangzhou, China
| | - Yue Lan
- Department of Rehabilitation Medicine, Joint Research Centre for Disorders of Consciousness, Zhujiang Hospital of Southern Medical University, Guangzhou, China
| | - Yang Bai
- Department of Rehabilitation Medicine, The First Affiliated Hospital of Nanchang University, Nanchang, China.,School of Basic Medical Sciences, Hangzhou Normal University, Hangzhou, China
| | - Qiuyou Xie
- Department of Rehabilitation Medicine, Joint Research Centre for Disorders of Consciousness, Zhujiang Hospital of Southern Medical University, Guangzhou, China
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Zheng RZ, Qi ZX, Wang Z, Xu ZY, Wu XH, Mao Y. Clinical Decision on Disorders of Consciousness After Acquired Brain Injury: Stepping Forward. Neurosci Bull 2023; 39:138-162. [PMID: 35804219 PMCID: PMC9849546 DOI: 10.1007/s12264-022-00909-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Accepted: 04/10/2022] [Indexed: 01/22/2023] Open
Abstract
Major advances have been made over the past few decades in identifying and managing disorders of consciousness (DOC) in patients with acquired brain injury (ABI), bringing the transformation from a conceptualized definition to a complex clinical scenario worthy of scientific exploration. Given the continuously-evolving framework of precision medicine that integrates valuable behavioral assessment tools, sophisticated neuroimaging, and electrophysiological techniques, a considerably higher diagnostic accuracy rate of DOC may now be reached. During the treatment of patients with DOC, a variety of intervention methods are available, including amantadine and transcranial direct current stimulation, which have both provided class II evidence, zolpidem, which is also of high quality, and non-invasive stimulation, which appears to be more encouraging than pharmacological therapy. However, heterogeneity is profoundly ingrained in study designs, and only rare schemes have been recommended by authoritative institutions. There is still a lack of an effective clinical protocol for managing patients with DOC following ABI. To advance future clinical studies on DOC, we present a comprehensive review of the progress in clinical identification and management as well as some challenges in the pathophysiology of DOC. We propose a preliminary clinical decision protocol, which could serve as an ideal reference tool for many medical institutions.
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Affiliation(s)
- Rui-Zhe Zheng
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, 200040, China
- National Center for Neurological Disorders, Shanghai, 200040, China
- Shanghai Key Laboratory of Brain Function and Restoration and Neural Regeneration, Shanghai, 200040, China
- Neurosurgical Institute of Fudan University, Shanghai, 200040, China
- Shanghai Clinical Medical Center of Neurosurgery, Shanghai, 200040, China
- State Key Laboratory of Medical Neurobiology, MOE Frontiers Center for Brain Science, School of Basic Medical Sciences and Institutes of Brain Science, Fudan University, Shanghai, 200032, China
| | - Zeng-Xin Qi
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, 200040, China
- National Center for Neurological Disorders, Shanghai, 200040, China
- Shanghai Key Laboratory of Brain Function and Restoration and Neural Regeneration, Shanghai, 200040, China
- Neurosurgical Institute of Fudan University, Shanghai, 200040, China
- Shanghai Clinical Medical Center of Neurosurgery, Shanghai, 200040, China
- State Key Laboratory of Medical Neurobiology, MOE Frontiers Center for Brain Science, School of Basic Medical Sciences and Institutes of Brain Science, Fudan University, Shanghai, 200032, China
| | - Zhe Wang
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, 200040, China
- National Center for Neurological Disorders, Shanghai, 200040, China
- Shanghai Key Laboratory of Brain Function and Restoration and Neural Regeneration, Shanghai, 200040, China
- Neurosurgical Institute of Fudan University, Shanghai, 200040, China
- Shanghai Clinical Medical Center of Neurosurgery, Shanghai, 200040, China
- State Key Laboratory of Medical Neurobiology, MOE Frontiers Center for Brain Science, School of Basic Medical Sciences and Institutes of Brain Science, Fudan University, Shanghai, 200032, China
| | - Ze-Yu Xu
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, 200040, China
- National Center for Neurological Disorders, Shanghai, 200040, China
- Shanghai Key Laboratory of Brain Function and Restoration and Neural Regeneration, Shanghai, 200040, China
- Neurosurgical Institute of Fudan University, Shanghai, 200040, China
- Shanghai Clinical Medical Center of Neurosurgery, Shanghai, 200040, China
- State Key Laboratory of Medical Neurobiology, MOE Frontiers Center for Brain Science, School of Basic Medical Sciences and Institutes of Brain Science, Fudan University, Shanghai, 200032, China
| | - Xue-Hai Wu
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, 200040, China.
- National Center for Neurological Disorders, Shanghai, 200040, China.
- Shanghai Key Laboratory of Brain Function and Restoration and Neural Regeneration, Shanghai, 200040, China.
- Neurosurgical Institute of Fudan University, Shanghai, 200040, China.
- Shanghai Clinical Medical Center of Neurosurgery, Shanghai, 200040, China.
- State Key Laboratory of Medical Neurobiology, MOE Frontiers Center for Brain Science, School of Basic Medical Sciences and Institutes of Brain Science, Fudan University, Shanghai, 200032, China.
| | - Ying Mao
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, 200040, China.
- National Center for Neurological Disorders, Shanghai, 200040, China.
- Shanghai Key Laboratory of Brain Function and Restoration and Neural Regeneration, Shanghai, 200040, China.
- Neurosurgical Institute of Fudan University, Shanghai, 200040, China.
- Shanghai Clinical Medical Center of Neurosurgery, Shanghai, 200040, China.
- State Key Laboratory of Medical Neurobiology, MOE Frontiers Center for Brain Science, School of Basic Medical Sciences and Institutes of Brain Science, Fudan University, Shanghai, 200032, China.
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Yu J, Wu Y, Wu B, Xu C, Cai J, Wen X, Meng F, Zhang L, He F, Hong L, Gao J, Li J, Yu J, Luo B. Sleep patterns correlates with the efficacy of tDCS on post-stroke patients with prolonged disorders of consciousness. J Transl Med 2022; 20:601. [PMID: 36522680 PMCID: PMC9756665 DOI: 10.1186/s12967-022-03710-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Accepted: 10/18/2022] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND The subclassification of prolonged disorders of consciousness (DoC) based on sleep patterns is important for the evaluation and treatment of the disease. This study evaluates the correlation between polysomnographic patterns and the efficacy of transcranial direct current stimulation (tDCS) in patients with prolonged DoC due to stroke. METHODS In total, 33 patients in the vegetative state (VS) with sleep cycles or without sleep cycles were randomly assigned to either active or sham tDCS groups. Polysomnography was used to monitor sleep changes before and after intervention. Additionally, clinical scale scores and electroencephalogram (EEG) analysis were performed before and after intervention to evaluate the efficacy of tDCS on the patients subclassified according to their sleep patterns. RESULTS The results suggest that tDCS improved the sleep structure, significantly prolonged total sleep time (TST) (95%CI: 14.387-283.527, P = 0.013) and NREM sleep stage 2 (95%CI: 3.157-246.165, P = 0.040) of the VS patients with sleep cycles. It also significantly enhanced brain function of patients with sleep cycles, which were reflected by the increased clinical scores (95%CI: 0.340-3.440, P < 0.001), the EEG powers and functional connectivity in the brain and the 6-month prognosis. Moreover, the changes in NREM sleep stage 2 had a significant positive correlation with each index of the β band. CONCLUSION This study reveals the importance of sleep patterns in the prognosis and treatment of prolonged DoC and provides new evidence for the efficacy of tDCS in post-stroke patients with VS patients subclassified by sleep pattern. Trial registration URL: https://www. CLINICALTRIALS gov . Unique identifier: NCT03809936. Registered 18 January 2019.
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Affiliation(s)
- Jie Yu
- grid.452661.20000 0004 1803 6319Department of Neurology, First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, 310003 Zhejiang China
| | - Yuehao Wu
- grid.452661.20000 0004 1803 6319Department of Neurology, First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, 310003 Zhejiang China ,Department of Neurology, First People’s Hospital of Linping District, Hangzhou, 310003 Zhejiang China
| | - Biwen Wu
- grid.415999.90000 0004 1798 9361Center for Sleep Medicine, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, 310003 China
| | - Chuan Xu
- grid.452661.20000 0004 1803 6319Department of Neurology, First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, 310003 Zhejiang China
| | - Jiaye Cai
- grid.415999.90000 0004 1798 9361Center for Sleep Medicine, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, 310003 China
| | - Xinrui Wen
- grid.452661.20000 0004 1803 6319Department of Neurology, First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, 310003 Zhejiang China
| | - Fanxia Meng
- grid.452661.20000 0004 1803 6319Department of Neurology, First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, 310003 Zhejiang China
| | - Li Zhang
- grid.417401.70000 0004 1798 6507Rehabilitation Medicine Center, Department of Rehabilitation Medicine, Zhejiang Provincial People’s Hospital, Affiliated People’s Hospital of Hangzhou Medical College, Hangzhou, Zhejiang China
| | - Fangping He
- grid.452661.20000 0004 1803 6319Department of Neurology, First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, 310003 Zhejiang China
| | - Lirong Hong
- Department of Rehabilitation, Hangzhou Hospital of Zhejiang Armed Police Corps, Hangzhou, 310051 China
| | - Jian Gao
- Department of Rehabilitation, Hangzhou Mingzhou Brain Rehabilitation Hospital, Hangzhou, 311215 China
| | - Jingqi Li
- Department of Rehabilitation, Hangzhou Mingzhou Brain Rehabilitation Hospital, Hangzhou, 311215 China
| | - Jintai Yu
- grid.411405.50000 0004 1757 8861Department of Neurology and Institute of Neurology, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, 200031 China
| | - Benyan Luo
- grid.452661.20000 0004 1803 6319Department of Neurology, First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, 310003 Zhejiang China
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Huang W, Chen Q, Liu J, Liu L, Tang J, Zou M, Zeng T, Li H, Jiang Q, Jiang Q. Transcranial Magnetic Stimulation in Disorders of Consciousness: An Update and Perspectives. Aging Dis 2022:AD.2022.1114. [PMID: 37163434 PMCID: PMC10389824 DOI: 10.14336/ad.2022.1114] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2022] [Accepted: 11/14/2022] [Indexed: 05/12/2023] Open
Abstract
Disorders of consciousness (DOC) is a state in which consciousness is affected by brain injuries, leading to dysfunction in vigilance, awareness, and behavior. DOC encompasses coma, vegetative state, and minimally conscious state based on neurobehavioral function. Currently, DOC is one of the most common neurological disorders with a rapidly increasing incidence worldwide. Therefore, DOC not only impacts the lives of individuals and their families but is also becoming a serious public health threat. Repetitive transcranial magnetic stimulation (rTMS) can stimulate electrical activity using a pulsed magnetic field in the brain, with great value in the treatment of chronic pain, neurological diseases, and mental illnesses. However, the clinical application of rTMS in patients with DOC is debatable. Herein, we report the recent main findings of the clinical therapeutics of rTMS for DOC, including its efficacy and possible mechanisms. In addition, we discuss the potential key parameters (timing, location, frequency, strength, and secession of rTMS applications) that affect the therapeutic efficiency of rTMS in patients with DOC. This review may help develop clinical guidelines for the therapeutic application of rTMS in DOC.
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Affiliation(s)
| | | | - Jun Liu
- Department of Neurosurgery, Ganzhou People's Hospital, Jiangxi, China
| | - Lin Liu
- Key Laboratory of Prevention and Treatment of Cardiovascular and Cerebrovascular Diseases of Ministry of Education, Gannan Medical University, Jiangxi, China
| | - Jianhong Tang
- Laboratory Animal Engineering Research Center of Ganzhou, Gannan Medical University, Jiangxi, China
| | - Mingang Zou
- Department of Neurosurgery, Ganzhou People's Hospital, Jiangxi, China
| | - Tianxiang Zeng
- Department of Neurosurgery, Ganzhou People's Hospital, Jiangxi, China
| | - Huichen Li
- Department of Neurosurgery, Ganzhou People's Hospital, Jiangxi, China
| | - Qing Jiang
- Department of Neurosurgery, Ganzhou People's Hospital, Jiangxi, China
| | - QiuHua Jiang
- Department of Neurosurgery, Ganzhou People's Hospital, Jiangxi, China
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Influence of High-Frequency Repetitive Transcranial Magnetic Stimulation on Neurobehavioral and Electrophysiology in Patients with Disorders of Consciousness. Neural Plast 2022; 2022:7195699. [PMID: 36437902 PMCID: PMC9699789 DOI: 10.1155/2022/7195699] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2022] [Revised: 10/21/2022] [Accepted: 10/28/2022] [Indexed: 11/17/2022] Open
Abstract
Objective High-frequency repetitive transcranial magnetic stimulation (HF-rTMS) has been proposed as a promising therapeutic intervention for patients with disorders of consciousness (DOC). However, its therapeutic effects in the literature are inconsistently documented. The primary aim of this study was to explore the alterations in neural connectivity and neurobehavioral reactivity during rTMS modulation in patients with DOC. In addition, safety was investigated as a secondary aim. Methods The presence of bilateral N20 components in DOC patients was determined by somatosensory-evoked potential (SEP) before enrollment in the study. A total of 64 patients were enrolled and randomly placed into the active and sham groups. Ultimately, 50 patients completed the study. Twenty-five patients in the active group underwent real HF-rTMS, and 25 patients in the sham group underwent sham HF-rTMS, which was delivered over the left dorsolateral prefrontal cortex (DLPFC). The outcome measures of performed pre- and postintervention included the latencies of the N20 and N20-P25 amplitudes of SEP, brainstem auditory-evoked potential (BAEP) grade, JFK Coma Recovery Scale-Revised (CRS-R) score, and Glasgow Coma Scale (GCS) score; any adverse events were recorded at any time during the intervention. Result Following six weeks of treatment, a significant increase was observed in the total CRS-R and GCS scores, and the N20-P25 amplitudes of patients in the two groups were compared with that obtained from preintervention (all p values < 0.05). The waves of BAEP in the two groups also showed a trend toward normalized activity compared with preintervention grades (p values < 0.05). A significant decrease in the latencies of N20 (p values < 0.001) was observed in the active group compared with measurements obtained from preintervention, whereas no significant decrease was observed in the sham group (p values = 0.013). The improvement in total CRS-R scores (p values = 0.002), total GCS scores (p values = 0.023), and N20-P25 amplitudes (p values = 0.011) as well as the decrease in latencies of N20 (p values = 0.018) and change in BAEP grades (p values = 0.013) were significantly different between the two groups. The parameters in neural connectivity (N20-P25 amplitudes, N20 latencies, and BAEP grades) were significantly correlated with the total CRS-R and GCS scores at postintervention, and the changes of CRS-R before and after interventions have a positive relationship with N20-P25 amplitudes. No adverse events related to the rTMS protocol were recorded. Conclusion Neural connectivity levels are affected by HF-rTMS and are significantly related to clinical responses in DOC patients with the presence of bilateral N20. The elevation of neural connectivity levels may lay a foundation for successful HF-rTMS treatment for DOC patients.
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Lindsey A, Ellison RL, Herrold AA, Aaronson AL, Kletzel SL, Stika MM, Guernon A, Bender Pape T. rTMS/iTBS and Cognitive Rehabilitation for Deficits Associated With TBI and PTSD: A Theoretical Framework and Review. J Neuropsychiatry Clin Neurosci 2022; 35:28-38. [PMID: 35872613 DOI: 10.1176/appi.neuropsych.21090227] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Rehabilitation of cognitive and psychosocial deficits resulting from traumatic brain injury (TBI) continues to be an area of concern in health care. Commonly co-occurring psychiatric disorders, such as major depressive disorder and posttraumatic stress disorder, create additional hurdles when attempting to remediate cognitive sequelae. There is increased need for procedures that will yield consistent gains indicative of recovery of function. Intermittent theta-burst stimulation (iTBS), a form of repetitive transcranial magnetic stimulation, has potential as an instrument that can be tailored to aid cognitive processes and support functional gains. The use of iTBS enables direct stimulation of desired neural systems. iTBS, performed in conjunction with behavioral interventions (e.g., cognitive rehabilitation, psychotherapy), may result in additive success in facilitating cognitive restoration and adaptation. The purpose of this theoretical review is to illustrate how the technical and physiological aspects of iTBS may enhance other forms of neurorehabilitation for individuals with TBI. Future research on combinatorial iTBS interventions has the potential to translate to other complex neuropsychiatric conditions.
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Affiliation(s)
- André Lindsey
- Research Service (Lindsey, Ellison, Herrold, Kletzel, Guernon, Pape), Center for Innovation for Complex Chronic Healthcare (Herrold, aronson, Kletzel, Pape), and Spinal Cord Injury/Disorder Service (Stika), Edward Hines, Jr., Veterans Affairs (VA) Hospital, Hines, IL; School of Education, Nevada State College, Henderson (Lindsey); Department of Psychology, Illinois Institute of Technology, Chicago (Ellison); Departments of Psychiatry and Behavioral Medicine (Herrold, Aaronson) and Physical Medicine and Rehabilitation (Pape), Feinberg School of Medicine, Northwestern University, Chicago; Speech-Language Pathology Program, College of Nursing and Health Sciences, Lewis University, Romeoville, IL (Guernon)
| | - Rachael L Ellison
- Research Service (Lindsey, Ellison, Herrold, Kletzel, Guernon, Pape), Center for Innovation for Complex Chronic Healthcare (Herrold, aronson, Kletzel, Pape), and Spinal Cord Injury/Disorder Service (Stika), Edward Hines, Jr., Veterans Affairs (VA) Hospital, Hines, IL; School of Education, Nevada State College, Henderson (Lindsey); Department of Psychology, Illinois Institute of Technology, Chicago (Ellison); Departments of Psychiatry and Behavioral Medicine (Herrold, Aaronson) and Physical Medicine and Rehabilitation (Pape), Feinberg School of Medicine, Northwestern University, Chicago; Speech-Language Pathology Program, College of Nursing and Health Sciences, Lewis University, Romeoville, IL (Guernon)
| | - Amy A Herrold
- Research Service (Lindsey, Ellison, Herrold, Kletzel, Guernon, Pape), Center for Innovation for Complex Chronic Healthcare (Herrold, aronson, Kletzel, Pape), and Spinal Cord Injury/Disorder Service (Stika), Edward Hines, Jr., Veterans Affairs (VA) Hospital, Hines, IL; School of Education, Nevada State College, Henderson (Lindsey); Department of Psychology, Illinois Institute of Technology, Chicago (Ellison); Departments of Psychiatry and Behavioral Medicine (Herrold, Aaronson) and Physical Medicine and Rehabilitation (Pape), Feinberg School of Medicine, Northwestern University, Chicago; Speech-Language Pathology Program, College of Nursing and Health Sciences, Lewis University, Romeoville, IL (Guernon)
| | - Alexandra L Aaronson
- Research Service (Lindsey, Ellison, Herrold, Kletzel, Guernon, Pape), Center for Innovation for Complex Chronic Healthcare (Herrold, aronson, Kletzel, Pape), and Spinal Cord Injury/Disorder Service (Stika), Edward Hines, Jr., Veterans Affairs (VA) Hospital, Hines, IL; School of Education, Nevada State College, Henderson (Lindsey); Department of Psychology, Illinois Institute of Technology, Chicago (Ellison); Departments of Psychiatry and Behavioral Medicine (Herrold, Aaronson) and Physical Medicine and Rehabilitation (Pape), Feinberg School of Medicine, Northwestern University, Chicago; Speech-Language Pathology Program, College of Nursing and Health Sciences, Lewis University, Romeoville, IL (Guernon)
| | - Sandra L Kletzel
- Research Service (Lindsey, Ellison, Herrold, Kletzel, Guernon, Pape), Center for Innovation for Complex Chronic Healthcare (Herrold, aronson, Kletzel, Pape), and Spinal Cord Injury/Disorder Service (Stika), Edward Hines, Jr., Veterans Affairs (VA) Hospital, Hines, IL; School of Education, Nevada State College, Henderson (Lindsey); Department of Psychology, Illinois Institute of Technology, Chicago (Ellison); Departments of Psychiatry and Behavioral Medicine (Herrold, Aaronson) and Physical Medicine and Rehabilitation (Pape), Feinberg School of Medicine, Northwestern University, Chicago; Speech-Language Pathology Program, College of Nursing and Health Sciences, Lewis University, Romeoville, IL (Guernon)
| | - Monica M Stika
- Research Service (Lindsey, Ellison, Herrold, Kletzel, Guernon, Pape), Center for Innovation for Complex Chronic Healthcare (Herrold, aronson, Kletzel, Pape), and Spinal Cord Injury/Disorder Service (Stika), Edward Hines, Jr., Veterans Affairs (VA) Hospital, Hines, IL; School of Education, Nevada State College, Henderson (Lindsey); Department of Psychology, Illinois Institute of Technology, Chicago (Ellison); Departments of Psychiatry and Behavioral Medicine (Herrold, Aaronson) and Physical Medicine and Rehabilitation (Pape), Feinberg School of Medicine, Northwestern University, Chicago; Speech-Language Pathology Program, College of Nursing and Health Sciences, Lewis University, Romeoville, IL (Guernon)
| | - Ann Guernon
- Research Service (Lindsey, Ellison, Herrold, Kletzel, Guernon, Pape), Center for Innovation for Complex Chronic Healthcare (Herrold, aronson, Kletzel, Pape), and Spinal Cord Injury/Disorder Service (Stika), Edward Hines, Jr., Veterans Affairs (VA) Hospital, Hines, IL; School of Education, Nevada State College, Henderson (Lindsey); Department of Psychology, Illinois Institute of Technology, Chicago (Ellison); Departments of Psychiatry and Behavioral Medicine (Herrold, Aaronson) and Physical Medicine and Rehabilitation (Pape), Feinberg School of Medicine, Northwestern University, Chicago; Speech-Language Pathology Program, College of Nursing and Health Sciences, Lewis University, Romeoville, IL (Guernon)
| | - Theresa Bender Pape
- Research Service (Lindsey, Ellison, Herrold, Kletzel, Guernon, Pape), Center for Innovation for Complex Chronic Healthcare (Herrold, aronson, Kletzel, Pape), and Spinal Cord Injury/Disorder Service (Stika), Edward Hines, Jr., Veterans Affairs (VA) Hospital, Hines, IL; School of Education, Nevada State College, Henderson (Lindsey); Department of Psychology, Illinois Institute of Technology, Chicago (Ellison); Departments of Psychiatry and Behavioral Medicine (Herrold, Aaronson) and Physical Medicine and Rehabilitation (Pape), Feinberg School of Medicine, Northwestern University, Chicago; Speech-Language Pathology Program, College of Nursing and Health Sciences, Lewis University, Romeoville, IL (Guernon)
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Yu J, Cheng Q, He F, Meng F, Yu Y, Xu C, Wen X, Hong L, Gao J, Li J, Pan G, Li MD, Luo B. Altered Intestinal Microbiomes and Lipid Metabolism in Patients With Prolonged Disorders of Consciousness. Front Immunol 2022; 13:781148. [PMID: 35911767 PMCID: PMC9326017 DOI: 10.3389/fimmu.2022.781148] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2021] [Accepted: 06/06/2022] [Indexed: 11/22/2022] Open
Abstract
The intestinal microbiota regulate the brain function of the host through the production of a myriad of metabolites and are associated with various neurological diseases. Understanding the intestinal microbiome of patients with prolonged disorders of consciousness (DoC) is important for the evaluation and treatment of the disease. To investigate the differences in the intestinal microbiome and short-chain fatty acids (SCFAs) among patients in a vegetative state (VS), a minimally conscious state (MCS), and emerged from MCS (EMCS), as well as the influence of antibiotics on these patients, 16S ribosomal RNA (16S rRNA) sequencing and targeted lipidomics were performed on fecal samples from patients; in addition, analysis of the electroencephalogram (EEG) signals was performed to evaluate the brain function of these patients. The results showed that the intestinal microbiome of the three groups differed greatly, and some microbial communities showed a reduced production of SCFAs in VS patients compared to the other two groups. Moreover, reduced microbial communities and five major SCFAs, along with attenuated brain functional connectivity, were observed in MCS patients who were treated with antibiotics compared to those who did not receive antibiotic treatment, but not in the other pairwise comparisons. Finally, three genus-level microbiota—Faecailbacterium, Enterococcus, and Methanobrevibacter—were considered as potential biomarkers to distinguish MCS from VS patients, with high accuracy both in the discovery and validation cohorts. Together, our findings improved the understanding of patients with prolonged DoC from the intestinal microbiome perspective and provided a new reference for the exploration of therapeutic targets.
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Affiliation(s)
- Jie Yu
- Department of Neurology, First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Qisheng Cheng
- Department of Neurology, First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Fangping He
- Department of Neurology, First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Fanxia Meng
- Department of Neurology, First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Yamei Yu
- Department of Neurology, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Zhejiang, China
| | - Chuan Xu
- Department of Neurology, First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Xinrui Wen
- Department of Neurology, First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Lirong Hong
- Department of Rehabilitation, Hangzhou Hospital of Zhejiang Armed Police Corps, Hangzhou, China
| | - Jian Gao
- Department of Rehabilitation, Hangzhou Mingzhou Brain Rehabilitation Hospital, Hangzhou, China
| | - Jingqi Li
- Department of Rehabilitation, Hangzhou Mingzhou Brain Rehabilitation Hospital, Hangzhou, China
| | - Gang Pan
- State Key Lab of Computer Aided Design & Computer Graphics, Hangzhou, China
| | - Ming D. Li
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, Zhejiang University School of Medicine, Hangzhou, China
- *Correspondence: Benyan Luo, ; Ming D. Li,
| | - Benyan Luo
- Department of Neurology, First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
- *Correspondence: Benyan Luo, ; Ming D. Li,
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Somaa FA, de Graaf TA, Sack AT. Transcranial Magnetic Stimulation in the Treatment of Neurological Diseases. Front Neurol 2022; 13:793253. [PMID: 35669870 PMCID: PMC9163300 DOI: 10.3389/fneur.2022.793253] [Citation(s) in RCA: 37] [Impact Index Per Article: 18.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2021] [Accepted: 02/25/2022] [Indexed: 12/16/2022] Open
Abstract
Transcranial Magnetic Stimulation (TMS) has widespread use in research and clinical application. For psychiatric applications, such as depression or OCD, repetitive TMS protocols (rTMS) are an established and globally applied treatment option. While promising, rTMS is not yet as common in treating neurological diseases, except for neurorehabilitation after (motor) stroke and neuropathic pain treatment. This may soon change. New clinical studies testing the potential of rTMS in various other neurological conditions appear at a rapid pace. This can prove challenging for both practitioners and clinical researchers. Although most of these neurological applications have not yet received the same level of scientific/empirical scrutiny as motor stroke and neuropathic pain, the results are encouraging, opening new doors for TMS in neurology. We here review the latest clinical evidence for rTMS in pioneering neurological applications including movement disorders, Alzheimer's disease/mild cognitive impairment, epilepsy, multiple sclerosis, and disorders of consciousness.
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Affiliation(s)
- Fahad A. Somaa
- Department of Occupational Therapy, Faculty of Medical Rehabilitation, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Tom A. de Graaf
- Section Brain Stimulation and Cognition, Department of Cognitive Neuroscience, Faculty of Psychology and Neuroscience, Maastricht University, Maastricht, Netherlands
- Center of Integrative Neuroscience, Maastricht University, Maastricht, Netherlands
| | - Alexander T. Sack
- Section Brain Stimulation and Cognition, Department of Cognitive Neuroscience, Faculty of Psychology and Neuroscience, Maastricht University, Maastricht, Netherlands
- Center of Integrative Neuroscience, Maastricht University, Maastricht, Netherlands
- Department of Psychiatry and Neuropsychology, School for Mental Health and Neuroscience, Brain + Nerve Centre, Maastricht University Medical Centre+, Maastricht, Netherlands
- *Correspondence: Alexander T. Sack
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Fan J, Zhong Y, Wang H, Aierken N, He R. Repetitive transcranial magnetic stimulation improves consciousness in some patients with disorders of consciousness. Clin Rehabil 2022; 36:916-925. [PMID: 35322709 DOI: 10.1177/02692155221089455] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To investigate the therapeutic efficacy of repetitive transcranial magnetic stimulation (rTMS) in patients with disorders of consciousness. DESIGN AND SETTING We performed a randomized, double-blinded, sham-controlled trial. PARTICIPANTS Patients (N = 40) with disorders of consciousness. INTERVENTIONS Forty patients with disorders of consciousness (time since onset of the disorder 49.0 ± 24.6 days) were enrolled and randomized to groups receiving either active-rTMS or sham-rTMS. The active-TMS protocol had a frequency of 20 Hz, was delivered over the left dorsolateral prefrontal cortex and had a 100% rest motor threshold. The sham-rTMS protocol was the same as the active protocol without magnetic stimulation over the cortex. MAIN OUTCOME MEASURES Consciousness was evaluated by the Coma Recovery Scale-Revised (CRS-R) before and after the four-week intervention. The ratio of patients that awakened from disorders of consciousness was followed up at discharge. RESULTS Before rTMS sessions, there were no significant differences in consciousness scores between groups. Compared to sham-rTMS (6.25 ± 1.29), patients with disorders of consciousness treated by active rTMS showed strikingly improved consciousness (8.45 ± 3.55). In-depth analysis revealed that only some patients showed obvious increases in consciousness scores induced by active rTMS. Furthermore, rTMS did not significantly enhance the awakening ratio. CONCLUSIONS rTMS showed therapeutic efficacy for improving consciousness in some, but not all, patients with disorders of consciousness. It is essential to discern the potential patients whose consciousness can be improved by rTMS.
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Affiliation(s)
- Jianzhong Fan
- Department of Rehabilitation Medicine, Nanfang Hospital, 198153Southern Medical University, Guangzhou 510515, China
| | - Yuhua Zhong
- Department of Rehabilitation Medicine, Nanfang Hospital, 198153Southern Medical University, Guangzhou 510515, China
| | - Huijuan Wang
- Department of Rehabilitation Medicine, Nanfang Hospital, 198153Southern Medical University, Guangzhou 510515, China
| | - Nilubaier Aierken
- Department of Rehabilitation Medicine, Nanfang Hospital, 198153Southern Medical University, Guangzhou 510515, China
| | - Renhong He
- Department of Rehabilitation Medicine, Nanfang Hospital, 198153Southern Medical University, Guangzhou 510515, China
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O'Neal CM, Schroeder LN, Wells AA, Chen S, Stephens TM, Glenn CA, Conner AK. Patient Outcomes in Disorders of Consciousness Following Transcranial Magnetic Stimulation: A Systematic Review and Meta-Analysis of Individual Patient Data. Front Neurol 2021; 12:694970. [PMID: 34475848 PMCID: PMC8407074 DOI: 10.3389/fneur.2021.694970] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2021] [Accepted: 07/13/2021] [Indexed: 12/27/2022] Open
Abstract
Background: There are few treatments with limited efficacy for patients with disorders of consciousness (DoC), such as minimally conscious and persistent vegetative state (MCS and PVS). Objective: In this meta-analysis of individual patient data (IPD), we examine studies utilizing transcranial magnetic stimulation (TMS) as a treatment in DoC to determine patient and protocol-specific factors associated with improved outcomes. Methods: We conducted a systematic review of PubMed, Ovid Medline, and Clinicaltrials.gov through April 2020 using the following terms: “minimally conscious state,” or “persistent vegetative state,” or “unresponsive wakefulness syndrome,” or “disorders of consciousness” and “transcranial magnetic stimulation.” Studies utilizing TMS as an intervention and reporting individual pre- and post-TMS Coma Recovery Scale-Revised (CRS-R) scores and subscores were included. Studies utilizing diagnostic TMS were excluded. We performed a meta-analysis at two time points to generate a pooled estimate for absolute change in CRS-R Index, and performed a second meta-analysis to determine the treatment effect of TMS using data from sham-controlled crossover studies. A linear regression model was also created using significant predictors of absolute CRS-R index change. Results: The search yielded 118 papers, of which 10 papers with 90 patients were included. Patients demonstrated a mean pooled absolute change in CRS-R Index of 2.74 (95% CI, 0.62–4.85) after one session of TMS and 5.88 (95% CI, 3.68–8.07) at last post-TMS CRS-R assessment. The standardized mean difference between real rTMS and sham was 2.82 (95% CI, −1.50 to 7.14), favoring rTMS. The linear regression model showed that patients had significantly greater CRS-R index changes if they were in MCS, had an etiology of stroke or intracranial hemorrhage, received 10 or more sessions of TMS, or if TMS was initiated within 3 months from injury. Conclusions: TMS may improve outcomes in MCS and PVS. Further evaluation with randomized, clinical trials is necessary to determine its efficacy in this patient population.
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Affiliation(s)
- Christen M O'Neal
- Department of Neurosurgery, University of Oklahoma Health Sciences Center, Oklahoma City, OK, United States
| | - Lindsey N Schroeder
- Department of Neurosurgery, University of Oklahoma Health Sciences Center, Oklahoma City, OK, United States
| | - Allison A Wells
- Biostatistics and Epidemiology, University of Oklahoma Health Sciences Center, Oklahoma City, OK, United States
| | - Sixia Chen
- Biostatistics and Epidemiology, University of Oklahoma Health Sciences Center, Oklahoma City, OK, United States
| | - Tressie M Stephens
- Department of Neurosurgery, University of Oklahoma Health Sciences Center, Oklahoma City, OK, United States
| | - Chad A Glenn
- Department of Neurosurgery, University of Oklahoma Health Sciences Center, Oklahoma City, OK, United States
| | - Andrew K Conner
- Department of Neurosurgery, University of Oklahoma Health Sciences Center, Oklahoma City, OK, United States
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Therapies to Restore Consciousness in Patients with Severe Brain Injuries: A Gap Analysis and Future Directions. Neurocrit Care 2021; 35:68-85. [PMID: 34236624 PMCID: PMC8266715 DOI: 10.1007/s12028-021-01227-y] [Citation(s) in RCA: 53] [Impact Index Per Article: 17.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2021] [Accepted: 03/04/2021] [Indexed: 02/06/2023]
Abstract
Background/Objective For patients with disorders of consciousness (DoC) and their families, the search for new therapies has been a source of hope and frustration. Almost all clinical trials in patients with DoC have been limited by small sample sizes, lack of placebo groups, and use of heterogeneous outcome measures. As a result, few therapies have strong evidence to support their use; amantadine is the only therapy recommended by current clinical guidelines, specifically for patients with DoC caused by severe traumatic brain injury. To foster and advance development of consciousness-promoting therapies for patients with DoC, the Curing Coma Campaign convened a Coma Science Work Group to perform a gap analysis. Methods We consider five classes of therapies: (1) pharmacologic; (2) electromagnetic; (3) mechanical; (4) sensory; and (5) regenerative. For each class of therapy, we summarize the state of the science, identify gaps in knowledge, and suggest future directions for therapy development. Results Knowledge gaps in all five therapeutic classes can be attributed to the lack of: (1) a unifying conceptual framework for evaluating therapeutic mechanisms of action; (2) large-scale randomized controlled trials; and (3) pharmacodynamic biomarkers that measure subclinical therapeutic effects in early-phase trials. To address these gaps, we propose a precision medicine approach in which clinical trials selectively enroll patients based upon their physiological receptivity to targeted therapies, and therapeutic effects are measured by complementary behavioral, neuroimaging, and electrophysiologic endpoints. Conclusions This personalized approach can be realized through rigorous clinical trial design and international collaboration, both of which will be essential for advancing the development of new therapies and ultimately improving the lives of patients with DoC. Supplementary Information The online version contains supplementary material available at 10.1007/s12028-021-01227-y.
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Claassen J, Akbari Y, Alexander S, Bader MK, Bell K, Bleck TP, Boly M, Brown J, Chou SHY, Diringer MN, Edlow BL, Foreman B, Giacino JT, Gosseries O, Green T, Greer DM, Hanley DF, Hartings JA, Helbok R, Hemphill JC, Hinson HE, Hirsch K, Human T, James ML, Ko N, Kondziella D, Livesay S, Madden LK, Mainali S, Mayer SA, McCredie V, McNett MM, Meyfroidt G, Monti MM, Muehlschlegel S, Murthy S, Nyquist P, Olson DM, Provencio JJ, Rosenthal E, Sampaio Silva G, Sarasso S, Schiff ND, Sharshar T, Shutter L, Stevens RD, Vespa P, Videtta W, Wagner A, Ziai W, Whyte J, Zink E, Suarez JI. Proceedings of the First Curing Coma Campaign NIH Symposium: Challenging the Future of Research for Coma and Disorders of Consciousness. Neurocrit Care 2021; 35:4-23. [PMID: 34236619 PMCID: PMC8264966 DOI: 10.1007/s12028-021-01260-x] [Citation(s) in RCA: 40] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2021] [Accepted: 04/15/2021] [Indexed: 01/04/2023]
Abstract
Coma and disorders of consciousness (DoC) are highly prevalent and constitute a burden for patients, families, and society worldwide. As part of the Curing Coma Campaign, the Neurocritical Care Society partnered with the National Institutes of Health to organize a symposium bringing together experts from all over the world to develop research targets for DoC. The conference was structured along six domains: (1) defining endotype/phenotypes, (2) biomarkers, (3) proof-of-concept clinical trials, (4) neuroprognostication, (5) long-term recovery, and (6) large datasets. This proceedings paper presents actionable research targets based on the presentations and discussions that occurred at the conference. We summarize the background, main research gaps, overall goals, the panel discussion of the approach, limitations and challenges, and deliverables that were identified.
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Affiliation(s)
- Jan Claassen
- Department of Neurology, Columbia University and New York-Presbyterian Hospital, 177 Fort Washington Avenue, MHB 8 Center, Room 300, New York City, NY, 10032, USA.
| | - Yama Akbari
- Departments of Neurology, Neurological Surgery, and Anatomy & Neurobiology and Beckman Laser Institute and Medical Clinic, University of California, Irvine, Irvine, CA, USA
| | - Sheila Alexander
- Acute and Tertiary Care, School of Nursing and Critical Care Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | | | - Kathleen Bell
- Department of Physical Medicine and Rehabilitation, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Thomas P Bleck
- Davee Department of Neurology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Melanie Boly
- Department of Neurology, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, WI, USA
| | - Jeremy Brown
- Office of Emergency Care Research, Division of Clinical Research, National Institute of Neurological Disorders and Stroke, Bethesda, MD, USA
| | - Sherry H-Y Chou
- Departments of Critical Care Medicine, Neurology, and Neurosurgery, School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Michael N Diringer
- Department of Neurology, Washington University in St. Louis, St. Louis, MO, USA
| | - Brian L Edlow
- Department of Neurology, Center for Neurotechnology and Neurorecovery, Massachusetts General Hospital and Harvard Medical School, Harvard University, Boston, MA, USA
| | - Brandon Foreman
- Departments of Neurology and Rehabilitation Medicine, College of Medicine, University of Cincinnati, Cincinnati, OH, USA
| | - Joseph T Giacino
- Department of Physical Medicine and Rehabilitation, Harvard Medical School, Harvard University, Boston, MA, USA
| | - Olivia Gosseries
- GIGA Consciousness After Coma Science Group, University of Liege, Liege, Belgium
| | - Theresa Green
- School of Nursing, Queensland University of Technology, Kelvin Grove, QLD, Australia
| | - David M Greer
- Department of Neurology, School of Medicine, Boston University, Boston, MA, USA
| | - Daniel F Hanley
- Division of Brain Injury Outcomes, Department of Neurology, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Jed A Hartings
- Department of Neurosurgery, College of Medicine, University of Cincinnati, Cincinnati, OH, USA
| | - Raimund Helbok
- Neurocritical Care Unit, Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - J Claude Hemphill
- Department of Neurology, Weill Institute for Neurosciences, School of Medicine, University of California, San Francisco, San Francisco, CA, USA
| | - H E Hinson
- Department of Neurology, School of Medicine, Oregon Health & Science University, Portland, OR, USA
| | - Karen Hirsch
- Department of Neurology, Stanford University, Palo Alto, CA, USA
| | - Theresa Human
- Department of Pharmacy, Barnes Jewish Hospital, St. Louis, MO, USA
| | - Michael L James
- Departments of Anesthesiology and Neurology, Duke University, Durham, NC, USA
| | - Nerissa Ko
- Department of Neurology, Weill Institute for Neurosciences, School of Medicine, University of California, San Francisco, San Francisco, CA, USA
| | - Daniel Kondziella
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
- Department of Neurology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Sarah Livesay
- College of Nursing, Rush University, Chicago, IL, USA
| | - Lori K Madden
- Center for Nursing Science, University of California, Davis, Sacramento, CA, USA
| | - Shraddha Mainali
- Department of Neurology, The Ohio State University, Columbus, OH, USA
| | - Stephan A Mayer
- Department of Neurology, New York Medical College, Valhalla, NY, USA
| | - Victoria McCredie
- Interdepartmental Division of Critical Care, Department of Respirology, University of Toronto, Toronto, ON, Canada
| | - Molly M McNett
- College of Nursing, The Ohio State University, Columbus, OH, USA
| | - Geert Meyfroidt
- Department of Intensive Care Medicine, University Hospitals Leuven and University of Leuven, Leuven, Belgium
| | - Martin M Monti
- Departments of Neurosurgery and Psychology, Brain Injury Research Center, University of California, Los Angeles, Los Angeles, CA, USA
| | - Susanne Muehlschlegel
- Departments of Neurology, Anesthesiology/Critical Care, and Surgery, Medical School, University of Massachusetts, Worcester, MA, USA
| | - Santosh Murthy
- Department of Neurology, Weill Cornell Medical College, New York City, NY, USA
| | - Paul Nyquist
- Division of Neurosciences Critical Care, Departments of Anesthesiology and Critical Care Medicine, Neurology, and Neurosurgery, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - DaiWai M Olson
- Departments of Neurology and Neurosurgery, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - J Javier Provencio
- Departments of Neurology and Neuroscience, School of Medicine, University of Virginia, Charlottesville, VA, USA
| | - Eric Rosenthal
- Department of Neurology, Harvard Medical School, Harvard University, Boston, MA, USA
| | - Gisele Sampaio Silva
- Department of Neurology, Albert Einstein Israelite Hospital and Universidade Federal de São Paulo, São Paulo, Brazil
| | - Simone Sarasso
- Department of Biomedical and Clinical Sciences "L. Sacco", Università degli Studi di Milano, Milan, Italy
| | - Nicholas D Schiff
- Department of Neurology and Brain Mind Research Institute, Weill Cornell Medicine, Cornell University, New York City, NY, USA
| | - Tarek Sharshar
- Department of Intensive Care, Paris Descartes University, Paris, France
| | - Lori Shutter
- Departments of Critical Care Medicine, Neurology, and Neurosurgery, School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Robert D Stevens
- Division of Neurosciences Critical Care, Departments of Anesthesiology and Critical Care Medicine, Neurology, and Neurosurgery, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Paul Vespa
- Departments of Neurosurgery and Neurology, University of California, Los Angeles, Los Angeles, CA, USA
| | - Walter Videtta
- National Hospital Alejandro Posadas, Buenos Aires, Argentina
| | - Amy Wagner
- Department of Physical Medicine and Rehabilitation, School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Wendy Ziai
- Division of Neurosciences Critical Care, Departments of Anesthesiology and Critical Care Medicine, Neurology, and Neurosurgery, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - John Whyte
- Moss Rehabilitation Research Institute, Elkins Park, PA, USA
| | - Elizabeth Zink
- Division of Neurosciences Critical Care, Department of Neurology, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Jose I Suarez
- Division of Neurosciences Critical Care, Departments of Anesthesiology and Critical Care Medicine, Neurology, and Neurosurgery, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
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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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He R, Fan J, Wang H, Zhong Y, Ma J. Differentiating Responders and Non-responders to rTMS Treatment for Disorder of Consciousness Using EEG After-Effects. Front Neurol 2020; 11:583268. [PMID: 33329325 PMCID: PMC7714935 DOI: 10.3389/fneur.2020.583268] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Accepted: 10/26/2020] [Indexed: 12/17/2022] Open
Abstract
Background: It is controversial whether repetitive transcranial magnetic stimulation (rTMS) has potential benefits in improving the awareness of patients with disorder of consciousness (DOC). We hypothesized that rTMS could improve consciousness only in DOC patients who have measurable brain responses to rTMS. Objective: In this study, we aimed to investigate the EEG after-effects induced by rTMS in DOC patients and attempted to propose a prediction algorithm to discriminate between DOC patients who would respond to rTMS treatment from those who would not. Methods: Twenty-five DOC patients were enrolled in this study. Over 4 weeks, each patient received 20 sessions of 20 Hz rTMS that was applied over the left dorsolateral prefrontal cortex (DLPFC). For each patient, resting-state EEG was recorded before and immediately after one session of rTMS to assess the neurophysiologic modification induced by rTMS. The coma recovery scale revised (CRS-R) was used to define responders with improved consciousness. Results: Of the 25 DOC patients, 10 patients regained improved consciousness and were classified as responders. The responders were characterized by more preserved alpha power and a significant reduction of delta power induced by rTMS. The analysis of receiver operating characteristic (ROC) curves showed that the algorithm calculated from the relative alpha power and the relative delta power had a high accuracy in identifying DOC patients who were responders. Conclusions: DOC patients who had more preserved alpha power and a significant reduction in the delta band that was induced by rTMS are likely to regain improved consciousness, which provides a tool to identify DOC patients who may benefit in terms of therapeutic consciousness.
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Affiliation(s)
- Renhong He
- School of Biomedical Engineering, Southern Medical University, Guangzhou, China.,Department of Rehabilitation Medicine, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Jianzhong Fan
- Department of Rehabilitation Medicine, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Huijuan Wang
- Department of Rehabilitation Medicine, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Yuhua Zhong
- Department of Rehabilitation Medicine, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Jianhua Ma
- School of Biomedical Engineering, Southern Medical University, Guangzhou, China
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29
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Sex Differences in Neuromodulation Treatment Approaches for Traumatic Brain Injury: A Scoping Review. J Head Trauma Rehabil 2020; 35:412-429. [PMID: 33165154 DOI: 10.1097/htr.0000000000000631] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Neuromodulatory brain stimulation interventions for traumatic brain injury (TBI)-related health sequelae, such as psychiatric, cognitive, and pain disorders, are on the rise. Because of disproportionate recruitment and epidemiological reporting of TBI-related research in men, there is limited understanding of TBI development, pathophysiology, and treatment intervention outcomes in women. With data suggesting sex-related variances in treatment outcomes, it is important that these gaps are addressed in emerging, neuromodulatory treatment approaches for TBI populations. METHODS Four research databases (PubMED, EMBASE, CINAHL, and PsycINFO) were electronically searched in February 2020. DESIGN This PRISMA Scoping Review (PRISMA-ScR)-guided report contextualizes the importance of reporting sex differences in TBI + neuromodulatory intervention studies and summarizes the current state of reporting sex differences when investigating 3 emerging interventions for TBI outcomes. RESULTS Fifty-four studies were identified for the final review including 12 controlled trials, 16 single or case series reports, and 26 empirical studies. Across all studies reviewed, 68% of participants were male, and only 7 studies reported sex differences as a part of their methodological approach, analysis, or discussion. CONCLUSION This review is hoped to update the TBI community on the current state of evidence in reporting sex differences across these 3 neuromodulatory treatments of post-TBI sequelae. The proposed recommendations aim to improve future research and clinical treatment of all individuals suffering from post-TBI sequelae.
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30
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Feng Y, Zhang J, Zhou Y, Bai Z, Yin Y. Noninvasive brain stimulation for patients with a disorder of consciousness: a systematic review and meta-analysis. Rev Neurosci 2020; 31:/j/revneuro.ahead-of-print/revneuro-2020-0033/revneuro-2020-0033.xml. [PMID: 32845870 DOI: 10.1515/revneuro-2020-0033] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Accepted: 06/11/2020] [Indexed: 01/08/2023]
Abstract
Noninvasive brain stimulation (NIBS) techniques have been used to facilitate the recovery from prolonged unconsciousness as a result of brain injury. The aim of this study is to systematically assess the effects of NIBS in patients with a disorder of consciousness (DOC). We searched four databases for any randomized controlled trials on the effect of NIBS in patients with a DOC, which used the JFK Coma Recovery Scale-Revised (CRS-R) as the primary outcome measure. A random-effects meta-analysis was conducted to pool effect sizes. Fourteen studies with 273 participants were included in this review, of which 12 studies with sufficient data were included in the meta-analysis. Our meta-analysis showed a significant effect on increasing CRS-R scores in favor of real stimulation as compared to sham (Hedges' g = 0.522; 95% confidence interval [CI], 0.318-0.726; P < 0.0001, I2 = 0.00%). Subgroup analysis demonstrated that only anodal transcranial direct current stimulation (tDCS) of the left dorsolateral prefrontal cortex (DLPFC) significantly enhances the CRS-R scores in patients with a DOC, as compared to sham (Hedges' g = 0.703; 95% CI, 0.419-0.986; P < 0.001), and this effect was predominant in patients in a minimally conscious state (MCS) (Hedges' g = 0.815; 95% CI, 0.429-1.200; P < 0.001). Anodal tDCS of the left DLPFC appears to be an effective approach for patients with MCS.
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Affiliation(s)
- Yali Feng
- Department of Rehabilitation Medicine, The Second Affiliated Hospital of Chongqing Medical University, Linjiang Road 74, Chongqing 400010, China
| | - Jiaqi Zhang
- Department of Rehabilitation Sciences, The Hong Kong Polytechnic University, Hong Kong SAR, China
| | - Yi Zhou
- Department of Rehabilitation Medicine, The Second Affiliated Hospital of Chongqing Medical University, Linjiang Road 74, Chongqing 400010, China
| | - Zhongfei Bai
- Department of Rehabilitation Sciences, The Hong Kong Polytechnic University, Hong Kong SAR, China
- Department of Occupational Therapy, Shanghai YangZhi Rehabilitation Hospital (Shanghai Sunshine Rehabilitation Center), Shanghai, China
| | - Ying Yin
- Department of Rehabilitation Medicine, The Second Affiliated Hospital of Chongqing Medical University, Linjiang Road 74, Chongqing 400010, China
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31
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Bikson M, Hanlon CA, Woods AJ, Gillick BT, Charvet L, Lamm C, Madeo G, Holczer A, Almeida J, Antal A, Ay MR, Baeken C, Blumberger DM, Campanella S, Camprodon JA, Christiansen L, Loo C, Crinion JT, Fitzgerald P, Gallimberti L, Ghobadi-Azbari P, Ghodratitoostani I, Grabner RH, Hartwigsen G, Hirata A, Kirton A, Knotkova H, Krupitsky E, Marangolo P, Nakamura-Palacios EM, Potok W, Praharaj SK, Ruff CC, Schlaug G, Siebner HR, Stagg CJ, Thielscher A, Wenderoth N, Yuan TF, Zhang X, Ekhtiari H. Guidelines for TMS/tES clinical services and research through the COVID-19 pandemic. Brain Stimul 2020; 13:1124-1149. [PMID: 32413554 PMCID: PMC7217075 DOI: 10.1016/j.brs.2020.05.010] [Citation(s) in RCA: 68] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2020] [Accepted: 05/10/2020] [Indexed: 01/10/2023] Open
Abstract
BACKGROUND The COVID-19 pandemic has broadly disrupted biomedical treatment and research including non-invasive brain stimulation (NIBS). Moreover, the rapid onset of societal disruption and evolving regulatory restrictions may not have allowed for systematic planning of how clinical and research work may continue throughout the pandemic or be restarted as restrictions are abated. The urgency to provide and develop NIBS as an intervention for diverse neurological and mental health indications, and as a catalyst of fundamental brain research, is not dampened by the parallel efforts to address the most life-threatening aspects of COVID-19; rather in many cases the need for NIBS is heightened including the potential to mitigate mental health consequences related to COVID-19. OBJECTIVE To facilitate the re-establishment of access to NIBS clinical services and research operations during the current COVID-19 pandemic and possible future outbreaks, we develop and discuss a framework for balancing the importance of NIBS operations with safety considerations, while addressing the needs of all stakeholders. We focus on Transcranial Magnetic Stimulation (TMS) and low intensity transcranial Electrical Stimulation (tES) - including transcranial Direct Current Stimulation (tDCS) and transcranial Alternating Current Stimulation (tACS). METHODS The present consensus paper provides guidelines and good practices for managing and reopening NIBS clinics and laboratories through the immediate and ongoing stages of COVID-19. The document reflects the analysis of experts with domain-relevant expertise spanning NIBS technology, clinical services, and basic and clinical research - with an international perspective. We outline regulatory aspects, human resources, NIBS optimization, as well as accommodations for specific demographics. RESULTS A model based on three phases (early COVID-19 impact, current practices, and future preparation) with an 11-step checklist (spanning removing or streamlining in-person protocols, incorporating telemedicine, and addressing COVID-19-associated adverse events) is proposed. Recommendations on implementing social distancing and sterilization of NIBS related equipment, specific considerations of COVID-19 positive populations including mental health comorbidities, as well as considerations regarding regulatory and human resource in the era of COVID-19 are outlined. We discuss COVID-19 considerations specifically for clinical (sub-)populations including pediatric, stroke, addiction, and the elderly. Numerous case-examples across the world are described. CONCLUSION There is an evident, and in cases urgent, need to maintain NIBS operations through the COVID-19 pandemic, including anticipating future pandemic waves and addressing effects of COVID-19 on brain and mind. The proposed robust and structured strategy aims to address the current and anticipated future challenges while maintaining scientific rigor and managing risk.
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Affiliation(s)
- Marom Bikson
- Department of Biomedical Engineering, The City College of New York of CUNY, New York, NY, USA
| | - Colleen A Hanlon
- Department of Cancer Biology, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Adam J Woods
- Center for Cognitive Aging and Memory, McKnight Brain Institute, Department of Clinical and Health Psychology, University of Florida, Gainesville, FL, USA
| | - Bernadette T Gillick
- Department of Rehabilitation Medicine, School of Medicine, University of Minnesota, MN, Minneapolis, USA
| | - Leigh Charvet
- Department of Neurology, NYU Grossman School of Medicine, New York, NY, USA
| | - Claus Lamm
- Social, Cognitive and Affective Neuroscience Unit, Department of Cognition, Emotion, and Methods in Psychology, Faculty of Psychology, University of Vienna, Vienna, Austria
| | | | - Adrienn Holczer
- Department of Neurology, Albert Szent-Györgyi Health Center, Faculty of Medicine, University of Szeged, Hungary
| | - Jorge Almeida
- Proaction Lab, Faculty of Psychology and Educational Sciences, University of Coimbra, Portugal; CINEICC, Faculty of Psychology and Educational Sciences, University of Coimbra, Portugal
| | - Andrea Antal
- Department of Clinical Neurophysiology, University Medical Center Göttingen, Göttingen, Germany; Institute of Medical Psychology, Otto-von-Guericke University Magdeburg, Magdeburg, Germany
| | - Mohammad Reza Ay
- Department of Medical Physics and Biomedical Engineering, Tehran University of Medical Sciences, Tehran, Iran
| | - Chris Baeken
- Faculty of Medicine and Health Sciences, Ghent Experimental Psychiatry (GHEP) Lab, Ghent University, Ghent, Belgium; Department of Psychiatry, University Hospital (UZBrussel), Brussels, Belgium; Department of Electrical Engineering, Eindhoven University of Technology, Eindhoven, the Netherlands
| | - Daniel M Blumberger
- Temerty Centre for Therapeutic Brain Intervention, Centre for Addiction and Mental Health, Toronto, Canada; Department of Psychiatry, Faculty of Medicine, University of Toronto, Toronto, Canada
| | - Salvatore Campanella
- Laboratoire de Psychologie Médicale et D'Addiction, ULB Neuroscience Institute (UNI), Université Libre de Bruxelles (ULB), Place Vangehuchten, B-1020, Brussels, Belgium
| | - Joan A Camprodon
- Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Lasse Christiansen
- Danish Research Centre for Magnetic Resonance (DRCMR), Centre for Functional and Diagnostic Imaging and Research, Copenhagen University Hospital Hvidovre, Hvidovre, Denmark
| | - Colleen Loo
- School of Psychiatry & Black Dog Institute, University of New South Wales, Sydney, Australia
| | - Jennifer T Crinion
- Institute of Cognitive Neuroscience, University College London, London, UK
| | - Paul Fitzgerald
- Epworth Centre for Innovation in Mental Health, Epworth HealthCare and Department of Psychiatry, Monash University, Camberwell, Victoria, Australia
| | | | - Peyman Ghobadi-Azbari
- Department of Biomedical Engineering, Shahed University, Tehran, Iran; Iranian National Center for Addiction Studies (INCAS), Tehran, Iran
| | - Iman Ghodratitoostani
- Neurocognitive Engineering Laboratory (NEL), Center for Mathematical Sciences Applied to Industry, Institute of Mathematical and Computer Sciences, University of Sao Paulo, Brazil
| | - Roland H Grabner
- Educational Neuroscience, Institute of Psychology, University of Graz, Austria
| | - Gesa Hartwigsen
- Lise Meitner Research Group Cognition and Plasticity, Max Planck Institute for Human Cognitive and Brain Sciences, Leipzig, Germany
| | - Akimasa Hirata
- Department of Electrical and Mechanical Engineering, Nagoya Institute of Technology, Nagoya, Japan
| | - Adam Kirton
- Departments of Pediatrics and Clinical Neuroscience, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Helena Knotkova
- MJHS Institute for Innovation in Palliative Care, New York, NY, USA; Department of Family and Social Medicine, Albert Einstein College of Medicine, The Bronx, NY, USA
| | - Evgeny Krupitsky
- First Pavlov State Medical University, V. M. Bekhterev National Research Medical Center for Psychiatry and Neurology, St. Petersburg, Russia
| | - Paola Marangolo
- Department of Humanities Studies, University Federico II, Naples, Italy; Aphasia Research Lab, IRCCS Santa Lucia Foundation, Rome, Italy
| | | | - Weronika Potok
- Neural Control of Movement Lab, Department of Health Science and Technology, ETH Zurich, Switzerland
| | - Samir K Praharaj
- Department of Psychiatry, Kasturba Medical College, Manipal, Manipal Academy of Higher Education, Manipal, India
| | - Christian C Ruff
- Zurich Center for Neuroeconomics (ZNE), Department of Economics, University of Zurich, Zurich, Switzerland
| | - Gottfried Schlaug
- Neuroimaging-Neuromodulation and Stroke Recovery Laboratory, Department of Neurology, Beth Israel Deaconess Medical Center and Baystate Medical Center, UMass Medical School, MA, USA
| | - Hartwig R Siebner
- Danish Research Centre for Magnetic Resonance (DRCMR), Centre for Functional and Diagnostic Imaging and Research, Copenhagen University Hospital Hvidovre, Hvidovre, Denmark; Institute of Clinical Medicine, Faculty of Health Sciences and Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Charlotte J Stagg
- Wellcome Centre for Integrative Neuroimaging and MRC Brain Network Dynamics Unit, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
| | - Axel Thielscher
- Danish Research Centre for Magnetic Resonance (DRCMR), Centre for Functional and Diagnostic Imaging and Research, Copenhagen University Hospital Hvidovre, Hvidovre, Denmark; Department of Health Technology, Technical University of Denmark, Kgs. Lyngby, Denmark
| | - Nicole Wenderoth
- Neural Control of Movement Lab, Department of Health Science and Technology, ETH Zurich, Switzerland
| | - Ti-Fei Yuan
- Shanghai Mental Health Center, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Xiaochu Zhang
- CAS Key Laboratory of Brain Function and Disease and School of Life Sciences, Division of Life Science and Medicine, University of Science & Technology of China, Hefei, China
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Nardone R, Sebastianelli L, Versace V, Brigo F, Golaszewski S, Manganotti P, Saltuari L, Trinka E. Repetitive transcranial magnetic stimulation in traumatic brain injury: Evidence from animal and human studies. Brain Res Bull 2020; 159:44-52. [PMID: 32251693 DOI: 10.1016/j.brainresbull.2020.03.016] [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: 12/26/2019] [Revised: 03/16/2020] [Accepted: 03/23/2020] [Indexed: 12/19/2022]
Abstract
We provide here the first systematic review on the studies dealing with repetitive transcranial magnetic stimulation (rTMS) for traumatic brain injury (TBI) in animals and humans. Several experimental studies in animal models have explored with promising results the use of rTMS to enhance neuroprotection and recovery after TBI. However, there are surprisingly few studies that have obtained substantial evidence regarding effects of rTMS in humans with TBI, many of them are case reports investigating the heterogeneous conditions linked to TBI. The most studies have investigated the effects of rTMS in subjects with post-traumatic depression and variable effects have been observed. rTMS has been proposed as an experimental approach for the treatment of disorders of consciousness (DOC), but in subjects with TBI therapeutic effects on DOC have also been variously documented. Beneficial effects have been reported in subjects with cognitive/emotional disturbances and auditory dysfunction (tinnitus and hallucinations), although the results are somewhat conflicting. rTMS applied over the left prefrontal cortex may relieve, at least transiently, post-traumatic headache. Isolated rTMS studies have been performed in TBI patients with motor impairment, chronic dizziness or pain. Especially whether provided in combination, rTMS and neurorehabilitation may be synergistic in the potential to translate experimental findings in the clinical practice. In order to reach definitive conclusions, well-designed randomized controlled studies with larger patient samples, improved design and optimized rTMS setup, are warranted to verify and corroborate the initial promising findings.
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Affiliation(s)
- Raffaele Nardone
- Department of Neurology, Franz Tappeiner Hospital, Merano, Italy; Department of Neurology, Christian Doppler Klinik, Paracelsus Medical University, Salzburg, Austria; Spinal Cord Injury and Tissue Regeneration Center, Salzburg, Austria; Karl Landsteiner Institut für Neurorehabilitation und Raumfahrtneurologie, Salzburg, Austria.
| | - Luca Sebastianelli
- Department of Neurorehabilitation, Hospital of Vipiteno, Vipiteno, Italy; Research Unit for Neurorehabilitation South Tyrol, Bolzano, Italy
| | - Viviana Versace
- Department of Neurorehabilitation, Hospital of Vipiteno, Vipiteno, Italy; Research Unit for Neurorehabilitation South Tyrol, Bolzano, Italy
| | - Francesco Brigo
- Department of Neurology, Franz Tappeiner Hospital, Merano, Italy; Department of Neuroscience, Biomedicine and Movement Science, University of Verona, Italy
| | - Stefan Golaszewski
- Department of Neurology, Christian Doppler Klinik, Paracelsus Medical University, Salzburg, Austria; Karl Landsteiner Institut für Neurorehabilitation und Raumfahrtneurologie, Salzburg, Austria
| | | | - Leopold Saltuari
- Department of Neurorehabilitation, Hospital of Vipiteno, Vipiteno, Italy; Research Unit for Neurorehabilitation South Tyrol, Bolzano, Italy
| | - Eugen Trinka
- Department of Neurology, Christian Doppler Klinik, Paracelsus Medical University, Salzburg, Austria; Centre for Cognitive Neurosciences Salzburg, Salzburg, Austria; University for Medical Informatics and Health Technology, UMIT, Hall in Tirol, Austria
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33
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Billeri L, Filoni S, Russo EF, Portaro S, Militi D, Calabrò RS, Naro A. Toward Improving Diagnostic Strategies in Chronic Disorders of Consciousness: An Overview on the (Re-)Emergent Role of Neurophysiology. Brain Sci 2020; 10:brainsci10010042. [PMID: 31936844 PMCID: PMC7016627 DOI: 10.3390/brainsci10010042] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2019] [Revised: 01/03/2020] [Accepted: 01/08/2020] [Indexed: 12/13/2022] Open
Abstract
The differential diagnosis of patients with Disorder of Consciousness (DoC), in particular in the chronic phase, is significantly difficult. Actually, about 40% of patients with unresponsive wakefulness syndrome (UWS) and the minimally conscious state (MCS) are misdiagnosed. Indeed, only advanced paraclinical approaches, including advanced EEG analyses, can allow achieving a more reliable diagnosis, that is, discovering residual traces of awareness in patients with UWS (namely, functional Locked-In Syndrome (fLIS)). These approaches aim at capturing the residual brain network models, at rest or that may be activated in response to relevant stimuli, which may be appropriate for awareness to emerge (despite their insufficiency to generate purposeful motor behaviors). For this, different brain network models have been studied in patients with DoC by using sensory stimuli (i.e., passive tasks), probing response to commands (i.e., active tasks), and during resting-state. Since it can be difficult for patients with DoC to perform even simple active tasks, this scoping review aims at summarizing the current, innovative neurophysiological examination methods in resting state/passive modality to differentiate and prognosticate patients with DoC. We conclude that the electrophysiologically-based diagnostic procedures represent an important resource for diagnosis, prognosis, and, therefore, management of patients with DoC, using advance passive and resting state paradigm analyses for the patients who lie in the “greyzones” between MCS, UWS, and fLIS.
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Affiliation(s)
- Luana Billeri
- IRCCS Centro Neurolesi Bonino Pulejo, 98124 Messina, Italy; (L.B.); (S.P.); (A.N.)
| | - Serena Filoni
- Padre Pio Foundation and Rehabilitation Centers, San Giovanni Rotondo, 71013 Foggia, Italy;
- Correspondence: (S.F.); (R.S.C.); Tel.: +39-090-6012-8166 (R.S.C.)
| | | | - Simona Portaro
- IRCCS Centro Neurolesi Bonino Pulejo, 98124 Messina, Italy; (L.B.); (S.P.); (A.N.)
| | | | - Rocco Salvatore Calabrò
- IRCCS Centro Neurolesi Bonino Pulejo, 98124 Messina, Italy; (L.B.); (S.P.); (A.N.)
- Correspondence: (S.F.); (R.S.C.); Tel.: +39-090-6012-8166 (R.S.C.)
| | - Antonino Naro
- IRCCS Centro Neurolesi Bonino Pulejo, 98124 Messina, Italy; (L.B.); (S.P.); (A.N.)
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34
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Lefaucheur JP, Aleman A, Baeken C, Benninger DH, Brunelin J, Di Lazzaro V, Filipović SR, Grefkes C, Hasan A, Hummel FC, Jääskeläinen SK, Langguth B, Leocani L, Londero A, Nardone R, Nguyen JP, Nyffeler T, Oliveira-Maia AJ, Oliviero A, Padberg F, Palm U, Paulus W, Poulet E, Quartarone A, Rachid F, Rektorová I, Rossi S, Sahlsten H, Schecklmann M, Szekely D, Ziemann U. Evidence-based guidelines on the therapeutic use of repetitive transcranial magnetic stimulation (rTMS): An update (2014-2018). Clin Neurophysiol 2020; 131:474-528. [PMID: 31901449 DOI: 10.1016/j.clinph.2019.11.002] [Citation(s) in RCA: 985] [Impact Index Per Article: 246.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2019] [Revised: 10/21/2019] [Accepted: 11/02/2019] [Indexed: 02/08/2023]
Abstract
A group of European experts reappraised the guidelines on the therapeutic efficacy of repetitive transcranial magnetic stimulation (rTMS) previously published in 2014 [Lefaucheur et al., Clin Neurophysiol 2014;125:2150-206]. These updated recommendations take into account all rTMS publications, including data prior to 2014, as well as currently reviewed literature until the end of 2018. Level A evidence (definite efficacy) was reached for: high-frequency (HF) rTMS of the primary motor cortex (M1) contralateral to the painful side for neuropathic pain; HF-rTMS of the left dorsolateral prefrontal cortex (DLPFC) using a figure-of-8 or a H1-coil for depression; low-frequency (LF) rTMS of contralesional M1 for hand motor recovery in the post-acute stage of stroke. Level B evidence (probable efficacy) was reached for: HF-rTMS of the left M1 or DLPFC for improving quality of life or pain, respectively, in fibromyalgia; HF-rTMS of bilateral M1 regions or the left DLPFC for improving motor impairment or depression, respectively, in Parkinson's disease; HF-rTMS of ipsilesional M1 for promoting motor recovery at the post-acute stage of stroke; intermittent theta burst stimulation targeted to the leg motor cortex for lower limb spasticity in multiple sclerosis; HF-rTMS of the right DLPFC in posttraumatic stress disorder; LF-rTMS of the right inferior frontal gyrus in chronic post-stroke non-fluent aphasia; LF-rTMS of the right DLPFC in depression; and bihemispheric stimulation of the DLPFC combining right-sided LF-rTMS (or continuous theta burst stimulation) and left-sided HF-rTMS (or intermittent theta burst stimulation) in depression. Level A/B evidence is not reached concerning efficacy of rTMS in any other condition. The current recommendations are based on the differences reached in therapeutic efficacy of real vs. sham rTMS protocols, replicated in a sufficient number of independent studies. This does not mean that the benefit produced by rTMS inevitably reaches a level of clinical relevance.
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Affiliation(s)
- Jean-Pascal Lefaucheur
- ENT Team, EA4391, Faculty of Medicine, Paris Est Créteil University, Créteil, France; Clinical Neurophysiology Unit, Department of Physiology, Henri Mondor Hospital, Assistance Publique - Hôpitaux de Paris, Créteil, France.
| | - André Aleman
- Department of Biomedical Sciences of Cells and Systems, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Chris Baeken
- Department of Psychiatry and Medical Psychology, Ghent Experimental Psychiatry (GHEP) Lab, Ghent University, Ghent, Belgium; Department of Psychiatry, University Hospital (UZBrussel), Brussels, Belgium; Department of Electrical Engineering, Eindhoven University of Technology, Eindhoven, the Netherlands
| | - David H Benninger
- Neurology Service, Department of Clinical Neurosciences, Centre Hospitalier Universitaire Vaudois (CHUV), Lausanne, Switzerland
| | - Jérôme Brunelin
- PsyR2 Team, U1028, INSERM and UMR5292, CNRS, Center for Neuroscience Research of Lyon (CRNL), Centre Hospitalier Le Vinatier, Lyon-1 University, Bron, France
| | - Vincenzo Di Lazzaro
- Unit of Neurology, Neurophysiology, Neurobiology, Department of Medicine, Università Campus Bio-Medico di Roma, Rome, Italy
| | - Saša R Filipović
- Department of Human Neuroscience, Institute for Medical Research, University of Belgrade, Belgrade, Serbia
| | - Christian Grefkes
- Department of Neurology, Cologne University Hospital, Cologne, Germany; Institute of Neurosciences and Medicine (INM3), Jülich Research Centre, Jülich, Germany
| | - Alkomiet Hasan
- Department of Psychiatry and Psychotherapy, University Hospital, LMU Munich, Munich, Germany
| | - Friedhelm C Hummel
- Defitech Chair in Clinical Neuroengineering, Center for Neuroprosthetics (CNP) and Brain Mind Institute (BMI), Swiss Federal Institute of Technology (EPFL), Geneva, Switzerland; Defitech Chair in Clinical Neuroengineering, Swiss Federal Institute of Technology (EPFL) Valais and Clinique Romande de Réadaptation, Sion, Switzerland; Clinical Neuroscience, University of Geneva Medical School, Geneva, Switzerland
| | - Satu K Jääskeläinen
- Department of Clinical Neurophysiology, Turku University Hospital and University of Turku, Turku, Finland
| | - Berthold Langguth
- Department of Psychiatry and Psychotherapy, University of Regensburg, Regensburg, Germany
| | - Letizia Leocani
- Department of Neurorehabilitation and Experimental Neurophysiology Unit, Institute of Experimental Neurology (INSPE), IRCCS San Raffaele, University Vita-Salute San Raffaele, Milan, Italy
| | - Alain Londero
- Department of Otorhinolaryngology - Head and Neck Surgery, Université Paris Descartes Sorbonne Paris Cité, Hôpital Européen Georges Pompidou, Paris, France
| | - Raffaele Nardone
- Department of Neurology, Franz Tappeiner Hospital, Merano, Italy; Department of Neurology, Christian Doppler Medical Center, Paracelsus Medical University, Salzburg, Austria; Karl Landsteiner Institut für Neurorehabilitation und Raumfahrtneurologie, Salzburg, Austria
| | - Jean-Paul Nguyen
- Multidisciplinary Pain Center, Clinique Bretéché, ELSAN, Nantes, France; Multidisciplinary Pain, Palliative and Supportive Care Center, UIC22-CAT2-EA3826, University Hospital, CHU Nord-Laënnec, Nantes, France
| | - Thomas Nyffeler
- Gerontechnology and Rehabilitation Group, ARTORG Center for Biomedical Engineering Research, University of Bern, Bern, Switzerland; Perception and Eye Movement Laboratory, Department of Neurology, University of Bern, Bern, Switzerland; Neurocenter, Luzerner Kantonsspital, Lucerne, Switzerland
| | - Albino J Oliveira-Maia
- Champalimaud Research & Clinical Centre, Champalimaud Centre for the Unknown, Lisbon, Portugal; Department of Psychiatry and Mental Health, Centro Hospitalar de Lisboa Ocidental, Lisbon, Portugal; NOVA Medical School
- Faculdade de Ciências Médicas, Universidade Nova de Lisboa, Lisbon, Portugal
| | - Antonio Oliviero
- FENNSI Group, Hospital Nacional de Parapléjicos, SESCAM, Toledo, Spain
| | - Frank Padberg
- Department of Psychiatry and Psychotherapy, University Hospital, LMU Munich, Munich, Germany
| | - Ulrich Palm
- Department of Psychiatry and Psychotherapy, University Hospital, LMU Munich, Munich, Germany; Medical Park Chiemseeblick, Bernau, Germany
| | - Walter Paulus
- Department of Clinical Neurophysiology, University Medical Center Göttingen, Göttingen, Germany
| | - Emmanuel Poulet
- PsyR2 Team, U1028, INSERM and UMR5292, CNRS, Center for Neuroscience Research of Lyon (CRNL), Centre Hospitalier Le Vinatier, Lyon-1 University, Bron, France; Department of Emergency Psychiatry, Edouard Herriot Hospital, Groupement Hospitalier Centre, Hospices Civils de Lyon, Lyon, France
| | - Angelo Quartarone
- Department of Biomedical, Dental Sciences and Morphological and Functional Images, University of Messina, Messina, Italy
| | | | - Irena Rektorová
- Applied Neuroscience Research Group, Central European Institute of Technology, CEITEC MU, Masaryk University, Brno, Czech Republic; First Department of Neurology, St. Anne's University Hospital and Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Simone Rossi
- Department of Medicine, Surgery and Neuroscience, Si-BIN Lab Human Physiology Section, Neurology and Clinical Neurophysiology Unit, University of Siena, Siena, Italy
| | - Hanna Sahlsten
- ENT Clinic, Mehiläinen and University of Turku, Turku, Finland
| | - Martin Schecklmann
- Department of Psychiatry and Psychotherapy, University of Regensburg, Regensburg, Germany
| | - David Szekely
- Department of Psychiatry, Princess Grace Hospital, Monaco
| | - Ulf Ziemann
- Department of Neurology and Stroke, and Hertie Institute for Clinical Brain Research, Eberhard Karls University, Tübingen, Germany
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Pink AE, Williams C, Alderman N, Stoffels M. The use of repetitive transcranial magnetic stimulation (rTMS) following traumatic brain injury (TBI): A scoping review. Neuropsychol Rehabil 2019; 31:479-505. [PMID: 31880207 DOI: 10.1080/09602011.2019.1706585] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
There is continued interest in developing effective and innovative treatment approaches to manage and improve outcomes after traumatic brain injury (TBI). Included in this, is the potential use of repetitive transcranial magnetic stimulation (rTMS), a neuromodulatory tool currently recommended by the National Institute for Health and Care Excellence as a treatment for depression. This review considers the application of rTMS after TBI, focussing on its therapeutic efficacy for a broad range of sequalae, whether an optimal and safe rTMS protocol can be determined, and recommendations for future clinical and research work. Five research databases (MEDLINE, CINAHL, PsychINFO, SCOPUS, and Web of Science) were electronically searched, identifying 30 empirical studies (single and multiple subject case reports; randomized controlled trials) for the full review. Evidence suggests that rTMS has the potential to be an efficacious therapeutic intervention for multiple symptoms after TBI, including depression, dizziness, central pain, and visual neglect. However, the picture is less encouraging for prolonged disorders of consciousness and mixed for cognitive outcomes. Overall, rTMS was well-tolerated by patients, although some incidents of side effects and seizures have been reported. Recommendations are made for more comprehensive guidelines and sufficient reporting of rTMS parameters and procedures.
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Affiliation(s)
- Aimee E Pink
- Department of Psychology, Swansea University, Swansea, UK.,Independent Neurorehabilitation Providers Alliance, Newcastle upon Tyne, UK
| | | | - Nick Alderman
- Department of Psychology, Swansea University, Swansea, UK.,Elysium Neurological Services, Elysium Healthcare, Daventry, UK
| | - Martine Stoffels
- Priory Neurobehavioural Brain Injury Services, Burton Park Brain Injury Hospital, Priory Group, Melton Mowbray, UK
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Corchs S, Chioma G, Dondi R, Gasparini F, Manzoni S, Markowska-Kacznar U, Mauri G, Zoppis I, Morreale A. Computational Methods for Resting-State EEG of Patients With Disorders of Consciousness. Front Neurosci 2019; 13:807. [PMID: 31447631 PMCID: PMC6691089 DOI: 10.3389/fnins.2019.00807] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2019] [Accepted: 07/19/2019] [Indexed: 12/16/2022] Open
Abstract
Patients who survive brain injuries may develop Disorders of Consciousness (DOC) such as Coma, Vegetative State (VS) or Minimally Conscious State (MCS). Unfortunately, the rate of misdiagnosis between VS and MCS due to clinical judgment is high. Therefore, diagnostic decision support systems aiming to correct any differentiation between VS and MCS are essential for the characterization of an adequate treatment and an effective prognosis. In recent decades, there has been a growing interest in the new EEG computational techniques. We have reviewed how resting-state EEG is computationally analyzed to support differential diagnosis between VS and MCS in view of applicability of these methods in clinical practice. The studies available so far have used different techniques and analyses; it is therefore hard to draw general conclusions. Studies using a discriminant analysis with a combination of various factors and reporting a cut-off are among the most interesting ones for a future clinical application.
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Affiliation(s)
- Silvia Corchs
- Department of Computer Science, University Milano-Bicocca, Milan, Italy
| | - Giovanni Chioma
- Behavioral Neurology, Montecatone Rehabilitation Institute, Imola, Italy
| | - Riccardo Dondi
- Department of Letter and Communication, University of Bergamo, Bergamo, Italy
| | | | - Sara Manzoni
- Department of Computer Science, University Milano-Bicocca, Milan, Italy
| | - Urszula Markowska-Kacznar
- Department of Computational Intelligence, Faculty of Computer Science and Management, Wrocław University of Science and Technology, Wroclaw, Poland
| | - Giancarlo Mauri
- Department of Computer Science, University Milano-Bicocca, Milan, Italy
| | - Italo Zoppis
- Department of Computer Science, University Milano-Bicocca, Milan, Italy
| | - Angela Morreale
- Behavioral Neurology, Montecatone Rehabilitation Institute, Imola, Italy
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Thibaut A, Schiff N, Giacino J, Laureys S, Gosseries O. Therapeutic interventions in patients with prolonged disorders of consciousness. Lancet Neurol 2019; 18:600-614. [DOI: 10.1016/s1474-4422(19)30031-6] [Citation(s) in RCA: 78] [Impact Index Per Article: 15.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2018] [Revised: 01/10/2019] [Accepted: 01/10/2019] [Indexed: 12/21/2022]
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38
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Emotional consciousness preserved in patients with disorders of consciousness? Neurol Sci 2019; 40:1409-1418. [PMID: 30941627 PMCID: PMC6579782 DOI: 10.1007/s10072-019-03848-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2019] [Accepted: 03/13/2019] [Indexed: 12/23/2022]
Abstract
Increasing evidence from studies of brain responses to subject’s own name (SON) indicates that residual consciousness is preserved in patients with disorders of consciousness (DOC) and that specific network activation might provide evidence of consciousness. However, it remains unclear whether SON is suitable for detection of emotional consciousness; moreover, the particular aspects of brain network organization that are critical for consciousness are unknown. The present study used an innovative approach to explore affective consciousness in patients with DOC during emotional stimuli. EEG data were acquired from 15 patients and 15 healthy volunteers. We analyzed brain potentials and functional network connectivity with a passive emotional paradigm based on graph theoretical methods. Larger N1 or P3a was detected in patients upon exposure to emotional sound, relative to neutral stimuli. Brain topology revealed that emotional sound evoked significantly stronger network linkages in healthy controls; additionally, it evoked several connectivity changes in patients with DOC. In conclusion, emotional consciousness might be partially preserved in patients with DOC; moreover, EEG network patterns could provide new insights into the neural activity of emotional perception in these patients.
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Bourdillon P, Hermann B, Sitt JD, Naccache L. Electromagnetic Brain Stimulation in Patients With Disorders of Consciousness. Front Neurosci 2019; 13:223. [PMID: 30936822 PMCID: PMC6432925 DOI: 10.3389/fnins.2019.00223] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2018] [Accepted: 02/26/2019] [Indexed: 12/27/2022] Open
Abstract
Severe brain injury is a common cause of coma. In some cases, despite vigilance improvement, disorders of consciousness (DoC) persist. Several states of impaired consciousness have been defined, according to whether the patient exhibits only reflexive behaviors as in the vegetative state/unresponsive wakefulness syndrome (VS/UWS) or purposeful behaviors distinct from reflexes as in the minimally conscious state (MCS). Recently, this clinical distinction has been enriched by electrophysiological and neuroimaging data resulting from a better understanding of the physiopathology of DoC. However, therapeutic options, especially pharmacological ones, remain very limited. In this context, electroceuticals, a new category of therapeutic agents which act by targeting the neural circuits with electromagnetic stimulations, started to develop in the field of DoC. We performed a systematic review of the studies evaluating therapeutics relying on the direct or indirect electro-magnetic stimulation of the brain in DoC patients. Current evidence seems to support the efficacy of deep brain stimulation (DBS) and non-invasive brain stimulation (NIBS) on consciousness in some of these patients. However, while the latter is non-invasive and well tolerated, the former is associated with potential major side effects. We propose that all chronic DoC patients should be given the possibility to benefit from NIBS, and that transcranial direct current stimulation (tDCS) should be preferred over repetitive transcranial magnetic stimulation (rTMS), based on the literature and its simple use. Surgical techniques less invasive than DBS, such as vagus nerve stimulation (VNS) might represent a good compromise between efficacy and invasiveness but still need to be further investigated.
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Affiliation(s)
- Pierre Bourdillon
- Department of Neurosurgery, Adolphe de Rothschild Foundation, Paris, France
- Sorbonne Université, Faculté de Médecine Pitié-Salpêtrière, Paris, France
- Institut du Cerveau et de la Moelle Épinière, ICM, PICNIC Lab, Paris, France
- Inserm U 1127, Paris, France
- CNRS, UMR 7225, Paris, France
| | - Bertrand Hermann
- Sorbonne Université, Faculté de Médecine Pitié-Salpêtrière, Paris, France
- Institut du Cerveau et de la Moelle Épinière, ICM, PICNIC Lab, Paris, France
- Inserm U 1127, Paris, France
- CNRS, UMR 7225, Paris, France
- Department of Neurology, Neuro ICU, Groupe Hospitalier Pitié-Salpêtrière, AP-HP, Paris, France
| | - Jacobo D. Sitt
- Institut du Cerveau et de la Moelle Épinière, ICM, PICNIC Lab, Paris, France
- Inserm U 1127, Paris, France
- CNRS, UMR 7225, Paris, France
| | - Lionel Naccache
- Sorbonne Université, Faculté de Médecine Pitié-Salpêtrière, Paris, France
- Institut du Cerveau et de la Moelle Épinière, ICM, PICNIC Lab, Paris, France
- Inserm U 1127, Paris, France
- CNRS, UMR 7225, Paris, France
- Department of Neurophysiology, Groupe Hospitalier Pitié-Salpêtrière, AP-HP, Paris, France
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