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Draghi F, Pancani S, De Nisco A, Romoli AM, Maccanti D, Burali R, Grippo A, Macchi C, Cecchi F, Hakiki B. Implications of the Consciousness State on Decannulation in Patients With a Prolonged Disorder of Consciousness. Arch Phys Med Rehabil 2024:S0003-9993(24)00994-8. [PMID: 38734048 DOI: 10.1016/j.apmr.2024.05.006] [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: 10/09/2023] [Revised: 05/02/2024] [Accepted: 05/02/2024] [Indexed: 05/13/2024]
Abstract
OBJECTIVE To prospectively investigate the evolution of the consciousness state and the cannula-weaning progression in patients with prolonged disorders of consciousness. DESIGN Nonconcurrent cohort study. SETTING A rehabilitation unit. PARTICIPANTS Adult patients (N=144) with prolonged disorders of consciousness after a severe acquired brain injury admitted between June 2020 and September 2022. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES Consciousness state was assessed by repeated Coma Recovery Scale-Revised (CRS-R) questionnaire administration at admission and weekly afterward. The dates of the first improvement of consciousness state and the achievement of decannulation were recorded. Decannulation followed an internal protocol of multiprofessional rehabilitation. RESULTS One hundred forty-four patients were included: age, 69 years; 64 (44.4%) with hemorrhagic etiology; time post onset, 40 days, CRS-R score at admission, 9, median length of stay, 90 days. Seventy-three (50.7%) patients were decannulated. They showed a significantly higher CRS-R (P<.001) and states of consciousness (P<.001) at admission, at the first improvement of the consciousness state (P=.003), and at discharge (P<.001); a lower severity in the Cumulative Illness Rating Scale at admission (P=.01); and a lower rate of pulmonary infections with recurrence (P=.021), compared with nondecannulated patients. Almost all decannulated patients (97.3%) improved their consciousness before decannulation. Consciousness states at decannulation were as follows: unresponsive wakefulness syndrome, 0 (0%); minimally conscious state (MCS) minus, 4 (5.5%); MCS plus, 7 (9.6%); and emergence from MCS, 62 (84.9%). Kaplan-Meier analysis showed a significant divergence between the curves with a higher probability of decannulation in patients who improved consciousness (P<.001). CONCLUSIONS This study showed that the presence of signs of consciousness, even subtle, is a necessary condition for decannulation, suggesting that consciousness may influence some of the components implied in the decannulation process.
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Affiliation(s)
- Francesca Draghi
- Istituto di Ricovero e Cura a Carattere Scientifico Fondazione Don Carlo Gnocchi Onlus, Florence
| | - Silvia Pancani
- Istituto di Ricovero e Cura a Carattere Scientifico Fondazione Don Carlo Gnocchi Onlus, Florence.
| | - Agnese De Nisco
- Istituto di Ricovero e Cura a Carattere Scientifico Fondazione Don Carlo Gnocchi Onlus, Florence
| | - Anna Maria Romoli
- Istituto di Ricovero e Cura a Carattere Scientifico Fondazione Don Carlo Gnocchi Onlus, Florence
| | - Daniela Maccanti
- Istituto di Ricovero e Cura a Carattere Scientifico Fondazione Don Carlo Gnocchi Onlus, Florence
| | - Rachele Burali
- Istituto di Ricovero e Cura a Carattere Scientifico Fondazione Don Carlo Gnocchi Onlus, Florence
| | - Antonello Grippo
- Istituto di Ricovero e Cura a Carattere Scientifico Fondazione Don Carlo Gnocchi Onlus, Florence
| | - Claudio Macchi
- Istituto di Ricovero e Cura a Carattere Scientifico Fondazione Don Carlo Gnocchi Onlus, Florence; Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Francesca Cecchi
- Istituto di Ricovero e Cura a Carattere Scientifico Fondazione Don Carlo Gnocchi Onlus, Florence; Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Bahia Hakiki
- Istituto di Ricovero e Cura a Carattere Scientifico Fondazione Don Carlo Gnocchi Onlus, Florence; Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
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Fischer D, Edlow BL. Coma Prognostication After Acute Brain Injury: A Review. JAMA Neurol 2024:2815829. [PMID: 38436946 DOI: 10.1001/jamaneurol.2023.5634] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/05/2024]
Abstract
Importance Among the most impactful neurologic assessments is that of neuroprognostication, defined here as the prediction of neurologic recovery from disorders of consciousness caused by severe, acute brain injury. Across a range of brain injury etiologies, these determinations often dictate whether life-sustaining treatment is continued or withdrawn; thus, they have major implications for morbidity, mortality, and health care costs. Neuroprognostication relies on a diverse array of tests, including behavioral, radiologic, physiological, and serologic markers, that evaluate the brain's functional and structural integrity. Observations Prognostic markers, such as the neurologic examination, electroencephalography, and conventional computed tomography and magnetic resonance imaging (MRI), have been foundational in assessing a patient's current level of consciousness and capacity for recovery. Emerging techniques, such as functional MRI, diffusion MRI, and advanced forms of electroencephalography, provide new ways of evaluating the brain, leading to evolving schemes for characterizing neurologic function and novel methods for predicting recovery. Conclusions and Relevance Neuroprognostic markers are rapidly evolving as new ways of assessing the brain's structural and functional integrity after brain injury are discovered. Many of these techniques remain in development, and further research is needed to optimize their prognostic utility. However, even as such efforts are underway, a series of promising findings coupled with the imperfect predictive value of conventional prognostic markers and the high stakes of these assessments have prompted clinical guidelines to endorse emerging techniques for neuroprognostication. Thus, clinicians have been thrust into an uncertain predicament in which emerging techniques are not yet perfected but too promising to ignore. This review illustrates the current, and likely future, landscapes of prognostic markers. No matter how much prognostic markers evolve and improve, these assessments must be approached with humility and individualized to reflect each patient's values.
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Affiliation(s)
- David Fischer
- Division of Neurocritical Care, Department of Neurology, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Brian L Edlow
- Center for Neurotechnology and Neurorecovery, Department of Neurology, Massachusetts General Hospital and Harvard Medical School, Boston
- Athinoula A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital and Harvard Medical School, Charlestown
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Regnier A, Mélotte E, Aubinet C, Alnagger N, Fischer D, Lagier A, Thibaut A, Laureys S, Kaux JF, Gosseries O. Swallowing dysfunctions in patients with disorders of consciousness: Evidence from neuroimaging data, assessment, and management. NeuroRehabilitation 2024; 54:91-107. [PMID: 38217621 DOI: 10.3233/nre-230135] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2024]
Abstract
Following severe brain injuries, a subset of patients may remain in an altered state of consciousness; most of these patients require artificial feeding. Currently, a functional oral phase and the presence of exclusive oral feeding may constitute signs of consciousness. Additionally, the presence of pharyngo-laryngeal secretions, saliva aspiration, cough reflex and tracheostomy are related to the level of consciousness. However, the link between swallowing and consciousness is yet to be fully understood. The primary aim of this review is to establish a comprehensive overview of the relationship between an individual's conscious behaviour and swallowing (reflexive and voluntary). Previous studies of brain activation during volitional and non-volitional swallowing tasks in healthy subjects are also reviewed. We demonstrate that the areas activated by voluntary swallowing tasks (primary sensorimotor, cingulate, insula, premotor, supplementary motor, cerebellum, and operculum) are not specific to deglutitive function but are shared with other motor tasks and brain networks involved in consciousness. This review also outlines suitable assessment and treatment methods for dysphagic patients with disorders of consciousness. Finally, we propose that markers of swallowing could contribute to the development of novel diagnostic guidelines for patients with disorders of consciousness.
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Affiliation(s)
- Amandine Regnier
- Coma Science Group, GIGA-Consciousness, University of Liège, Liège, Belgium
- Centre du Cerveau, University Hospital of Liège, Liège, Belgium
- Department of Physical and Rehabilitation Medicine, University Hospital of Liège, Liège, Belgium
| | - Evelyne Mélotte
- Coma Science Group, GIGA-Consciousness, University of Liège, Liège, Belgium
| | - Charlène Aubinet
- Coma Science Group, GIGA-Consciousness, University of Liège, Liège, Belgium
- Centre du Cerveau, University Hospital of Liège, Liège, Belgium
- Psychology and Neuroscience of Cognition Research Unit, University of Liège, Liège, Belgium
| | - Naji Alnagger
- Coma Science Group, GIGA-Consciousness, University of Liège, Liège, Belgium
- Centre du Cerveau, University Hospital of Liège, Liège, Belgium
| | - David Fischer
- Department of Neurology, Division of Neurocritical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Aude Lagier
- Department of Otorhinolaryngology, University Hospital of Liège, Liège, Belgium
| | - Aurore Thibaut
- Coma Science Group, GIGA-Consciousness, University of Liège, Liège, Belgium
- Centre du Cerveau, University Hospital of Liège, Liège, Belgium
| | - Steven Laureys
- Coma Science Group, GIGA-Consciousness, University of Liège, Liège, Belgium
- Centre du Cerveau, University Hospital of Liège, Liège, Belgium
- Joint International Research Unit on Consciousness, CERVO Brain Research Centre, CIUSS, Laval University, Québec, QC, Canada
| | - Jean-François Kaux
- Department of Physical and Rehabilitation Medicine, University Hospital of Liège, Liège, Belgium
| | - Olivia Gosseries
- Coma Science Group, GIGA-Consciousness, University of Liège, Liège, Belgium
- Centre du Cerveau, University Hospital of Liège, Liège, Belgium
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Mélotte E, Maudoux A, Panda R, Kaux JF, Lagier A, Herr R, Belorgeot M, Laureys S, Gosseries O. Links Between Swallowing and Consciousness: A Narrative Review. Dysphagia 2023; 38:42-64. [PMID: 35773497 DOI: 10.1007/s00455-022-10452-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Accepted: 12/06/2021] [Indexed: 01/27/2023]
Abstract
This literature review explores a wide range of themes addressing the links between swallowing and consciousness. Signs of consciousness are historically based on the principle of differentiating reflexive from volitional behaviors. We show that the sequencing of the components of swallowing falls on a continuum of voluntary to reflex behaviors and we describe several types of volitional and non-volitional swallowing tasks. The frequency, speed of initiation of the swallowing reflex, efficacy of the pharyngeal phase of swallowing and coordination between respiration and swallowing are influenced by the level of consciousness during non-pathological modifications of consciousness such as sleep and general anesthesia. In patients with severe brain injury, the level of consciousness is associated with several components related to swallowing, such as the possibility of extubation, risk of pneumonia, type of feeding or components directly related to swallowing such as oral or pharyngeal abnormalities. Based on our theoretical and empirical analysis, the efficacy of the oral phase and the ability to receive exclusive oral feeding seem to be the most robust signs of consciousness related to swallowing in patients with disorders of consciousness. Components of the pharyngeal phase (in terms of abilities of saliva management) and evoked cough may be influenced by consciousness, but further studies are necessary to determine if they constitute signs of consciousness as such or only cortically mediated behaviors. This review also highlights the critical lack of tools and techniques to assess and treat dysphagia in patients with disorders of consciousness.
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Affiliation(s)
- Evelyne Mélotte
- Coma Science Group, GIGA-Consciousness, University of Liège, Liège, Belgium.
- Physical and Rehabilitation Medicine Department, University and University Hospital of Liège, Avenue de l'Hopital 1, 4000, Liège, Belgium.
- Centre du Cerveau², University Hospital of Liège, Liège, Belgium.
| | - Audrey Maudoux
- Sensation and Perception Research Group, GIGA, University and University Hospital of Liège, Liège, Belgium
- Otorhinolaryngology Head and Neck Surgery Department, Robert Debré University Hospital, APHP, Paris, France
| | - Rajanikant Panda
- Coma Science Group, GIGA-Consciousness, University of Liège, Liège, Belgium
| | - Jean-François Kaux
- Physical and Rehabilitation Medicine Department, University and University Hospital of Liège, Avenue de l'Hopital 1, 4000, Liège, Belgium
| | - Aude Lagier
- Otorhinolaryngology Head and Neck Surgery Department, University Hospital of Liège, Liège, Belgium
| | - Roxanne Herr
- Department of Speech and Language Pathology, Faculty of Medicine, University of Strasbourg, Strasbourg, France
| | - Marion Belorgeot
- Physical and Rehabilitation Medicine Department, University Hospital of Nîmes, Nîmes, France
| | - Steven Laureys
- Coma Science Group, GIGA-Consciousness, University of Liège, Liège, Belgium
- Centre du Cerveau², University Hospital of Liège, Liège, Belgium
| | - Olivia Gosseries
- Coma Science Group, GIGA-Consciousness, University of Liège, Liège, Belgium
- Centre du Cerveau², University Hospital of Liège, Liège, Belgium
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5
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Peters K, Miller S, Ptok M, Jungheim M. Phonation-induced Upper Esophageal Sphincter Contraction Caused by Different Phonation Types. J Voice 2022:S0892-1997(22)00160-6. [PMID: 35906176 DOI: 10.1016/j.jvoice.2022.06.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Revised: 06/07/2022] [Accepted: 06/08/2022] [Indexed: 10/16/2022]
Abstract
INTRODUCTION The upper esophageal sphincter (UES) has been reported to show activity during phonation. As it is still unknown whether the phonation-induced UES contraction represents a reflex or a simultaneous activation phenomenon, i.e. co-innervation, this study aims to investigate and characterize the phonation-induced contraction of the UES in healthy individuals by analyzing the influence of various phonation tasks on pressure parameters of the UES. METHODS Twenty-five healthy volunteers produced the German neutral vowel [ə] in five different phonation tasks (modal voice, whispering, voiceless speech, creaky voice, and whispery voice). Simultaneously, they underwent high resolution manometry and electroglottography for measurement of pressure parameters in the region of the UES and latencies between larynx and UES activation. RESULTS During all types of phonation, the maximum pressures of the UES increased significantly (maximum pressure increases of 72%-132%). With regard to mean pressures this was valid for modal voice and whispering (mean pressure increases of 20%-25%). Differences concerning total pressure changes reached statistical significance when comparing whispering and voiceless speech as well as whispery voice. However, differences concerning the total pressure change between modal voices on the one hand and voiceless speech and whispery voice on the other hand turned out to be small. The averaged time delay between larynx and UES activation ranged from approximately -15 ms (whispery voice) to +15 ms (whispering). CONCLUSION A phonation induced pressure increase of the UES was confirmed in this study and did exist for different types of phonation. The extent of total pressure changes in the UES increases in relation with laryngeal muscle activity necessary for the phonation type. Next to varying effects of different types of phonation on UES activation, very short latencies indicate that a phonation induced contraction of the UES exists most likely due to co-innervation of UES and laryngeal muscles by the vagus nerve.
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Affiliation(s)
- Katharina Peters
- Department of Phoniatrics and Pediatric Audiology, Hannover Medical School, Hannover, Germany.
| | - Simone Miller
- Department of Phoniatrics and Pediatric Audiology, Hannover Medical School, Hannover, Germany
| | - Martin Ptok
- Department of Phoniatrics and Pediatric Audiology, Hannover Medical School, Hannover, Germany
| | - Michael Jungheim
- Department of Phoniatrics and Pediatric Audiology, Hannover Medical School, Hannover, Germany
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7
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Lane TJ. The minimal self hypothesis. Conscious Cogn 2020; 85:103029. [PMID: 33091792 DOI: 10.1016/j.concog.2020.103029] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2019] [Revised: 09/07/2020] [Accepted: 09/26/2020] [Indexed: 12/01/2022]
Abstract
For millennia self has been conjectured to be necessary for consciousness. But scant empirical evidence has been adduced to support this hypothesis. Inconsistent explications of "self" and failure to design apt experiments have impeded progress. Advocates of phenomenological psychiatry, however, have helped explicate "self," and employed it to explain some psychopathological symptoms. In those studies, "self" is understood in a minimalist sense, sheer "for-me-ness." Unfortunately, explication of the "minimal self" (MS) has relied on conceptual analysis, and applications to psychopathology have been hermeneutic, allowing for many degrees of interpretive latitude. The result is that MS's current scientific status is analogous to that of the "atom," at the time when "atom" was just beginning to undergo transformation from a philosophical to a scientific concept. Fortunately, there is now an opportunity to promote a similar transformation for "MS." Discovery of the brain's Default Mode Network (DMN) opened the door to neuroimaging investigations of self. Taking the DMN and other forms of intrinsic activity as a starting point, an empirical foothold can be established, one that spurs experimental research and that enables extension of research into multiple phenomena. New experimental protocols that posit "MS" can help explain phenomena hitherto not thought to be related to self, thereby hastening development of a mature science of self. In particular, targeting phenomena wherein consciousness is lost and recovered, as in some cases of Unresponsive Wakefulness Syndrome (UWS), allow for design of neuroimaging probes that enable detection of MS during non-conscious states. These probes, as well as other experimental protocols applied to NREM Sleep, General Anesthesia (GA), and the waking state, provide some evidence to suggest that not only can self and consciousness dissociate, MS might be a necessary precondition for conscious experience. Finally, these findings have implications for the science of consciousness: it has been suggested that "levels of consciousness" (LoC) is not a legitimate concept for the science of consciousness. But because we have the conceptual and methodological tools with which to refine investigations of MS, we have the means to identify a possible foundation-a bifurcation point-for consciousness, as well as the means by which to measure degrees of distance from that foundation. These neuroimaging investigations of MS position us to better assess whether LoC has a role to play in a mature science of consciousness.
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Affiliation(s)
- Timothy Joseph Lane
- Graduate Institute of Mind, Brain and Consciousness, Taipei Medical University, Taipei, Taiwan; Brain and Consciousness Research Centre, TMU Shuang-Ho Hospital, New Taipei City, Taiwan; Institute of European and American Studies, Academia Sinica, Taipei, Taiwan.
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8
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Hermann B, Salah AB, Perlbarg V, Valente M, Pyatigorskaya N, Habert MO, Raimondo F, Stender J, Galanaud D, Kas A, Puybasset L, Perez P, Sitt JD, Rohaut B, Naccache L. Habituation of auditory startle reflex is a new sign of minimally conscious state. Brain 2020; 143:2154-2172. [PMID: 32582938 PMCID: PMC7364741 DOI: 10.1093/brain/awaa159] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2019] [Revised: 03/05/2020] [Accepted: 03/30/2020] [Indexed: 02/07/2023] Open
Abstract
Neurological examination of non-communicating patients relies on a few decisive items that enable the crucial distinction between vegetative state (VS)-also coined unresponsive wakefulness syndrome (UWS)-and minimally conscious state. Over the past 10 years, this distinction has proven its diagnostic value as well as its important prognostic value on consciousness recovery. However, clinicians are currently limited by three factors: (i) the current behavioural repertoire of minimally conscious state items is limited and restricted to a few cognitive domains in the goldstandard revised version of the Coma Recovery Scale; (ii) a proportion of ∼15-20% clinically VS/UWS patients are actually in a richer state than VS/UWS as evidenced by functional brain imaging; and (iii) the neurophysiological and cognitive interpretation of each minimally conscious state item is still unclear and debated. In the current study we demonstrate that habituation of the auditory startle reflex (hASR) tested at bedside constitutes a novel, simple and powerful behavioural sign that can accurately distinguish minimally conscious state from VS/UWS. In addition to enlarging the minimally conscious state items repertoire, and therefore decreasing the low sensitivity of current behavioural measures, we also provide an original and rigorous description of the neurophysiological basis of hASR through a combination of functional (high density EEG and 18F-fluorodeoxyglucose PET imaging) and structural (diffusion tensor imaging MRI) measures. We show that preservation of hASR is associated with the functional and structural integrity of a brain-scale fronto-parietal network, including prefrontal regions related to control of action and inhibition, and meso-parietal areas associated with minimally conscious and conscious states. Lastly, we show that hASR predicts 6-month improvement of consciousness. Taken together, our results show that hASR is a cortically-mediated behaviour, and suggest that it could be a new clinical item to clearly and accurately identify non-communicating patients who are in the minimally conscious state.
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Affiliation(s)
- Bertrand Hermann
- Institut du Cerveau et de la Moelle épinière - ICM, Inserm U1127, CNRS UMR 7225, F-75013, Paris, France
- Department of Neurology, Groupe hospitalier Pitié-Salpêtrière, AP-HP, F-75013, Paris, France
- Faculté de Médecine Pitié-Salpêtrière, Sorbonne Universités, UPMC Université Paris 06, Paris, France
| | - Amina Ben Salah
- Institut du Cerveau et de la Moelle épinière - ICM, Inserm U1127, CNRS UMR 7225, F-75013, Paris, France
| | - Vincent Perlbarg
- Sorbonne Université, CNRS, INSERM, Laboratoire d’Imagerie Biomédicale, LIB, F-75006, Paris, France
- BrainTale SAS, F-75013, Paris, France
| | - Mélanie Valente
- Institut du Cerveau et de la Moelle épinière - ICM, Inserm U1127, CNRS UMR 7225, F-75013, Paris, France
- Department of Clinical Neurophysiology, Groupe hospitalier Pitié-Salpêtrière, AP-HP, F-75013, Paris, France
| | - Nadya Pyatigorskaya
- Institut du Cerveau et de la Moelle épinière - ICM, Inserm U1127, CNRS UMR 7225, F-75013, Paris, France
- Faculté de Médecine Pitié-Salpêtrière, Sorbonne Universités, UPMC Université Paris 06, Paris, France
- Department of Neuroradiology, Groupe hospitalier Pitié-Salpêtrière, AP-HP, F-75013, Paris, France
| | - Marie-Odile Habert
- Sorbonne Université, CNRS, INSERM, Laboratoire d’Imagerie Biomédicale, LIB, F-75006, Paris, France
- Department of Nuclear Medicine, Groupe hospitalier Pitié-Salpêtrière, AP-HP, F-75013, Paris, France
| | - Federico Raimondo
- Institut du Cerveau et de la Moelle épinière - ICM, Inserm U1127, CNRS UMR 7225, F-75013, Paris, France
- Coma Science Group, GIGA Consciousness, University of Liège, Belgium
- Centre du Cerveau, University Hospital of Liège, Belgium
| | - Johan Stender
- Institut du Cerveau et de la Moelle épinière - ICM, Inserm U1127, CNRS UMR 7225, F-75013, Paris, France
| | - Damien Galanaud
- Institut du Cerveau et de la Moelle épinière - ICM, Inserm U1127, CNRS UMR 7225, F-75013, Paris, France
- Faculté de Médecine Pitié-Salpêtrière, Sorbonne Universités, UPMC Université Paris 06, Paris, France
- Department of Neuroradiology, Groupe hospitalier Pitié-Salpêtrière, AP-HP, F-75013, Paris, France
| | - Aurélie Kas
- Sorbonne Université, CNRS, INSERM, Laboratoire d’Imagerie Biomédicale, LIB, F-75006, Paris, France
- Department of Nuclear Medicine, Groupe hospitalier Pitié-Salpêtrière, AP-HP, F-75013, Paris, France
| | - Louis Puybasset
- Faculté de Médecine Pitié-Salpêtrière, Sorbonne Universités, UPMC Université Paris 06, Paris, France
- Sorbonne Université, CNRS, INSERM, Laboratoire d’Imagerie Biomédicale, LIB, F-75006, Paris, France
- Department of Anesthesia and Critical Care, Multidisciplinary Intensive Care Unit, Groupe hospitalier Pitié-Salpêtrière, AP-HP, F-75013, Paris, France
| | - Pauline Perez
- Institut du Cerveau et de la Moelle épinière - ICM, Inserm U1127, CNRS UMR 7225, F-75013, Paris, France
| | - Jacobo D Sitt
- Institut du Cerveau et de la Moelle épinière - ICM, Inserm U1127, CNRS UMR 7225, F-75013, Paris, France
| | - Benjamin Rohaut
- Institut du Cerveau et de la Moelle épinière - ICM, Inserm U1127, CNRS UMR 7225, F-75013, Paris, France
- Department of Neurology, Groupe hospitalier Pitié-Salpêtrière, AP-HP, F-75013, Paris, France
- Faculté de Médecine Pitié-Salpêtrière, Sorbonne Universités, UPMC Université Paris 06, Paris, France
- Department of Neurology, Columbia University, New York, NY 10027, USA
| | - Lionel Naccache
- Institut du Cerveau et de la Moelle épinière - ICM, Inserm U1127, CNRS UMR 7225, F-75013, Paris, France
- Department of Neurology, Groupe hospitalier Pitié-Salpêtrière, AP-HP, F-75013, Paris, France
- Faculté de Médecine Pitié-Salpêtrière, Sorbonne Universités, UPMC Université Paris 06, Paris, France
- Department of Clinical Neurophysiology, Groupe hospitalier Pitié-Salpêtrière, AP-HP, F-75013, Paris, France
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Pincherle A, Jöhr J, Chatelle C, Pignat JM, Du Pasquier R, Ryvlin P, Oddo M, Diserens K. Motor behavior unmasks residual cognition in disorders of consciousness. Ann Neurol 2019; 85:443-447. [PMID: 30661258 DOI: 10.1002/ana.25417] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2018] [Revised: 01/15/2019] [Accepted: 01/15/2019] [Indexed: 12/24/2022]
Abstract
Disorders of consciousness (DOC) are a common consequence of severe brain injuries, and clinical evaluation is critical to provide a correct diagnosis and prognosis. The revised Motor Behavior Tool (MBT-r) is a clinical complementary tool aiming to identify subtle motor behaviors that might reflect residual cognition in DOC. In this prospective study including 30 DOC patients in the early stage after brain injury, we show that the revised MBT-r has an excellent inter-rater agreement and has the ability to identify a subgroup of patients, underestimated by the Coma Recovery Scale-Revised, showing residual cognition and a subsequent recovery of consciousness. ANN NEUROL 2019;85:443-447.
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Affiliation(s)
- Alessandro Pincherle
- Department of Clinical Neurosciences, University Hospital CHUV, Lausanne, Switzerland.,Department of Neurology and Acute Neurorehabilitation Unit, University Hospital CHUV, Lausanne, Switzerland
| | - Jane Jöhr
- Department of Clinical Neurosciences, University Hospital CHUV, Lausanne, Switzerland.,Department of Neurology and Acute Neurorehabilitation Unit, University Hospital CHUV, Lausanne, Switzerland
| | - Camille Chatelle
- Coma Science Group, GIGA Consciousness, University Hospital of Liege, Liege, Belgium
| | - Jean-Michel Pignat
- Department of Clinical Neurosciences, University Hospital CHUV, Lausanne, Switzerland.,Department of Neurology and Acute Neurorehabilitation Unit, University Hospital CHUV, Lausanne, Switzerland
| | - Renaud Du Pasquier
- Department of Clinical Neurosciences, University Hospital CHUV, Lausanne, Switzerland.,Department of Neurology and Acute Neurorehabilitation Unit, University Hospital CHUV, Lausanne, Switzerland
| | - Philippe Ryvlin
- Department of Clinical Neurosciences, University Hospital CHUV, Lausanne, Switzerland.,Department of Neurology and Acute Neurorehabilitation Unit, University Hospital CHUV, Lausanne, Switzerland
| | - Mauro Oddo
- Neurointensive Care Unit, University Hospital CHUV, Lausanne, Switzerland
| | - Karin Diserens
- Department of Clinical Neurosciences, University Hospital CHUV, Lausanne, Switzerland.,Department of Neurology and Acute Neurorehabilitation Unit, University Hospital CHUV, Lausanne, Switzerland
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Wade DT. Using best interests meetings for people in a prolonged disorder of consciousness to improve clinical and ethical management. JOURNAL OF MEDICAL ETHICS 2018; 44:336-342. [PMID: 28912289 DOI: 10.1136/medethics-2017-104244] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/27/2017] [Revised: 07/14/2017] [Accepted: 07/18/2017] [Indexed: 06/07/2023]
Abstract
Current management of people with prolonged disorders of consciousness is failing patients, families and society. The causes include a general lack of concern, knowledge and expertise; a legal and professional framework which impedes timely and appropriate decision-making and/or enactment of the decision; and the exclusive focus on the patient, with no legitimate means to consider the broader consequences of healthcare decisions. This article argues that a clinical pathway based on the principles of (a) the English Mental Capacity Act 2005 and (b) using time-limited treatment trials could greatly improve patient management and reduce stress on families. There needs to be early and continuing use of formal best interests meetings, starting between 7 and 21 days after onset of unconsciousness (from any cause, including progressive disorders). The treatment options need to evolve as the clinical state and prognosis becomes more certain. A formal discussion of treatment withdrawal should occur when the upper bound of predicted recovery falls below a level the patient would have considered acceptable, and it should always be discussed when the condition is considered permanent. Any decision to stop treatment should be contingent on a formal second opinion from an independent expert who should review the clinical situation and expected prognosis, but not the best interests decision. The article also asks how, if at all, the adverse effects on the family and the resource implications of long-term care of people left in a prolonged state of unconsciousness should be incorporated in the process.
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Naccache L. Minimally conscious state or cortically mediated state? Brain 2018; 141:949-960. [PMID: 29206895 PMCID: PMC5888986 DOI: 10.1093/brain/awx324] [Citation(s) in RCA: 91] [Impact Index Per Article: 15.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2017] [Revised: 09/07/2017] [Accepted: 09/27/2017] [Indexed: 01/04/2023] Open
Abstract
Durable impairments of consciousness are currently classified in three main neurological categories: comatose state, vegetative state (also recently coined unresponsive wakefulness syndrome) and minimally conscious state. While the introduction of minimally conscious state, in 2002, was a major progress to help clinicians recognize complex non-reflexive behaviours in the absence of functional communication, it raises several problems. The most important issue related to minimally conscious state lies in its criteria: while behavioural definition of minimally conscious state lacks any direct evidence of patient's conscious content or conscious state, it includes the adjective 'conscious'. I discuss this major problem in this review and propose a novel interpretation of minimally conscious state: its criteria do not inform us about the potential residual consciousness of patients, but they do inform us with certainty about the presence of a cortically mediated state. Based on this constructive criticism review, I suggest three proposals aiming at improving the way we describe the subjective and cognitive state of non-communicating patients. In particular, I present a tentative new classification of impairments of consciousness that combines behavioural evidence with functional brain imaging data, in order to probe directly and univocally residual conscious processes.
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Affiliation(s)
- Lionel Naccache
- AP-HP, Groupe hospitalier Pitié-Salpêtrière, Department of Neurology, 75013, Paris, France
- AP-HP, Groupe hospitalier Pitié-Salpêtrière, Department of Neurophysiology, 75013, Paris, France
- INSERM, U 1127, F-75013, Paris, France
- Institut du Cerveau et de la Moelle épinière, ICM, PICNIC Lab, F-75013, Paris, France
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12
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Wade DT. How often is the diagnosis of the permanent vegetative state incorrect? A review of the evidence. Eur J Neurol 2018; 25:619-625. [DOI: 10.1111/ene.13572] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2017] [Accepted: 01/08/2018] [Indexed: 12/11/2022]
Affiliation(s)
- D. T. Wade
- OxINMAHR, and Movement Science Group; Faculty of Health and Life Sciences; Oxford Brookes University; Oxford UK
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13
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Edlow BL, Chatelle C, Spencer CA, Chu CJ, Bodien YG, O'Connor KL, Hirschberg RE, Hochberg LR, Giacino JT, Rosenthal ES, Wu O. Early detection of consciousness in patients with acute severe traumatic brain injury. Brain 2017; 140:2399-2414. [PMID: 29050383 DOI: 10.1093/brain/awx176] [Citation(s) in RCA: 205] [Impact Index Per Article: 29.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2017] [Accepted: 05/29/2017] [Indexed: 01/03/2023] Open
Abstract
See Schiff (doi:10.1093/awx209) for a scientific commentary on this article. Patients with acute severe traumatic brain injury may recover consciousness before self-expression. Without behavioural evidence of consciousness at the bedside, clinicians may render an inaccurate prognosis, increasing the likelihood of withholding life-sustaining therapies or denying rehabilitative services. Task-based functional magnetic resonance imaging and electroencephalography techniques have revealed covert consciousness in the chronic setting, but these techniques have not been tested in the intensive care unit. We prospectively enrolled 16 patients admitted to the intensive care unit for acute severe traumatic brain injury to test two hypotheses: (i) in patients who lack behavioural evidence of language expression and comprehension, functional magnetic resonance imaging and electroencephalography detect command-following during a motor imagery task (i.e. cognitive motor dissociation) and association cortex responses during language and music stimuli (i.e. higher-order cortex motor dissociation); and (ii) early responses to these paradigms are associated with better 6-month outcomes on the Glasgow Outcome Scale-Extended. Patients underwent functional magnetic resonance imaging on post-injury Day 9.2 ± 5.0 and electroencephalography on Day 9.8 ± 4.6. At the time of imaging, behavioural evaluation with the Coma Recovery Scale-Revised indicated coma (n = 2), vegetative state (n = 3), minimally conscious state without language (n = 3), minimally conscious state with language (n = 4) or post-traumatic confusional state (n = 4). Cognitive motor dissociation was identified in four patients, including three whose behavioural diagnosis suggested a vegetative state. Higher-order cortex motor dissociation was identified in two additional patients. Complete absence of responses to language, music and motor imagery was only observed in coma patients. In patients with behavioural evidence of language function, responses to language and music were more frequently observed than responses to motor imagery (62.5-80% versus 33.3-42.9%). Similarly, in 16 matched healthy subjects, responses to language and music were more frequently observed than responses to motor imagery (87.5-100% versus 68.8-75.0%). Except for one patient who died in the intensive care unit, all patients with cognitive motor dissociation and higher-order cortex motor dissociation recovered beyond a confusional state by 6 months. However, 6-month outcomes were not associated with early functional magnetic resonance imaging and electroencephalography responses for the entire cohort. These observations suggest that functional magnetic resonance imaging and electroencephalography can detect command-following and higher-order cortical function in patients with acute severe traumatic brain injury. Early detection of covert consciousness and cortical responses in the intensive care unit could alter time-sensitive decisions about withholding life-sustaining therapies.
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Affiliation(s)
- Brian L Edlow
- Center for Neurotechnology and Neurorecovery, Massachusetts General Hospital, 175 Cambridge Street, Boston, MA, 02114, USA.,Department of Neurology, Massachusetts General Hospital, Harvard Medical School, 175 Cambridge Street, Boston, MA, 02114, USA.,Athinoula A. Martinos Center for Biomedical Imaging, Department of Radiology, Massachusetts General Hospital, Harvard Medical School, 149 13th Street, Charlestown, MA 02129, USA
| | - Camille Chatelle
- Center for Neurotechnology and Neurorecovery, Massachusetts General Hospital, 175 Cambridge Street, Boston, MA, 02114, USA.,Department of Neurology, Massachusetts General Hospital, Harvard Medical School, 175 Cambridge Street, Boston, MA, 02114, USA.,Coma Science Group, GIGA Consciousness, University and University Hospital of Liège, Liège, Belgium
| | - Camille A Spencer
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, 175 Cambridge Street, Boston, MA, 02114, USA
| | - Catherine J Chu
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, 175 Cambridge Street, Boston, MA, 02114, USA
| | - Yelena G Bodien
- Center for Neurotechnology and Neurorecovery, Massachusetts General Hospital, 175 Cambridge Street, Boston, MA, 02114, USA.,Department of Neurology, Massachusetts General Hospital, Harvard Medical School, 175 Cambridge Street, Boston, MA, 02114, USA.,Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Harvard Medical School, 300 First Avenue, Charlestown, MA, 02129, USA
| | - Kathryn L O'Connor
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, 175 Cambridge Street, Boston, MA, 02114, USA
| | - Ronald E Hirschberg
- Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Harvard Medical School, 300 First Avenue, Charlestown, MA, 02129, USA.,Department of Physical Medicine and Rehabilitation, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Boston, MA, 02114, USA
| | - Leigh R Hochberg
- Center for Neurotechnology and Neurorecovery, Massachusetts General Hospital, 175 Cambridge Street, Boston, MA, 02114, USA.,Department of Neurology, Massachusetts General Hospital, Harvard Medical School, 175 Cambridge Street, Boston, MA, 02114, USA.,Department of Engineering, Brown University, 184 Hope St, Providence, RI, 02912, USA
| | - Joseph T Giacino
- Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Harvard Medical School, 300 First Avenue, Charlestown, MA, 02129, USA.,Department of Physical Medicine and Rehabilitation, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Boston, MA, 02114, USA
| | - Eric S Rosenthal
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, 175 Cambridge Street, Boston, MA, 02114, USA
| | - Ona Wu
- Athinoula A. Martinos Center for Biomedical Imaging, Department of Radiology, Massachusetts General Hospital, Harvard Medical School, 149 13th Street, Charlestown, MA 02129, USA
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Peterson A. Consilience, clinical validation, and global disorders of consciousness. Neurosci Conscious 2016; 2016:niw011. [PMID: 30356913 PMCID: PMC6192376 DOI: 10.1093/nc/niw011] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2016] [Revised: 06/08/2016] [Accepted: 07/09/2016] [Indexed: 11/14/2022] Open
Abstract
Behavioral diagnosis of global disorders of consciousness is difficult and errors in diagnosis occur often. Recent advances in neuroimaging may resolve this problem. However, clinical translation of neuroimaging requires clinical validation. Applying the orthodox approach of clinical validation to neuroimaging raises two critical questions: (i) What exactly is being validated? and (ii) what counts as a gold standard? I argue that confusion over these questions leads to systematic errors in the empirical literature. I propose an alternative approach to clinical validation motivated by reasoning by consilience. Consilience is a mode of reasoning that assigns a degree of plausibility to a hypothesis based on its fit with multiple pieces of evidence from independent sources. I argue that this approach resolves the questions raised by the orthodox approach and may be a useful framework for optimizing future clinical validation studies in the science of consciousness.
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Affiliation(s)
- Andrew Peterson
- Rotman Institute of Philosophy and The Brain and Mind Institute,
University of Western Ontario, London, ON, Canada
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