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Alkhachroum A, Fló E, Manolovitz B, Cohan H, Shammassian B, Bass D, Aklepi G, Monexe E, Ghamasaee P, Sobczak E, Samano D, Saavedra AB, Massad N, Kottapally M, Merenda A, Cordeiro JG, Jagid J, Kanner AM, Rundek T, O'Phelan K, Claassen J, Sitt JD. Resting-State EEG Signature of Early Consciousness Recovery in Comatose Patients with Traumatic Brain Injury. Neurocrit Care 2024:10.1007/s12028-024-02005-2. [PMID: 38811512 DOI: 10.1007/s12028-024-02005-2] [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: 01/24/2024] [Accepted: 04/25/2024] [Indexed: 05/31/2024]
Abstract
BACKGROUND Resting-state electroencephalography (rsEEG) is usually obtained to assess seizures in comatose patients with traumatic brain injury (TBI). We aim to investigate rsEEG measures and their prediction of early recovery of consciousness in patients with TBI. METHODS This is a retrospective study of comatose patients with TBI who were admitted to a trauma center (October 2013 to January 2022). Demographics, basic clinical data, imaging characteristics, and EEGs were collected. We calculated the following using 10-min rsEEGs: power spectral density, permutation entropy (complexity measure), weighted symbolic mutual information (wSMI, global information sharing measure), Kolmogorov complexity (Kolcom, complexity measure), and heart-evoked potentials (the averaged EEG signal relative to the corresponding QRS complex on electrocardiography). We evaluated the prediction of consciousness recovery before hospital discharge using clinical, imaging, and rsEEG data via a support vector machine. RESULTS We studied 113 of 134 (84%) patients with rsEEGs. A total of 73 (65%) patients recovered consciousness before discharge. Patients who recovered consciousness were younger (40 vs. 50 years, p = 0.01). Patients who recovered also had higher Kolcom (U = 1688, p = 0.01), increased beta power (U = 1,652 p = 0.003) with higher variability across channels (U = 1534, p = 0.034) and epochs (U = 1711, p = 0.004), lower delta power (U = 981, p = 0.04), and higher connectivity across time and channels as measured by wSMI in the theta band (U = 1636, p = 0.026; U = 1639, p = 0.024) than those who did not recover. The area under the receiver operating characteristic curve for rsEEG was higher than that for clinical data (using age, motor response, pupil reactivity) and higher than that for the Marshall computed tomography classification (0.69 vs. 0.66 vs. 0.56, respectively; p < 0.001). CONCLUSIONS We describe the rsEEG signature in recovery of consciousness prior to discharge in comatose patients with TBI. rsEEG measures performed modestly better than the clinical and imaging data in predicting recovery.
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Affiliation(s)
- Ayham Alkhachroum
- Division of Neurocritical Care, Department of Neurology, University of Miami, 1120 NW 14th Street, Suite 1353, Miami, FL, USA.
- Department of Neurology, Jackson Memorial Hospital, Miami, FL, USA.
| | - Emilia Fló
- Institut du Cerveau-Paris Brain Institute, Sorbonne Université, Paris, France
| | - Brian Manolovitz
- Division of Neurocritical Care, Department of Neurology, University of Miami, 1120 NW 14th Street, Suite 1353, Miami, FL, USA
| | - Holly Cohan
- Division of Neurocritical Care, Department of Neurology, University of Miami, 1120 NW 14th Street, Suite 1353, Miami, FL, USA
- Department of Neurology, Jackson Memorial Hospital, Miami, FL, USA
| | - Berje Shammassian
- Division of Neurocritical Care, Department of Neurology, University of Miami, 1120 NW 14th Street, Suite 1353, Miami, FL, USA
- Department of Neurology, Jackson Memorial Hospital, Miami, FL, USA
| | - Danielle Bass
- Division of Neurocritical Care, Department of Neurology, University of Miami, 1120 NW 14th Street, Suite 1353, Miami, FL, USA
- Department of Neurology, Jackson Memorial Hospital, Miami, FL, USA
| | - Gabriela Aklepi
- Division of Neurocritical Care, Department of Neurology, University of Miami, 1120 NW 14th Street, Suite 1353, Miami, FL, USA
- Department of Neurology, Jackson Memorial Hospital, Miami, FL, USA
| | - Esther Monexe
- Division of Neurocritical Care, Department of Neurology, University of Miami, 1120 NW 14th Street, Suite 1353, Miami, FL, USA
- Department of Neurology, Jackson Memorial Hospital, Miami, FL, USA
| | - Pardis Ghamasaee
- Division of Neurocritical Care, Department of Neurology, University of Miami, 1120 NW 14th Street, Suite 1353, Miami, FL, USA
- Department of Neurology, Jackson Memorial Hospital, Miami, FL, USA
| | - Evie Sobczak
- Division of Neurocritical Care, Department of Neurology, University of Miami, 1120 NW 14th Street, Suite 1353, Miami, FL, USA
- Department of Neurology, Jackson Memorial Hospital, Miami, FL, USA
| | - Daniel Samano
- Division of Neurocritical Care, Department of Neurology, University of Miami, 1120 NW 14th Street, Suite 1353, Miami, FL, USA
- Department of Neurology, Jackson Memorial Hospital, Miami, FL, USA
| | - Ana Bolaños Saavedra
- Division of Neurocritical Care, Department of Neurology, University of Miami, 1120 NW 14th Street, Suite 1353, Miami, FL, USA
- Department of Neurology, Jackson Memorial Hospital, Miami, FL, USA
| | - Nina Massad
- Division of Neurocritical Care, Department of Neurology, University of Miami, 1120 NW 14th Street, Suite 1353, Miami, FL, USA
- Department of Neurology, Jackson Memorial Hospital, Miami, FL, USA
| | - Mohan Kottapally
- Division of Neurocritical Care, Department of Neurology, University of Miami, 1120 NW 14th Street, Suite 1353, Miami, FL, USA
- Department of Neurology, Jackson Memorial Hospital, Miami, FL, USA
| | - Amedeo Merenda
- Division of Neurocritical Care, Department of Neurology, University of Miami, 1120 NW 14th Street, Suite 1353, Miami, FL, USA
- Department of Neurology, Jackson Memorial Hospital, Miami, FL, USA
| | | | - Jonathan Jagid
- Department of Neurosurgery, University of Miami, Miami, FL, USA
| | - Andres M Kanner
- Division of Neurocritical Care, Department of Neurology, University of Miami, 1120 NW 14th Street, Suite 1353, Miami, FL, USA
- Department of Neurology, Jackson Memorial Hospital, Miami, FL, USA
| | - Tatjana Rundek
- Division of Neurocritical Care, Department of Neurology, University of Miami, 1120 NW 14th Street, Suite 1353, Miami, FL, USA
- Department of Neurology, Jackson Memorial Hospital, Miami, FL, USA
| | - Kristine O'Phelan
- Division of Neurocritical Care, Department of Neurology, University of Miami, 1120 NW 14th Street, Suite 1353, Miami, FL, USA
- Department of Neurology, Jackson Memorial Hospital, Miami, FL, USA
| | - Jan Claassen
- Department of Neurology, Columbia University, New York, NY, USA
| | - Jacobo D Sitt
- Institut du Cerveau-Paris Brain Institute, Sorbonne Université, Paris, France
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Sanders WR, Barber JK, Temkin NR, Foreman B, Giacino JT, Williamson T, Edlow BL, Manley GT, Bodien YG. Recovery Potential in Patients Who Died After Withdrawal of Life-Sustaining Treatment: A TRACK-TBI Propensity Score Analysis. J Neurotrauma 2024. [PMID: 38739032 DOI: 10.1089/neu.2024.0014] [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: 05/14/2024] Open
Abstract
Among patients with severe traumatic brain injury (TBI), there is high prognostic uncertainty but growing evidence that recovery of independence is possible. Nevertheless, families are often asked to make decisions about withdrawal of life-sustaining treatment (WLST) within days of injury. The range of potential outcomes for patients who died after WLST (WLST+) is unknown, posing a challenge for prognostic modeling and clinical counseling. We investigated the potential for survival and recovery of independence after acute TBI in patients who died after WLST. We used Transforming Research and Clinical Knowledge in TBI (TRACK-TBI) data and propensity score matching to pair participants with WLST+ to those with a similar probability of WLST (based on demographic and clinical characteristics), but for whom life-sustaining treatment was not withdrawn (WLST-). To optimize matching, we divided the WLST- cohort into tiers (Tier 1 = 0-11%, Tier 2 = 11-27%, Tier 3 = 27-70% WLST propensity). We estimated the level of recovery that could be expected in WLST+ participants by evaluating 3-, 6-, and 12-month Glasgow Outcome Scale-Extended (GOSE) and Disability Rating Scale outcomes in matched WLST- participants. Of 90 WLST+ participants (80% male, mean [standard deviation; SD] age = 59.2 [17.9] years, median [IQR] days to WLST = 5.4 [2.2, 11.7]), 80 could be matched to WLST- participants. Of 56 WLST- participants who were followed at 6 months, 31 (55%) died. Among survivors in the overall sample and survivors in Tiers 1 and 2, more than 30% recovered at least partial independence (GOSE ≥4). In Tier 3, recovery to GOSE ≥4 occurred at 12 months, but not 6 months, post-injury. These results suggest a substantial proportion of patients with TBI and WLST may have survived and achieved at least partial independence. However, death or severe disability is a common outcome when the probability of WLST is high. While further validation is needed, our findings support a more cautious clinical approach to WLST and more complete reporting on WLST in TBI studies.
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Affiliation(s)
- William R Sanders
- Center for Neurotechnology and Neurorecovery, Department of Neurology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
- Geisel School of Medicine, Dartmouth College, Hanover, New Hampshire, USA
| | - Jason K Barber
- Department of Neurological Surgery, University of Washington, Seattle, Washington, USA
| | - Nancy R Temkin
- Department of Neurological Surgery, University of Washington, Seattle, Washington, USA
- Department of Biostatistics, University of Washington, Seattle, Washington, USA
| | - Brandon Foreman
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati, Cincinnati, Ohio, USA
| | - Joseph T Giacino
- Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Charlestown, Massachusetts, USA
- Department of Physical Medicine and Rehabilitation, Harvard Medical School, Boston, Massachusetts, USA
| | - Theresa Williamson
- Department of Neurosurgery, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Brian L Edlow
- Center for Neurotechnology and Neurorecovery, Department of Neurology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
- Department of Radiology, Athinoula A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital and Harvard Medical School, Charlestown, Massachusetts, USA
| | - Geoffrey T Manley
- Department of Neurological Surgery, University of California San Francisco, San Francisco, California, USA
| | - Yelena G Bodien
- Center for Neurotechnology and Neurorecovery, Department of Neurology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
- Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Charlestown, Massachusetts, USA
- Department of Physical Medicine and Rehabilitation, Harvard Medical School, Boston, Massachusetts, USA
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Alkhachroum A, Flo E, Manolovitz B, Stradecki-Cohan HM, Shammassian B, Bass D, Aklepi G, Monexe E, Ghamasaee P, Sobczak E, Samano D, Saavedra AB, Massad N, Kottapally M, Merenda A, Cordeiro JG, Jagid J, Kanner AM, Rundek T, O'Phelan K, Claassen J, Sitt J. Resting-State EEG Signature of Early Consciousness Recovery in Comatose Traumatic Brain Injury Patients. RESEARCH SQUARE 2024:rs.3.rs-3895330. [PMID: 38352430 PMCID: PMC10862951 DOI: 10.21203/rs.3.rs-3895330/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 02/23/2024]
Abstract
Background Resting-state electroencephalogram (rsEEG) is usually obtained to assess seizures in comatose patients with traumatic brain injury (TBI) patients. We aim to investigate rsEEG measures and their prediction of early recovery of consciousness in comatose TBI patients. Methods This is a retrospective study of comatose TBI patients who were admitted to a level-1 trauma center (10/2013-1/2022). Demographics, basic clinical data, imaging characteristics, and EEG data were collected. We calculated using 10-minute rsEEGs: power spectral density (PSD), permutation entropy (PE - complexity measure), weighted symbolic-mutual-information (wSMI - global information sharing measure), Kolmogorov complexity (Kolcom - complexity measure), and heart-evoked potentials (HEP - the averaged EEG signal relative to the corresponding QRS complex on electrocardiogram). We evaluated the prediction of consciousness recovery before hospital discharge using clinical, imaging, rsEEG data via Support Vector Machine with a linear kernel (SVM). Results We studied 113 (out of 134, 84%) patients with rsEEGs. A total of 73 (65%) patients recovered consciousness before discharge. Patients who recovered consciousness were younger (40 vs. 50, p .01). Patients who recovered consciousness had higher Kolcom (U = 1688, p = 0.01,), increased beta power (U = 1652 p = 0.003), with higher variability across channels ( U = 1534, p = 0.034), and epochs (U = 1711, p = 0.004), lower delta power (U = 981, p = 0.04) and showed higher connectivity across time and channels as measured by wSMI in the theta band (U = 1636, p = .026, U = 1639, p = 0.024) than those who didn't recover. The ROC-AUC improved from 0.66 (using age, motor response, pupils' reactivity, and CT Marshall classification) to 0.69 (p < 0.001) when adding rsEEG measures. Conclusion We describe the rsEEG EEG signature in recovery of consciousness prior to discharge in comatose TBI patients. Resting-state EEG measures improved prediction beyond the clinical and imaging data.
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Niemeyer MJS, Jochems D, Van Ditshuizen JC, de Kanter J, Cremers L, van Hattem M, Den Hartog D, Houwert RM, Leenen LPH, van Wessem KJP. Clinical outcomes and end-of-life treatment in 596 patients with isolated traumatic brain injury: a retrospective comparison of two Dutch level-I trauma centers. Eur J Trauma Emerg Surg 2024:10.1007/s00068-023-02407-5. [PMID: 38226991 DOI: 10.1007/s00068-023-02407-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Accepted: 11/12/2023] [Indexed: 01/17/2024]
Abstract
PURPOSE With an increasingly older population and rise in incidence of traumatic brain injury (TBI), end-of-life decisions have become frequent. This study investigated the rate of withdrawal of life sustaining treatment (WLST) and compared treatment outcomes in patients with isolated TBI in two Dutch level-I trauma centers. METHODS From 2011 to 2016, a retrospective cohort study of patients aged ≥ 18 years with isolated moderate-to-severe TBI (Abbreviated Injury Scale (AIS) head ≥ 3) was conducted at the University Medical Center Rotterdam (UMC-R) and the University Medical Center Utrecht (UMC-U). Demographics, radiologic injury characteristics, clinical outcomes, and functional outcomes at 3-6 months post-discharge were collected. RESULTS The study population included 596 patients (UMC-R: n = 326; UMC-U: n = 270). There were no statistical differences in age, gender, mechanism of injury, and radiologic parameters between both institutes. UMC-R patients had a higher AIShead (UMC-R: 5 [4-5] vs. UMC-U: 4 [4-5], p < 0.001). There was no difference in the prehospital Glasgow Coma Scale (GCS). However, UMC-R patients had lower GCSs in the Emergency Department and used more prehospital sedation. Total in-hospital mortality was 29% (n = 170), of which 71% (n = 123) occurred after WLST. Two percent (n = 10) remained in unresponsive wakefulness syndrome (UWS) state during follow-up. DISCUSSION This study demonstrated a high WLST rate among deceased patients with isolated TBI. Demographics and outcomes were similar for both centers even though AIShead was significantly higher in UMC-R patients. Possibly, prehospital sedation might have influenced AIS coding. Few patients persisted in UWS. Further research is needed on WLST patients in a broader spectrum of ethics, culture, and complex medical profiles, as it is a growing practice in modern critical care. LEVEL OF EVIDENCE Level III, retrospective cohort study.
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Affiliation(s)
- Menco J S Niemeyer
- Department of Trauma Surgery, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands.
| | - Denise Jochems
- Department of Trauma Surgery, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - Jan C Van Ditshuizen
- Trauma Research Unit, Department of Surgery, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
- Trauma Center Southwest Netherlands, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Janneke de Kanter
- Department of Radiology, UMC Division Imaging and Oncology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Lotte Cremers
- Department of Radiology, Jeroen Bosch Hospital, 's Hertogenbosch, The Netherlands
| | - Martijn van Hattem
- Department of Radiology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Dennis Den Hartog
- Trauma Research Unit, Department of Surgery, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
- Trauma Center Southwest Netherlands, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Roderick Marijn Houwert
- Department of Trauma Surgery, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - Luke P H Leenen
- Department of Trauma Surgery, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - Karlijn J P van Wessem
- Department of Trauma Surgery, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
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van Erp IA, van Essen T, Kompanje EJ, van der Jagt M, Moojen WA, Peul WC, van Dijck JT. Treatment-limiting decisions in patients with severe traumatic brain injury in the Netherlands. BRAIN & SPINE 2024; 4:102746. [PMID: 38510637 PMCID: PMC10951765 DOI: 10.1016/j.bas.2024.102746] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 08/27/2023] [Revised: 11/28/2023] [Accepted: 01/03/2024] [Indexed: 03/22/2024]
Abstract
Introduction Treatment-limiting decisions (TLDs) can be inevitable severe traumatic brain injury (s-TBI) patients, but data on their use remain scarce. Research question To investigate the prevalence, timing and considerations of TLDs in s-TBI patients. Material and methods s-TBI patients between 2008 and 2017 were analysed retrospecively. Patient data, timing, location, involvement of proxies, and reasons for TLDs were collected. Baseline characteristics and in-hospital outcomes were compared between s-TBI patients with and without TLDs. Results TLDs were reported in 117 of 270 s-TBI patients (43.3%) and 95.9% of deaths after s-TBI were preceded by a TLD. The majority of TLDs (68.4%) were categorized as withdrawal of therapy, of which withdrawal of organ-support in 64.1%. Neurosurgical intervention was withheld in 29.9%. The median time from admission to TLD was 2 days [IQR, 0-8] and 50.4% of TLDs were made within 3 days of admission. The main reason for a TLD was that the patients were perceived as unsalvageable (66.7%). Nearly all decisions were made multidisciplinary (99.1%) with proxies involvement (75.2%). The predicted mortality (CRASH-score) between patients with and without TLDs were 72.6 vs. 70.6%. The percentage of TLDs in s-TBI patients increased from 20.0% in 2008 to 42.9% in 2012 and 64.3% in 2017. Discussion and conclusion TLDs occurred in almost half of s-TBI patients and were instituted more frequently over time. Half of TLDs were made within 3 days of admission in spite of baseline prognosis between groups being similar. Future research should address whether prognostic nihilism contributes to self-fulfilling prophecies.
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Affiliation(s)
- Inge A.M. van Erp
- University Neurosurgical Center Holland, Leiden University Medical Center, Haaglanden Medical Center and HaGa Hospital, Leiden and The Hague, the Netherlands
| | - T.A. van Essen
- University Neurosurgical Center Holland, Leiden University Medical Center, Haaglanden Medical Center and HaGa Hospital, Leiden and The Hague, the Netherlands
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge and Addenbrooke's Hospital, Cambridge, United Kingdom
| | - Erwin J.O. Kompanje
- Department of Intensive Care Adults, Erasmus MC – University Medical Center, Rotterdam, the Netherlands
- Department of Ethics and Philosophy of Medicine, Erasmus MC – University Medical Center, Rotterdam, the Netherlands
| | - Mathieu van der Jagt
- Department of Intensive Care Adults, Erasmus MC – University Medical Center, Rotterdam, the Netherlands
| | - Wouter A. Moojen
- University Neurosurgical Center Holland, Leiden University Medical Center, Haaglanden Medical Center and HaGa Hospital, Leiden and The Hague, the Netherlands
| | - Wilco C. Peul
- University Neurosurgical Center Holland, Leiden University Medical Center, Haaglanden Medical Center and HaGa Hospital, Leiden and The Hague, the Netherlands
| | - Jeroen T.J.M. van Dijck
- University Neurosurgical Center Holland, Leiden University Medical Center, Haaglanden Medical Center and HaGa Hospital, Leiden and The Hague, the Netherlands
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Li B, Li WG, Guo Y, Wang Y, Xu LY, Yang Y, Xu SG, Tan ZL, Mei YR, Wang KY. Integrating fractional amplitude of low-frequency fluctuation and functional connectivity to investigate the mechanism and prognosis of severe traumatic brain injury. Front Neurol 2023; 14:1266167. [PMID: 38145123 PMCID: PMC10748505 DOI: 10.3389/fneur.2023.1266167] [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: 07/24/2023] [Accepted: 11/08/2023] [Indexed: 12/26/2023] Open
Abstract
Objective Functional magnetic resonance imaging (fMRI) has been used for evaluating residual brain function and predicting the prognosis of patients with severe traumatic brain injury (sTBI). This study aimed to integrate the fractional amplitude of low-frequency fluctuation (fALFF) and functional connectivity (FC) to investigate the mechanism and prognosis of patients with sTBI. Methods Sixty-five patients with sTBI were included and underwent fMRI scanning within 14 days after brain injury. The patient's outcome was assessed using the Glasgow Outcome Scale-Extended (GOSE) at 6 months post-injury. Of the 63 patients who met fMRI data analysis standards, the prognosis of 18 patients was good (GOSE scores ≥ 5), and the prognosis of 45 patients was poor (GOSE scores ≤ 4). First, we apply fALFF to identify residual brain functional differences in patients who present different prognoses and conjoined it in regions of interest (ROI)-based FC analysis to investigate the residual brain function of sTBI at the acute phase of sTBI. Then, the area under the curve (AUC) was used to evaluate the predictive ability of the brain regions with the difference of fALFF and FC values. Results Patients who present good outcomes at 6 months post-injury have increased fALFF values in the Brodmann area (7, 18, 31, 13, 39 40, 42, 19, 23) and decreased FC values in the Brodmann area (28, 34, 35, 36, 20, 28, 34, 35, 36, 38, 1, 2, 3, 4, 6, 13, 40, 41, 43, 44, 20, 28 35, 36, 38) at the acute phase of sTBI. The parameters of these alterations can be used for predicting the long-term outcomes of patients with sTBI, of which the fALFF increase in the temporal lobe, occipital lobe, precuneus, and middle temporal gyrus showed the highest predictive ability (AUC = 0.883). Conclusion We provide a compensatory mechanism that several regions of the brain can be spontaneously activated at the acute phase of sTBI in those who present with a good prognosis in the 6-month follow-up, that is, a destructive mode that increases its fALFF in the local regions and weakens its FC to the whole brain. These findings provide a theoretical basis for developing early intervention targets for sTBI patients.
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Affiliation(s)
- Biao Li
- Department of Emergency, The Second Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China
- Department of Emergency, Nanchang Hongdu Hospital of Traditional Chinese Medicine, Nanchang, Jiangxi, China
| | - Wu-gen Li
- Department of Imaging, The Second Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China
| | - Yao Guo
- Department of Emergency, The Second Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China
| | - Yang Wang
- Department of Neurosurgery, Shanghai Ninth People’s Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Lu-yang Xu
- Department of Emergency, The Second Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China
| | - Yuan Yang
- Department of Emergency, The Second Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China
| | - Shi-guo Xu
- Department of Imaging, The Second Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China
| | - Zi-long Tan
- Department of Neurosurgery, The Second Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China
| | - Yu-ran Mei
- Department of Neurosurgery, The Second Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China
| | - Kai-yang Wang
- Department of Emergency, The Second Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China
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Sullivan MD, Owattanapanich N, Schellenberg M, Matsushima K, Lewis MR, Lam L, Martin M, Inaba K. Examining the independent risk factors for withdrawal of life sustaining treatment in trauma patients. Injury 2023; 54:111088. [PMID: 37833232 DOI: 10.1016/j.injury.2023.111088] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2023] [Accepted: 10/02/2023] [Indexed: 10/15/2023]
Abstract
INTRODUCTION Withdrawal of life sustaining treatment (WLST) occurs when medical intervention no longer benefits a patient's acute goals for care. The incidence of WLST in the trauma patient population is not well understood. The purpose of this study was to examine the incidence and independent risk factors associated with WLST. METHODS The Trauma Quality Improvement Program (2017-2018) was utilized. Patients arrived without signs of life or without mortality or WLST data were excluded. Demographics, injury data, and outcomes were analyzed. Categorical variables are presented as number (percentage) and continuous variables as median [interquartile range]. WLST and non-WLST patients were compared. Early (<24 h) WLST patients were compared to all other WLST patients. RESULTS Of 749,754 patients, 35,464 (4.7 %) died. Of these, 19,424 (2.6 %) died after WLST, constituting 54.8 % of all deaths. Median age was 67 [50-79], 67.6 % male, 17,557 (90.4 %) blunt injuries, 11,334 (58.4 %) GCS < 9. Median ISS 26 [17-30]. Median head AIS 4 (3-5). The WLST group had a much higher incidence of elderly (60+) patients (65.1% vs 41.0 %), blunt mechanism of injury (90.4% vs 76.9 %) and hypertension (43.5% vs 26.5 %). Black patients (8.2% vs 19.5 %) and Hispanic patients (7.9% vs 12.2 %) were less likely to undergo WLST. On multivariate analysis, patients 80+ years old (OR 12.939, p < 0.001), GCS < 9 (OR 15.621, p < 0.001), and head AIS = 5, head AIS = 6 (OR 3.886, p < 0.001 and OR 5.283, p < 0.001) were independently associated with WLST. GCS < 9 (OR 4.006, p < 0.001) and penetrating injury (OR 2.825, p < 0.001) were independently associated with early WLST within 24 h. CONCLUSIONS More than half who die from trauma undergo withdrawal of life sustaining treatment. Elderly patients and those with severe TBI and low GCS scores are at high risk of experiencing withdrawal of life sustaining treatment. Further prospective evaluation is warranted.
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Affiliation(s)
- Michael D Sullivan
- Division of Trauma and Surgical Critical Care, Los Angeles General Medical Center, Keck School of Medicine of the University of Southern California, 2051 Marengo St C5L100, Los Angeles, CA, USA
| | - Natthida Owattanapanich
- Division of Trauma and Surgical Critical Care, Los Angeles General Medical Center, Keck School of Medicine of the University of Southern California, 2051 Marengo St C5L100, Los Angeles, CA, USA
| | - Morgan Schellenberg
- Division of Trauma and Surgical Critical Care, Los Angeles General Medical Center, Keck School of Medicine of the University of Southern California, 2051 Marengo St C5L100, Los Angeles, CA, USA
| | - Kazuhide Matsushima
- Division of Trauma and Surgical Critical Care, Los Angeles General Medical Center, Keck School of Medicine of the University of Southern California, 2051 Marengo St C5L100, Los Angeles, CA, USA
| | - Meghan R Lewis
- Division of Trauma and Surgical Critical Care, Los Angeles General Medical Center, Keck School of Medicine of the University of Southern California, 2051 Marengo St C5L100, Los Angeles, CA, USA
| | - Lydia Lam
- Division of Trauma and Surgical Critical Care, Los Angeles General Medical Center, Keck School of Medicine of the University of Southern California, 2051 Marengo St C5L100, Los Angeles, CA, USA
| | - Matthew Martin
- Division of Trauma and Surgical Critical Care, Los Angeles General Medical Center, Keck School of Medicine of the University of Southern California, 2051 Marengo St C5L100, Los Angeles, CA, USA
| | - Kenji Inaba
- Division of Trauma and Surgical Critical Care, Los Angeles General Medical Center, Keck School of Medicine of the University of Southern California, 2051 Marengo St C5L100, Los Angeles, CA, USA.
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Lissak IA, Edlow BL, Rosenthal E, Young MJ. Ethical Considerations in Neuroprognostication Following Acute Brain Injury. Semin Neurol 2023; 43:758-767. [PMID: 37802121 DOI: 10.1055/s-0043-1775597] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/08/2023]
Abstract
Neuroprognostication following acute brain injury (ABI) is a complex process that involves integrating vast amounts of information to predict a patient's likely trajectory of neurologic recovery. In this setting, critically evaluating salient ethical questions is imperative, and the implications often inform high-stakes conversations about the continuation, limitation, or withdrawal of life-sustaining therapy. While neuroprognostication is central to these clinical "life-or-death" decisions, the ethical underpinnings of neuroprognostication itself have been underexplored for patients with ABI. In this article, we discuss the ethical challenges of individualized neuroprognostication including parsing and communicating its inherent uncertainty to surrogate decision-makers. We also explore the population-based ethical considerations that arise in the context of heterogenous prognostication practices. Finally, we examine the emergence of artificial intelligence-aided neuroprognostication, proposing an ethical framework relevant to both modern and longstanding prognostic tools.
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Affiliation(s)
- India A Lissak
- Department of Neurology, Center for Neurotechnology and Neurorecovery, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Brian L Edlow
- Department of Neurology, Center for Neurotechnology and Neurorecovery, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
- Athinoula A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital, Charlestown, Massachusetts
| | - Eric Rosenthal
- Department of Neurology, Center for Neurotechnology and Neurorecovery, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Michael J Young
- Department of Neurology, Center for Neurotechnology and Neurorecovery, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
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Alkhachroum A, Aklepi G, Sarafraz A, Robayo LE, Manolovitz BM, Blandino CF, Arwari B, Sobczak E, Bass DH, Ghamasaee P, Samano D, Massad N, Kottapally M, Merenda A, Dib S, Jagid JR, Dietrich WD, Rundek T, O'Phelan K, Claassen J, Walker MF. Covert Tracking to Visual Stimuli in Comatose Patients With Traumatic Brain Injury. Neurology 2023; 101:489-494. [PMID: 37076304 PMCID: PMC10513885 DOI: 10.1212/wnl.0000000000207302] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Accepted: 03/02/2023] [Indexed: 04/21/2023] Open
Abstract
OBJECTIVES This study investigated video eye tracking (VET) in comatose patients with traumatic brain injury (TBI). METHODS We recruited healthy participants and unresponsive patients with TBI. We surveyed the patients' clinicians on whether the patient was tracking and performed the Coma Recovery Scale-Revised (CRS-R). We recorded eye movements in response to motion of a finger, a face, a mirror, and an optokinetic stimulus using VET glasses. Patients were classified as covert tracking (tracking on VET alone) and overt tracking (VET and clinical examination). The ability to obey commands was evaluated at 6-month follow-up. RESULTS We recruited 20 healthy participants and 10 patients with TBI. The use of VET was feasible in all participants and patients. Two patients demonstrated covert tracking (CRS-R of 6 and 8), 2 demonstrated overt tracking (CRS-R of 22 and 11), and 6 patients had no tracking (CRS-R of 8, 6, 5, 7, 6, and 7). Five of 56 (9%) tracking assessments were missed on clinical examination. All patients with tracking recovered consciousness at follow-up, whereas only 2 of 6 patients without tracking recovered at follow-up. DISCUSSION VET is a feasible method to measure covert tracking. Future studies are needed to confirm the prognostic value of covert tracking.
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Affiliation(s)
- Ayham Alkhachroum
- From the Department of Neurology (A.A., G.A., B.M.M., E.S., D.H.B., P.G., D.S., N.M., M.K., A.M., S.D., T.R., K.O.P.), University of Miami; Jackson Memorial Hospital (A.A., G.A., C.F.B., E.S., D.H.B., P.G., D.S., N.M., M.K., A.M., S.D., T.R., K.O.P.); University of Miami Center for Computational Science (A.S.); Neuroscience Graduate Program (L.E.R.), The Miami Project to Cure Paralysis (L.E.R., W.D.D.), Department of Kinesiology and Sport Sciences (B.A.), and Department of Neurosurgery (J.R.J., W.D.D.), University of Miami, FL; Department of Neurology (J.C.), Columbia University, New York, NY; and Department of Neurology (M.F.W.), Case Western Reserve University, Louis Stokes Cleveland VA Medical Center, OH.
| | - Gabriela Aklepi
- From the Department of Neurology (A.A., G.A., B.M.M., E.S., D.H.B., P.G., D.S., N.M., M.K., A.M., S.D., T.R., K.O.P.), University of Miami; Jackson Memorial Hospital (A.A., G.A., C.F.B., E.S., D.H.B., P.G., D.S., N.M., M.K., A.M., S.D., T.R., K.O.P.); University of Miami Center for Computational Science (A.S.); Neuroscience Graduate Program (L.E.R.), The Miami Project to Cure Paralysis (L.E.R., W.D.D.), Department of Kinesiology and Sport Sciences (B.A.), and Department of Neurosurgery (J.R.J., W.D.D.), University of Miami, FL; Department of Neurology (J.C.), Columbia University, New York, NY; and Department of Neurology (M.F.W.), Case Western Reserve University, Louis Stokes Cleveland VA Medical Center, OH
| | - Amin Sarafraz
- From the Department of Neurology (A.A., G.A., B.M.M., E.S., D.H.B., P.G., D.S., N.M., M.K., A.M., S.D., T.R., K.O.P.), University of Miami; Jackson Memorial Hospital (A.A., G.A., C.F.B., E.S., D.H.B., P.G., D.S., N.M., M.K., A.M., S.D., T.R., K.O.P.); University of Miami Center for Computational Science (A.S.); Neuroscience Graduate Program (L.E.R.), The Miami Project to Cure Paralysis (L.E.R., W.D.D.), Department of Kinesiology and Sport Sciences (B.A.), and Department of Neurosurgery (J.R.J., W.D.D.), University of Miami, FL; Department of Neurology (J.C.), Columbia University, New York, NY; and Department of Neurology (M.F.W.), Case Western Reserve University, Louis Stokes Cleveland VA Medical Center, OH
| | - Linda E Robayo
- From the Department of Neurology (A.A., G.A., B.M.M., E.S., D.H.B., P.G., D.S., N.M., M.K., A.M., S.D., T.R., K.O.P.), University of Miami; Jackson Memorial Hospital (A.A., G.A., C.F.B., E.S., D.H.B., P.G., D.S., N.M., M.K., A.M., S.D., T.R., K.O.P.); University of Miami Center for Computational Science (A.S.); Neuroscience Graduate Program (L.E.R.), The Miami Project to Cure Paralysis (L.E.R., W.D.D.), Department of Kinesiology and Sport Sciences (B.A.), and Department of Neurosurgery (J.R.J., W.D.D.), University of Miami, FL; Department of Neurology (J.C.), Columbia University, New York, NY; and Department of Neurology (M.F.W.), Case Western Reserve University, Louis Stokes Cleveland VA Medical Center, OH
| | - Brian M Manolovitz
- From the Department of Neurology (A.A., G.A., B.M.M., E.S., D.H.B., P.G., D.S., N.M., M.K., A.M., S.D., T.R., K.O.P.), University of Miami; Jackson Memorial Hospital (A.A., G.A., C.F.B., E.S., D.H.B., P.G., D.S., N.M., M.K., A.M., S.D., T.R., K.O.P.); University of Miami Center for Computational Science (A.S.); Neuroscience Graduate Program (L.E.R.), The Miami Project to Cure Paralysis (L.E.R., W.D.D.), Department of Kinesiology and Sport Sciences (B.A.), and Department of Neurosurgery (J.R.J., W.D.D.), University of Miami, FL; Department of Neurology (J.C.), Columbia University, New York, NY; and Department of Neurology (M.F.W.), Case Western Reserve University, Louis Stokes Cleveland VA Medical Center, OH
| | - Carlos F Blandino
- From the Department of Neurology (A.A., G.A., B.M.M., E.S., D.H.B., P.G., D.S., N.M., M.K., A.M., S.D., T.R., K.O.P.), University of Miami; Jackson Memorial Hospital (A.A., G.A., C.F.B., E.S., D.H.B., P.G., D.S., N.M., M.K., A.M., S.D., T.R., K.O.P.); University of Miami Center for Computational Science (A.S.); Neuroscience Graduate Program (L.E.R.), The Miami Project to Cure Paralysis (L.E.R., W.D.D.), Department of Kinesiology and Sport Sciences (B.A.), and Department of Neurosurgery (J.R.J., W.D.D.), University of Miami, FL; Department of Neurology (J.C.), Columbia University, New York, NY; and Department of Neurology (M.F.W.), Case Western Reserve University, Louis Stokes Cleveland VA Medical Center, OH
| | - Brian Arwari
- From the Department of Neurology (A.A., G.A., B.M.M., E.S., D.H.B., P.G., D.S., N.M., M.K., A.M., S.D., T.R., K.O.P.), University of Miami; Jackson Memorial Hospital (A.A., G.A., C.F.B., E.S., D.H.B., P.G., D.S., N.M., M.K., A.M., S.D., T.R., K.O.P.); University of Miami Center for Computational Science (A.S.); Neuroscience Graduate Program (L.E.R.), The Miami Project to Cure Paralysis (L.E.R., W.D.D.), Department of Kinesiology and Sport Sciences (B.A.), and Department of Neurosurgery (J.R.J., W.D.D.), University of Miami, FL; Department of Neurology (J.C.), Columbia University, New York, NY; and Department of Neurology (M.F.W.), Case Western Reserve University, Louis Stokes Cleveland VA Medical Center, OH
| | - Evie Sobczak
- From the Department of Neurology (A.A., G.A., B.M.M., E.S., D.H.B., P.G., D.S., N.M., M.K., A.M., S.D., T.R., K.O.P.), University of Miami; Jackson Memorial Hospital (A.A., G.A., C.F.B., E.S., D.H.B., P.G., D.S., N.M., M.K., A.M., S.D., T.R., K.O.P.); University of Miami Center for Computational Science (A.S.); Neuroscience Graduate Program (L.E.R.), The Miami Project to Cure Paralysis (L.E.R., W.D.D.), Department of Kinesiology and Sport Sciences (B.A.), and Department of Neurosurgery (J.R.J., W.D.D.), University of Miami, FL; Department of Neurology (J.C.), Columbia University, New York, NY; and Department of Neurology (M.F.W.), Case Western Reserve University, Louis Stokes Cleveland VA Medical Center, OH
| | - Danielle H Bass
- From the Department of Neurology (A.A., G.A., B.M.M., E.S., D.H.B., P.G., D.S., N.M., M.K., A.M., S.D., T.R., K.O.P.), University of Miami; Jackson Memorial Hospital (A.A., G.A., C.F.B., E.S., D.H.B., P.G., D.S., N.M., M.K., A.M., S.D., T.R., K.O.P.); University of Miami Center for Computational Science (A.S.); Neuroscience Graduate Program (L.E.R.), The Miami Project to Cure Paralysis (L.E.R., W.D.D.), Department of Kinesiology and Sport Sciences (B.A.), and Department of Neurosurgery (J.R.J., W.D.D.), University of Miami, FL; Department of Neurology (J.C.), Columbia University, New York, NY; and Department of Neurology (M.F.W.), Case Western Reserve University, Louis Stokes Cleveland VA Medical Center, OH
| | - Pardis Ghamasaee
- From the Department of Neurology (A.A., G.A., B.M.M., E.S., D.H.B., P.G., D.S., N.M., M.K., A.M., S.D., T.R., K.O.P.), University of Miami; Jackson Memorial Hospital (A.A., G.A., C.F.B., E.S., D.H.B., P.G., D.S., N.M., M.K., A.M., S.D., T.R., K.O.P.); University of Miami Center for Computational Science (A.S.); Neuroscience Graduate Program (L.E.R.), The Miami Project to Cure Paralysis (L.E.R., W.D.D.), Department of Kinesiology and Sport Sciences (B.A.), and Department of Neurosurgery (J.R.J., W.D.D.), University of Miami, FL; Department of Neurology (J.C.), Columbia University, New York, NY; and Department of Neurology (M.F.W.), Case Western Reserve University, Louis Stokes Cleveland VA Medical Center, OH
| | - Daniel Samano
- From the Department of Neurology (A.A., G.A., B.M.M., E.S., D.H.B., P.G., D.S., N.M., M.K., A.M., S.D., T.R., K.O.P.), University of Miami; Jackson Memorial Hospital (A.A., G.A., C.F.B., E.S., D.H.B., P.G., D.S., N.M., M.K., A.M., S.D., T.R., K.O.P.); University of Miami Center for Computational Science (A.S.); Neuroscience Graduate Program (L.E.R.), The Miami Project to Cure Paralysis (L.E.R., W.D.D.), Department of Kinesiology and Sport Sciences (B.A.), and Department of Neurosurgery (J.R.J., W.D.D.), University of Miami, FL; Department of Neurology (J.C.), Columbia University, New York, NY; and Department of Neurology (M.F.W.), Case Western Reserve University, Louis Stokes Cleveland VA Medical Center, OH
| | - Nina Massad
- From the Department of Neurology (A.A., G.A., B.M.M., E.S., D.H.B., P.G., D.S., N.M., M.K., A.M., S.D., T.R., K.O.P.), University of Miami; Jackson Memorial Hospital (A.A., G.A., C.F.B., E.S., D.H.B., P.G., D.S., N.M., M.K., A.M., S.D., T.R., K.O.P.); University of Miami Center for Computational Science (A.S.); Neuroscience Graduate Program (L.E.R.), The Miami Project to Cure Paralysis (L.E.R., W.D.D.), Department of Kinesiology and Sport Sciences (B.A.), and Department of Neurosurgery (J.R.J., W.D.D.), University of Miami, FL; Department of Neurology (J.C.), Columbia University, New York, NY; and Department of Neurology (M.F.W.), Case Western Reserve University, Louis Stokes Cleveland VA Medical Center, OH
| | - Mohan Kottapally
- From the Department of Neurology (A.A., G.A., B.M.M., E.S., D.H.B., P.G., D.S., N.M., M.K., A.M., S.D., T.R., K.O.P.), University of Miami; Jackson Memorial Hospital (A.A., G.A., C.F.B., E.S., D.H.B., P.G., D.S., N.M., M.K., A.M., S.D., T.R., K.O.P.); University of Miami Center for Computational Science (A.S.); Neuroscience Graduate Program (L.E.R.), The Miami Project to Cure Paralysis (L.E.R., W.D.D.), Department of Kinesiology and Sport Sciences (B.A.), and Department of Neurosurgery (J.R.J., W.D.D.), University of Miami, FL; Department of Neurology (J.C.), Columbia University, New York, NY; and Department of Neurology (M.F.W.), Case Western Reserve University, Louis Stokes Cleveland VA Medical Center, OH
| | - Amedeo Merenda
- From the Department of Neurology (A.A., G.A., B.M.M., E.S., D.H.B., P.G., D.S., N.M., M.K., A.M., S.D., T.R., K.O.P.), University of Miami; Jackson Memorial Hospital (A.A., G.A., C.F.B., E.S., D.H.B., P.G., D.S., N.M., M.K., A.M., S.D., T.R., K.O.P.); University of Miami Center for Computational Science (A.S.); Neuroscience Graduate Program (L.E.R.), The Miami Project to Cure Paralysis (L.E.R., W.D.D.), Department of Kinesiology and Sport Sciences (B.A.), and Department of Neurosurgery (J.R.J., W.D.D.), University of Miami, FL; Department of Neurology (J.C.), Columbia University, New York, NY; and Department of Neurology (M.F.W.), Case Western Reserve University, Louis Stokes Cleveland VA Medical Center, OH
| | - Salim Dib
- From the Department of Neurology (A.A., G.A., B.M.M., E.S., D.H.B., P.G., D.S., N.M., M.K., A.M., S.D., T.R., K.O.P.), University of Miami; Jackson Memorial Hospital (A.A., G.A., C.F.B., E.S., D.H.B., P.G., D.S., N.M., M.K., A.M., S.D., T.R., K.O.P.); University of Miami Center for Computational Science (A.S.); Neuroscience Graduate Program (L.E.R.), The Miami Project to Cure Paralysis (L.E.R., W.D.D.), Department of Kinesiology and Sport Sciences (B.A.), and Department of Neurosurgery (J.R.J., W.D.D.), University of Miami, FL; Department of Neurology (J.C.), Columbia University, New York, NY; and Department of Neurology (M.F.W.), Case Western Reserve University, Louis Stokes Cleveland VA Medical Center, OH
| | - Jonathan R Jagid
- From the Department of Neurology (A.A., G.A., B.M.M., E.S., D.H.B., P.G., D.S., N.M., M.K., A.M., S.D., T.R., K.O.P.), University of Miami; Jackson Memorial Hospital (A.A., G.A., C.F.B., E.S., D.H.B., P.G., D.S., N.M., M.K., A.M., S.D., T.R., K.O.P.); University of Miami Center for Computational Science (A.S.); Neuroscience Graduate Program (L.E.R.), The Miami Project to Cure Paralysis (L.E.R., W.D.D.), Department of Kinesiology and Sport Sciences (B.A.), and Department of Neurosurgery (J.R.J., W.D.D.), University of Miami, FL; Department of Neurology (J.C.), Columbia University, New York, NY; and Department of Neurology (M.F.W.), Case Western Reserve University, Louis Stokes Cleveland VA Medical Center, OH
| | - W Dalton Dietrich
- From the Department of Neurology (A.A., G.A., B.M.M., E.S., D.H.B., P.G., D.S., N.M., M.K., A.M., S.D., T.R., K.O.P.), University of Miami; Jackson Memorial Hospital (A.A., G.A., C.F.B., E.S., D.H.B., P.G., D.S., N.M., M.K., A.M., S.D., T.R., K.O.P.); University of Miami Center for Computational Science (A.S.); Neuroscience Graduate Program (L.E.R.), The Miami Project to Cure Paralysis (L.E.R., W.D.D.), Department of Kinesiology and Sport Sciences (B.A.), and Department of Neurosurgery (J.R.J., W.D.D.), University of Miami, FL; Department of Neurology (J.C.), Columbia University, New York, NY; and Department of Neurology (M.F.W.), Case Western Reserve University, Louis Stokes Cleveland VA Medical Center, OH
| | - Tatjana Rundek
- From the Department of Neurology (A.A., G.A., B.M.M., E.S., D.H.B., P.G., D.S., N.M., M.K., A.M., S.D., T.R., K.O.P.), University of Miami; Jackson Memorial Hospital (A.A., G.A., C.F.B., E.S., D.H.B., P.G., D.S., N.M., M.K., A.M., S.D., T.R., K.O.P.); University of Miami Center for Computational Science (A.S.); Neuroscience Graduate Program (L.E.R.), The Miami Project to Cure Paralysis (L.E.R., W.D.D.), Department of Kinesiology and Sport Sciences (B.A.), and Department of Neurosurgery (J.R.J., W.D.D.), University of Miami, FL; Department of Neurology (J.C.), Columbia University, New York, NY; and Department of Neurology (M.F.W.), Case Western Reserve University, Louis Stokes Cleveland VA Medical Center, OH
| | - Kristine O'Phelan
- From the Department of Neurology (A.A., G.A., B.M.M., E.S., D.H.B., P.G., D.S., N.M., M.K., A.M., S.D., T.R., K.O.P.), University of Miami; Jackson Memorial Hospital (A.A., G.A., C.F.B., E.S., D.H.B., P.G., D.S., N.M., M.K., A.M., S.D., T.R., K.O.P.); University of Miami Center for Computational Science (A.S.); Neuroscience Graduate Program (L.E.R.), The Miami Project to Cure Paralysis (L.E.R., W.D.D.), Department of Kinesiology and Sport Sciences (B.A.), and Department of Neurosurgery (J.R.J., W.D.D.), University of Miami, FL; Department of Neurology (J.C.), Columbia University, New York, NY; and Department of Neurology (M.F.W.), Case Western Reserve University, Louis Stokes Cleveland VA Medical Center, OH
| | - Jan Claassen
- From the Department of Neurology (A.A., G.A., B.M.M., E.S., D.H.B., P.G., D.S., N.M., M.K., A.M., S.D., T.R., K.O.P.), University of Miami; Jackson Memorial Hospital (A.A., G.A., C.F.B., E.S., D.H.B., P.G., D.S., N.M., M.K., A.M., S.D., T.R., K.O.P.); University of Miami Center for Computational Science (A.S.); Neuroscience Graduate Program (L.E.R.), The Miami Project to Cure Paralysis (L.E.R., W.D.D.), Department of Kinesiology and Sport Sciences (B.A.), and Department of Neurosurgery (J.R.J., W.D.D.), University of Miami, FL; Department of Neurology (J.C.), Columbia University, New York, NY; and Department of Neurology (M.F.W.), Case Western Reserve University, Louis Stokes Cleveland VA Medical Center, OH
| | - Mark F Walker
- From the Department of Neurology (A.A., G.A., B.M.M., E.S., D.H.B., P.G., D.S., N.M., M.K., A.M., S.D., T.R., K.O.P.), University of Miami; Jackson Memorial Hospital (A.A., G.A., C.F.B., E.S., D.H.B., P.G., D.S., N.M., M.K., A.M., S.D., T.R., K.O.P.); University of Miami Center for Computational Science (A.S.); Neuroscience Graduate Program (L.E.R.), The Miami Project to Cure Paralysis (L.E.R., W.D.D.), Department of Kinesiology and Sport Sciences (B.A.), and Department of Neurosurgery (J.R.J., W.D.D.), University of Miami, FL; Department of Neurology (J.C.), Columbia University, New York, NY; and Department of Neurology (M.F.W.), Case Western Reserve University, Louis Stokes Cleveland VA Medical Center, OH
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Marino MH, Koffer J, Nalla S. Update on Disorders of Consciousness. CURRENT PHYSICAL MEDICINE AND REHABILITATION REPORTS 2023. [DOI: 10.1007/s40141-023-00384-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/18/2023]
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Zheng RZ, Xu CX, Zhou LY, Feng DF. Default mode network overshadow executive control network in coma emergence and awakening prediction of patients with sTBI. Neuroimage Clin 2023; 37:103361. [PMID: 36871404 PMCID: PMC9995458 DOI: 10.1016/j.nicl.2023.103361] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2022] [Revised: 02/12/2023] [Accepted: 02/24/2023] [Indexed: 03/06/2023]
Abstract
OBJECTIVE We aimed to explore the pathogenesis of traumatic coma related to functional connectivity (FC) within the default mode network (DMN), within the executive control network (ECN) and between the DMN and ECN and to investigate its capacity for predicting awakening. METHODS We carried out resting-state functional magnetic resonance imaging (fMRI) examinations on 28 traumatic coma patients and 28 age-matched healthy controls. DMN and ECN nodes were split into regions of interest (ROIs), and node-to-node FC analysis was conducted on individual participants. To identify coma pathogenesis, we compared the pairwise FC differences between coma patients and healthy controls. Meanwhile, we divided the traumatic coma patients into different subgroups based on their clinical outcome scores at 6 months postinjury. Considering the awakening prediction, we calculated the area under the curve (AUC) to evaluate the predictive ability of changed FC pairs. RESULTS We found a massive pairwise FC alteration in the patients with traumatic coma compared to the healthy controls [45% (33/74) pairwise FC located in the DMN, 27% (20/74) pairwise FC located in the ECN, and 28% (21/74) pairwise FC located between the DMN and ECN]. Moreover, in the awake and coma groups, there were 67% (12/18) pairwise FC alterations located in the DMN and 33% (6/18) pairwise FC alterations located between the DMN and ECN. We also indicated that pairwise FC that showed a predictive value of 6-month awakening was mainly located in the DMN rather than in the ECN. Specifically, decreased FC between the right superior frontal gyrus and right parahippocampal gyrus (in the DMN) showed the highest predictive ability (AUC = 0.827). CONCLUSION In the acute phase of severe traumatic brain injury (sTBI), the DMN plays a more prominent role than the ECN and the DMN-ECN interaction in the emergence of traumatic coma and the prediction of 6-month awakening.
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Affiliation(s)
- Rui-Zhe Zheng
- Department of Neurosurgery, Southern Medical University Affiliated Fengxian Hospital, Shanghai, China; Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China
| | - Can-Xin Xu
- Department of Neurosurgery, Ruijin Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China; Department of Neurosurgery, Shanghai Ninth People's Hospital, Shanghai, China
| | - Lai-Yang Zhou
- School of Preclinical Medicine, Wannan Medical College, Wuhu, Anhui, China
| | - Dong-Fu Feng
- Department of Neurosurgery, Southern Medical University Affiliated Fengxian Hospital, Shanghai, China; Institute of Traumatic Medicine, Shanghai Jiao Tong University School of Medicine, Shanghai, China.
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Fischer D, Newcombe V, Fernandez-Espejo D, Snider SB. Applications of Advanced MRI to Disorders of Consciousness. Semin Neurol 2022; 42:325-334. [PMID: 35790201 DOI: 10.1055/a-1892-1894] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
Disorder of consciousness (DoC) after severe brain injury presents numerous challenges to clinicians, as the diagnosis, prognosis, and management are often uncertain. Magnetic resonance imaging (MRI) has long been used to evaluate brain structure in patients with DoC. More recently, advances in MRI technology have permitted more detailed investigations of the brain's structural integrity (via diffusion MRI) and function (via functional MRI). A growing literature has begun to show that these advanced forms of MRI may improve our understanding of DoC pathophysiology, facilitate the identification of patient consciousness, and improve the accuracy of clinical prognostication. Here we review the emerging evidence for the application of advanced MRI for patients with DoC.
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Affiliation(s)
- David Fischer
- Division of Neurocritical Care, Department of Neurology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Virginia Newcombe
- Division of Anaesthesia, Department of Medicine, University of Cambridge, Cambridge, United Kingdom
| | - Davinia Fernandez-Espejo
- School of Psychology and Centre for Human Brain Health, University of Birmingham, Birmingham, United Kingdom
| | - Samuel B Snider
- Division of Neurocritical Care, Department of Neurology, Brigham and Women's Hospital, Boston, Massachusetts
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Abstract
Disorders of consciousness (DOC) continue to profoundly challenge both families and medical professionals. Once a brain-injured patient has been stabilized, questions turn to the prospect of recovery. However, what “recovery” means in the context of patients with prolonged DOC is not always clear. Failure to recognize potential differences of interpretation—and the assumptions about the relationship between health and well-being that underlie these differences—can inhibit communication between surrogate decisionmakers and a patient’s clinical team, and make it difficult to establish the goals of care. The authors examine the relationship between health and well-being as it pertains to patients with prolonged DOC. They argue that changes in awareness or other function should not be equated to changes in well-being, in the absence of a clear understanding of the constituents of well-being for that particular patient. The authors further maintain that a comprehensive conception of recovery for patients with prolonged DOC should incorporate aspects of both experienced well-being and evaluative well-being.
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15
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O'Phelan KH. Not Always a Nail in the Coffin! Brainstem Lesions After Traumatic Brain Injury. Neurocrit Care 2021; 35:306-307. [PMID: 34312790 DOI: 10.1007/s12028-021-01264-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2021] [Accepted: 04/21/2021] [Indexed: 11/28/2022]
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16
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Edlow BL, Claassen J, Schiff ND, Greer DM. Recovery from disorders of consciousness: mechanisms, prognosis and emerging therapies. Nat Rev Neurol 2021; 17:135-156. [PMID: 33318675 PMCID: PMC7734616 DOI: 10.1038/s41582-020-00428-x] [Citation(s) in RCA: 238] [Impact Index Per Article: 79.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/23/2020] [Indexed: 12/16/2022]
Abstract
Substantial progress has been made over the past two decades in detecting, predicting and promoting recovery of consciousness in patients with disorders of consciousness (DoC) caused by severe brain injuries. Advanced neuroimaging and electrophysiological techniques have revealed new insights into the biological mechanisms underlying recovery of consciousness and have enabled the identification of preserved brain networks in patients who seem unresponsive, thus raising hope for more accurate diagnosis and prognosis. Emerging evidence suggests that covert consciousness, or cognitive motor dissociation (CMD), is present in up to 15-20% of patients with DoC and that detection of CMD in the intensive care unit can predict functional recovery at 1 year post injury. Although fundamental questions remain about which patients with DoC have the potential for recovery, novel pharmacological and electrophysiological therapies have shown the potential to reactivate injured neural networks and promote re-emergence of consciousness. In this Review, we focus on mechanisms of recovery from DoC in the acute and subacute-to-chronic stages, and we discuss recent progress in detecting and predicting recovery of consciousness. We also describe the developments in pharmacological and electrophysiological therapies that are creating new opportunities to improve the lives of patients with DoC.
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Affiliation(s)
- Brian L Edlow
- Center for Neurotechnology and Neurorecovery, Department of Neurology, Massachusetts General Hospital, Boston, MA, USA
- Athinoula A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital, Charlestown, MA, USA
| | - Jan Claassen
- Department of Neurology, Columbia University Medical Center, New York Presbyterian Hospital, New York, NY, USA
| | - Nicholas D Schiff
- Feil Family Brain Mind Research Institute, Weill Cornell Medical College, New York, NY, USA
| | - David M Greer
- Department of Neurology, Boston University School of Medicine, Boston, MA, USA.
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17
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Kandelman S, Allary J, Porcher R, Righy C, Valdez CF, Rasulo F, Heming N, Moneger G, Azabou E, Savary G, Annane D, Chretien F, Latronico N, Bozza FA, Rohaut B, Sharshar T. Early abolition of cough reflex predicts mortality in deeply sedated brain-injured patients. PeerJ 2020; 8:e10326. [PMID: 33304651 PMCID: PMC7700733 DOI: 10.7717/peerj.10326] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Accepted: 10/19/2020] [Indexed: 11/20/2022] Open
Abstract
Background Deep sedation may hamper the detection of neurological deterioration in brain-injured patients. Impaired brainstem reflexes within the first 24 h of deep sedation are associated with increased mortality in non-brain-injured patients. Our objective was to confirm this association in brain-injured patients. Methods This was an observational prospective multicenter cohort study involving four neuro-intensive care units. We included acute brain-injured patients requiring deep sedation, defined by a Richmond Assessment Sedation Scale (RASS) < −3. Neurological assessment was performed at day 1 and included pupillary diameter, pupillary light, corneal and cough reflexes, and grimace and motor response to noxious stimuli. Pre-sedation Glasgow Coma Scale (GCS) and Simplified Acute Physiology Score (SAPS-II) were collected, as well as the cause of death in the Intensive Care Unit (ICU). Results A total of 137 brain-injured patients were recruited, including 70 (51%) traumatic brain-injured patients, 40 (29%) vascular (subarachnoid hemorrhage or intracerebral hemorrhage). Thirty patients (22%) died in the ICU. At day 1, the corneal (OR 2.69, p = 0.034) and cough reflexes (OR 5.12, p = 0.0003) were more frequently abolished in patients that died in the ICU. In a multivariate analysis, abolished cough reflex was associated with ICU mortality after adjustment to pre-sedation GCS, SAPS-II, RASS (OR: 5.19, 95% CI [1.92–14.1], p = 0.001) or dose of sedatives (OR: 8.89, 95% CI [2.64–30.0], p = 0.0004). Conclusion Early (day 1) cough reflex abolition is an independent predictor of mortality in deeply sedated brain-injured patients. Abolished cough reflex likely reflects a brainstem dysfunction that might result from the combination of primary and secondary neuro-inflammatory cerebral insults revealed and/or worsened by sedation.
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Affiliation(s)
- Stanislas Kandelman
- Department of Anesthesiology and Intensive Care Unit, Beaujon Hospital, University Denis Diderot, Clichy, France.,Department of Anesthesia, Royal Victoria Hospital, McGill University Health Center, Montréal, QC, Canada
| | - Jérémy Allary
- Department of Anesthesiology and Intensive Care Unit, Beaujon Hospital, University Denis Diderot, Clichy, France
| | - Raphael Porcher
- Center for Clinical Epidemiology, Assistance Publique Hôpitaux de Paris, Hotel Dieu Hospital, University Paris Descartes, Paris, France
| | - Cássia Righy
- Intensive Care Unit, Instituto Estadual do Cérebro Paulo Niemeyer, Rio de Janeiro, Brazil.,Instituto Nacional de Infectologia Evandro Chagas, Fundação Oswaldo Cruz (Fiocruz), Rio de Janeiro, Brazil
| | - Clarissa Francisca Valdez
- Intensive Care Unit, Instituto Estadual do Cérebro Paulo Niemeyer, Rio de Janeiro, Brazil.,Intensive Care Unit, Hospital das Américas, Rio de Janeiro, Brazil
| | - Frank Rasulo
- Department of Anesthesia, Critical Care and Emergency, Spedali Civili University Hospital, Brescia, Italy.,Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | - Nicholas Heming
- General Intensive Care Unit, Assistance Publique Hôpitaux de Paris, Raymond-Poincaré Hospital, University of Versailles Saint-Quentin en Yvelines, Garches, France
| | - Guy Moneger
- General Intensive Care Unit, Assistance Publique Hôpitaux de Paris, Raymond-Poincaré Hospital, University of Versailles Saint-Quentin en Yvelines, Garches, France
| | - Eric Azabou
- Department of Physiology, INSERM U 1179, Assistance Publique Hôpitaux de Paris, Raymond-Poincaré Hospital, University of Versailles Saint-Quentin en Yvelines, Garches, France
| | - Guillaume Savary
- Department of Anesthesiology and Intensive Care Unit, Beaujon Hospital, University Denis Diderot, Clichy, France
| | - Djillali Annane
- General Intensive Care Unit, Assistance Publique Hôpitaux de Paris, Raymond-Poincaré Hospital, University of Versailles Saint-Quentin en Yvelines, Garches, France
| | - Fabrice Chretien
- Laboratory of Human Histopathology and Animal Models, Institut Pasteur, Paris, France
| | - Nicola Latronico
- Department of Anesthesia, Critical Care and Emergency, Spedali Civili University Hospital, Brescia, Italy.,Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | - Fernando Augusto Bozza
- Instituto Nacional de Infectologia Evandro Chagas, Fundação Oswaldo Cruz (Fiocruz), Rio de Janeiro, Brazil.,D'Or Institute for Research and Education, Rio de Janeiro, Brazil
| | - Benjamin Rohaut
- Department of Neurology, Intensive Care Unit, Groupe Hospitalier Pitié-Salpêtrière, AP-HP, Paris, Sorbonne Universités, Faculté de Médecine Pitié-Salpêtrière, Paris, France, Paris, France.,Department of Neurology, Critical Care Neurology, Columbia University, New York, NY, USA
| | - Tarek Sharshar
- Laboratory of Human Histopathology and Animal Models, Institut Pasteur, Paris, France.,D'Or Institute for Research and Education, Rio de Janeiro, Brazil.,Neuro-Anesthesiology and Intensive Care Unit, Sainte-Anne Teaching Hospital, University of Paris-Descartes, Paris, France
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18
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Estraneo A, Fiorenza S, Magliacano A, Formisano R, Mattia D, Grippo A, Romoli AM, Angelakis E, Cassol H, Thibaut A, Gosseries O, Lamberti G, Noé E, Bagnato S, Edlow BL, Chatelle C, Lejeune N, Veeramuthu V, Bartolo M, Toppi J, Zasler N, Schnakers C, Trojano L. Multicenter prospective study on predictors of short-term outcome in disorders of consciousness. Neurology 2020; 95:e1488-e1499. [PMID: 32661102 PMCID: PMC7713739 DOI: 10.1212/wnl.0000000000010254] [Citation(s) in RCA: 49] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2019] [Accepted: 03/20/2020] [Indexed: 01/13/2023] Open
Abstract
OBJECTIVE This international multicenter, prospective, observational study aimed at identifying predictors of short-term clinical outcome in patients with prolonged disorders of consciousness (DoC) due to acquired severe brain injury. METHODS Patients in vegetative state/unresponsive wakefulness syndrome (VS/UWS) or in minimally conscious state (MCS) were enrolled within 3 months from their brain injury in 12 specialized medical institutions. Demographic, anamnestic, clinical, and neurophysiologic data were collected at study entry. Patients were then followed up for assessing the primary outcome, that is, clinical diagnosis according to standardized criteria at 6 months postinjury. RESULTS We enrolled 147 patients (44 women; mean age 49.4 [95% confidence interval 46.1-52.6] years; VS/UWS 71, MCS 76; traumatic 55, vascular 56, anoxic 36; mean time postinjury 59.6 [55.4-63.6] days). The 6-month follow-up was complete for 143 patients (VS/UWS 70; MCS 73). With respect to study entry, the clinical diagnosis improved in 72 patients (VS/UWS 27; MCS 45). Younger age, shorter time postinjury, higher Coma Recovery Scale-Revised total score, and presence of EEG reactivity to eye opening at study entry predicted better outcome, whereas etiology, clinical diagnosis, Disability Rating Scale score, EEG background activity, acoustic reactivity, and P300 on event-related potentials were not associated with outcome. CONCLUSIONS Multimodal assessment could identify patients with higher likelihood of clinical improvement in order to help clinicians, families, and funding sources with various aspects of decision-making. This multicenter, international study aims to stimulate further research that drives international consensus regarding standardization of prognostic procedures for patients with DoC.
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Affiliation(s)
- Anna Estraneo
- From IRCCS Fondazione Don Carlo Gnocchi (A.E., A.G., A.M.R.), Florence; Istituti Clinici Scientifici Maugeri IRCCS (S.F.), SB S.p.A., Laboratorio di Valutazione Multimodale dei Disordini della Coscienza, Telese Terme (BN); Department of Psychology (A.M., L.T.), University of Campania L. Vanvitelli, Caserta; Fondazione Santa Lucia IRCCS (R.F., D.M.), Rome, Italy; Neurosurgery Department (E.A.), University of Athens Medical School, Greece; Coma Science Group (H.C., A.T., O.G.), GIGA Consciousness, University and University Hospital of Liège, Belgium; Neurorehabilitation and Vegetative State Unit (G.L.), E. Viglietta, Cuneo, Italy; NEURORHB-Servicio de Neurorrehabilitación de Hospitales Vithas (E.N.), Valencia, Spain; Unit of Neurophysiology and Unit for Severe Acquired Brain Injuries (S.B.), Rehabilitation Department, Giuseppe Giglio Foundation, Cefalù, Italy; Center for Neurotechnology and Neurorecovery (B.L.E., C.C.), Department of Neurology, Massachusetts General Hospital, Boston; CHN William Lennox (N.L.), Ottignies, Belgium; Department of Psychology (V.V.), University of Reading Malaysia; Neurorehabilitation Unit (M.B.), HABILITA Zingonia/Ciserano, Bergamo; Department of Computer, Control and Management Engineering (J.T.), Sapienza University of Rome, Italy; Concussion Care Centre of Virginia, Ltd. (N.Z.), Richmond; and Research Institute (C.S.), Casa Colina Hospital and Centers for Healthcare, Pomona, CA.
| | - Salvatore Fiorenza
- From IRCCS Fondazione Don Carlo Gnocchi (A.E., A.G., A.M.R.), Florence; Istituti Clinici Scientifici Maugeri IRCCS (S.F.), SB S.p.A., Laboratorio di Valutazione Multimodale dei Disordini della Coscienza, Telese Terme (BN); Department of Psychology (A.M., L.T.), University of Campania L. Vanvitelli, Caserta; Fondazione Santa Lucia IRCCS (R.F., D.M.), Rome, Italy; Neurosurgery Department (E.A.), University of Athens Medical School, Greece; Coma Science Group (H.C., A.T., O.G.), GIGA Consciousness, University and University Hospital of Liège, Belgium; Neurorehabilitation and Vegetative State Unit (G.L.), E. Viglietta, Cuneo, Italy; NEURORHB-Servicio de Neurorrehabilitación de Hospitales Vithas (E.N.), Valencia, Spain; Unit of Neurophysiology and Unit for Severe Acquired Brain Injuries (S.B.), Rehabilitation Department, Giuseppe Giglio Foundation, Cefalù, Italy; Center for Neurotechnology and Neurorecovery (B.L.E., C.C.), Department of Neurology, Massachusetts General Hospital, Boston; CHN William Lennox (N.L.), Ottignies, Belgium; Department of Psychology (V.V.), University of Reading Malaysia; Neurorehabilitation Unit (M.B.), HABILITA Zingonia/Ciserano, Bergamo; Department of Computer, Control and Management Engineering (J.T.), Sapienza University of Rome, Italy; Concussion Care Centre of Virginia, Ltd. (N.Z.), Richmond; and Research Institute (C.S.), Casa Colina Hospital and Centers for Healthcare, Pomona, CA
| | - Alfonso Magliacano
- From IRCCS Fondazione Don Carlo Gnocchi (A.E., A.G., A.M.R.), Florence; Istituti Clinici Scientifici Maugeri IRCCS (S.F.), SB S.p.A., Laboratorio di Valutazione Multimodale dei Disordini della Coscienza, Telese Terme (BN); Department of Psychology (A.M., L.T.), University of Campania L. Vanvitelli, Caserta; Fondazione Santa Lucia IRCCS (R.F., D.M.), Rome, Italy; Neurosurgery Department (E.A.), University of Athens Medical School, Greece; Coma Science Group (H.C., A.T., O.G.), GIGA Consciousness, University and University Hospital of Liège, Belgium; Neurorehabilitation and Vegetative State Unit (G.L.), E. Viglietta, Cuneo, Italy; NEURORHB-Servicio de Neurorrehabilitación de Hospitales Vithas (E.N.), Valencia, Spain; Unit of Neurophysiology and Unit for Severe Acquired Brain Injuries (S.B.), Rehabilitation Department, Giuseppe Giglio Foundation, Cefalù, Italy; Center for Neurotechnology and Neurorecovery (B.L.E., C.C.), Department of Neurology, Massachusetts General Hospital, Boston; CHN William Lennox (N.L.), Ottignies, Belgium; Department of Psychology (V.V.), University of Reading Malaysia; Neurorehabilitation Unit (M.B.), HABILITA Zingonia/Ciserano, Bergamo; Department of Computer, Control and Management Engineering (J.T.), Sapienza University of Rome, Italy; Concussion Care Centre of Virginia, Ltd. (N.Z.), Richmond; and Research Institute (C.S.), Casa Colina Hospital and Centers for Healthcare, Pomona, CA
| | - Rita Formisano
- From IRCCS Fondazione Don Carlo Gnocchi (A.E., A.G., A.M.R.), Florence; Istituti Clinici Scientifici Maugeri IRCCS (S.F.), SB S.p.A., Laboratorio di Valutazione Multimodale dei Disordini della Coscienza, Telese Terme (BN); Department of Psychology (A.M., L.T.), University of Campania L. Vanvitelli, Caserta; Fondazione Santa Lucia IRCCS (R.F., D.M.), Rome, Italy; Neurosurgery Department (E.A.), University of Athens Medical School, Greece; Coma Science Group (H.C., A.T., O.G.), GIGA Consciousness, University and University Hospital of Liège, Belgium; Neurorehabilitation and Vegetative State Unit (G.L.), E. Viglietta, Cuneo, Italy; NEURORHB-Servicio de Neurorrehabilitación de Hospitales Vithas (E.N.), Valencia, Spain; Unit of Neurophysiology and Unit for Severe Acquired Brain Injuries (S.B.), Rehabilitation Department, Giuseppe Giglio Foundation, Cefalù, Italy; Center for Neurotechnology and Neurorecovery (B.L.E., C.C.), Department of Neurology, Massachusetts General Hospital, Boston; CHN William Lennox (N.L.), Ottignies, Belgium; Department of Psychology (V.V.), University of Reading Malaysia; Neurorehabilitation Unit (M.B.), HABILITA Zingonia/Ciserano, Bergamo; Department of Computer, Control and Management Engineering (J.T.), Sapienza University of Rome, Italy; Concussion Care Centre of Virginia, Ltd. (N.Z.), Richmond; and Research Institute (C.S.), Casa Colina Hospital and Centers for Healthcare, Pomona, CA
| | - Donatella Mattia
- From IRCCS Fondazione Don Carlo Gnocchi (A.E., A.G., A.M.R.), Florence; Istituti Clinici Scientifici Maugeri IRCCS (S.F.), SB S.p.A., Laboratorio di Valutazione Multimodale dei Disordini della Coscienza, Telese Terme (BN); Department of Psychology (A.M., L.T.), University of Campania L. Vanvitelli, Caserta; Fondazione Santa Lucia IRCCS (R.F., D.M.), Rome, Italy; Neurosurgery Department (E.A.), University of Athens Medical School, Greece; Coma Science Group (H.C., A.T., O.G.), GIGA Consciousness, University and University Hospital of Liège, Belgium; Neurorehabilitation and Vegetative State Unit (G.L.), E. Viglietta, Cuneo, Italy; NEURORHB-Servicio de Neurorrehabilitación de Hospitales Vithas (E.N.), Valencia, Spain; Unit of Neurophysiology and Unit for Severe Acquired Brain Injuries (S.B.), Rehabilitation Department, Giuseppe Giglio Foundation, Cefalù, Italy; Center for Neurotechnology and Neurorecovery (B.L.E., C.C.), Department of Neurology, Massachusetts General Hospital, Boston; CHN William Lennox (N.L.), Ottignies, Belgium; Department of Psychology (V.V.), University of Reading Malaysia; Neurorehabilitation Unit (M.B.), HABILITA Zingonia/Ciserano, Bergamo; Department of Computer, Control and Management Engineering (J.T.), Sapienza University of Rome, Italy; Concussion Care Centre of Virginia, Ltd. (N.Z.), Richmond; and Research Institute (C.S.), Casa Colina Hospital and Centers for Healthcare, Pomona, CA
| | - Antonello Grippo
- From IRCCS Fondazione Don Carlo Gnocchi (A.E., A.G., A.M.R.), Florence; Istituti Clinici Scientifici Maugeri IRCCS (S.F.), SB S.p.A., Laboratorio di Valutazione Multimodale dei Disordini della Coscienza, Telese Terme (BN); Department of Psychology (A.M., L.T.), University of Campania L. Vanvitelli, Caserta; Fondazione Santa Lucia IRCCS (R.F., D.M.), Rome, Italy; Neurosurgery Department (E.A.), University of Athens Medical School, Greece; Coma Science Group (H.C., A.T., O.G.), GIGA Consciousness, University and University Hospital of Liège, Belgium; Neurorehabilitation and Vegetative State Unit (G.L.), E. Viglietta, Cuneo, Italy; NEURORHB-Servicio de Neurorrehabilitación de Hospitales Vithas (E.N.), Valencia, Spain; Unit of Neurophysiology and Unit for Severe Acquired Brain Injuries (S.B.), Rehabilitation Department, Giuseppe Giglio Foundation, Cefalù, Italy; Center for Neurotechnology and Neurorecovery (B.L.E., C.C.), Department of Neurology, Massachusetts General Hospital, Boston; CHN William Lennox (N.L.), Ottignies, Belgium; Department of Psychology (V.V.), University of Reading Malaysia; Neurorehabilitation Unit (M.B.), HABILITA Zingonia/Ciserano, Bergamo; Department of Computer, Control and Management Engineering (J.T.), Sapienza University of Rome, Italy; Concussion Care Centre of Virginia, Ltd. (N.Z.), Richmond; and Research Institute (C.S.), Casa Colina Hospital and Centers for Healthcare, Pomona, CA
| | - Anna Maria Romoli
- From IRCCS Fondazione Don Carlo Gnocchi (A.E., A.G., A.M.R.), Florence; Istituti Clinici Scientifici Maugeri IRCCS (S.F.), SB S.p.A., Laboratorio di Valutazione Multimodale dei Disordini della Coscienza, Telese Terme (BN); Department of Psychology (A.M., L.T.), University of Campania L. Vanvitelli, Caserta; Fondazione Santa Lucia IRCCS (R.F., D.M.), Rome, Italy; Neurosurgery Department (E.A.), University of Athens Medical School, Greece; Coma Science Group (H.C., A.T., O.G.), GIGA Consciousness, University and University Hospital of Liège, Belgium; Neurorehabilitation and Vegetative State Unit (G.L.), E. Viglietta, Cuneo, Italy; NEURORHB-Servicio de Neurorrehabilitación de Hospitales Vithas (E.N.), Valencia, Spain; Unit of Neurophysiology and Unit for Severe Acquired Brain Injuries (S.B.), Rehabilitation Department, Giuseppe Giglio Foundation, Cefalù, Italy; Center for Neurotechnology and Neurorecovery (B.L.E., C.C.), Department of Neurology, Massachusetts General Hospital, Boston; CHN William Lennox (N.L.), Ottignies, Belgium; Department of Psychology (V.V.), University of Reading Malaysia; Neurorehabilitation Unit (M.B.), HABILITA Zingonia/Ciserano, Bergamo; Department of Computer, Control and Management Engineering (J.T.), Sapienza University of Rome, Italy; Concussion Care Centre of Virginia, Ltd. (N.Z.), Richmond; and Research Institute (C.S.), Casa Colina Hospital and Centers for Healthcare, Pomona, CA
| | - Efthymios Angelakis
- From IRCCS Fondazione Don Carlo Gnocchi (A.E., A.G., A.M.R.), Florence; Istituti Clinici Scientifici Maugeri IRCCS (S.F.), SB S.p.A., Laboratorio di Valutazione Multimodale dei Disordini della Coscienza, Telese Terme (BN); Department of Psychology (A.M., L.T.), University of Campania L. Vanvitelli, Caserta; Fondazione Santa Lucia IRCCS (R.F., D.M.), Rome, Italy; Neurosurgery Department (E.A.), University of Athens Medical School, Greece; Coma Science Group (H.C., A.T., O.G.), GIGA Consciousness, University and University Hospital of Liège, Belgium; Neurorehabilitation and Vegetative State Unit (G.L.), E. Viglietta, Cuneo, Italy; NEURORHB-Servicio de Neurorrehabilitación de Hospitales Vithas (E.N.), Valencia, Spain; Unit of Neurophysiology and Unit for Severe Acquired Brain Injuries (S.B.), Rehabilitation Department, Giuseppe Giglio Foundation, Cefalù, Italy; Center for Neurotechnology and Neurorecovery (B.L.E., C.C.), Department of Neurology, Massachusetts General Hospital, Boston; CHN William Lennox (N.L.), Ottignies, Belgium; Department of Psychology (V.V.), University of Reading Malaysia; Neurorehabilitation Unit (M.B.), HABILITA Zingonia/Ciserano, Bergamo; Department of Computer, Control and Management Engineering (J.T.), Sapienza University of Rome, Italy; Concussion Care Centre of Virginia, Ltd. (N.Z.), Richmond; and Research Institute (C.S.), Casa Colina Hospital and Centers for Healthcare, Pomona, CA
| | - Helena Cassol
- From IRCCS Fondazione Don Carlo Gnocchi (A.E., A.G., A.M.R.), Florence; Istituti Clinici Scientifici Maugeri IRCCS (S.F.), SB S.p.A., Laboratorio di Valutazione Multimodale dei Disordini della Coscienza, Telese Terme (BN); Department of Psychology (A.M., L.T.), University of Campania L. Vanvitelli, Caserta; Fondazione Santa Lucia IRCCS (R.F., D.M.), Rome, Italy; Neurosurgery Department (E.A.), University of Athens Medical School, Greece; Coma Science Group (H.C., A.T., O.G.), GIGA Consciousness, University and University Hospital of Liège, Belgium; Neurorehabilitation and Vegetative State Unit (G.L.), E. Viglietta, Cuneo, Italy; NEURORHB-Servicio de Neurorrehabilitación de Hospitales Vithas (E.N.), Valencia, Spain; Unit of Neurophysiology and Unit for Severe Acquired Brain Injuries (S.B.), Rehabilitation Department, Giuseppe Giglio Foundation, Cefalù, Italy; Center for Neurotechnology and Neurorecovery (B.L.E., C.C.), Department of Neurology, Massachusetts General Hospital, Boston; CHN William Lennox (N.L.), Ottignies, Belgium; Department of Psychology (V.V.), University of Reading Malaysia; Neurorehabilitation Unit (M.B.), HABILITA Zingonia/Ciserano, Bergamo; Department of Computer, Control and Management Engineering (J.T.), Sapienza University of Rome, Italy; Concussion Care Centre of Virginia, Ltd. (N.Z.), Richmond; and Research Institute (C.S.), Casa Colina Hospital and Centers for Healthcare, Pomona, CA
| | - Aurore Thibaut
- From IRCCS Fondazione Don Carlo Gnocchi (A.E., A.G., A.M.R.), Florence; Istituti Clinici Scientifici Maugeri IRCCS (S.F.), SB S.p.A., Laboratorio di Valutazione Multimodale dei Disordini della Coscienza, Telese Terme (BN); Department of Psychology (A.M., L.T.), University of Campania L. Vanvitelli, Caserta; Fondazione Santa Lucia IRCCS (R.F., D.M.), Rome, Italy; Neurosurgery Department (E.A.), University of Athens Medical School, Greece; Coma Science Group (H.C., A.T., O.G.), GIGA Consciousness, University and University Hospital of Liège, Belgium; Neurorehabilitation and Vegetative State Unit (G.L.), E. Viglietta, Cuneo, Italy; NEURORHB-Servicio de Neurorrehabilitación de Hospitales Vithas (E.N.), Valencia, Spain; Unit of Neurophysiology and Unit for Severe Acquired Brain Injuries (S.B.), Rehabilitation Department, Giuseppe Giglio Foundation, Cefalù, Italy; Center for Neurotechnology and Neurorecovery (B.L.E., C.C.), Department of Neurology, Massachusetts General Hospital, Boston; CHN William Lennox (N.L.), Ottignies, Belgium; Department of Psychology (V.V.), University of Reading Malaysia; Neurorehabilitation Unit (M.B.), HABILITA Zingonia/Ciserano, Bergamo; Department of Computer, Control and Management Engineering (J.T.), Sapienza University of Rome, Italy; Concussion Care Centre of Virginia, Ltd. (N.Z.), Richmond; and Research Institute (C.S.), Casa Colina Hospital and Centers for Healthcare, Pomona, CA
| | - Olivia Gosseries
- From IRCCS Fondazione Don Carlo Gnocchi (A.E., A.G., A.M.R.), Florence; Istituti Clinici Scientifici Maugeri IRCCS (S.F.), SB S.p.A., Laboratorio di Valutazione Multimodale dei Disordini della Coscienza, Telese Terme (BN); Department of Psychology (A.M., L.T.), University of Campania L. Vanvitelli, Caserta; Fondazione Santa Lucia IRCCS (R.F., D.M.), Rome, Italy; Neurosurgery Department (E.A.), University of Athens Medical School, Greece; Coma Science Group (H.C., A.T., O.G.), GIGA Consciousness, University and University Hospital of Liège, Belgium; Neurorehabilitation and Vegetative State Unit (G.L.), E. Viglietta, Cuneo, Italy; NEURORHB-Servicio de Neurorrehabilitación de Hospitales Vithas (E.N.), Valencia, Spain; Unit of Neurophysiology and Unit for Severe Acquired Brain Injuries (S.B.), Rehabilitation Department, Giuseppe Giglio Foundation, Cefalù, Italy; Center for Neurotechnology and Neurorecovery (B.L.E., C.C.), Department of Neurology, Massachusetts General Hospital, Boston; CHN William Lennox (N.L.), Ottignies, Belgium; Department of Psychology (V.V.), University of Reading Malaysia; Neurorehabilitation Unit (M.B.), HABILITA Zingonia/Ciserano, Bergamo; Department of Computer, Control and Management Engineering (J.T.), Sapienza University of Rome, Italy; Concussion Care Centre of Virginia, Ltd. (N.Z.), Richmond; and Research Institute (C.S.), Casa Colina Hospital and Centers for Healthcare, Pomona, CA
| | - Gianfranco Lamberti
- From IRCCS Fondazione Don Carlo Gnocchi (A.E., A.G., A.M.R.), Florence; Istituti Clinici Scientifici Maugeri IRCCS (S.F.), SB S.p.A., Laboratorio di Valutazione Multimodale dei Disordini della Coscienza, Telese Terme (BN); Department of Psychology (A.M., L.T.), University of Campania L. Vanvitelli, Caserta; Fondazione Santa Lucia IRCCS (R.F., D.M.), Rome, Italy; Neurosurgery Department (E.A.), University of Athens Medical School, Greece; Coma Science Group (H.C., A.T., O.G.), GIGA Consciousness, University and University Hospital of Liège, Belgium; Neurorehabilitation and Vegetative State Unit (G.L.), E. Viglietta, Cuneo, Italy; NEURORHB-Servicio de Neurorrehabilitación de Hospitales Vithas (E.N.), Valencia, Spain; Unit of Neurophysiology and Unit for Severe Acquired Brain Injuries (S.B.), Rehabilitation Department, Giuseppe Giglio Foundation, Cefalù, Italy; Center for Neurotechnology and Neurorecovery (B.L.E., C.C.), Department of Neurology, Massachusetts General Hospital, Boston; CHN William Lennox (N.L.), Ottignies, Belgium; Department of Psychology (V.V.), University of Reading Malaysia; Neurorehabilitation Unit (M.B.), HABILITA Zingonia/Ciserano, Bergamo; Department of Computer, Control and Management Engineering (J.T.), Sapienza University of Rome, Italy; Concussion Care Centre of Virginia, Ltd. (N.Z.), Richmond; and Research Institute (C.S.), Casa Colina Hospital and Centers for Healthcare, Pomona, CA
| | - Enrique Noé
- From IRCCS Fondazione Don Carlo Gnocchi (A.E., A.G., A.M.R.), Florence; Istituti Clinici Scientifici Maugeri IRCCS (S.F.), SB S.p.A., Laboratorio di Valutazione Multimodale dei Disordini della Coscienza, Telese Terme (BN); Department of Psychology (A.M., L.T.), University of Campania L. Vanvitelli, Caserta; Fondazione Santa Lucia IRCCS (R.F., D.M.), Rome, Italy; Neurosurgery Department (E.A.), University of Athens Medical School, Greece; Coma Science Group (H.C., A.T., O.G.), GIGA Consciousness, University and University Hospital of Liège, Belgium; Neurorehabilitation and Vegetative State Unit (G.L.), E. Viglietta, Cuneo, Italy; NEURORHB-Servicio de Neurorrehabilitación de Hospitales Vithas (E.N.), Valencia, Spain; Unit of Neurophysiology and Unit for Severe Acquired Brain Injuries (S.B.), Rehabilitation Department, Giuseppe Giglio Foundation, Cefalù, Italy; Center for Neurotechnology and Neurorecovery (B.L.E., C.C.), Department of Neurology, Massachusetts General Hospital, Boston; CHN William Lennox (N.L.), Ottignies, Belgium; Department of Psychology (V.V.), University of Reading Malaysia; Neurorehabilitation Unit (M.B.), HABILITA Zingonia/Ciserano, Bergamo; Department of Computer, Control and Management Engineering (J.T.), Sapienza University of Rome, Italy; Concussion Care Centre of Virginia, Ltd. (N.Z.), Richmond; and Research Institute (C.S.), Casa Colina Hospital and Centers for Healthcare, Pomona, CA
| | - Sergio Bagnato
- From IRCCS Fondazione Don Carlo Gnocchi (A.E., A.G., A.M.R.), Florence; Istituti Clinici Scientifici Maugeri IRCCS (S.F.), SB S.p.A., Laboratorio di Valutazione Multimodale dei Disordini della Coscienza, Telese Terme (BN); Department of Psychology (A.M., L.T.), University of Campania L. Vanvitelli, Caserta; Fondazione Santa Lucia IRCCS (R.F., D.M.), Rome, Italy; Neurosurgery Department (E.A.), University of Athens Medical School, Greece; Coma Science Group (H.C., A.T., O.G.), GIGA Consciousness, University and University Hospital of Liège, Belgium; Neurorehabilitation and Vegetative State Unit (G.L.), E. Viglietta, Cuneo, Italy; NEURORHB-Servicio de Neurorrehabilitación de Hospitales Vithas (E.N.), Valencia, Spain; Unit of Neurophysiology and Unit for Severe Acquired Brain Injuries (S.B.), Rehabilitation Department, Giuseppe Giglio Foundation, Cefalù, Italy; Center for Neurotechnology and Neurorecovery (B.L.E., C.C.), Department of Neurology, Massachusetts General Hospital, Boston; CHN William Lennox (N.L.), Ottignies, Belgium; Department of Psychology (V.V.), University of Reading Malaysia; Neurorehabilitation Unit (M.B.), HABILITA Zingonia/Ciserano, Bergamo; Department of Computer, Control and Management Engineering (J.T.), Sapienza University of Rome, Italy; Concussion Care Centre of Virginia, Ltd. (N.Z.), Richmond; and Research Institute (C.S.), Casa Colina Hospital and Centers for Healthcare, Pomona, CA
| | - Brian L Edlow
- From IRCCS Fondazione Don Carlo Gnocchi (A.E., A.G., A.M.R.), Florence; Istituti Clinici Scientifici Maugeri IRCCS (S.F.), SB S.p.A., Laboratorio di Valutazione Multimodale dei Disordini della Coscienza, Telese Terme (BN); Department of Psychology (A.M., L.T.), University of Campania L. Vanvitelli, Caserta; Fondazione Santa Lucia IRCCS (R.F., D.M.), Rome, Italy; Neurosurgery Department (E.A.), University of Athens Medical School, Greece; Coma Science Group (H.C., A.T., O.G.), GIGA Consciousness, University and University Hospital of Liège, Belgium; Neurorehabilitation and Vegetative State Unit (G.L.), E. Viglietta, Cuneo, Italy; NEURORHB-Servicio de Neurorrehabilitación de Hospitales Vithas (E.N.), Valencia, Spain; Unit of Neurophysiology and Unit for Severe Acquired Brain Injuries (S.B.), Rehabilitation Department, Giuseppe Giglio Foundation, Cefalù, Italy; Center for Neurotechnology and Neurorecovery (B.L.E., C.C.), Department of Neurology, Massachusetts General Hospital, Boston; CHN William Lennox (N.L.), Ottignies, Belgium; Department of Psychology (V.V.), University of Reading Malaysia; Neurorehabilitation Unit (M.B.), HABILITA Zingonia/Ciserano, Bergamo; Department of Computer, Control and Management Engineering (J.T.), Sapienza University of Rome, Italy; Concussion Care Centre of Virginia, Ltd. (N.Z.), Richmond; and Research Institute (C.S.), Casa Colina Hospital and Centers for Healthcare, Pomona, CA
| | - Camille Chatelle
- From IRCCS Fondazione Don Carlo Gnocchi (A.E., A.G., A.M.R.), Florence; Istituti Clinici Scientifici Maugeri IRCCS (S.F.), SB S.p.A., Laboratorio di Valutazione Multimodale dei Disordini della Coscienza, Telese Terme (BN); Department of Psychology (A.M., L.T.), University of Campania L. Vanvitelli, Caserta; Fondazione Santa Lucia IRCCS (R.F., D.M.), Rome, Italy; Neurosurgery Department (E.A.), University of Athens Medical School, Greece; Coma Science Group (H.C., A.T., O.G.), GIGA Consciousness, University and University Hospital of Liège, Belgium; Neurorehabilitation and Vegetative State Unit (G.L.), E. Viglietta, Cuneo, Italy; NEURORHB-Servicio de Neurorrehabilitación de Hospitales Vithas (E.N.), Valencia, Spain; Unit of Neurophysiology and Unit for Severe Acquired Brain Injuries (S.B.), Rehabilitation Department, Giuseppe Giglio Foundation, Cefalù, Italy; Center for Neurotechnology and Neurorecovery (B.L.E., C.C.), Department of Neurology, Massachusetts General Hospital, Boston; CHN William Lennox (N.L.), Ottignies, Belgium; Department of Psychology (V.V.), University of Reading Malaysia; Neurorehabilitation Unit (M.B.), HABILITA Zingonia/Ciserano, Bergamo; Department of Computer, Control and Management Engineering (J.T.), Sapienza University of Rome, Italy; Concussion Care Centre of Virginia, Ltd. (N.Z.), Richmond; and Research Institute (C.S.), Casa Colina Hospital and Centers for Healthcare, Pomona, CA
| | - Nicolas Lejeune
- From IRCCS Fondazione Don Carlo Gnocchi (A.E., A.G., A.M.R.), Florence; Istituti Clinici Scientifici Maugeri IRCCS (S.F.), SB S.p.A., Laboratorio di Valutazione Multimodale dei Disordini della Coscienza, Telese Terme (BN); Department of Psychology (A.M., L.T.), University of Campania L. Vanvitelli, Caserta; Fondazione Santa Lucia IRCCS (R.F., D.M.), Rome, Italy; Neurosurgery Department (E.A.), University of Athens Medical School, Greece; Coma Science Group (H.C., A.T., O.G.), GIGA Consciousness, University and University Hospital of Liège, Belgium; Neurorehabilitation and Vegetative State Unit (G.L.), E. Viglietta, Cuneo, Italy; NEURORHB-Servicio de Neurorrehabilitación de Hospitales Vithas (E.N.), Valencia, Spain; Unit of Neurophysiology and Unit for Severe Acquired Brain Injuries (S.B.), Rehabilitation Department, Giuseppe Giglio Foundation, Cefalù, Italy; Center for Neurotechnology and Neurorecovery (B.L.E., C.C.), Department of Neurology, Massachusetts General Hospital, Boston; CHN William Lennox (N.L.), Ottignies, Belgium; Department of Psychology (V.V.), University of Reading Malaysia; Neurorehabilitation Unit (M.B.), HABILITA Zingonia/Ciserano, Bergamo; Department of Computer, Control and Management Engineering (J.T.), Sapienza University of Rome, Italy; Concussion Care Centre of Virginia, Ltd. (N.Z.), Richmond; and Research Institute (C.S.), Casa Colina Hospital and Centers for Healthcare, Pomona, CA
| | - Vigneswaran Veeramuthu
- From IRCCS Fondazione Don Carlo Gnocchi (A.E., A.G., A.M.R.), Florence; Istituti Clinici Scientifici Maugeri IRCCS (S.F.), SB S.p.A., Laboratorio di Valutazione Multimodale dei Disordini della Coscienza, Telese Terme (BN); Department of Psychology (A.M., L.T.), University of Campania L. Vanvitelli, Caserta; Fondazione Santa Lucia IRCCS (R.F., D.M.), Rome, Italy; Neurosurgery Department (E.A.), University of Athens Medical School, Greece; Coma Science Group (H.C., A.T., O.G.), GIGA Consciousness, University and University Hospital of Liège, Belgium; Neurorehabilitation and Vegetative State Unit (G.L.), E. Viglietta, Cuneo, Italy; NEURORHB-Servicio de Neurorrehabilitación de Hospitales Vithas (E.N.), Valencia, Spain; Unit of Neurophysiology and Unit for Severe Acquired Brain Injuries (S.B.), Rehabilitation Department, Giuseppe Giglio Foundation, Cefalù, Italy; Center for Neurotechnology and Neurorecovery (B.L.E., C.C.), Department of Neurology, Massachusetts General Hospital, Boston; CHN William Lennox (N.L.), Ottignies, Belgium; Department of Psychology (V.V.), University of Reading Malaysia; Neurorehabilitation Unit (M.B.), HABILITA Zingonia/Ciserano, Bergamo; Department of Computer, Control and Management Engineering (J.T.), Sapienza University of Rome, Italy; Concussion Care Centre of Virginia, Ltd. (N.Z.), Richmond; and Research Institute (C.S.), Casa Colina Hospital and Centers for Healthcare, Pomona, CA
| | - Michelangelo Bartolo
- From IRCCS Fondazione Don Carlo Gnocchi (A.E., A.G., A.M.R.), Florence; Istituti Clinici Scientifici Maugeri IRCCS (S.F.), SB S.p.A., Laboratorio di Valutazione Multimodale dei Disordini della Coscienza, Telese Terme (BN); Department of Psychology (A.M., L.T.), University of Campania L. Vanvitelli, Caserta; Fondazione Santa Lucia IRCCS (R.F., D.M.), Rome, Italy; Neurosurgery Department (E.A.), University of Athens Medical School, Greece; Coma Science Group (H.C., A.T., O.G.), GIGA Consciousness, University and University Hospital of Liège, Belgium; Neurorehabilitation and Vegetative State Unit (G.L.), E. Viglietta, Cuneo, Italy; NEURORHB-Servicio de Neurorrehabilitación de Hospitales Vithas (E.N.), Valencia, Spain; Unit of Neurophysiology and Unit for Severe Acquired Brain Injuries (S.B.), Rehabilitation Department, Giuseppe Giglio Foundation, Cefalù, Italy; Center for Neurotechnology and Neurorecovery (B.L.E., C.C.), Department of Neurology, Massachusetts General Hospital, Boston; CHN William Lennox (N.L.), Ottignies, Belgium; Department of Psychology (V.V.), University of Reading Malaysia; Neurorehabilitation Unit (M.B.), HABILITA Zingonia/Ciserano, Bergamo; Department of Computer, Control and Management Engineering (J.T.), Sapienza University of Rome, Italy; Concussion Care Centre of Virginia, Ltd. (N.Z.), Richmond; and Research Institute (C.S.), Casa Colina Hospital and Centers for Healthcare, Pomona, CA
| | - Jlenia Toppi
- From IRCCS Fondazione Don Carlo Gnocchi (A.E., A.G., A.M.R.), Florence; Istituti Clinici Scientifici Maugeri IRCCS (S.F.), SB S.p.A., Laboratorio di Valutazione Multimodale dei Disordini della Coscienza, Telese Terme (BN); Department of Psychology (A.M., L.T.), University of Campania L. Vanvitelli, Caserta; Fondazione Santa Lucia IRCCS (R.F., D.M.), Rome, Italy; Neurosurgery Department (E.A.), University of Athens Medical School, Greece; Coma Science Group (H.C., A.T., O.G.), GIGA Consciousness, University and University Hospital of Liège, Belgium; Neurorehabilitation and Vegetative State Unit (G.L.), E. Viglietta, Cuneo, Italy; NEURORHB-Servicio de Neurorrehabilitación de Hospitales Vithas (E.N.), Valencia, Spain; Unit of Neurophysiology and Unit for Severe Acquired Brain Injuries (S.B.), Rehabilitation Department, Giuseppe Giglio Foundation, Cefalù, Italy; Center for Neurotechnology and Neurorecovery (B.L.E., C.C.), Department of Neurology, Massachusetts General Hospital, Boston; CHN William Lennox (N.L.), Ottignies, Belgium; Department of Psychology (V.V.), University of Reading Malaysia; Neurorehabilitation Unit (M.B.), HABILITA Zingonia/Ciserano, Bergamo; Department of Computer, Control and Management Engineering (J.T.), Sapienza University of Rome, Italy; Concussion Care Centre of Virginia, Ltd. (N.Z.), Richmond; and Research Institute (C.S.), Casa Colina Hospital and Centers for Healthcare, Pomona, CA
| | - Nathan Zasler
- From IRCCS Fondazione Don Carlo Gnocchi (A.E., A.G., A.M.R.), Florence; Istituti Clinici Scientifici Maugeri IRCCS (S.F.), SB S.p.A., Laboratorio di Valutazione Multimodale dei Disordini della Coscienza, Telese Terme (BN); Department of Psychology (A.M., L.T.), University of Campania L. Vanvitelli, Caserta; Fondazione Santa Lucia IRCCS (R.F., D.M.), Rome, Italy; Neurosurgery Department (E.A.), University of Athens Medical School, Greece; Coma Science Group (H.C., A.T., O.G.), GIGA Consciousness, University and University Hospital of Liège, Belgium; Neurorehabilitation and Vegetative State Unit (G.L.), E. Viglietta, Cuneo, Italy; NEURORHB-Servicio de Neurorrehabilitación de Hospitales Vithas (E.N.), Valencia, Spain; Unit of Neurophysiology and Unit for Severe Acquired Brain Injuries (S.B.), Rehabilitation Department, Giuseppe Giglio Foundation, Cefalù, Italy; Center for Neurotechnology and Neurorecovery (B.L.E., C.C.), Department of Neurology, Massachusetts General Hospital, Boston; CHN William Lennox (N.L.), Ottignies, Belgium; Department of Psychology (V.V.), University of Reading Malaysia; Neurorehabilitation Unit (M.B.), HABILITA Zingonia/Ciserano, Bergamo; Department of Computer, Control and Management Engineering (J.T.), Sapienza University of Rome, Italy; Concussion Care Centre of Virginia, Ltd. (N.Z.), Richmond; and Research Institute (C.S.), Casa Colina Hospital and Centers for Healthcare, Pomona, CA
| | - Caroline Schnakers
- From IRCCS Fondazione Don Carlo Gnocchi (A.E., A.G., A.M.R.), Florence; Istituti Clinici Scientifici Maugeri IRCCS (S.F.), SB S.p.A., Laboratorio di Valutazione Multimodale dei Disordini della Coscienza, Telese Terme (BN); Department of Psychology (A.M., L.T.), University of Campania L. Vanvitelli, Caserta; Fondazione Santa Lucia IRCCS (R.F., D.M.), Rome, Italy; Neurosurgery Department (E.A.), University of Athens Medical School, Greece; Coma Science Group (H.C., A.T., O.G.), GIGA Consciousness, University and University Hospital of Liège, Belgium; Neurorehabilitation and Vegetative State Unit (G.L.), E. Viglietta, Cuneo, Italy; NEURORHB-Servicio de Neurorrehabilitación de Hospitales Vithas (E.N.), Valencia, Spain; Unit of Neurophysiology and Unit for Severe Acquired Brain Injuries (S.B.), Rehabilitation Department, Giuseppe Giglio Foundation, Cefalù, Italy; Center for Neurotechnology and Neurorecovery (B.L.E., C.C.), Department of Neurology, Massachusetts General Hospital, Boston; CHN William Lennox (N.L.), Ottignies, Belgium; Department of Psychology (V.V.), University of Reading Malaysia; Neurorehabilitation Unit (M.B.), HABILITA Zingonia/Ciserano, Bergamo; Department of Computer, Control and Management Engineering (J.T.), Sapienza University of Rome, Italy; Concussion Care Centre of Virginia, Ltd. (N.Z.), Richmond; and Research Institute (C.S.), Casa Colina Hospital and Centers for Healthcare, Pomona, CA
| | - Luigi Trojano
- From IRCCS Fondazione Don Carlo Gnocchi (A.E., A.G., A.M.R.), Florence; Istituti Clinici Scientifici Maugeri IRCCS (S.F.), SB S.p.A., Laboratorio di Valutazione Multimodale dei Disordini della Coscienza, Telese Terme (BN); Department of Psychology (A.M., L.T.), University of Campania L. Vanvitelli, Caserta; Fondazione Santa Lucia IRCCS (R.F., D.M.), Rome, Italy; Neurosurgery Department (E.A.), University of Athens Medical School, Greece; Coma Science Group (H.C., A.T., O.G.), GIGA Consciousness, University and University Hospital of Liège, Belgium; Neurorehabilitation and Vegetative State Unit (G.L.), E. Viglietta, Cuneo, Italy; NEURORHB-Servicio de Neurorrehabilitación de Hospitales Vithas (E.N.), Valencia, Spain; Unit of Neurophysiology and Unit for Severe Acquired Brain Injuries (S.B.), Rehabilitation Department, Giuseppe Giglio Foundation, Cefalù, Italy; Center for Neurotechnology and Neurorecovery (B.L.E., C.C.), Department of Neurology, Massachusetts General Hospital, Boston; CHN William Lennox (N.L.), Ottignies, Belgium; Department of Psychology (V.V.), University of Reading Malaysia; Neurorehabilitation Unit (M.B.), HABILITA Zingonia/Ciserano, Bergamo; Department of Computer, Control and Management Engineering (J.T.), Sapienza University of Rome, Italy; Concussion Care Centre of Virginia, Ltd. (N.Z.), Richmond; and Research Institute (C.S.), Casa Colina Hospital and Centers for Healthcare, Pomona, CA
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Murray NM, Threlkeld ZD, Hirsch KG. Will We Ever Make Headway in Severe Traumatic Brain Injury Treatment Trials? JAMA Neurol 2020; 77:411-412. [PMID: 31961381 DOI: 10.1001/jamaneurol.2019.4672] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Affiliation(s)
- Nick M Murray
- Neurocritical Care Division, Department of Neurology, Stanford University, Stanford, California
| | - Zachary D Threlkeld
- Neurocritical Care Division, Department of Neurology, Stanford University, Stanford, California
| | - Karen G Hirsch
- Neurocritical Care Division, Department of Neurology, Stanford University, Stanford, California
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The patient with severe traumatic brain injury: clinical decision-making: the first 60 min and beyond. Curr Opin Crit Care 2020; 25:622-629. [PMID: 31574013 DOI: 10.1097/mcc.0000000000000671] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
PURPOSE OF REVIEW There is an urgent need to discuss the uncertainties and paradoxes in clinical decision-making after severe traumatic brain injury (s-TBI). This could improve transparency, reduce variability of practice and enhance shared decision-making with proxies. RECENT FINDINGS Clinical decision-making on initiation, continuation and discontinuation of medical treatment may encompass substantial consequences as well as lead to presumed patient benefits. Such decisions, unfortunately, often lack transparency and may be controversial in nature. The very process of decision-making is frequently characterized by both a lack of objective criteria and the absence of validated prognostic models that could predict relevant outcome measures, such as long-term quality and satisfaction with life. In practice, while treatment-limiting decisions are often made in patients during the acute phase immediately after s-TBI, other such severely injured TBI patients have been managed with continued aggressive medical care, and surgical or other procedural interventions have been undertaken in the context of pursuing a more favorable patient outcome. Given this spectrum of care offered to identical patient cohorts, there is clearly a need to identify and decrease existing selectivity, and better ascertain the objective criteria helpful towards more consistent decision-making and thereby reduce the impact of subjective valuations of predicted patient outcome. SUMMARY Recent efforts by multiple medical groups have contributed to reduce uncertainty and to improve care and outcome along the entire chain of care. Although an unlimited endeavor for sustaining life seems unrealistic, treatment-limiting decisions should not deprive patients of a chance on achieving an outcome they would have considered acceptable.
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