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Choi W. The conceptual injustice of the brain death standard. THEORETICAL MEDICINE AND BIOETHICS 2024; 45:261-276. [PMID: 38714610 DOI: 10.1007/s11017-024-09663-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 04/09/2024] [Indexed: 05/10/2024]
Abstract
Family disputes over the diagnosis of brain death have caused much controversy in the bioethics literature over the conceptual validity of the brain death standard. Given the tenuous status of brain death as death, it is pragmatically fruitful to reframe intractable debates about the metaphysical nature of brain death as metalinguistic disputes about its conceptual deployment. This new framework leaves the metaphysical debate open and brings into focus the social functions that are served by deploying the concept of brain death. In doing so, it highlights the epistemic injustice of medicolegal authorities that force people to uniformly accept brain death as a diagnosis of death based on normative considerations of institutional interests, such as saving hospital resources and organ supplies, rather than empirical evidence of brain death as death, which is insufficient at best and nonexistent at worst. In light of this injustice, I propose the rejection of the uniform standard of brain death in favor of a choice-based system that respects families' individualized views of death.
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Affiliation(s)
- William Choi
- Warren Alpert Medical School of Brown University, Providence, RI, USA.
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2
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Kazazian K, Edlow BL, Owen AM. Detecting awareness after acute brain injury. Lancet Neurol 2024; 23:836-844. [PMID: 39030043 DOI: 10.1016/s1474-4422(24)00209-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2024] [Revised: 04/28/2024] [Accepted: 05/07/2024] [Indexed: 07/21/2024]
Abstract
Advances over the past two decades in functional neuroimaging have provided new diagnostic and prognostic tools for patients with severe brain injury. Some of the most pertinent developments in this area involve the assessment of residual brain function in patients in the intensive care unit during the acute phase of severe injury, when they are at their most vulnerable and prognosis is uncertain. Advanced neuroimaging techniques, such as functional MRI and EEG, have now been used to identify preserved cognitive processing, including covert conscious awareness, and to relate them to outcome in patients who are behaviourally unresponsive. Yet, technical and logistical challenges to clinical integration of these advanced neuroimaging techniques remain, such as the need for specialised expertise to acquire, analyse, and interpret data and to determine the appropriate timing for such assessments. Once these barriers are overcome, advanced functional neuroimaging technologies could improve diagnosis and prognosis for millions of patients worldwide.
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Affiliation(s)
- Karnig Kazazian
- Western Institute of Neuroscience, Western University, London, ON, Canada.
| | - Brian L Edlow
- Center for Neurotechnology and Neurorecovery, Department of Neurology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA; Athinoula A Martinos Center for Biomedical Imaging, Massachusetts General Hospital, Charlestown, MA, USA
| | - Adrian M Owen
- Western Institute of Neuroscience, Western University, London, ON, Canada; Department of Physiology and Pharmacology and Department of Psychology, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada.
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Keech K, Asiello J. Conscious care: a proposed model to improve interprofessional care of patients with disorders of consciousness in the acute hospital setting. Brain Inj 2024:1-8. [PMID: 39016349 DOI: 10.1080/02699052.2024.2376767] [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: 06/20/2023] [Accepted: 06/30/2024] [Indexed: 07/18/2024]
Abstract
BACKGROUND Forty percent of individuals within the Disorders of Consciousness (DoC) spectrum are misdiagnosed as in a vegetative state/unresponsive wakefulness syndrome (VS/UWS) when in fact they are minimally conscious or emerged, underscoring a need to optimize evaluation techniques and interprofessional care management. PRIMARY OBJECTIVE Conscious Care is a proposed care model that aims to improve interprofessional care of patients with DoC in the hospital setting. The aim of this paper is to describe this model's key ingredients and various components. CONCLUSIONS This care model will advance clinician and caregiver preparedness to manage the complexities of this population and advocate for equal access to post-hospital medical and rehabilitative services. Evaluation and treatment of survivors of DoC should incorporate current evidence which drives continuous quality improvement and education to clinicians across the continuum of care. Immediate action must be taken to decrease the vulnerability and neglect of this marginalized population. Conscious Care is an innovative, sustainable solution that will improve interprofessional awareness of best practices and available science, strengthen care, and advocate for the right to quality of life that this population is so often denied.
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Affiliation(s)
- Kristen Keech
- Department of Rehabilitation Services, The Queen's Medical Center, Certified Brain Injury Specialist, Honolulu, Hawaii, USA
- Adjunct Professor, Department of Occupational Therapy, Hawaii Pacific University, Honolulu, Hawaii, USA
| | - Jessica Asiello
- Assistant Professor, Department of Occupational Therapy, MGH Institute of Health Professions, Boston, Massachusetts, USA
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Barra ME, Solt K, Yu X, Edlow BL. Restoring consciousness with pharmacologic therapy: Mechanisms, targets, and future directions. Neurotherapeutics 2024:e00374. [PMID: 39019729 DOI: 10.1016/j.neurot.2024.e00374] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2023] [Revised: 04/16/2024] [Accepted: 05/03/2024] [Indexed: 07/19/2024] Open
Abstract
Severe brain injury impairs consciousness by disrupting a broad spectrum of neurotransmitter systems. Emerging evidence suggests that pharmacologic modulation of specific neurotransmitter systems, such as dopamine, promotes recovery of consciousness. Clinical guidelines now endorse the use of amantadine in individuals with traumatic disorders of consciousness (DoC) based on level 1 evidence, and multiple neurostimulants are used off-label in clinical practice, including methylphenidate, modafinil, bromocriptine, levodopa, and zolpidem. However, the relative contributions of monoaminergic, glutamatergic, cholinergic, GABAergic, and orexinergic neurotransmitter systems to recovery of consciousness after severe brain injury are unknown, and personalized approaches to targeted therapy have yet to be developed. This review summarizes the state-of-the-science in the neurochemistry and neurobiology of neurotransmitter systems involved in conscious behaviors, followed by a discussion of how pharmacologic therapies may be used to modulate these neurotransmitter systems and promote recovery of consciousness. We consider pharmacologic modulation of consciousness at the synapse, circuit, and network levels, with a focus on the mesocircuit model that has been proposed to explain the consciousness-promoting effects of various monoaminergic, glutamatergic, and paradoxically, GABAergic therapies. Though fundamental questions remain about neurotransmitter mechanisms, target engagement and optimal therapy selection for individual patients, we propose that pharmacologic therapies hold great promise to promote recovery and improve quality of life for patients with severe brain injuries.
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Affiliation(s)
- Megan E Barra
- Department of Pharmacy, Massachusetts General Hospital, Boston, MA, USA; Center for Neurotechnology and Neurorecovery, Massachusetts General Hospital, Boston, MA, USA
| | - Ken Solt
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Xin Yu
- Department of Radiology, Athinoula A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital, Boston, MA, USA
| | - Brian L Edlow
- Center for Neurotechnology and Neurorecovery, Massachusetts General Hospital, Boston, MA, USA; Department of Radiology, Athinoula A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital, Boston, MA, USA; Department of Neurology, Massachusetts General Hospital, Boston, MA, USA.
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He Q, Yang C, Xu Y, Niu H, Wu H, Huang H, Chai X, Cao T, Wang N, Wong P, He J, Yang Y, Zhao J. Anatomical-related factors and outcome of percutaneous short-term spinal cord stimulation electrode shift in patients with disorders of consciousness: a retrospective study. Front Aging Neurosci 2024; 16:1403156. [PMID: 39015472 PMCID: PMC11249574 DOI: 10.3389/fnagi.2024.1403156] [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: 03/18/2024] [Accepted: 06/17/2024] [Indexed: 07/18/2024] Open
Abstract
Background Disorders of consciousness (DoC) represent a spectrum of neurological conditions that pose significant treatment challenges. Percutaneous short-term spinal cord stimulation (SCS) has emerged as a promising experimental diagnostic treatment to assess and potentially improve consciousness levels. However, the effectiveness of this intervention is frequently compromised by the shift of electrodes, particularly in the cervical region, which can negatively affect therapeutic outcomes. Methods This retrospective study aimed to study if electrodes shift in percutaneous short-term SCS in patients with DoC would affect the outcome. We analyzed the relationship between electrode shift length and patient outcome, as well as the correlation with various anatomical parameters, including the actual length of the cervical spine, linear length, spinal canal transverse diameter, spinal canal diameter, and C2 cone height, in a cohort of patients undergoing the procedure. Results Our findings revealed that in patients with better outcome, there are significant less patient with electrode shift (p = 0.019). Further, a linear correlation was found between the length of electrode shift and patients' outcome (Rho = 0.583, p = 0.002), with longer shift lengths associated with poorer outcomes. Contrary to our expectations, there was no significant association between the measured anatomical parameters and the extent of electrode shift. However, a trend was found between the actual length of the cervical spine and the shift of the electrode (p = 0.098). Notably, the shorter spinal canal transverse diameter was found to be significantly associated with better outcome in patients with DoC receiving percutaneous short-term SCS (p = 0.033). Conclusion These results highlight the clinical importance of electrode stability in the cervical region during SCS treatment for patients with DoC. Ensuring secure placement of electrodes may play a crucial role in enhancing patients' outcome and minimize postoperative complications. Given the lack of association with expected anatomical parameters, future research should investigate other factors that could impact electrode stability to optimize this therapeutic intervention.
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Affiliation(s)
- Qiheng He
- Brain Computer Interface Transitional Research Center, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Chaozhi Yang
- Department of Neurosurgery, Affiliated Hospital of Zunyi Medical University, Zunyi, Guizhou, China
| | - Yangxi Xu
- Department of Neurosurgery, The People’s Hospital of Liaoning Province, Shengyang, China
| | - Hongchuan Niu
- Department of Neurosurgery, Peking University International Hospital, Beijing, China
| | - Haitao Wu
- Department of Neurosurgery, Affiliated Hospital of Zunyi Medical University, Zunyi, Guizhou, China
| | - Haitao Huang
- Department of Neurosurgery, The People’s Hospital of Liaoning Province, Shengyang, China
| | - Xiaoke Chai
- Brain Computer Interface Transitional Research Center, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Center for Neurological Disorders, Beijing, China
| | - Tianqing Cao
- Brain Computer Interface Transitional Research Center, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Nan Wang
- Brain Computer Interface Transitional Research Center, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Peiling Wong
- Department of Physical Therapy and Assistive Technology, National Yang Ming Chiao Tung University, Hsinchu, Taiwan
| | - Jianghong He
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yi Yang
- Brain Computer Interface Transitional Research Center, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Center for Neurological Disorders, Beijing, China
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- Chinese Institute for Brain Research, Beijing, China
- Beijing Institute of Brain Disorders, Beijing, China
| | - Jizong Zhao
- China National Center for Neurological Disorders, Beijing, China
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
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Woodward MR, Wells CL, Arnold S, Dorman F, Ahmed Z, Morris NA, Ciryam P, Podell JE, Chang WTW, Zimmerman WD, Motta M, Butt B, Pergakis MB, Labib M, Wang TI, Edlow BL, Badjatia N, Braun R, Parikh GY. Behavioral Assessment With the Coma Recovery Scale-Revised Is Safe and Feasible in Critically Ill Patients With Disorders of Consciousness. Crit Care Explor 2024; 6:e1101. [PMID: 38912722 PMCID: PMC11199005 DOI: 10.1097/cce.0000000000001101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/25/2024] Open
Abstract
OBJECTIVES Accurate classification of disorders of consciousness (DoC) is key in developing rehabilitation plans after brain injury. The Coma Recovery Scale-Revised (CRS-R) is a sensitive measure of consciousness validated in the rehabilitation phase of care. We tested the feasibility, safety, and impact of CRS-R-guided rehabilitation in the ICU for patients with DoC after acute hemorrhagic stroke. DESIGN Retrospective cohort study. SETTING This single-center study was conducted in the neurocritical care unit at the University of Maryland Medical Center. PATIENTS We analyzed records from consecutive patients with subarachnoid hemorrhage (SAH) or intracerebral hemorrhage (ICH), who underwent serial CRS-R assessments during ICU admission from April 1, 2018, to December 31, 2021, where CRS-R less than 8 is vegetative state/unresponsive wakefulness syndrome (VS/UWS); CRS-R greater than or equal to 8 is a minimally conscious state (MCS). INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Outcomes included adverse events during CRS-R evaluations and associations between CRS-R and discharge disposition, therapy-based function, and mobility. We examined the utility of CRS-R compared with other therapist clinical assessment tools in predicting discharge disposition. Seventy-six patients (22 SAH, 54 ICH, median age = 59, 50% female) underwent 276 CRS-R sessions without adverse events. Discharge to acute rehabilitation occurred in 4.4% versus 41.9% of patients with a final CRS-R less than 8 and CRS-R greater than or equal to 8, respectively (odds ratio [OR] 13.4; 95% CI, 2.7-66.1; p < 0.001). Patients with MCS on final CRS-R completed more therapy sessions during hospitalization and had improved mobility and functional performance. Compared with other therapy assessment tools, the CRS-R had the best performance in predicting discharge disposition (area under the curve: 0.83; 95% CI, 0.72-0.94; p < 0.0001). CONCLUSIONS Early neurorehabilitation guided by CRS-R appears to be feasible and safe in the ICU following hemorrhagic stroke complicated by DoC and may enhance access to inpatient rehabilitation, with the potential for lasting benefit on recovery. Further research is needed to assess generalizability and understand the impact on long-term outcomes.
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Affiliation(s)
| | - Chris L. Wells
- Department of Rehabilitation Medicine, University of Maryland School of Medicine, Baltimore, MD
| | - Shannon Arnold
- Department of Neurology, University of Maryland School of Medicine, Baltimore, MD
| | - Farra Dorman
- Department of Rehabilitation Medicine, University of Maryland School of Medicine, Baltimore, MD
| | - Zaka Ahmed
- Department of Neurology, University of Maryland School of Medicine, Baltimore, MD
| | - Nicholas A. Morris
- Program in Trauma, R Adams Cowley Shock Trauma Center, Baltimore, MD
- Department of Neurology, University of Maryland School of Medicine, Baltimore, MD
| | - Prajwal Ciryam
- Program in Trauma, R Adams Cowley Shock Trauma Center, Baltimore, MD
- Department of Neurology, University of Maryland School of Medicine, Baltimore, MD
| | - Jamie E. Podell
- Program in Trauma, R Adams Cowley Shock Trauma Center, Baltimore, MD
- Department of Neurology, University of Maryland School of Medicine, Baltimore, MD
| | - Wan-Tsu W. Chang
- Program in Trauma, R Adams Cowley Shock Trauma Center, Baltimore, MD
- Department of Neurology, University of Maryland School of Medicine, Baltimore, MD
- Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, MD
| | - W. Denney Zimmerman
- Program in Trauma, R Adams Cowley Shock Trauma Center, Baltimore, MD
- Department of Neurology, University of Maryland School of Medicine, Baltimore, MD
| | - Melissa Motta
- Program in Trauma, R Adams Cowley Shock Trauma Center, Baltimore, MD
- Department of Neurology, University of Maryland School of Medicine, Baltimore, MD
| | - Bilal Butt
- Program in Trauma, R Adams Cowley Shock Trauma Center, Baltimore, MD
- Department of Neurology, University of Maryland School of Medicine, Baltimore, MD
| | - Melissa B. Pergakis
- Program in Trauma, R Adams Cowley Shock Trauma Center, Baltimore, MD
- Department of Neurology, University of Maryland School of Medicine, Baltimore, MD
| | - Mohamed Labib
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, MD
| | - Ting I. Wang
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, MD
| | - Brian L. Edlow
- Department of Neurology, Massachusetts General Hospital, Boston, MA
| | - Neeraj Badjatia
- Program in Trauma, R Adams Cowley Shock Trauma Center, Baltimore, MD
- Department of Neurology, University of Maryland School of Medicine, Baltimore, MD
| | - Robynne Braun
- Department of Rehabilitation Medicine, University of Maryland School of Medicine, Baltimore, MD
- Department of Neurology, University of Maryland School of Medicine, Baltimore, MD
| | - Gunjan Y. Parikh
- Program in Trauma, R Adams Cowley Shock Trauma Center, Baltimore, MD
- Department of Neurology, University of Maryland School of Medicine, Baltimore, MD
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Fins JJ, Shulman KS. Neuroethics, Covert Consciousness, and Disability Rights: What Happens When Artificial Intelligence Meets Cognitive Motor Dissociation? J Cogn Neurosci 2024; 36:1667-1674. [PMID: 38579252 DOI: 10.1162/jocn_a_02157] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/07/2024]
Abstract
In this article, we consider the intersection of cognitive motor dissociation (CMD) and artificial intelligence (AI), hence when CMD meets AI. In covert consciousness, there is a discordance between the observed behavior, the traditional bedside mode of assessment, and the response to volitional commands as depicted by neuroimaging or EEG studies. This alphabet soup of acronyms represents both the promise and peril of nascent technology in covert consciousness. On the diagnostic side, there is the complexity and uncertainty of identifying the discordance between cognitive activity and overt behavior. On the therapeutic side, when AI is used to generate speech, there is the possibility of misrepresenting the thoughts and intentions of those who are otherwise voiceless. This concordance of factors makes the application of AI to CMD worthy of deeper consideration. We offer this analysis in the spirit of anticipatory governance, a prudential process by which one plans to prevent or mitigate unintended consequences of novel technology. We first consider the normative challenges posed by CMD for clinical practice, neuroethics, and the law. We then explore the history of covert consciousness and the relationship of severe brain injury to the right-to-die movement, before introducing three biographies of brain injury that highlight the potential impact of disability bias or ableism in clinical practice, assistive technology, and translational research. Subsequently, we explore how AI might give voice to conscious individuals who are unable to communicate and the ethical challenges that this technology must overcome to promote human flourishing drawing upon what Nussbaum and Sen have described as a "capabilities approach" to promote normative reasoning.
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Xiao Q, Zheng X, Wen Y, Yuan Z, Chen Z, Lan Y, Li S, Huang X, Zhong H, Xu C, Zhan C, Pan J, Xie Q. Individualized music induces theta-gamma phase-amplitude coupling in patients with disorders of consciousness. Front Neurosci 2024; 18:1395627. [PMID: 39010944 PMCID: PMC11248187 DOI: 10.3389/fnins.2024.1395627] [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: 03/04/2024] [Accepted: 06/18/2024] [Indexed: 07/17/2024] Open
Abstract
Objective This study aimed to determine whether patients with disorders of consciousness (DoC) could experience neural entrainment to individualized music, which explored the cross-modal influences of music on patients with DoC through phase-amplitude coupling (PAC). Furthermore, the study assessed the efficacy of individualized music or preferred music (PM) versus relaxing music (RM) in impacting patient outcomes, and examined the role of cross-modal influences in determining these outcomes. Methods Thirty-two patients with DoC [17 with vegetative state/unresponsive wakefulness syndrome (VS/UWS) and 15 with minimally conscious state (MCS)], alongside 16 healthy controls (HCs), were recruited for this study. Neural activities in the frontal-parietal network were recorded using scalp electroencephalography (EEG) during baseline (BL), RM and PM. Cerebral-acoustic coherence (CACoh) was explored to investigate participants' abilitiy to track music, meanwhile, the phase-amplitude coupling (PAC) was utilized to evaluate the cross-modal influences of music. Three months post-intervention, the outcomes of patients with DoC were followed up using the Coma Recovery Scale-Revised (CRS-R). Results HCs and patients with MCS showed higher CACoh compared to VS/UWS patients within musical pulse frequency (p = 0.016, p = 0.045; p < 0.001, p = 0.048, for RM and PM, respectively, following Bonferroni correction). Only theta-gamma PAC demonstrated a significant interaction effect between groups and music conditions (F (2,44) = 2.685, p = 0.036). For HCs, the theta-gamma PAC in the frontal-parietal network was stronger in the PM condition compared to the RM (p = 0.016) and BL condition (p < 0.001). For patients with MCS, the theta-gamma PAC was stronger in the PM than in the BL (p = 0.040), while no difference was observed among the three music conditions in patients with VS/UWS. Additionally, we found that MCS patients who showed improved outcomes after 3 months exhibited evident neural responses to preferred music (p = 0.019). Furthermore, the ratio of theta-gamma coupling changes in PM relative to BL could predict clinical outcomes in MCS patients (r = 0.992, p < 0.001). Conclusion Individualized music may serve as a potential therapeutic method for patients with DoC through cross-modal influences, which rely on enhanced theta-gamma PAC within the consciousness-related network.
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Affiliation(s)
- Qiuyi Xiao
- Joint Research Centre for Disorders of Consciousness, Department of Rehabilitation Medicine, Zhujiang Hospital, Southern Medical University, Guangzhou, Guangdong, China
- School of Laboratory Medicine and Biotechnology, Southern Medical University, Guangzhou, Guangdong, China
| | - Xiaochun Zheng
- Joint Research Centre for Disorders of Consciousness, Department of Rehabilitation Medicine, Zhujiang Hospital, Southern Medical University, Guangzhou, Guangdong, China
- School of Laboratory Medicine and Biotechnology, Southern Medical University, Guangzhou, Guangdong, China
| | - Yun Wen
- Music and Reflection Incorporated, Guangzhou, Guangdong, China
| | - Zhanxing Yuan
- Joint Research Centre for Disorders of Consciousness, Department of Rehabilitation Medicine, Zhujiang Hospital, Southern Medical University, Guangzhou, Guangdong, China
| | - Zerong Chen
- Joint Research Centre for Disorders of Consciousness, Department of Rehabilitation Medicine, Zhujiang Hospital, Southern Medical University, Guangzhou, Guangdong, China
- School of Laboratory Medicine and Biotechnology, Southern Medical University, Guangzhou, Guangdong, China
| | - Yue Lan
- Joint Research Centre for Disorders of Consciousness, Department of Rehabilitation Medicine, Zhujiang Hospital, Southern Medical University, Guangzhou, Guangdong, China
| | - Shuiyan Li
- Joint Research Centre for Disorders of Consciousness, Department of Rehabilitation Medicine, Zhujiang Hospital, Southern Medical University, Guangzhou, Guangdong, China
- School of Laboratory Medicine and Biotechnology, Southern Medical University, Guangzhou, Guangdong, China
| | - Xiyan Huang
- Joint Research Centre for Disorders of Consciousness, Department of Rehabilitation Medicine, Zhujiang Hospital, Southern Medical University, Guangzhou, Guangdong, China
| | - Haili Zhong
- Joint Research Centre for Disorders of Consciousness, Department of Rehabilitation Medicine, Zhujiang Hospital, Southern Medical University, Guangzhou, Guangdong, China
| | - Chengwei Xu
- Joint Research Centre for Disorders of Consciousness, Department of Rehabilitation Medicine, Zhujiang Hospital, Southern Medical University, Guangzhou, Guangdong, China
| | - Chang'an Zhan
- Guangdong Provincial Key Laboratory of Medical Image Processing, Southern Medical University, Guangzhou, Guangdong, China
| | - Jiahui Pan
- School of Software, South China Normal University, Guangzhou, Guangdong, China
| | - Qiuyou Xie
- Joint Research Centre for Disorders of Consciousness, Department of Rehabilitation Medicine, Zhujiang Hospital, Southern Medical University, Guangzhou, Guangdong, China
- School of Laboratory Medicine and Biotechnology, Southern Medical University, Guangzhou, Guangdong, China
- Department of Hyperbaric Oxygen, Zhujiang Hospital, Southern Medical University, Guangzhou, Guangdong, China
- School of Rehabilitation Sciences, Southern Medical University, Guangzhou, Guangdong, China
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Liu W, Guo Y, Xie J, Wu Y, Zhao D, Xing Z, Fu X, Zhou S, Zhang H, Wang X. Establishment and validation of a bad outcomes prediction model based on EEG and clinical parameters in prolonged disorder of consciousness. Front Hum Neurosci 2024; 18:1387471. [PMID: 38952644 PMCID: PMC11215084 DOI: 10.3389/fnhum.2024.1387471] [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: 02/17/2024] [Accepted: 06/04/2024] [Indexed: 07/03/2024] Open
Abstract
Objective This study aimed to explore the electroencephalogram (EEG) indicators and clinical factors that may lead to poor prognosis in patients with prolonged disorder of consciousness (pDOC), and establish and verify a clinical predictive model based on these factors. Methods This study included 134 patients suffering from prolonged disorder of consciousness enrolled in our department of neurosurgery. We collected the data of sex, age, etiology, coma recovery scales (CRS-R) score, complications, blood routine, liver function, coagulation and other laboratory tests, resting EEG data and follow-up after discharge. These patients were divided into two groups: training set (n = 107) and verification set (n = 27). These patients were divided into a training set of 107 and a validation set of 27 for this study. Univariate and multivariate regression analysis were used to determine the factors affecting the poor prognosis of pDOC and to establish nomogram model. We use the receiver operating characteristic (ROC) and calibration curves to quantitatively test the effectiveness of the training set and the verification set. In order to further verify the clinical practical value of the model, we use decision curve analysis (DCA) to evaluate the model. Result The results from univariate and multivariate logistic regression analyses suggested that an increased frequency of occurrence microstate A, reduced CRS-R scores at the time of admission, the presence of episodes associated with paroxysmal sympathetic hyperactivity (PSH), and decreased fibrinogen levels all function as independent prognostic factors. These factors were used to construct the nomogram. The training and verification sets had areas under the curve of 0.854 and 0.920, respectively. Calibration curves and DCA demonstrated good model performance and significant clinical benefits in both sets. Conclusion This study is based on the use of clinically available and low-cost clinical indicators combined with EEG to construct a highly applicable and accurate model for predicting the adverse prognosis of patients with prolonged disorder of consciousness. It provides an objective and reliable tool for clinicians to evaluate the prognosis of prolonged disorder of consciousness, and helps clinicians to provide personalized clinical care and decision-making for patients with prolonged disorder of consciousness and their families.
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Affiliation(s)
- Wanqing Liu
- Department of Neurosurgery, The Fifth Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Yongkun Guo
- Department of Neurosurgery, The Fifth Affiliated Hospital of Zhengzhou University, Zhengzhou, China
- Henan Engineering Research Center for Prevention and Treatment of Brain Injuries, Zhengzhou, China
- Henan Key Laboratory of Brain Science and Brain Computer Interface Technology, Zhengzhou, China
| | - Jingwei Xie
- Department of Neurosurgery, The Fifth Affiliated Hospital of Zhengzhou University, Zhengzhou, China
- Henan Engineering Research Center for Prevention and Treatment of Brain Injuries, Zhengzhou, China
- Henan Key Laboratory of Brain Science and Brain Computer Interface Technology, Zhengzhou, China
| | - Yanzhi Wu
- Department of Neurosurgery, The Fifth Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Dexiao Zhao
- Department of Neurosurgery, The Fifth Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Zhe Xing
- Department of Neurosurgery, The Fifth Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Xudong Fu
- Department of Neurosurgery, The Fifth Affiliated Hospital of Zhengzhou University, Zhengzhou, China
- Henan Engineering Research Center for Prevention and Treatment of Brain Injuries, Zhengzhou, China
- Henan Key Laboratory of Brain Science and Brain Computer Interface Technology, Zhengzhou, China
| | - Shaolong Zhou
- Department of Neurosurgery, The Fifth Affiliated Hospital of Zhengzhou University, Zhengzhou, China
- Henan Engineering Research Center for Prevention and Treatment of Brain Injuries, Zhengzhou, China
- Henan Key Laboratory of Brain Science and Brain Computer Interface Technology, Zhengzhou, China
| | - Hengwei Zhang
- Department of Neurosurgery, The Fifth Affiliated Hospital of Zhengzhou University, Zhengzhou, China
- Henan Engineering Research Center for Prevention and Treatment of Brain Injuries, Zhengzhou, China
- Henan Key Laboratory of Brain Science and Brain Computer Interface Technology, Zhengzhou, China
| | - Xinjun Wang
- Department of Neurosurgery, The Fifth Affiliated Hospital of Zhengzhou University, Zhengzhou, China
- Henan Engineering Research Center for Prevention and Treatment of Brain Injuries, Zhengzhou, China
- Henan Key Laboratory of Brain Science and Brain Computer Interface Technology, Zhengzhou, China
- Department of Neurosurgery, The Third Affiliated Hospital of Zhengzhou University, Zhengzhou, China
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10
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Muehlschlegel S. Prognostication in Neurocritical Care. Continuum (Minneap Minn) 2024; 30:878-903. [PMID: 38830074 DOI: 10.1212/con.0000000000001433] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/05/2024]
Abstract
OBJECTIVE This article synthesizes the current literature on prognostication in neurocritical care, identifies existing challenges, and proposes future research directions to reduce variability and enhance scientific and patient-centered approaches to neuroprognostication. LATEST DEVELOPMENTS Patients with severe acute brain injury often lack the capacity to make their own medical decisions, leaving surrogate decision makers responsible for life-or-death choices. These decisions heavily rely on clinicians' prognostication, which is still considered an art because of the previous lack of specific guidelines. Consequently, there is significant variability in neuroprognostication practices. This article examines various aspects of neuroprognostication. It explores the cognitive approach to prognostication, highlights the use of statistical modeling such as Bayesian models and machine learning, emphasizes the importance of clinician-family communication during prognostic disclosures, and proposes shared decision making for more patient-centered care. ESSENTIAL POINTS This article identifies ongoing challenges in the field and emphasizes the need for future research to ameliorate variability in neuroprognostication. By focusing on scientific methodologies and patient-centered approaches, this research aims to provide guidance and tools that may enhance neuroprognostication in neurocritical care.
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Lejeune N, Fritz P, Cardone P, Szymkowicz E, Vitello MM, Martial C, Thibaut A, Gosseries O. Exploring the Significance of Cognitive Motor Dissociation on Patient Outcome in Acute Disorders of Consciousness. Semin Neurol 2024; 44:271-280. [PMID: 38604229 DOI: 10.1055/s-0044-1785507] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/13/2024]
Abstract
Cognitive motor dissociation (CMD) is characterized by a dissociation between volitional brain responses and motor control, detectable only through techniques such as electroencephalography (EEG) and functional magnetic resonance imaging. Hence, it has recently emerged as a major challenge in the assessment of patients with disorders of consciousness. Specifically, this review focuses on the prognostic implications of CMD detection during the acute stage of brain injury. CMD patients were identified in each diagnostic category (coma, unresponsive wakefulness syndrome/vegetative state, minimally conscious state minus) with a relatively similar prevalence of around 20%. Current knowledge tends to indicate that the diagnosis of CMD in the acute phase often predicts a more favorable clinical outcome compared with other unresponsive non-CMD patients. Nevertheless, the review underscores the limited research in this domain, probably at least partially explained by its nascent nature and the lack of uniformity in the nomenclature for CMD-related disorders, hindering the impact of the literature in the field.
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Affiliation(s)
- Nicolas Lejeune
- Coma Science Group, GIGA-Consciousness, University of Liège, Liège, Belgium
- Centre du Cerveau, University Hospital of Liège, Liège, Belgium
- DoC Care Unit, Centre Hospitalier Neurologique William Lennox, Ottignies-Louvain-la-Neuve, Belgium
- Institute of NeuroScience, UCLouvain, Brussels, Belgium
| | - Pauline Fritz
- Coma Science Group, GIGA-Consciousness, University of Liège, Liège, Belgium
- Centre du Cerveau, University Hospital of Liège, Liège, Belgium
| | - Paolo Cardone
- Coma Science Group, GIGA-Consciousness, University of Liège, Liège, Belgium
- Centre du Cerveau, University Hospital of Liège, Liège, Belgium
| | - Emilie Szymkowicz
- Coma Science Group, GIGA-Consciousness, University of Liège, Liège, Belgium
- Centre du Cerveau, University Hospital of Liège, Liège, Belgium
| | - Marie M Vitello
- Coma Science Group, GIGA-Consciousness, University of Liège, Liège, Belgium
- Centre du Cerveau, University Hospital of Liège, Liège, Belgium
| | - Charlotte Martial
- Coma Science Group, GIGA-Consciousness, University of Liège, Liège, Belgium
- Centre du Cerveau, University Hospital of Liège, Liège, Belgium
| | - Aurore Thibaut
- Coma Science Group, GIGA-Consciousness, University of Liège, Liège, Belgium
- Centre du Cerveau, University Hospital of Liège, Liège, Belgium
| | - Olivia Gosseries
- Coma Science Group, GIGA-Consciousness, University of Liège, Liège, Belgium
- Centre du Cerveau, University Hospital of Liège, Liège, Belgium
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12
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Wang Y, Li Z, Wu Y, Zhao G, Cheng Y, Feng K, Yin S. Analysis of Factors Related to the Efficacy of Consciousness-Regaining Therapy for Prolonged Disorder of Consciousness: A Retrospective Cohort Study. World Neurosurg 2024; 186:e600-e607. [PMID: 38599375 DOI: 10.1016/j.wneu.2024.04.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2024] [Revised: 04/01/2024] [Accepted: 04/02/2024] [Indexed: 04/12/2024]
Abstract
OBJECTIVE To analyze the factors related to the efficacy of consciousness-regaining therapy (CRT) for prolonged disorder of consciousness. METHODS A retrospective analysis was conducted on the case data of 114 patients with prolonged disorder of consciousness (pDOC) admitted to the Department of Functional Neurosurgery of Tianjin Huanhu Hospital from January 2019 to January 2022 to explore the relevant factors that affect the efficacy of CRT for pDOC. Next, basic information on the cases, data on pDOC disease assessment, CRT methods, and efficacy evaluation were collected. RESULTS These 114 patients were grouped, and a comparative analysis was done based on the efficacy at the end of treatment. Of these, 61 cases were allotted to the ineffective group and 53 cases to the effective group. There was a lack of statistical difference (P > 0.05) between the 2 groups based on gender, age, etiology, acute cerebral herniation, emergency craniotomy surgery, emergency decompressive craniectomy, time from onset to start of CRT, and CRT duration (P > 0.05). However, secondary hydrocephalus, CRT methods, JFK Coma Recovery Scale-Revised grading before treatment, and extended Glasgow Outcome Scale score at six months after treatment were found to be statistically different. The results of binary logistic regression analysis showed that the type of therapy (OR = 0.169, 95% CI: 0.057-0.508) affected the efficacy of CRT (P < 0.05). CONCLUSIONS Personalized awakening therapy using various invasive CRT methods could improve the efficacy of therapy for pDOC compared with noninvasive therapy.
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Affiliation(s)
- Yan'gang Wang
- Clinical College of Neurology, Neurosurgery and Neurorehabilitation, Tianjin Medical University, Tianjin, China; Department of Neurosurgery, Jiaozuo People's Hospital, Jiaozuo, China
| | - Zhongzhen Li
- Clinical College of Neurology, Neurosurgery and Neurorehabilitation, Tianjin Medical University, Tianjin, China
| | - Yuzhang Wu
- Clinical College of Neurology, Neurosurgery and Neurorehabilitation, Tianjin Medical University, Tianjin, China
| | - Guangrui Zhao
- Clinical College of Neurology, Neurosurgery and Neurorehabilitation, Tianjin Medical University, Tianjin, China
| | - Yifeng Cheng
- Department of Neurosurgery, Tianjin Huanhu Hospital, Tianjin, China
| | - Keke Feng
- Department of Neurosurgery, Tianjin Huanhu Hospital, Tianjin, China
| | - Shaoya Yin
- Department of Neurosurgery, Tianjin Huanhu Hospital, Tianjin, China.
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Wang X, Yang Y, Laforge G, Chen X, Norton L, Owen AM, He J, Cong F. Global Field Time-Frequency Representation-Based Discriminative Similarity Analysis of Passive Auditory ERPs for Diagnosis of Disorders of Consciousness. IEEE Trans Biomed Eng 2024; 71:1820-1830. [PMID: 38215326 DOI: 10.1109/tbme.2024.3353110] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2024]
Abstract
Behavioural diagnosis of patients with disorders of consciousness (DOC) is challenging and prone to inaccuracies. Consequently, there have been increased efforts to develop bedside assessment based on EEG and event-related potentials (ERPs) that are more sensitive to the neural factors supporting conscious awareness. However, individual detection of residual consciousness using these techniques is less established. Here, we hypothesize that the cross-state similarity (defined as the similarity between healthy and impaired conscious states) of passive brain responses to auditory stimuli can index the level of awareness in individual DOC patients. To this end, we introduce the global field time-frequency representation-based discriminative similarity analysis (GFTFR-DSA). This method quantifies the average cross-state similarity index between an individual patient and our constructed healthy templates using the GFTFR as an EEG feature. We demonstrate that the proposed GFTFR feature exhibits superior within-group consistency in 34 healthy controls over traditional EEG features such as temporal waveforms. Second, we observed the GFTFR-based similarity index was significantly higher in patients with a minimally conscious state (MCS, 40 patients) than those with unresponsive wakefulness syndrome (UWS, 54 patients), supporting our hypothesis. Finally, applying a linear support vector machine classifier for individual MCS/UWS classification, the model achieved a balanced accuracy and F1 score of 0.77. Overall, our findings indicate that combining discriminative and interpretable markers, along with automatic machine learning algorithms, is effective for the differential diagnosis in patients with DOC. Importantly, this approach can, in principle, be transferred into any ERP of interest to better inform DOC diagnoses.
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Plante V, Basu M, Gettings JV, Luchette M, LaRovere KL. Update in Pediatric Neurocritical Care: What a Neurologist Caring for Critically Ill Children Needs to Know. Semin Neurol 2024; 44:362-388. [PMID: 38788765 DOI: 10.1055/s-0044-1787047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/26/2024]
Abstract
Currently nearly one-quarter of admissions to pediatric intensive care units (PICUs) worldwide are for neurocritical care diagnoses that are associated with significant morbidity and mortality. Pediatric neurocritical care is a rapidly evolving field with unique challenges due to not only age-related responses to primary neurologic insults and their treatments but also the rarity of pediatric neurocritical care conditions at any given institution. The structure of pediatric neurocritical care services therefore is most commonly a collaborative model where critical care medicine physicians coordinate care and are supported by a multidisciplinary team of pediatric subspecialists, including neurologists. While pediatric neurocritical care lies at the intersection between critical care and the neurosciences, this narrative review focuses on the most common clinical scenarios encountered by pediatric neurologists as consultants in the PICU and synthesizes the recent evidence, best practices, and ongoing research in these cases. We provide an in-depth review of (1) the evaluation and management of abnormal movements (seizures/status epilepticus and status dystonicus); (2) acute weakness and paralysis (focusing on pediatric stroke and select pediatric neuroimmune conditions); (3) neuromonitoring modalities using a pathophysiology-driven approach; (4) neuroprotective strategies for which there is evidence (e.g., pediatric severe traumatic brain injury, post-cardiac arrest care, and ischemic stroke and hemorrhagic stroke); and (5) best practices for neuroprognostication in pediatric traumatic brain injury, cardiac arrest, and disorders of consciousness, with highlights of the 2023 updates on Brain Death/Death by Neurological Criteria. Our review of the current state of pediatric neurocritical care from the viewpoint of what a pediatric neurologist in the PICU needs to know is intended to improve knowledge for providers at the bedside with the goal of better patient care and outcomes.
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Affiliation(s)
- Virginie Plante
- Division of Critical Care Medicine, Department of Anesthesiology, Perioperative and Pain Medicine, Boston Children's Hospital, Boston, Massachusetts
| | - Meera Basu
- Division of Critical Care Medicine, Department of Anesthesiology, Perioperative and Pain Medicine, Boston Children's Hospital, Boston, Massachusetts
- Department of Neurology, Boston Children's Hospital, Boston, Massachusetts
| | | | - Matthew Luchette
- Division of Critical Care Medicine, Department of Anesthesiology, Perioperative and Pain Medicine, Boston Children's Hospital, Boston, Massachusetts
| | - Kerri L LaRovere
- Department of Neurology, Boston Children's Hospital, Boston, Massachusetts
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Yakhkind A, Niznick N, Bodien YG, Hammond FM, Katz D, Luaute J, McNett M, Naccache L, O'Brien K, Schnakers C, Sharshar T, Slomine BS, Giacino JT. Common Data Elements for Disorders of Consciousness: Recommendations from the Working Group on Behavioral Phenotyping. Neurocrit Care 2024; 40:909-917. [PMID: 37726548 DOI: 10.1007/s12028-023-01844-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2023] [Accepted: 07/26/2023] [Indexed: 09/21/2023]
Abstract
BACKGROUND The recent publication of practice guidelines for management of patients with disorders of consciousness (DoC) in the United States and Europe was a major step forward in improving the accuracy and consistency of terminology, diagnostic criteria, and prognostication in this population. There remains a pressing need for a more precise brain injury classification system that combines clinical semiology with neuroimaging, electrophysiologic, and other biomarker data. To address this need, the National Institute of Neurological Disorders and Stroke launched the Common Data Elements (CDEs) initiative to facilitate systematic collection of high-quality research data in studies involving patients with neurological disease. The Neurocritical Care Society's Curing Coma Campaign expanded this effort in 2018 to develop CDEs for DoC. Herein, we present CDE recommendations for behavioral phenotyping of patients with DoC. METHODS The Behavioral Phenotyping Workgroup used a preestablished, five-step process to identify and select candidate CDEs that included review of existing National Institute of Neurological Disorders and Stroke CDEs, nomination and systematic vetting of new CDEs, CDE classification, iterative review, and approval of panel recommendations and development of corresponding case review forms. RESULTS We identified a slate of existing and newly proposed basic, supplemental, and exploratory CDEs that can be used for behavioral phenotyping of adult and pediatric patients with DoC. CONCLUSIONS The proposed behavioral phenotyping CDEs will assist with international harmonization of DoC studies and allow for more precise characterization of study cohorts, favorably impacting observational studies and clinical trials aimed at improving outcome in this population.
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Affiliation(s)
- Aleksandra Yakhkind
- Department of Neurology, Tufts University School of Medicine, Boston, MA, USA
| | - Naomi Niznick
- Department of Medicine (Critical Care), The Ottawa Hospital, Ottawa, Canada
| | - Yelena G Bodien
- Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Charlestown, MA, USA
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Flora M Hammond
- Department of Physical Medicine and Rehabilitation, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Douglas Katz
- Department of Neurology, Boston University Chobanian & Avedisian School of Medicine, and Brain Injury Program, Encompass Health Braintree Rehabilitation Hospital, Braintree, MA, USA
| | - Jacques Luaute
- Department of Neuro-Rehabilitation, Hospices Civils de Lyon, Université Claude Bernard Lyon 1, Lyon, France
| | - Molly McNett
- College of Nursing, The Ohio State University, Columbus, OH, USA
| | - Lionel Naccache
- Sorbonne Université, Paris Brain Institute - Institut du Cerveau, ICM, INSERM, CNRS, AP-HP, Pitié-Salpêtrière Hospital, Paris, France
| | - Katherine O'Brien
- TIRR Disorders of Consciousness Program, TIRR Memorial Hermann Hospital, H. Ben Taub Department of Physical Medicine and Rehabilitation, Baylor College of Medicine, Houston, TX, USA
| | - Caroline Schnakers
- Research Institute, Casa Colina Hospital and Centers for Healthcare, Pomona, CA, USA
| | - Tarek Sharshar
- Neurosciences, Pole Neuro, Sainte-Anne Hospital, Institute of Psychiatry and Neurosciences of Paris, INSERM U1266, Université Paris Cité, Paris, France
| | - Beth S Slomine
- Department of Neuropsychology, Kennedy Krieger Institute, Baltimore, MD, USA
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Joseph T Giacino
- Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Charlestown, MA, USA.
- Department of Physical Medicine and Rehabilitation, Harvard Medical School, Boston, MA, USA.
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Guo K, Zhang Q, Quan Z, Wang Y, Ma T, Jiang J, Kang F, Wang J. Whole-brain glucose metabolic pattern differentiates minimally conscious state from unresponsive wakefulness syndrome. CNS Neurosci Ther 2024; 30:e14787. [PMID: 38894559 PMCID: PMC11187933 DOI: 10.1111/cns.14787] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2024] [Revised: 05/05/2024] [Accepted: 05/14/2024] [Indexed: 06/21/2024] Open
Abstract
AIMS The patient being minimally conscious state (MCS) may benefit from wake-up interventions aimed at improving quality of life and have a higher probability of recovering higher level of consciousness compared to patients with the unresponsive wakefulness syndrome (UWS). However, differentiation of the MCS and UWS poses challenge in clinical practice. This study aimed to explore glucose metabolic pattern (GMP) obtained from 18F-labeled-fluorodeoxyglucose positron emission tomography (18F-FDG-PET) in distinguishing between UWS and MCS. METHODS Fifty-seven patients with disorders of consciousness (21 cases of UWS and 36 cases of MCS) who had undergone repeated standardized Coma Recovery Scale-Revised (CRS-R) evaluations were enrolled in this prospective study. 18F-FDG-PET was carried out in all patients and healthy controls (HCs). Voxel-based scaled subprofile model/principal component analysis (SSM/PCA) was used to generate GMPs. The expression score of whole-brain GMP was obtained, and its diagnostic accuracy was compared with the standardized uptake value ratio (SUVR). The diagnostic efficiency was validated by one-year later clinical outcomes. RESULTS UWS-MCS GMP exhibited hypometabolism in the frontal-parietal cortex, along with hypermetabolism in the unilateral lentiform nucleus, putamen, and anterior cingulate gyrus. The UWS-MCS-GMP expression score was significantly higher in UWS compared to MCS patients (0.90 ± 0.85 vs. 0 ± 0.93, p < 0.001). UWS-MCS-GMP expression score achieved an area under the curve (AUC) of 0.77 to distinguish MCS from UWS, surpassing that of SUVR based on the frontoparietal cortex (AUC = 0.623). UWS-MCS-GMP expression score was significantly correlated with the CRS-R score (r = -0.45, p = 0.004) and accurately predicted the one-year outcome in 73.7% of patients. CONCLUSION UWS and MCS exhibit specific glucose metabolism patterns, the UWS-MCS-GMP expression score significantly distinguishes MCS from UWS, making SSM/PCA a potential diagnostic methods in clinical practice for individual patients.
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Affiliation(s)
- Kun Guo
- Department of Nuclear Medicine, Xijing HospitalFourth Military Medical UniversityXi'anChina
| | - Qi Zhang
- School of Communication & Information EngineeringShanghai UniversityShanghaiChina
| | - Zhiyong Quan
- Department of Nuclear Medicine, Xijing HospitalFourth Military Medical UniversityXi'anChina
| | - Yirong Wang
- Department of Nuclear Medicine, Xijing HospitalFourth Military Medical UniversityXi'anChina
| | - Taoqi Ma
- Department of Nuclear Medicine, Xijing HospitalFourth Military Medical UniversityXi'anChina
| | - Jiehui Jiang
- School of Life SciencesShanghai UniversityShanghaiChina
| | - Fei Kang
- Department of Nuclear Medicine, Xijing HospitalFourth Military Medical UniversityXi'anChina
| | - Jing Wang
- Department of Nuclear Medicine, Xijing HospitalFourth Military Medical UniversityXi'anChina
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Young MJ, Kazazian K, Fischer D, Lissak IA, Bodien YG, Edlow BL. Disclosing Results of Tests for Covert Consciousness: A Framework for Ethical Translation. Neurocrit Care 2024; 40:865-878. [PMID: 38243150 PMCID: PMC11147696 DOI: 10.1007/s12028-023-01899-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Accepted: 11/22/2023] [Indexed: 01/21/2024]
Abstract
The advent of neurotechnologies including advanced functional magnetic resonance imaging and electroencephalography to detect states of awareness not detectable by traditional bedside neurobehavioral techniques (i.e., covert consciousness) promises to transform neuroscience research and clinical practice for patients with brain injury. As these interventions progress from research tools into actionable, guideline-endorsed clinical tests, ethical guidance for clinicians on how to responsibly communicate the sensitive results they yield is crucial yet remains underdeveloped. Drawing on insights from empirical and theoretical neuroethics research and our clinical experience with advanced neurotechnologies to detect consciousness in behaviorally unresponsive patients, we critically evaluate ethical promises and perils associated with disclosing the results of clinical covert consciousness assessments and describe a semistructured approach to responsible data sharing to mitigate potential risks.
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Affiliation(s)
- Michael J Young
- Center for Neurotechnology and Neurorecovery, Department of Neurology, Massachusetts General Hospital and Harvard Medical School, 101 Merrimac Street, Suite 310, Boston, MA, 02114, USA.
| | - Karnig Kazazian
- Center for Neurotechnology and Neurorecovery, Department of Neurology, Massachusetts General Hospital and Harvard Medical School, 101 Merrimac Street, Suite 310, Boston, MA, 02114, USA
- Western Institute of Neuroscience, Western University, London, ON, Canada
| | - David Fischer
- University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - India A Lissak
- Center for Neurotechnology and Neurorecovery, Department of Neurology, Massachusetts General Hospital and Harvard Medical School, 101 Merrimac Street, Suite 310, Boston, MA, 02114, USA
| | - Yelena G Bodien
- Center for Neurotechnology and Neurorecovery, Department of Neurology, Massachusetts General Hospital and Harvard Medical School, 101 Merrimac Street, Suite 310, Boston, MA, 02114, USA
| | - Brian L Edlow
- Center for Neurotechnology and Neurorecovery, Department of Neurology, Massachusetts General Hospital and Harvard Medical School, 101 Merrimac Street, Suite 310, Boston, MA, 02114, USA
- Athinoula A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital and Harvard Medical School, Charlestown, MA, USA
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Cao T, He S, Wang L, Chai X, He Q, Liu D, Wang D, Wang N, He J, Wang S, Yang Y, Zhao J, Tan H. Clinical neuromodulatory effects of deep brain stimulation in disorder of consciousness: A literature review. CNS Neurosci Ther 2024; 30:e14559. [PMID: 38115730 PMCID: PMC11163193 DOI: 10.1111/cns.14559] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2023] [Revised: 10/11/2023] [Accepted: 11/25/2023] [Indexed: 12/21/2023] Open
Abstract
BACKGROUND The management of patients with disorders of consciousness (DOC) presents substantial challenges in clinical practice. Deep brain stimulation (DBS) has emerged as a potential therapeutic approach, but the lack of standardized regulatory parameters for DBS in DOC hinders definitive conclusions. OBJECTIVE This comprehensive review aims to provide a detailed summary of the current issues concerning patient selection, target setting, and modulation parameters in clinical studies investigating the application of DBS for DOC patients. METHODS A meticulous systematic analysis of the literatures was conducted, encompassing articles published from 1968 to April 2023, retrieved from reputable databases (PubMed, Embase, Medline, and Web of Science). RESULTS The systematic analysis of 21 eligible articles, involving 146 patients with DOC resulting from acquired brain injury or other disorders, revealed significant insights. The most frequently targeted regions were the Centromedian-parafascicular complex (CM-pf) nuclei and central thalamus (CT), both recognized for their role in regulating consciousness. However, other targets have also been explored in different studies. The stimulation frequency was predominantly set at 25 or 100 Hz, with pulse width of 120 μs, and voltages ranged from 0 to 4 V. These parameters were customized based on individual patient responses and evaluations. The overall clinical efficacy rate in all included studies was 39.7%, indicating a positive effect of DBS in a subset of DOC patients. Nonetheless, the assessment methods, follow-up durations, and outcome measures varied across studies, potentially contributing to the variability in reported efficacy rates. CONCLUSION Despite the challenges arising from the lack of standardized parameters, DBS shows promising potential as a therapeutic option for patients with DOC. However, there still remains the need for standardized protocols and assessment methods, which are crucial to deepen the understanding and optimizing the therapeutic potential of DBS in this specific patient population.
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Affiliation(s)
- Tianqing Cao
- Department of Neurosurgery, Beijing Tiantan HospitalCapital Medical UniversityBeijingChina
- China National Clinical Research Center for Neurological DiseasesBeijingChina
| | - Shenghong He
- Medical Research Council Brain Network Dynamics Unit, Nuffield Department of Clinical NeurosciencesUniversity of OxfordOxfordUK
| | - Luchen Wang
- School of Information Science and TechnologyFudan UniversityShanghaiChina
| | - Xiaoke Chai
- Department of Neurosurgery, Beijing Tiantan HospitalCapital Medical UniversityBeijingChina
- China National Clinical Research Center for Neurological DiseasesBeijingChina
| | - Qiheng He
- Department of Neurosurgery, Beijing Tiantan HospitalCapital Medical UniversityBeijingChina
- China National Clinical Research Center for Neurological DiseasesBeijingChina
| | - Dongsheng Liu
- Department of NeurosurgeryAviation General HospitalBeijingChina
| | - Dong Wang
- Department of NeurosurgeryGanzhou People's HospitalGanzhouJiangxi ProvinceChina
| | - Nan Wang
- Department of Neurosurgery, Beijing Tiantan HospitalCapital Medical UniversityBeijingChina
- China National Clinical Research Center for Neurological DiseasesBeijingChina
| | - Jianghong He
- Department of Neurosurgery, Beijing Tiantan HospitalCapital Medical UniversityBeijingChina
| | - Shouyang Wang
- School of Information Science and TechnologyFudan UniversityShanghaiChina
| | - Yi Yang
- Department of Neurosurgery, Beijing Tiantan HospitalCapital Medical UniversityBeijingChina
- China National Clinical Research Center for Neurological DiseasesBeijingChina
- Medical Research Council Brain Network Dynamics Unit, Nuffield Department of Clinical NeurosciencesUniversity of OxfordOxfordUK
- Chinese Institute for Brain ResearchBeijingChina
- Beijing Institute of Brain DisordersBeijingChina
| | - Jizong Zhao
- Department of Neurosurgery, Beijing Tiantan HospitalCapital Medical UniversityBeijingChina
- China National Clinical Research Center for Neurological DiseasesBeijingChina
| | - Huiling Tan
- Medical Research Council Brain Network Dynamics Unit, Nuffield Department of Clinical NeurosciencesUniversity of OxfordOxfordUK
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Wang Y, Yang L, Liu W, Zhou Q, Huang M, Zou L, Feng Z, Bai Y. The efficacy and safety of bilateral synchronous transcutaneous auricular vagus nerve stimulation for prolonged disorders of consciousness: a multicenter, double-blind, stratified, randomized controlled trial protocol. Front Neurol 2024; 15:1418937. [PMID: 38882693 PMCID: PMC11176550 DOI: 10.3389/fneur.2024.1418937] [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: 04/17/2024] [Accepted: 05/21/2024] [Indexed: 06/18/2024] Open
Abstract
Background Treatment of disorders of consciousness (DOC) poses a huge challenge for clinical medicine. Transcutaneous auricular vagus nerve stimulation (taVNS) is a non-invasive neuromodulation method, which shows potential in improving recovery of DOC. However, the evidence came from single-center, small-sample randomized controlled trial, which is insufficient to form a conclusion. Thereby, we propose a prospective, multicenter, double-blind, stratified, two-arm randomized controlled trial protocol to investigate the efficacy and safety of bilateral synchronous taVNS for treatment of DOC. Methods We aim to recruit 382 patients with prolonged DOC, and divide them into an active stimulation group and a sham stimulation group. The patients in the active stimulation group will receive bilateral synchronous taVNS with a 200 μs pulse width, 20 Hz frequency, and personal adjusted intensity. The sham stimulation group will wear the same stimulator but without current output. Both groups will receive treatment for 30 min per session, twice per day, 6 days per week lasting for 4 weeks. The clinical assessment including Coma Recovery Scale-Revised (CRS-R), Full Outline of Unresponsiveness (FOUR), Glasgow Coma Scale (GCS), and Extended Glasgow Outcome Scale (GOS-E) will be conducted to evaluate its efficacy. Heart rate variability (HRV), blood pressure, and adverse events will be recorded to evaluate its safety. Discussion These results will enable us to investigate the efficacy and safety of taVNS for DOC. This protocol will provide multicenter, large-sample, high-quality Class II evidence to support bilateral synchronous taVNS for DOC, and will advance the field of treatment options for DOC.Clinical trial registration:https://www.chictr.org.cn/showproj.html?proj=221851, ChiCTR2400081978.
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Affiliation(s)
- Yan Wang
- Affiliated Rehabilitation Hospital, Jiangxi Medical College, Nanchang University, Nanchang, China
| | - Li Yang
- Affiliated Rehabilitation Hospital, Jiangxi Medical College, Nanchang University, Nanchang, China
| | - Wei Liu
- Affiliated Rehabilitation Hospital, Jiangxi Medical College, Nanchang University, Nanchang, China
| | - Qianhui Zhou
- Affiliated Rehabilitation Hospital, Jiangxi Medical College, Nanchang University, Nanchang, China
| | - Meiling Huang
- Affiliated Rehabilitation Hospital, Jiangxi Medical College, Nanchang University, Nanchang, China
| | - Leyao Zou
- Affiliated Rehabilitation Hospital, Jiangxi Medical College, Nanchang University, Nanchang, China
| | - Zhen Feng
- Affiliated Rehabilitation Hospital, Jiangxi Medical College, Nanchang University, Nanchang, China
| | - Yang Bai
- Affiliated Rehabilitation Hospital, Jiangxi Medical College, Nanchang University, Nanchang, China
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20
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Herr R, Regnier A, Belorgeot M, Mélotte E, Simon J, Sanz LRD, Lejeune N, Chavet V, Paluszkiewicz J, Pellas F, Chevallier JB, Laureys S, Kaux JF, Gosseries O. Swallowing Assessment in Post-Comatose Patients: A Feasibility Study on the SWADOC Tool. J Clin Med 2024; 13:3268. [PMID: 38892977 PMCID: PMC11173236 DOI: 10.3390/jcm13113268] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2024] [Revised: 05/10/2024] [Accepted: 05/22/2024] [Indexed: 06/21/2024] Open
Abstract
Background: After a severe brain injury and a coma, patients may develop disorders of consciousness (DoC), frequently accompanied by severe dysphagia. The evaluation and therapy of swallowing are therefore essential aspects of their management. Objectives: This study aims to evaluate the SWallowing Assessment in Disorders of Consciousness (SWADOC) tool in the assessment of swallowing in post-comatose patients. Here, we validate its quantitative items, describe preliminary results and identify limitations. Methods: Fourteen post-comatose patients were repeatedly evaluated with the Simplified Evaluation of CONsciousness Disorders (SECONDs) and with the SWADOC. Results: The internal consistency of the oral and pharyngeal subscales of the SWADOC was good. The test-retest reliability showed that all items, all subscores and the total score were stable except for two items (endo-buccal secretions and bronchial congestion). A comparison to the Facial Oral Tract Therapy Swallowing Assessment of Saliva (F.O.T.T-SAS) confirmed that scoring with the SWADOC offers a greater potential for quantitative observations in assessing swallowing abilities among patients with DoC. The SECONDs scores and SWADOC total scores showed a significant positive correlation (τ = 0.78, p < 0.001). Conclusions: This study provides preliminary but encouraging results on the psychometric properties of the SWADOC tool. It shows that this tool is relevant and feasible as a bedside assessment of dysphagia in patients with DoC.
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Affiliation(s)
- Roxanne Herr
- Neurology Department, Haguenau Hospital, 67500 Haguenau, France;
| | - Amandine Regnier
- Coma Science Group, GIGA-Consciousness, University of Liège, 4000 Liège, Belgium; (A.R.); (E.M.); (L.R.D.S.); (N.L.); (S.L.)
- Centre du Cerveau2, University Hospital of Liège, 4000 Liège, Belgium
- Physical Medicine and Rehabilitation Medicine Department, University of Liège and University Hospital of Liège, 4000 Liège, Belgium;
| | - Marion Belorgeot
- Physical Medecine and Rehabilitation Medicine Department, University Hospital of Nîmes, 30029 Nîmes, France; (M.B.); (F.P.)
| | - Evelyne Mélotte
- Coma Science Group, GIGA-Consciousness, University of Liège, 4000 Liège, Belgium; (A.R.); (E.M.); (L.R.D.S.); (N.L.); (S.L.)
- Centre du Cerveau2, University Hospital of Liège, 4000 Liège, Belgium
| | - Jessica Simon
- Psychology and Neuroscience of Cognition Research Unit (PsyNCog), University of Liège, 4000 Liège, Belgium;
| | - Leandro R. D. Sanz
- Coma Science Group, GIGA-Consciousness, University of Liège, 4000 Liège, Belgium; (A.R.); (E.M.); (L.R.D.S.); (N.L.); (S.L.)
- Centre du Cerveau2, University Hospital of Liège, 4000 Liège, Belgium
| | - Nicolas Lejeune
- Coma Science Group, GIGA-Consciousness, University of Liège, 4000 Liège, Belgium; (A.R.); (E.M.); (L.R.D.S.); (N.L.); (S.L.)
- Centre du Cerveau2, University Hospital of Liège, 4000 Liège, Belgium
- William Lennox Neurological Hospital Center, 1340 Ottignies-Louvain-la-Neuve, Belgium
- Institute of NeuroScience, Université Catholique de Louvain, 1200 Brussels, Belgium
| | - Valérie Chavet
- Physical Medicine and Rehabilitation Medicine Department, Center for Traumatology and Rehabilitation Erasme, 1070 Brussels, Belgium;
| | - Jenny Paluszkiewicz
- Physical Medicine and Rehabilitation Medicine Department, Neurological Center for Functional Rehabilitation, University Hospital of Liège, 4557 Fraiture, Belgium;
| | - Frédéric Pellas
- Physical Medecine and Rehabilitation Medicine Department, University Hospital of Nîmes, 30029 Nîmes, France; (M.B.); (F.P.)
| | | | - Steven Laureys
- Coma Science Group, GIGA-Consciousness, University of Liège, 4000 Liège, Belgium; (A.R.); (E.M.); (L.R.D.S.); (N.L.); (S.L.)
- Centre du Cerveau2, University Hospital of Liège, 4000 Liège, Belgium
- Joint International Research Unit on Consciousness, CERVO Brain Research Centre, Laval University, Québec, QC G1J2G3, Canada
| | - Jean-François Kaux
- Physical Medicine and Rehabilitation Medicine Department, University of Liège and University Hospital of Liège, 4000 Liège, Belgium;
| | - Olivia Gosseries
- Coma Science Group, GIGA-Consciousness, University of Liège, 4000 Liège, Belgium; (A.R.); (E.M.); (L.R.D.S.); (N.L.); (S.L.)
- Centre du Cerveau2, University Hospital of Liège, 4000 Liège, Belgium
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21
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Rohaut B, Calligaris C, Hermann B, Perez P, Faugeras F, Raimondo F, King JR, Engemann D, Marois C, Le Guennec L, Di Meglio L, Sangaré A, Munoz Musat E, Valente M, Ben Salah A, Demertzi A, Belloli L, Manasova D, Jodaitis L, Habert MO, Lambrecq V, Pyatigorskaya N, Galanaud D, Puybasset L, Weiss N, Demeret S, Lejeune FX, Sitt JD, Naccache L. Multimodal assessment improves neuroprognosis performance in clinically unresponsive critical-care patients with brain injury. Nat Med 2024:10.1038/s41591-024-03019-1. [PMID: 38816609 DOI: 10.1038/s41591-024-03019-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2023] [Accepted: 04/24/2024] [Indexed: 06/01/2024]
Abstract
Accurately predicting functional outcomes for unresponsive patients with acute brain injury is a medical, scientific and ethical challenge. This prospective study assesses how a multimodal approach combining various numbers of behavioral, neuroimaging and electrophysiological markers affects the performance of outcome predictions. We analyzed data from 349 patients admitted to a tertiary neurointensive care unit between 2009 and 2021, categorizing prognoses as good, uncertain or poor, and compared these predictions with observed outcomes using the Glasgow Outcome Scale-Extended (GOS-E, levels ranging from 1 to 8, with higher levels indicating better outcomes). After excluding cases with life-sustaining therapy withdrawal to mitigate the self-fulfilling prophecy bias, our findings reveal that a good prognosis, compared with a poor or uncertain one, is associated with better one-year functional outcomes (common odds ratio (95% CI) for higher GOS-E: OR = 14.57 (5.70-40.32), P < 0.001; and 2.9 (1.56-5.45), P < 0.001, respectively). Moreover, increasing the number of assessment modalities decreased uncertainty (OR = 0.35 (0.21-0.59), P < 0.001) and improved prognostic accuracy (OR = 2.72 (1.18-6.47), P = 0.011). Our results underscore the value of multimodal assessment in refining neuroprognostic precision, thereby offering a robust foundation for clinical decision-making processes for acutely brain-injured patients. ClinicalTrials.gov registration: NCT04534777 .
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Affiliation(s)
- B Rohaut
- Sorbonne Université, Paris, France.
- Paris Brain Institute - ICM, Inserm, CNRS, PICNIC-Lab, Paris, France.
- APHP, Hôpital de la Pitié Salpêtrière, DMU Neurosciences - Neuro ICU, Paris, France.
| | - C Calligaris
- APHP, Hôpital de la Pitié Salpêtrière, DMU Neurosciences - Neuro ICU, Paris, France
- GHU Paris Psychiatrie et Neurosciences, Pole Neuro, Sainte‑Anne Hospital, Anesthesia and Intensive Care Department, Paris, France
| | - B Hermann
- Paris Brain Institute - ICM, Inserm, CNRS, PICNIC-Lab, Paris, France
- APHP, Hôpital de la Pitié Salpêtrière, DMU Neurosciences - Neuro ICU, Paris, France
- GHU Paris Psychiatrie et Neurosciences, Pole Neuro, Sainte‑Anne Hospital, Anesthesia and Intensive Care Department, Paris, France
| | - P Perez
- Paris Brain Institute - ICM, Inserm, CNRS, PICNIC-Lab, Paris, France
- APHP, Hôpital de la Pitié Salpêtrière, DMU Neurosciences - Neuro ICU, Paris, France
| | - F Faugeras
- Paris Brain Institute - ICM, Inserm, CNRS, PICNIC-Lab, Paris, France
| | - F Raimondo
- Paris Brain Institute - ICM, Inserm, CNRS, PICNIC-Lab, Paris, France
| | - J-R King
- Paris Brain Institute - ICM, Inserm, CNRS, PICNIC-Lab, Paris, France
- Laboratoire des systèmes perceptifs, Département d'études cognitives, École normale supérieure, PSL University, CNRS, Paris, France
| | - D Engemann
- Paris Brain Institute - ICM, Inserm, CNRS, PICNIC-Lab, Paris, France
| | - C Marois
- Paris Brain Institute - ICM, Inserm, CNRS, PICNIC-Lab, Paris, France
- APHP, Hôpital de la Pitié Salpêtrière, DMU Neurosciences - Neuro ICU, Paris, France
| | - L Le Guennec
- Sorbonne Université, Paris, France
- APHP, Hôpital de la Pitié Salpêtrière, DMU Neurosciences - Neuro ICU, Paris, France
| | - L Di Meglio
- Sorbonne Université, Paris, France
- APHP, Hôpital de la Pitié Salpêtrière, DMU Neurosciences - Neuro ICU, Paris, France
- GHU Paris Psychiatrie et Neurosciences, Pole Neuro, Sainte‑Anne Hospital, Anesthesia and Intensive Care Department, Paris, France
| | - A Sangaré
- Sorbonne Université, Paris, France
- Paris Brain Institute - ICM, Inserm, CNRS, PICNIC-Lab, Paris, France
- APHP, Hôpital de la Pitié Salpêtrière, DMU Neurosciences - Neurophysiology, Paris, France
| | - E Munoz Musat
- Paris Brain Institute - ICM, Inserm, CNRS, PICNIC-Lab, Paris, France
- APHP, Hôpital de la Pitié Salpêtrière, DMU Neurosciences - Neurophysiology, Paris, France
| | - M Valente
- Paris Brain Institute - ICM, Inserm, CNRS, PICNIC-Lab, Paris, France
| | - A Ben Salah
- Sorbonne Université, Paris, France
- Paris Brain Institute - ICM, Inserm, CNRS, PICNIC-Lab, Paris, France
| | - A Demertzi
- Paris Brain Institute - ICM, Inserm, CNRS, PICNIC-Lab, Paris, France
- Physiology of Cognition GIGA-CRC In Vivo Imaging Center, University of Liège, Liège, Belgium
| | - L Belloli
- Paris Brain Institute - ICM, Inserm, CNRS, PICNIC-Lab, Paris, France
| | - D Manasova
- Paris Brain Institute - ICM, Inserm, CNRS, PICNIC-Lab, Paris, France
| | - L Jodaitis
- Paris Brain Institute - ICM, Inserm, CNRS, PICNIC-Lab, Paris, France
- APHP, Hôpital de la Pitié Salpêtrière, DMU Neurosciences - Neuro ICU, Paris, France
| | - M O Habert
- Sorbonne Université, Paris, France
- APHP, Hôpital de la Pitié Salpêtrière, Departement of Nuclear Medicine, Laboratoire d'Imagerie Biomédicale, Inserm, CNRS, Paris, France
| | - V Lambrecq
- Sorbonne Université, Paris, France
- APHP, Hôpital de la Pitié Salpêtrière, DMU Neurosciences - Neurophysiology, Paris, France
| | - N Pyatigorskaya
- Sorbonne Université, Paris, France
- APHP, Hôpital de la Pitié Salpêtrière, Departement of Neuro-radiology, Paris, France
| | - D Galanaud
- Sorbonne Université, Paris, France
- APHP, Hôpital de la Pitié Salpêtrière, Departement of Neuro-radiology, Paris, France
| | - L Puybasset
- Sorbonne Université, Paris, France
- APHP, Hôpital de la Pitié Salpêtrière, Departement of Neuro-anaesthesiology and Neurocritical care, Paris, France
| | - N Weiss
- Sorbonne Université, Paris, France
- APHP, Hôpital de la Pitié Salpêtrière, DMU Neurosciences - Neuro ICU, Paris, France
| | - S Demeret
- APHP, Hôpital de la Pitié Salpêtrière, DMU Neurosciences - Neuro ICU, Paris, France
| | - F X Lejeune
- Paris Brain Institute - ICM, Inserm, CNRS, Data Analysis Core, Paris, France
| | - J D Sitt
- Paris Brain Institute - ICM, Inserm, CNRS, PICNIC-Lab, Paris, France
| | - L Naccache
- Sorbonne Université, Paris, France
- Paris Brain Institute - ICM, Inserm, CNRS, PICNIC-Lab, Paris, France
- APHP, Hôpital de la Pitié Salpêtrière, DMU Neurosciences - Neurophysiology, Paris, France
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22
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Szirmai D, Zabihi A, Kói T, Hegyi P, Wenning AS, Engh MA, Molnár Z, Csukly G, Horváth AA. EEG connectivity and network analyses predict outcome in patients with disorders of consciousness - A systematic review and meta-analysis. Heliyon 2024; 10:e31277. [PMID: 38826755 PMCID: PMC11141356 DOI: 10.1016/j.heliyon.2024.e31277] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2023] [Revised: 05/13/2024] [Accepted: 05/14/2024] [Indexed: 06/04/2024] Open
Abstract
Outcome prediction in prolonged disorders of consciousness (DOC) remains challenging. This can result in either inappropriate withdrawal of treatment or unnecessary prolongation of treatment. Electroencephalography (EEG) is a cheap, portable, and non-invasive device with various opportunities for complex signal analysis. Computational EEG measures, such as EEG connectivity and network metrics, might be ideal candidates for the investigation of DOC, but their capacity in prognostication is still undisclosed. We conducted a meta-analysis aiming to compare the prognostic power of the widely used clinical scale, Coma Recovery Scale-Revised - CRS-R and EEG connectivity and network metrics. We found that the prognostic power of the CRS-R scale was moderate (AUC: 0.67 (0.60-0.75)), but EEG connectivity and network metrics predicted outcome with significantly (p = 0.0071) higher accuracy (AUC:0.78 (0.70-0.86)). We also estimated the prognostic capacity of EEG spectral power, which was not significantly (p = 0.3943) inferior to that of the EEG connectivity and graph-theory measures (AUC:0.75 (0.70-0.80)). Multivariate automated outcome prediction tools seemed to outperform clinical and EEG markers.
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Affiliation(s)
- Danuta Szirmai
- Centre for Translational Medicine, Semmelweis University, Budapest, Hungary (Baross utca 22., Budapest, H-1085, Hungary
| | - Arashk Zabihi
- Centre for Translational Medicine, Semmelweis University, Budapest, Hungary (Baross utca 22., Budapest, H-1085, Hungary
| | - Tamás Kói
- Centre for Translational Medicine, Semmelweis University, Budapest, Hungary (Baross utca 22., Budapest, H-1085, Hungary
- Mathematical Institute, Department of Stochastics, Budapest University of Technology and Economics, Budapest, Hungary (Műegyetem rkp. 3, Budapest, H-1111, Hungary
| | - Péter Hegyi
- Centre for Translational Medicine, Semmelweis University, Budapest, Hungary (Baross utca 22., Budapest, H-1085, Hungary
- Institute of Pancreatic Diseases, Semmelweis University, Budapest, Hungary (Tömő u. 25-29, Budapest, H-1083, Hungary
- Institute for Translational Medicine, Medical School, University of Pécs, Pécs, Hungary (Szigeti út 12., Pécs, H-7624, Hungary
| | - Alexander Schulze Wenning
- Centre for Translational Medicine, Semmelweis University, Budapest, Hungary (Baross utca 22., Budapest, H-1085, Hungary
| | - Marie Anne Engh
- Centre for Translational Medicine, Semmelweis University, Budapest, Hungary (Baross utca 22., Budapest, H-1085, Hungary
| | - Zsolt Molnár
- Department of Anesthesiology and Intensive Therapy, Semmelweis University, Budapest, Hungary (Üllői út 78., Budapest, H-1082, Hungary
- Department of Anesthesiology and Intensive Therapy, Poznan University of Medical Sciences, Poznan, Poland (49 Przybyszewskiego St, Poznan, Poland, 60-355, Poland
| | - Gábor Csukly
- Department of Psychiatry and Psychotherapy, Semmelweis University, Budapest, Hungary (Balassa u. 6, Budapest, H-1083, Hungary
| | - András Attila Horváth
- Centre for Translational Medicine, Semmelweis University, Budapest, Hungary (Baross utca 22., Budapest, H-1085, Hungary
- Neurocognitive Research Center, National Institute of Mental Health, Neurology, Neurosurgery, Budapest, Hungary (Amerikai út 57., Budapest, H-1145, Hungary
- Department of Anatomy, Histology and Embryology, Semmelweis University, Budapest, Hungary (Üllői út 26., Budapest, H-1085, Hungary
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23
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Lo CCH, Woo PYM, Cheung VCK. Task-based EEG and fMRI paradigms in a multimodal clinical diagnostic framework for disorders of consciousness. Rev Neurosci 2024; 0:revneuro-2023-0159. [PMID: 38804042 DOI: 10.1515/revneuro-2023-0159] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2023] [Accepted: 05/09/2024] [Indexed: 05/29/2024]
Abstract
Disorders of consciousness (DoC) are generally diagnosed by clinical assessment, which is a predominantly motor-driven process and accounts for up to 40 % of non-communication being misdiagnosed as unresponsive wakefulness syndrome (UWS) (previously known as prolonged/persistent vegetative state). Given the consequences of misdiagnosis, a more reliable and objective multimodal protocol to diagnosing DoC is needed, but has not been produced due to concerns regarding their interpretation and reliability. Of the techniques commonly used to detect consciousness in DoC, task-based paradigms (active paradigms) produce the most unequivocal result when findings are positive. It is well-established that command following (CF) reliably reflects preserved consciousness. Task-based electroencephalography (EEG) and functional magnetic resonance imaging (fMRI) can detect motor-independent CF and reveal preserved covert consciousness in up to 14 % of UWS patients. Accordingly, to improve the diagnostic accuracy of DoC, we propose a practical multimodal clinical decision framework centered on task-based EEG and fMRI, and complemented by measures like transcranial magnetic stimulation (TMS-EEG).
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Affiliation(s)
- Chris Chun Hei Lo
- School of Biomedical Sciences, and Gerald Choa Neuroscience Institute, The Chinese University of Hong Kong, Shatin, New Territories, Hong Kong, China
| | - Peter Yat Ming Woo
- Division of Neurosurgery, Department of Surgery, Faculty of Medicine, The Chinese University of Hong Kong, Shatin, New Territories, Hong Kong, China
| | - Vincent C K Cheung
- School of Biomedical Sciences, and Gerald Choa Neuroscience Institute, The Chinese University of Hong Kong, Shatin, New Territories, Hong Kong, China
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24
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Wan X, Zhang Y, Li Y, Song W. Effects of parietal repetitive transcranial magnetic stimulation in prolonged disorders of consciousness: A pilot study. Heliyon 2024; 10:e30192. [PMID: 38707352 PMCID: PMC11066627 DOI: 10.1016/j.heliyon.2024.e30192] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2023] [Revised: 04/21/2024] [Accepted: 04/22/2024] [Indexed: 05/07/2024] Open
Abstract
Objective Although the parietal cortex is related to consciousness, the dorsolateral prefrontal and primary motor cortices are the usual targets for repetitive transcranial magnetic stimulation (rTMS) for prolonged disorders of consciousness (pDoC). Herein, we applied parietal rTMS to patients with pDoC, to verify its neurobehavioral effects and explore a new potential rTMS target. Materials and methods Twenty-six patients with pDoC were assigned to a rTMS or sham group. The rTMS group received 10 sessions of parietal rTMS; the sham group received 10 sessions of sham stimulation. The Coma Recovery Scale-Revised (CRS-R) and event-related potential (ERP) were collected before and after the 10 sessions or sham sessions. Results After the 10 sessions, the rTMS group showed: a significant CRS-R score increase; ERP appearance of a P300 waveform and significantly increased Fz amplitudes; increased potentials on topographic mapping, especially in the left prefrontal cortex; and an increase in delta and theta band powers at Fz, Cz, and Pz. The sham group did not show such changes in CRS-R score or ERP results statistically. Conclusion Parietal rTMS shows promise as a novel intervention in the recovery of consciousness in pDoC. It showed neurobehavioral enhancement of residual brain function and may promote frontal activity by enhancing frontal-parietal connections. The parietal cortex may thus be an alternative for rTMS therapy protocols.
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Affiliation(s)
- Xiaoping Wan
- Department of Rehabilitation Medicine, Xuan Wu Hospital, Capital Medical University, No. 45 Chang Chun Street, Beijing, 100053, China
| | - Ye Zhang
- Department of Rehabilitation Medicine, Xuan Wu Hospital, Capital Medical University, No. 45 Chang Chun Street, Beijing, 100053, China
| | - Yanhua Li
- Department of Rehabilitation Medicine, Xuan Wu Hospital, Capital Medical University, No. 45 Chang Chun Street, Beijing, 100053, China
| | - Weiqun Song
- Department of Rehabilitation Medicine, Xuan Wu Hospital, Capital Medical University, No. 45 Chang Chun Street, Beijing, 100053, China
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25
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Schiff ND. Toward an interventional science of recovery after coma. Neuron 2024; 112:1595-1610. [PMID: 38754372 DOI: 10.1016/j.neuron.2024.04.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2024] [Revised: 04/04/2024] [Accepted: 04/24/2024] [Indexed: 05/18/2024]
Abstract
Recovery of consciousness after coma remains one of the most challenging areas for accurate diagnosis and effective therapeutic engagement in the clinical neurosciences. Recovery depends on preservation of neuronal integrity and evolving changes in network function that re-establish environmental responsiveness. It typically occurs in defined steps: it begins with eye opening and unresponsiveness in a vegetative state, then limited recovery of responsiveness characterizes the minimally conscious state, and this is followed by recovery of reliable communication. This review considers several points for novel interventions, for example, in persons with cognitive motor dissociation in whom a hidden cognitive reserve is revealed. Circuit mechanisms underlying restoration of behavioral responsiveness and communication are discussed. An emerging theme is the possibility to rescue latent capacities in partially damaged human networks across time. These opportunities should be exploited for therapeutic engagement to achieve individualized solutions for restoration of communication and environmental interaction across varying levels of recovery.
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Affiliation(s)
- Nicholas D Schiff
- Jerold B. Katz Professor of Neurology and Neuroscience, Weill Cornell Medicine, New York, NY, USA.
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26
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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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27
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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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Weaver JA, Cogan AM, Kozlowski AJ, Grady-Dominguez P, O'Brien KA, Bodien YG, Graham J, Aichele S, Ford P, Kot T, Bender Pape TL, Mallinson T, Giacino JT. Interpreting Change in Disorders of Consciousness Using the Coma Recovery Scale-Revised. J Neurotrauma 2024. [PMID: 38613812 DOI: 10.1089/neu.2023.0567] [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] [Indexed: 04/15/2024] Open
Abstract
The purpose of this study was to differentiate clinically meaningful improvement or deterioration from normal fluctuations in patients with disorders of consciousness (DoC) following severe brain injury. We computed indices of responsiveness for the Coma Recovery Scale-Revised (CRS-R) using data from a clinical trial of 180 participants with DoC. We used CRS-R scores from baseline (enrollment in a clinical trial) and a 4-week follow-up assessment period for these calculations. To improve precision, we transformed ordinal CRS-R total scores (0-23 points) to equal-interval measures on a 0-100 unit scale using Rasch Measurement theory. Using the 0-100 unit total Rasch measures, we calculated distribution-based 0.5 standard deviation (SD) minimal clinically important difference, minimal detectable change using 95% confidence intervals, and conditional minimal detectable change using 95% confidence intervals. The distribution-based minimal clinically important difference evaluates group-level changes, whereas the minimal detectable change values evaluate individual-level changes. The minimal clinically important difference and minimal detectable change are derived using the overall variability across total measures at baseline and 4 weeks. The conditional minimal detectable change is generated for each possible pair of CRS-R Rasch person measures and accounts for variation in standard error across the scale. We applied these indices to determine the proportions of participants who made a change beyond measurement error within each of the two subgroups, based on treatment arm (amantadine hydrochloride or placebo) or categorization of baseline Rasch person measure to states of consciousness (i.e., unresponsive wakefulness syndrome and minimally conscious state). We compared the proportion of participants in each treatment arm who made a change according to the minimal detectable change and determined whether they also changed to another state of consciousness. CRS-R indices of responsiveness (using the 0-100 transformed scale) were as follows: 0.5SD minimal clinically important difference = 9 units, minimal detectable change = 11 units, and the conditional minimal detectable change ranged from 11 to 42 units. For the amantadine and placebo groups, 70% and 58% of participants showed change beyond measurement error using the minimal detectable change, respectively. For the unresponsive wakefulness syndrome and minimally conscious state groups, 54% and 69% of participants changed beyond measurement error using the minimal detectable change, respectively. Among 115 participants (64% of the total sample) who made a change beyond measurement error, 29 participants (25%) did not change state of consciousness. CRS-R indices of responsiveness can support clinicians and researchers in discerning when behavioral changes in patients with DoC exceed measurement error. Notably, the minimal detectable change can support the detection of patients who make a "true" change within or across states of consciousness. Our findings highlight that the continued use of ordinal scores may result in incorrect inferences about the degree and relevance of a change score.
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Affiliation(s)
- Jennifer A Weaver
- Department of Occupational Therapy, College of Health and Human Sciences, Colorado State University, Fort Collins, Colorado, USA
| | - Alison M Cogan
- Mrs. T. H. Chan Division of Occupational Science & Occupational Therapy, Herman Ostrow School of Dentistry, University of Southern California, Los Angeles, California, USA
| | | | - Patricia Grady-Dominguez
- Department of Occupational Therapy, College of Health and Human Sciences, Colorado State University, Fort Collins, Colorado, USA
| | | | - Yelena G Bodien
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
- Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Charlestown, Massachusetts, USA
| | - James Graham
- Department of Occupational Therapy, College of Health and Human Sciences, Colorado State University, Fort Collins, Colorado, USA
| | - Stephen Aichele
- Department of Human Development and Family Studies, College of Health and Human Sciences, Colorado State University, Fort Collins, Colorado, USA
- Faculty of Epidemiology, Colorado School of Public Health, Fort Collins, Colorado, USA
| | - Paige Ford
- Lived Experience Consultants, Department of Occupational Therapy, College of Health and Human Sciences, Colorado State University, Fort Collins, Colorado, USA
| | - Trisha Kot
- Lived Experience Consultants, Department of Occupational Therapy, College of Health and Human Sciences, Colorado State University, Fort Collins, Colorado, USA
| | - Theresa L Bender Pape
- Department of Physical Medicine and Rehabilitation, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Trudy Mallinson
- Department of Clinical Research and Leadership, School of Medicine and Health Sciences, The George Washington University, Washington, District of Columbia, 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
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Caliendo E, Lowder R, McLaughlin MJ, Watson WD, Baum KT, Blackwell LS, Koterba CH, Hoskinson KR, Tlustos SJ, Shah SA, Suskauer SJ, Kurowski BG. The Use of Methylphenidate During Inpatient Rehabilitation After Pediatric Traumatic Brain Injury: Population Characteristics and Prescribing Patterns. J Head Trauma Rehabil 2024; 39:E122-E131. [PMID: 38709832 PMCID: PMC11076004 DOI: 10.1097/htr.0000000000000889] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/08/2024]
Abstract
OBJECTIVE To understand how methylphenidate (MPH) is used in youth with traumatic brain injury (TBI) during inpatient pediatric rehabilitation. SETTING Inpatient pediatric rehabilitation. PARTICIPANTS In total, 234 children with TBI; 62 of whom received MPH and 172 who did not. Patients were on average 11.6 years of age (range, 2 months to 21 years); 88 of 234 were female; the most common mechanism of injury was motor vehicle collision (49%); median (IQR) acute hospital length of stay (LOS) and inpatient rehabilitation LOS were 16 (10-29) and 23 (14-39), respectively; 51 of 234 were in a disorder of consciousness cognitive state at time of inpatient rehabilitation admission. DESIGN Multicenter, retrospective medical record review. MAIN MEASURES Patient demographic data, time to inpatient pediatric rehabilitation admission (TTA), cognitive state, MPH dosing (mg/kg/day). RESULTS Patients who received MPH were older (P = .011); TTA was significantly longer in patients who received MPH than those who did not (P =.002). The lowest recorded dose range by weight was 0.05 to 0.89 mg/kg/d, representing an 18-fold difference; the weight-based range for the maximum dose was 0.11 to 0.97 mg/kg/d, a 9-fold difference. Patients in lower cognitive states at admission (P = .001) and at discharge (P = .030) were more likely to receive MPH. Five patients had side effects known to be associated with MPH; no serious adverse events were reported. CONCLUSION This multicenter study indicates that there is variable use of MPH during acute inpatient rehabilitation for children with TBI. Children who receive MPH tend to be older with lower cognitive states. Dosing practices are likely consistent with underdosing. Clinical indications for MPH use during inpatient pediatric rehabilitation should be better defined. The use of MPH, as well as its combination with other medications and treatments, during inpatient rehabilitation needs to be further explored.
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Affiliation(s)
- Eric Caliendo
- Department of Medicine, Emory University, Atlanta, Georgia (Dr Caliendo); David Geffen School of Medicine at UCLA, Los Angeles, California (Ms Lowder); Department of Pediatrics, Children's Mercy-Kansas City, Kansas City, Missouri (Dr McLaughlin); University of Missouri-Kansas City School of Medicine (Dr McLaughlin); Blythedale Children's Hospital, Valhalla, New York (Dr Watson); Department of Rehabilitation and Regenerative Medicine, Columbia University Vagelos College of Physicians and Surgeons, New York City, New York (Dr Watson); Department of Radiology, Weill Cornell Medicine, New York City, New York (Dr Shah); Department of Rehabilitation, Children's Hospital Colorado, Aurora (Dr Tlustos); Department of Physical Medicine and Rehabilitation, University of Colorado School of Medicine, Aurora (Dr Tlustos); Department of Neuropsychology (Dr Koterba), and Center for Biobehavioral Health, Abigail Wexner Research Institute (Dr Hoskinson), Nationwide Children's Hospital, Columbus, Ohio; Department of Pediatrics, The Ohio State University, Columbus (Dr Koterba); Department of Pediatrics, The Ohio State University College of Medicine, Columbus (Dr Hoskinson); Division of Pediatric Rehabilitation Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio (Dr Kurowski); Departments of Pediatrics and Neurology and Rehabilitation Medicine, University of Cincinnati College of Medicine, Cincinnati, Ohio (Dr Kurowski); Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia (Dr Blackwell); Kennedy Krieger Institute, Baltimore, Maryland (Dr Suskauer); and Departments of Physical Medicine & Rehabilitation and Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland (Dr Suskauer). Dr Baum is in private practice, Paoli, Pennsylvania
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Wan X, Zhang Y, Li Y, Song W. An update on noninvasive neuromodulation in the treatment of patients with prolonged disorders of consciousness. CNS Neurosci Ther 2024; 30:e14757. [PMID: 38747078 PMCID: PMC11094579 DOI: 10.1111/cns.14757] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Revised: 04/16/2024] [Accepted: 04/28/2024] [Indexed: 05/18/2024] Open
Abstract
BACKGROUND With the improvement of emergency techniques, the survival rate of patients with severe brain injury has increased. However, this has also led to an annual increase in the number of patients with prolonged disorders of consciousness (pDoC). Hence, recovery of consciousness is an important part of treatment. With advancing techniques, noninvasive neuromodulation seems a promising intervention. The objective of this review was to summarize the latest techniques and provide the basis for protocols of noninvasive neuromodulations in pDoC. METHODS This review summarized the advances in noninvasive neuromodulation in the treatment of pDoC in the last 5 years. RESULTS Variable techniques of neuromodulation are used in pDoC. Transcranial ultrasonic stimulation (TUS) and transcutaneous auricular vagus nerve stimulation (taVNS) are very new techniques, while transcranial direct current stimulation (tDCS) and transcranial magnetic stimulation (TMS) are still the hotspots in pDoC. Median nerve electrical stimulation (MNS) has received little attention in the last 5 years. CONCLUSIONS Noninvasive neuromodulation is a valuable and promising technique to treat pDoC. Further studies are needed to determine a unified stimulus protocol to achieve optimal effects as well as safety.
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Affiliation(s)
- Xiaoping Wan
- Department of Rehabilitation Medicine, Xuan Wu Hospital, Capital Medical University, Beijing, China
| | - Ye Zhang
- Department of Rehabilitation Medicine, Xuan Wu Hospital, Capital Medical University, Beijing, China
| | - Yanhua Li
- Department of Rehabilitation Medicine, Xuan Wu Hospital, Capital Medical University, Beijing, China
| | - Weiqun Song
- Department of Rehabilitation Medicine, Xuan Wu Hospital, Capital Medical University, Beijing, China
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Toplutaş E, Aydın F, Hanoğlu L. EEG Microstate Analysis in Patients with Disorders of Consciousness and Its Clinical Significance. Brain Topogr 2024; 37:377-387. [PMID: 36735192 DOI: 10.1007/s10548-023-00939-y] [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: 09/30/2022] [Accepted: 01/19/2023] [Indexed: 02/04/2023]
Abstract
Disorders of Consciousness are divided into two major categories such as vegetative and minimally conscious states. Objective measures that allow correct identification of patients with vegetative and minimally conscious state are needed. EEG microstate analysis is a promising approach that we believe has the potential to be effective in examining the resting state activities of the brain in different stages of consciousness by allowing the proper identification of vegetative and minimally conscious patients. As a result, we try to identify clinical evaluation scales and microstate characteristics with resting state EEGs from individuals with disorders of consciousness. Our prospective observational study included 28 individuals with a disorder of consciousness. Control group included 18 healthy subjects with proper EEG data. We made clinical evaluations using patient behavior scales. We also analyzed the EEGs using microstate analysis. In our study, microstate D coverage differed substantially between vegetative and minimally conscious state patients. Also, there was a strong connection between microstate D characteristics and clinical scale scores. Consequently, we have demonstrated that the most accurate parameter for representing consciousness level is microstate D. Microstate analysis appears to be a strong option for future use in the diagnosis, follow-up, and treatment response of patients with Disorders of Consciousness.
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Affiliation(s)
- Eren Toplutaş
- Department of Neurology, Istanbul Eyupsultan Public Hospital, Istanbul, Turkey.
- Program of Neuroscience Ph.D., Graduate School of Health Sciences,, Istanbul Medipol University, Istanbul, Turkey.
| | - Fatma Aydın
- Program of Neuroscience Ph.D., Graduate School of Health Sciences,, Istanbul Medipol University, Istanbul, Turkey
| | - Lütfü Hanoğlu
- Department of Neurology, School of Medicine, Istanbul Medipol University, Istanbul, Turkey
- Neuroimaging and Neuromodulation Lab, Clinical Electrophysiology, REMER, Istanbul Medipol University, Istanbul, Turkey
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Kuyler A, Heyns T, Johnson E. Critical care nurses' experiences of communication-vulnerable patients in the intensive care unit and the influence on rendering compassionate care. SOUTHERN AFRICAN JOURNAL OF CRITICAL CARE 2024; 40:e750. [PMID: 38989477 PMCID: PMC11232566 DOI: 10.7196/sajcc.2024.v40i1.750] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/11/2023] [Indexed: 07/12/2024] Open
Abstract
Background Interventions administered to critically ill patients, including mechanical ventilation, sedation or other treatments may hinder communication between patients and nurses. These communication challenges may affect critical care nurses' ability to provide compassionate, person-centred care. Objectives To identify nurses' experiences with patients who are communication-vulnerable in the intensive care unit and how they affect nurses' ability to offer compassionate care. Methods This qualitative explorative descriptive study involved nurses who worked in intensive care units from four private hospitals in Gauteng, South Africa. Focus groups were conducted with 30 critical care nurses in groups of two to six participants each. Thematic analysis was used to identify themes. Results Five main themes were identified based on nurses' reports of their experiences with critically ill patients who experience communication difficulties and their impact on rendering compassionate care. Themes were deductively identified based on the social purposes of communication categories. Participants indicated that communication-vulnerable patients influence their ability to provide compassionate care. Generally, the physical, emotional, social and communication difficulties of assisting communication-vulnerable patients caused nurses to feel frustrated and negative towards their work environment, which added to their work stress and sometimes resulted in compassion fatigue. Conclusion The study shows that various factors could impact the nurses' ability to provide compassionate care and that they require support to provide person-centred care. These factors can include the physical environment, the patient's alertness and awareness and institutional barriers. To support nurses in providing compassionate care, communication partner training may be warranted. Contribution of the study This study aims to increase awareness of the aspects that may contribute to compassion fatigue for nurses. By identifying these aspects greater support can be provided by facilities where nurses work.
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Affiliation(s)
- A Kuyler
- University of South Africa, Department of Inclusive Education, Pretoria, South Africa
| | - T Heyns
- Department of Nursing Science, University of Pretoria, South Africa
| | - E Johnson
- University of South Africa, Department of Inclusive Education, Pretoria, South Africa
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Sarton B, Tauber C, Fridman E, Péran P, Riu B, Vinour H, David A, Geeraerts T, Bounes F, Minville V, Delmas C, Salabert AS, Albucher JF, Bataille B, Olivot JM, Cariou A, Naccache L, Payoux P, Schiff N, Silva S. Neuroimmune activation is associated with neurological outcome in anoxic and traumatic coma. Brain 2024; 147:1321-1330. [PMID: 38412555 PMCID: PMC10994537 DOI: 10.1093/brain/awae045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2023] [Revised: 12/22/2023] [Accepted: 01/09/2024] [Indexed: 02/29/2024] Open
Abstract
The pathophysiological underpinnings of critically disrupted brain connectomes resulting in coma are poorly understood. Inflammation is potentially an important but still undervalued factor. Here, we present a first-in-human prospective study using the 18-kDa translocator protein (TSPO) radioligand 18F-DPA714 for PET imaging to allow in vivo neuroimmune activation quantification in patients with coma (n = 17) following either anoxia or traumatic brain injuries in comparison with age- and sex-matched controls. Our findings yielded novel evidence of an early inflammatory component predominantly located within key cortical and subcortical brain structures that are putatively implicated in consciousness emergence and maintenance after severe brain injury (i.e. mesocircuit and frontoparietal networks). We observed that traumatic and anoxic patients with coma have distinct neuroimmune activation profiles, both in terms of intensity and spatial distribution. Finally, we demonstrated that both the total amount and specific distribution of PET-measurable neuroinflammation within the brain mesocircuit were associated with the patient's recovery potential. We suggest that our results can be developed for use both as a new neuroprognostication tool and as a promising biometric to guide future clinical trials targeting glial activity very early after severe brain injury.
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Affiliation(s)
- Benjamine Sarton
- Critical Care Unit, University Teaching Hospital of Purpan, F-31059 Toulouse Cedex 9, France
- Toulouse NeuroImaging Center, Toulouse University, Inserm 1214, UPS, F-31300 Toulouse, France
| | - Clovis Tauber
- Imaging and Brain laboratory, UMRS Inserm U930, Université de Tours, F-37000 Tours, France
| | - Estéban Fridman
- Brain and Mind Research Institute, Weill Cornell Medical College, New York, NY 10065, USA
| | - Patrice Péran
- Toulouse NeuroImaging Center, Toulouse University, Inserm 1214, UPS, F-31300 Toulouse, France
| | - Beatrice Riu
- Critical Care Unit, University Teaching Hospital of Purpan, F-31059 Toulouse Cedex 9, France
| | - Hélène Vinour
- Critical Care Unit, University Teaching Hospital of Purpan, F-31059 Toulouse Cedex 9, France
| | - Adrian David
- Critical Care Unit, University Teaching Hospital of Purpan, F-31059 Toulouse Cedex 9, France
| | - Thomas Geeraerts
- Neurocritical Care Unit, University Teaching Hospital of Purpan, F-31059 Toulouse Cedex 9, France
| | - Fanny Bounes
- Critical Care Unit, University Teaching Hospital of Rangueil, F-31400 Toulouse Cedex 9, France
| | - Vincent Minville
- Critical Care Unit, University Teaching Hospital of Rangueil, F-31400 Toulouse Cedex 9, France
| | - Clément Delmas
- Cardiology Department, University Teaching Hospital of Purpan, F-31059 Toulouse Cedex 9, France
| | - Anne-Sophie Salabert
- Toulouse NeuroImaging Center, Toulouse University, Inserm 1214, UPS, F-31300 Toulouse, France
| | - Jean François Albucher
- Neurology Department, University Teaching Hospital of Purpan, F-31059 Toulouse Cedex 9, France
| | - Benoit Bataille
- Critical Care Unit, Hôtel Dieu Hospital, F-11100 Narbonne, France
| | - Jean Marc Olivot
- Neurology Department, University Teaching Hospital of Purpan, F-31059 Toulouse Cedex 9, France
| | - Alain Cariou
- Critical Care Unit, APHP, Cochin Hospital, F-75014 Paris, France
| | - Lionel Naccache
- Institut du Cerveau et de la Moelle épinière, ICM, PICNIC Lab, F-75013 Paris, France
| | - Pierre Payoux
- Toulouse NeuroImaging Center, Toulouse University, Inserm 1214, UPS, F-31300 Toulouse, France
| | - Nicholas Schiff
- Brain and Mind Research Institute, Weill Cornell Medical College, New York, NY 10065, USA
| | - Stein Silva
- Critical Care Unit, University Teaching Hospital of Purpan, F-31059 Toulouse Cedex 9, France
- Toulouse NeuroImaging Center, Toulouse University, Inserm 1214, UPS, F-31300 Toulouse, France
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Moretta P, Femiano C, Cavallo ND, Lanzillo A, Luciano F, Ferrante C, Maiorino A, Santangelo G, Marcuccio L. Family caregivers improve the diagnostic accuracy of disorders of consciousness: from remote to near-bed auditory stimulation. Eur J Phys Rehabil Med 2024; 60:198-206. [PMID: 38381451 PMCID: PMC11114155 DOI: 10.23736/s1973-9087.24.08179-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Revised: 10/20/2023] [Accepted: 01/17/2024] [Indexed: 02/22/2024]
Abstract
BACKGROUND Family caregivers (FC) contribute to reducing the misdiagnosis rate in patients with disorders of consciousness (DOC). Unfortunately, the recent pandemic of COVID-19 imposed drastic restrictions that limited the access of FC to the sensory/cognitive stimulation protocols. Telemedicine approaches have been implemented to avoid discontinuity in care pathways and to ensure caregivers involvement in rehabilitation programs. AIM The aim was to investigate whether the presence of FC remotely connected might help clinicians in eliciting higher cortically mediated behavioral responses in patients with DOC. DESIGN Cross-sectional study. SETTING Post-acute Unit of Neurorehabilitation. POPULATION DOC due to severe brain injury. METHODS Consecutive patients with DOC were assessed by means of the Coma Recovery Scale-Revised (CRS-R) by two expert examiners. Each patient underwent to five assessments in two weeks in three different conditions: 1) by the examiner only (standard); 2) with the verbal stimulation given by the FC remotely connected by PC tablet (caregiver in remote); and 3) with the verbal stimulation given by the FC physically present (caregiver in presence). RESULTS Thirty patients with DOC (VS/UWS=10; MCS=20; mean age: 51, range: 21-79; vascular: 16; anoxic: 6; TBI=8) and their FC were enrolled. Higher total scores of CRS-R were recorded both in "caregiver in remote" and in "caregiver in presence" than in standard condition (standard vs. remote, Z=2.942, P=0.003; standard vs. presence, Z=3.736, P<0.001). Furthermore, the administration of the CRS-R with a FC, elicited higher levels of behavioral responses in MCS patients, than CRS-R performed in standard condition. In particular, 2 patients out of 30 (6.66%) showed higher scores and better diagnosis when the CRS-R was administered with FC in remote. Similarly, 5 out of 30 patients (16.66%) showed better diagnoses when the CRS-R was administered with FC in presence. Five patients changed diagnosis between standard and presence conditions (3 MCS- were diagnosed as MCS+; 2 MCS+ were diagnosed as conscious). CONCLUSIONS Our findings add new evidence regarding the beneficial role of family members in the diagnosis of DOC, even mediated by telemedicine approach. CLINICAL REHABILITATION IMPACT In future guidelines, FC should have an active and supporting role in the diagnostic and rehabilitative process of DOC.
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Affiliation(s)
- Pasquale Moretta
- Istituti Clinici Scientifici Maugeri IRCCS, Neurological Rehabilitation Unit of Telese Terme, Telese Terme, Benevento, Italy -
| | - Cinzia Femiano
- Istituti Clinici Scientifici Maugeri IRCCS, Neurological Rehabilitation Unit of Telese Terme, Telese Terme, Benevento, Italy
| | - Nicola D Cavallo
- Department of Psychology, Luigi Vanvitelli University of Campania, Caserta, Italy
| | - Anna Lanzillo
- Istituti Clinici Scientifici Maugeri IRCCS, Neurological Rehabilitation Unit of Telese Terme, Telese Terme, Benevento, Italy
| | - Fabrizio Luciano
- Istituti Clinici Scientifici Maugeri IRCCS, Neurological Rehabilitation Unit of Telese Terme, Telese Terme, Benevento, Italy
| | - Cesario Ferrante
- Istituti Clinici Scientifici Maugeri IRCCS, Neurological Rehabilitation Unit of Telese Terme, Telese Terme, Benevento, Italy
| | - Antonio Maiorino
- Istituti Clinici Scientifici Maugeri IRCCS, Neurological Rehabilitation Unit of Telese Terme, Telese Terme, Benevento, Italy
| | - Gabriella Santangelo
- Department of Psychology, Luigi Vanvitelli University of Campania, Caserta, Italy
| | - Laura Marcuccio
- Istituti Clinici Scientifici Maugeri IRCCS, Neurological Rehabilitation Unit of Telese Terme, Telese Terme, Benevento, Italy
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Edlow BL, Claassen J, Suarez JI. Common data elements for disorders of consciousness. Neurocrit Care 2024; 40:715-717. [PMID: 38291278 DOI: 10.1007/s12028-023-01931-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2024]
Affiliation(s)
- Brian L Edlow
- Center for Neurotechnology and Neurorecovery, Department of Neurology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA.
- Athinoula A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital, Charlestown, MA, USA.
| | - Jan Claassen
- Department of Neurology, Columbia University Medical Center, New York, NY, USA
- NewYork-Presbyterian Hospital, New York, NY, USA
| | - Jose I Suarez
- Division of Neurosciences Critical Care, Departments of Neurology, Neurosurgery, and Anesthesiology and Critical Care Medicine, The Johns Hopkins University and The Johns Hopkins Hospital, Baltimore, MD, USA
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Campagnini S, Llorens R, Navarro MD, Colomer C, Mannini A, Estraneo A, Ferri J, Noé E. Which information derived from the Coma Recovery Scale-Revised provides the most reliable prediction of clinical diagnosis and recovery of consciousness? A comparative study using machine learning techniques. Eur J Phys Rehabil Med 2024; 60:190-197. [PMID: 38193722 PMCID: PMC11114154 DOI: 10.23736/s1973-9087.23.08093-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2023] [Revised: 11/09/2023] [Accepted: 11/29/2023] [Indexed: 01/10/2024]
Abstract
BACKGROUND The Coma Recovery Scale-Revised (CRS-R) is the most recommended clinical tool to examine the neurobehavioral condition of individuals with disorders of consciousness (DOCs). Different studies have investigated the prognostic value of the information provided by the conventional administration of the scale, while other measures derived from the scale have been proposed to improve the prognosis of DOCs. However, the heterogeneity of the data used in the different studies prevents a reliable comparison of the identified predictors and measures. AIM This study investigates which information derived from the CRS-R provides the most reliable prediction of both the clinical diagnosis and recovery of consciousness at the discharge of a long-term neurorehabilitation program. DESIGN Retrospective observational multisite study. SETTING The enrollment was performed in three neurorehabilitation facilities of the same hospital network. POPULATION A total of 171 individuals with DOCs admitted to an inpatient neurorehabilitation program for a minimum of 3 months were enrolled. METHODS Machine learning classifiers were trained to predict the clinical diagnosis and recovery of consciousness at discharge using clinical confounders and different metrics extracted from the CRS-R scale. RESULTS Results showed that the neurobehavioral state at discharge was predicted with acceptable and comparable predictive value with all the indices and measures derived from the CRS-R, but for the clinical diagnosis and the Consciousness Domain Index, and the recovery of consciousness was predicted with higher accuracy and similarly by all the investigated measures, with the exception of initial clinical diagnosis. CONCLUSIONS Interestingly, the total score in the CRS-R and, especially, the total score in its subscales provided the best overall results, in contrast to the clinical diagnosis, which could indicate that a comprehensive measure of the clinical diagnosis rather than the condition of the individuals could provide a more reliable prediction of the neurobehavioral progress of individuals with prolonged DOC. CLINICAL REHABILITATION IMPACT The results of this work have important implications in clinical practice, offering a more accurate prognosis of patients and thus giving the possibility to personalize and optimize the rehabilitation plan of patients with DoC using low-cost and easily collectable information.
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Affiliation(s)
| | - Roberto Llorens
- Neurorehabilitation and Brain Research Group, Institute for Human-Centered Technology Research, Polytechnic University of Valencia, Valencia, Spain -
| | - M Dolores Navarro
- IRENEA Instituto de Rehabilitación Neurológica, Vithas Foundation, Valencia, Spain
| | - Carolina Colomer
- IRENEA Instituto de Rehabilitación Neurológica, Vithas Foundation, Valencia, Spain
| | - Andrea Mannini
- IRCCS Fondazione Don Carlo Gnocchi onlus, Florence, Italy
| | - Anna Estraneo
- IRCCS Fondazione Don Carlo Gnocchi onlus, Florence, Italy
| | - Joan Ferri
- IRENEA Instituto de Rehabilitación Neurológica, Vithas Foundation, Valencia, Spain
| | - Enrique Noé
- IRENEA Instituto de Rehabilitación Neurológica, Vithas Foundation, Valencia, Spain
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Kitano T, Giacino JT, Bodien Y, Waters A, Hioki D, Shinya J, Nakayama T, Ohgi S. Reliability and validation of the Japanese version of the coma recovery scale-revised (CRS-R). Brain Inj 2024; 38:249-259. [PMID: 38329043 DOI: 10.1080/02699052.2024.2309549] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2022] [Accepted: 01/19/2024] [Indexed: 02/09/2024]
Abstract
PRIMARY OBJECTIVE This study aimed to verify the reliability and validity of the Japanese version of the Coma Recovery Scale-Revised (CRS-R). METHODS Subjects included 59 patients with disorders of consciousness (DOC) due to acquired brain injury. To validate test-retest reliability, Evaluator A assessed the CRS-R twice on the same day (A1, A2). To examine inter-rater reliability, Evaluators A (A2) and B (B) assessed the CRS-R without a time interval. To test concurrent validity, Evaluator A (A1) assessed the CRS-R, Japan Coma Scale (JCS), and the Glasgow Coma Scale (GCS) consecutively. To validate diagnostic accuracy, we evaluated the degree of agreement between A1 and A2 and between A2 and B in their diagnosis of DOC by CRS-R. RESULTS The test-retest (ρ = 0.92) and inter- (ρ = 0.98) reliability of CRS-R were excellent" and Concurrent validity of CRS-R with JCS (ρ = -0.82) and GCS (ρ = 0.92) were high. Results of DOC diagnosis were consistent for 48/59 cases (κ = 0.82) for A1 and A2 and for 54/59 cases (κ = 0.92) for A2 and B. CONLCUSION The Japanese version of the CRS-R may be as reliable and valid as the original English and other language versions.
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Affiliation(s)
- Takayuki Kitano
- Department of Rehabilitation, Hamamatsu Medical Center, Hamamatsu City, Shizuoka Prefecture, Japan
| | - 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
| | - Yelena Bodien
- Department of Physical Medicine and Rehabilitation, Harvard Medical School, Boston, Massachusetts, USA
| | - Abigail Waters
- Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Charlestown, Massachusetts, USA
| | - Daichi Hioki
- Department of Rehabilitation, Hamamatsu Medical Center, Hamamatsu City, Shizuoka Prefecture, Japan
| | - Junko Shinya
- Department of Rehabilitation, Hamamatsu Medical Center, Hamamatsu City, Shizuoka Prefecture, Japan
| | - Teiji Nakayama
- Department of Neurosurgery, Hamamatsu Medical Center, Hamamatsu City, Shizuoka Prefecture, Japan
| | - Shohei Ohgi
- Faculty of Rehabilitation Studies, Seirei Christopher University, Hamamatsu City, Shizuoka Prefecture, Japan
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Bath J, Barylak M, Kedda E, Harvey E, Locklear T, Martinez M, Collier B, Weppner J. Timing of withdrawal of life-sustaining therapy in traumatic brain injury: exploring indicators of poor prognosis in adult and geriatric populations. Brain Inj 2024; 38:267-272. [PMID: 38294172 DOI: 10.1080/02699052.2024.2309656] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2023] [Accepted: 01/20/2024] [Indexed: 02/01/2024]
Abstract
OBJECTIVE The lack of objective prognostication tools for severe traumatic brain injury (TBI) causes variability in the application of withdrawal of life-saving treatment (WLST). We aimed to determine whether WLST in persons with severe TBI is associated with known indicators of poor prognosis. METHODS This retrospective descriptive study focused on adult (18-64 years) and geriatric (≥65 years) patients with severe TBI who were admitted between August 1, 2018 and July 31, 2021 at a Level I trauma center and subsequently underwent WLST. The data collected from the Trauma Registry and electronic health records included information regarding demographic characteristics, injury severity, clinical variables, and length of hospital stay and were used to examine the indicators of poor prognosis and WLST. RESULTS Among the 164 participants with TBI who met the inclusion criteria, 61.0% were geriatric, and 122 (74.4%) patients had 0 or only 1 of the poor prognostic indicators prior to WLST. The non-geriatric group had more indicators of poor prognosis than the geriatric group. Participants with fewer indicators of poor prognosis had a longer length-of-stay. CONCLUSION In severe TBI cases, standardized prognostication tools can help guide informed WLST decisions, particularly in geriatric patients, improving care consistency.
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Affiliation(s)
| | - Martin Barylak
- Virginia Tech Carilion School of Medicine, Roanoke, VA, USA
| | - Edward Kedda
- Edward Via College of Osteopathic Medicine, Blacksburg, VA, USA
| | | | | | | | - Bryan Collier
- Carilion Clinic, Roanoke, VA, USA
- Department of Surgery, Virginia Tech Carilion School of Medicine, Roanoke, VA, USA
| | - Justin Weppner
- Carilion Clinic, Roanoke, VA, USA
- Department of Internal Medicine, Virginia Tech Carilion School of Medicine, Roanoke, VA, USA
- Department of Internal Medicine, Edward Via College of Osteopathic Medicine, Blacksburg, VA, USA
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Saporito G, Gentili L, Cacchio A, Casalena A, Necozione S, Ricci A, Venturoni F, Marinangeli F, Pistoia F. Assessment of Frequency and Predictive Value of Comorbidities in Patients With Disorders of Consciousness in the Acute Setting. Neurotrauma Rep 2024; 5:267-276. [PMID: 38515549 PMCID: PMC10956526 DOI: 10.1089/neur.2023.0120] [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] [Indexed: 03/23/2024] Open
Abstract
Medical comorbidities are frequent in patients with disorders of consciousness (DoC) and their impact on outcomes is under investigation. The aim of this study was to investigate patients with DoC in the acute stage and the influence of comorbidities. Patients admitted to intensive care units and neurological units with a diagnosis of coma, vegetative state/unresponsive wakefulness syndrome (VS/UWS), and minimally conscious state (MCS) were investigated through the Glasgow Coma Scale (GCS), the Coma Recovery Scale - Revised (CRS-R) and the Comorbidities Coma Scale (CoCos). Forty-three patients (21 men and 22 women; mean age at admission: 60.4 ± 21.0) were included in the study. The most frequent diagnosis at admission was coma (72%) followed by VS/UWS (14%) and MCS (14%). The most frequent brain injury was subarachnoid hemorrhage (46%). At the 6-month follow-up, 19 patients had died (44%), 15 showed a full recovery of consciousness (35%), 7 were in a condition of emergence from MCS (16%), and 2 showed a persistent VS/UWS (5%). Forty-two (98%) patients showed at least one comorbidity: presence of life-support device (92.9%), anemia (76.2%), arterial hypertension (66,7%), hydrocephalus (45.3%), and respiratory infections (45.2%) were those most frequently reported. At the Multivariable Cox regression, the presence of renal disease (hazard ratio [HR] 33.37; p = 0.033) and malnutrition (HR 14.52; p = 0.001) were predictors of missed recovery of full consciousness. Although adverse outcomes are generally predicted by the severity of brain damage, the presence of medical comorbidities in an acute phase could influence outcomes and long-term prognosis.
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Affiliation(s)
- Gennaro Saporito
- Department of Biotechnological and Applied Clinical Sciences, Intensive Care, and Pain Treatment, University of L'Aquila, L'Aquila, Italy
| | - Luca Gentili
- Department of Anesthesia and Intensive Care Unit, Mazzini Hospital, Teramo, Italy
| | - Angelo Cacchio
- Department of Life, Health and Environmental Sciences, Intensive Care, and Pain Treatment, University of L'Aquila, L'Aquila, Italy
| | | | - Stefano Necozione
- Department of Life, Health and Environmental Sciences, Intensive Care, and Pain Treatment, University of L'Aquila, L'Aquila, Italy
| | - Alessandro Ricci
- Department of Neurosurgery, San Salvatore Hospital, L'Aquila, Italy
| | - Federica Venturoni
- Department of Anesthesia and Intensive Care Unit, Mazzini Hospital, Teramo, Italy
| | - Franco Marinangeli
- Department of Life, Health and Environmental Sciences, Intensive Care, and Pain Treatment, University of L'Aquila, L'Aquila, Italy
- Department of Anesthesiology, Intensive Care, and Pain Treatment, University of L'Aquila, L'Aquila, Italy
| | - Francesca Pistoia
- Department of Biotechnological and Applied Clinical Sciences, Intensive Care, and Pain Treatment, University of L'Aquila, L'Aquila, Italy
- Department of Neurology, San Salvatore Hospital, L'Aquila, 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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Casarotto S, Hassan G, Rosanova M, Sarasso S, Derchi CC, Trimarchi PD, Viganò A, Russo S, Fecchio M, Devalle G, Navarro J, Massimini M, Comanducci A. Dissociations between spontaneous electroencephalographic features and the perturbational complexity index in the minimally conscious state. Eur J Neurosci 2024; 59:934-947. [PMID: 38440949 DOI: 10.1111/ejn.16299] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2023] [Revised: 12/21/2023] [Accepted: 02/13/2024] [Indexed: 03/06/2024]
Abstract
The analysis of spontaneous electroencephalogram (EEG) is a cornerstone in the assessment of patients with disorders of consciousness (DoC). Although preserved EEG patterns are highly suggestive of consciousness even in unresponsive patients, moderately or severely abnormal patterns are difficult to interpret. Indeed, growing evidence shows that consciousness can be present despite either large delta or reduced alpha activity in spontaneous EEG. Quantifying the complexity of EEG responses to direct cortical perturbations (perturbational complexity index [PCI]) may complement the observational approach and provide a reliable assessment of consciousness even when spontaneous EEG features are inconclusive. To seek empirical evidence of this hypothesis, we compared PCI with EEG spectral measures in the same population of minimally conscious state (MCS) patients (n = 40) hospitalized in rehabilitation facilities. We found a remarkable variability in spontaneous EEG features across MCS patients as compared with healthy controls: in particular, a pattern of predominant delta and highly reduced alpha power-more often observed in vegetative state/unresponsive wakefulness syndrome (VS/UWS) patients-was found in a non-negligible number of MCS patients. Conversely, PCI values invariably fell above an externally validated empirical cutoff for consciousness in all MCS patients, consistent with the presence of clearly discernible, albeit fleeting, behavioural signs of awareness. These results confirm that, in some MCS patients, spontaneous EEG rhythms may be inconclusive about the actual capacity for consciousness and suggest that a perturbational approach can effectively compensate for this pitfall with practical implications for the individual patient's stratification and tailored rehabilitation.
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Affiliation(s)
- Silvia Casarotto
- Department of Biomedical and Clinical Sciences, University of Milan, Milan, Italy
- IRCCS Fondazione Don Carlo Gnocchi ONLUS, Milan, Italy
| | - Gabriel Hassan
- Department of Biomedical and Clinical Sciences, University of Milan, Milan, Italy
| | - Mario Rosanova
- Department of Biomedical and Clinical Sciences, University of Milan, Milan, Italy
| | - Simone Sarasso
- Department of Biomedical and Clinical Sciences, University of Milan, Milan, Italy
| | | | | | | | - Simone Russo
- Department of Biomedical and Clinical Sciences, University of Milan, Milan, Italy
| | - Matteo Fecchio
- Center for Neurotechnology and Neurorecovery, Department of Neurology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Guya Devalle
- IRCCS Fondazione Don Carlo Gnocchi ONLUS, Milan, Italy
| | - Jorge Navarro
- IRCCS Fondazione Don Carlo Gnocchi ONLUS, Milan, Italy
| | - Marcello Massimini
- Department of Biomedical and Clinical Sciences, University of Milan, Milan, Italy
- IRCCS Fondazione Don Carlo Gnocchi ONLUS, Milan, Italy
| | - Angela Comanducci
- IRCCS Fondazione Don Carlo Gnocchi ONLUS, Milan, Italy
- Università Campus Bio-Medico di Roma, Rome, Italy
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Vassar R, Mehta N, Epps L, Jiang F, Amorim E, Wietstock S. Mortality and Timing of Withdrawal of Life-Sustaining Therapies After Out-of-Hospital Cardiac Arrest: Two-Center Retrospective Pediatric Cohort Study. Pediatr Crit Care Med 2024; 25:241-249. [PMID: 37982686 DOI: 10.1097/pcc.0000000000003412] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/21/2023]
Abstract
OBJECTIVES Pediatric out-of-hospital cardiac arrest (OHCA) is associated with substantial morbidity and mortality. Limited data exist to guide timing and method of neurologic prognostication after pediatric OHCA, making counseling on withdrawal of life-sustaining therapies (WLSTs) challenging. This study investigates the timing and mode of death after pediatric OHCA and factors associated with mortality. Additionally, this study explores delayed recovery after comatose examination on day 3 postarrest. DESIGN This is a retrospective, observational study based on data collected from hospital databases and chart reviews. SETTING Data collection occurred in two pediatric academic hospitals between January 1, 2016, and December 31, 2020. PATIENTS Patients were identified from available databases and electronic medical record queries for the International Classification of Diseases , 10th Edition (ICD-10) code I46.9 (Cardiac Arrest). Patient inclusion criteria included age range greater than or equal to 48 hours to less than 18 years, OHCA within 24 hours of admission, greater than or equal to 1 min of cardiopulmonary resuscitation, and return-of-spontaneous circulation for greater than or equal to 20 min. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS One hundred thirty-five children (65% male) with a median age of 3 years (interquartile range 0.6-11.8) met inclusion criteria. Overall, 63 of 135 patients (47%) died before hospital discharge, including 34 of 63 patients (54%) after WLST. Among these, 20 of 34 patients underwent WLST less than or equal to 3 days postarrest, including 10 of 34 patients who underwent WLST within 1 day. WLST occurred because of poor perceived neurologic prognosis in all cases, although 7 of 34 also had poor perceived systemic prognosis. Delayed neurologic recovery from coma on day 3 postarrest was observed in 7 of 72 children (10%) who ultimately survived to discharge. CONCLUSIONS In our two centers between 2016 and 2020, more than half the deaths after pediatric OHCA occurred after WLST, and a majority of WLST occurred within 3 days postarrest. Additional research is warranted to determine optimal timing and predictors of neurologic prognosis after pediatric OHCA to better inform families during goals of care discussions.
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Affiliation(s)
- Rachel Vassar
- Division of Pediatric Neurology, Department of Neurology, Benioff Children's Hospital, University of California, San Francisco, CA
| | - Nehali Mehta
- Division of Pediatric Neurology, Department of Neurology, Benioff Children's Hospital, University of California, San Francisco, CA
- Department of Neurology, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Lane Epps
- Department of Emergency Medicine, University of California, San Francisco, CA
| | - Fei Jiang
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, CA
| | - Edilberto Amorim
- Department of Neurology, University of California, San Francisco, San Francisco, CA
- Division of Neurology, Zuckerberg San Francisco General Hospital, San Francisco, CA
| | - Sharon Wietstock
- Division of Pediatric Neurology, Department of Neurology, Benioff Children's Hospital, University of California, San Francisco, CA
- Division of Pediatric Neurology, Department of Neurology, Benioff Children's Hospital Oakland, University of California, San Francisco, Oakland, CA
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Ma X, Qi Y, Xu C, Weng Y, Yu J, Sun X, Yu Y, Wu Y, Gao J, Li J, Shu Y, Duan S, Luo B, Pan G. How well do neural signatures of resting-state EEG detect consciousness? A large-scale clinical study. Hum Brain Mapp 2024; 45:e26586. [PMID: 38433651 PMCID: PMC10910334 DOI: 10.1002/hbm.26586] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Revised: 12/12/2023] [Accepted: 12/21/2023] [Indexed: 03/05/2024] Open
Abstract
The assessment of consciousness states, especially distinguishing minimally conscious states (MCS) from unresponsive wakefulness states (UWS), constitutes a pivotal role in clinical therapies. Despite that numerous neural signatures of consciousness have been proposed, the effectiveness and reliability of such signatures for clinical consciousness assessment still remains an intense debate. Through a comprehensive review of the literature, inconsistent findings are observed about the effectiveness of diverse neural signatures. Notably, the majority of existing studies have evaluated neural signatures on a limited number of subjects (usually below 30), which may result in uncertain conclusions due to small data bias. This study presents a systematic evaluation of neural signatures with large-scale clinical resting-state electroencephalography (EEG) signals containing 99 UWS, 129 MCS, 36 emergence from the minimally conscious state, and 32 healthy subjects (296 total) collected over 3 years. A total of 380 EEG-based metrics for consciousness detection, including spectrum features, nonlinear measures, functional connectivity, and graph-based measures, are summarized and evaluated. To further mitigate the effect of data bias, the evaluation is performed with bootstrap sampling so that reliable measures can be obtained. The results of this study suggest that relative power in alpha and delta serve as dependable indicators of consciousness. With the MCS group, there is a notable increase in the phase lag index-related connectivity measures and enhanced functional connectivity between brain regions in comparison to the UWS group. A combination of features enables the development of an automatic detector of conscious states.
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Affiliation(s)
- Xiulin Ma
- Department of Neurobiology and Department of Neurology, First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
- NHC and CAMS Key Laboratory of Medical Neurobiology, School of Brain Science and Brain Medicine, Zhejiang University, Hangzhou, China
- MOE Frontier Science Center for Brain Science and Brain-machine Integration, and the Affiliated Mental Health Center & Hangzhou Seventh People's Hospital, Zhejiang University, Hangzhou, China
| | - Yu Qi
- MOE Frontier Science Center for Brain Science and Brain-machine Integration, and the Affiliated Mental Health Center & Hangzhou Seventh People's Hospital, Zhejiang University, Hangzhou, China
- The State Key Lab of Brain-Machine Intelligence, Zhejiang University, Hangzhou, China
| | - Chuan Xu
- Department of Neurobiology and Department of Neurology, First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
- Sir Run Run Shaw Hospital, Hangzhou, China
| | - Yijie Weng
- College of Computer Science and Technology, Zhejiang University, Hangzhou, China
| | - Jie Yu
- Department of Neurobiology and Department of Neurology, First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Xuyun Sun
- College of Computer Science and Technology, Zhejiang University, Hangzhou, China
| | - Yamei Yu
- Department of Neurobiology and Department of Neurology, First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
- Sir Run Run Shaw Hospital, Hangzhou, China
| | - Yuehao Wu
- Department of Neurobiology and Department of Neurology, First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Jian Gao
- Department of Rehabilitation, Hangzhou Mingzhou Brain Rehabilitation Hospital, Hangzhou, China
| | - Jingqi Li
- Department of Rehabilitation, Hangzhou Mingzhou Brain Rehabilitation Hospital, Hangzhou, China
| | - Yousheng Shu
- Department of Neurosurgery, Jinshan Hospital, State Key Laboratory of Medical Neurobiology, MOE Frontiers Center for Brain Science, Institute for Translational Brain Research, Fudan University, Shanghai, China
| | - Shumin Duan
- Department of Neurobiology and Department of Neurology, First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
- NHC and CAMS Key Laboratory of Medical Neurobiology, School of Brain Science and Brain Medicine, Zhejiang University, Hangzhou, China
- MOE Frontier Science Center for Brain Science and Brain-machine Integration, and the Affiliated Mental Health Center & Hangzhou Seventh People's Hospital, Zhejiang University, Hangzhou, China
| | - Benyan Luo
- Department of Neurobiology and Department of Neurology, First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
- MOE Frontier Science Center for Brain Science and Brain-machine Integration, and the Affiliated Mental Health Center & Hangzhou Seventh People's Hospital, Zhejiang University, Hangzhou, China
- The State Key Lab of Brain-Machine Intelligence, Zhejiang University, Hangzhou, China
| | - Gang Pan
- Department of Neurobiology and Department of Neurology, First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
- MOE Frontier Science Center for Brain Science and Brain-machine Integration, and the Affiliated Mental Health Center & Hangzhou Seventh People's Hospital, Zhejiang University, Hangzhou, China
- The State Key Lab of Brain-Machine Intelligence, Zhejiang University, Hangzhou, China
- College of Computer Science and Technology, Zhejiang University, Hangzhou, China
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Boerwinkle VL, Manjón I, Sussman BL, McGary A, Mirea L, Gillette K, Broman-Fulks J, Cediel EG, Arhin M, Hunter SE, Wyckoff SN, Allred K, Tom D. Resting-State Functional Magnetic Resonance Imaging Network Association With Mortality, Epilepsy, Cognition, and Motor Two-Year Outcomes in Suspected Severe Neonatal Acute Brain Injury. Pediatr Neurol 2024; 152:41-55. [PMID: 38198979 DOI: 10.1016/j.pediatrneurol.2023.12.003] [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: 06/12/2023] [Revised: 11/14/2023] [Accepted: 12/06/2023] [Indexed: 01/12/2024]
Abstract
BACKGROUND AND OBJECTIVES In acute brain injury of neonates, resting-state functional magnetic resonance imaging (MRI) (RS) showed incremental association with consciousness, mortality, cognitive and motor development, and epilepsy, with correction for multiple comparisons, at six months postgestation in neonates with suspected acute brain injury (ABI). However, there are relatively few developmental milestones at six months to benchmark against, thus, we extended this cohort study to evaluate two-year outcomes. METHODS In 40 consecutive neonates with ABI and RS, ordinal scores of resting-state networks; MRI, magnetic resonance spectroscopy, and electroencephalography; and up to 42-month outcomes of mortality, general and motor development, Pediatric Cerebral Performance Category Scale (PCPC), and epilepsy informed associations between tests and outcomes. RESULTS Mean gestational age was 37.8 weeks, 68% were male, and 60% had hypoxic-ischemic encephalopathy. Three died in-hospital, four at six to 42 months, and five were lost to follow-up. Associations included basal ganglia network with PCPC (P = 0.0003), all-mortality (P = 0.005), and motor (P = 0.0004); language/frontoparietal network with developmental delay (P = 0.009), PCPC (P = 0.006), and all-mortality (P = 0.01); default mode network with developmental delay (P = 0.003), PCPC (P = 0.004), neonatal intensive care unit mortality (P = 0.01), and motor (P = 0.009); RS seizure onset zone with epilepsy (P = 0.01); and anatomic MRI with epilepsy (P = 0.01). CONCLUSION For the first time, at any age, resting state functional MRI in ABI is associated with long-term epilepsy and RSNs predicted mortality in neonates. Severity of RSN abnormality was associated with incrementally worsened neurodevelopment including cognition, language, and motor function over two years.
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Affiliation(s)
- Varina L Boerwinkle
- Division of Child Neurology, University of North Carolina Medical School, Chapel Hill, North Carolina.
| | - Iliana Manjón
- University of Arizona College of Medicine - Tucson, Tucson, Arizona
| | - Bethany L Sussman
- Division of Neuroscience Research, Barrow Neurological Institute at Phoenix Children's Hospital, Phoenix, Arizona
| | - Alyssa McGary
- Department of Clinical Research, Phoenix Children's Hospital, Phoenix, Arizona
| | - Lucia Mirea
- Department of Clinical Research, Phoenix Children's Hospital, Phoenix, Arizona
| | - Kirsten Gillette
- Division of Child Neurology, University of North Carolina Medical School, Chapel Hill, North Carolina
| | - Jordan Broman-Fulks
- Division of Child Neurology, University of North Carolina Medical School, Chapel Hill, North Carolina
| | - Emilio G Cediel
- Division of Child Neurology, University of North Carolina Medical School, Chapel Hill, North Carolina
| | - Martin Arhin
- Division of Child Neurology, University of North Carolina Medical School, Chapel Hill, North Carolina
| | - Senyene E Hunter
- Division of Child Neurology, University of North Carolina Medical School, Chapel Hill, North Carolina
| | - Sarah N Wyckoff
- Division of Neuroscience Research, Barrow Neurological Institute at Phoenix Children's Hospital, Phoenix, Arizona
| | - Kimberlee Allred
- Division of Neonatology, Phoenix Children's Hospital, Phoenix, Arizona
| | - Deborah Tom
- Division of Neonatology, Phoenix Children's Hospital, Phoenix, Arizona
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Llorens R, Ippoliti C, Navarro MD, Colomer C, Maza A, Goizueta S, Olaya J, Moliner B, Ferri J, Noé E. Minimally conscious state plus versus minus: Likelihood of emergence and long-term functional independence. Ann Clin Transl Neurol 2024; 11:719-728. [PMID: 38366789 DOI: 10.1002/acn3.51993] [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: 07/31/2023] [Revised: 12/07/2023] [Accepted: 01/01/2024] [Indexed: 02/18/2024] Open
Abstract
OBJECTIVE Severe brain injuries can result in disorders of consciousness, such as the Minimally Conscious State (MCS), where individuals display intermittent yet discernible signs of conscious awareness. The varied levels of responsiveness and awareness observed in this state have spurred the progressive delineation of two subgroups within MCS, termed "plus" (MCS+) and "minus" (MCS-). However, the clinical validity of these classifications remains uncertain. This study aimed to investigate and compare the likelihood of emergence from MCS, as well as the functional independence after emergence, in individuals categorized as in MCS+ and MCS-. METHODS Demographic and behavioral data of 80 participants, admitted as either in MCS+ (n = 30) or MCS- (n = 50) to a long-term neurorehabilitation unit, were retrospectively analyzed. The neurobehavioral condition of each participant was evaluated weekly until discharge, demise, or emergence from MCS. The functional independence of those participants who emerged from MCS was assessed 6 months after emergence. RESULTS While only about half of the individuals classified as in MCS- (n = 24) emerged from the MCS, all those admitted as in MCS+ did, and in a shorter postinjury period. Despite these differences, all individuals who emerged from the MCS demonstrated similar high disability and low functional independence 6 months after emergence, regardless of their state at admission. INTERPRETATION Individuals classified as MCS+ exhibited a higher likelihood of emergence and a shorter time to emergence compared to those in MCS-. However, the level of functional independence 6 months after emergence was found to be unrelated to the initial state at admission.
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Affiliation(s)
- Roberto Llorens
- Neurorehabilitation and Brain Research Group, Universitat Politècnica de València, València, Spain
| | - Camilla Ippoliti
- SC Neurologia, Salute Pubblica, Disabilità - Fondazione IRCCS Istituto Neurologico Carlo Besta, Milano, Italy
| | | | - Carolina Colomer
- IRENEA, Instituto de Rehabilitación Neurológica, Fundación Vithas, València, Spain
| | - Anny Maza
- Neurorehabilitation and Brain Research Group, Universitat Politècnica de València, València, Spain
| | - Sandra Goizueta
- Neurorehabilitation and Brain Research Group, Universitat Politècnica de València, València, Spain
| | - José Olaya
- IRENEA, Instituto de Rehabilitación Neurológica, Fundación Vithas, València, Spain
| | - Belén Moliner
- IRENEA, Instituto de Rehabilitación Neurológica, Fundación Vithas, València, Spain
| | - Joan Ferri
- IRENEA, Instituto de Rehabilitación Neurológica, Fundación Vithas, València, Spain
| | - Enrique Noé
- IRENEA, Instituto de Rehabilitación Neurológica, Fundación Vithas, València, Spain
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Gallucci A, Varoli E, Del Mauro L, Hassan G, Rovida M, Comanducci A, Casarotto S, Lo Re V, Romero Lauro LJ. Multimodal approaches supporting the diagnosis, prognosis and investigation of neural correlates of disorders of consciousness: A systematic review. Eur J Neurosci 2024; 59:874-933. [PMID: 38140883 DOI: 10.1111/ejn.16149] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2022] [Revised: 08/30/2023] [Accepted: 09/11/2023] [Indexed: 12/24/2023]
Abstract
The limits of the standard, behaviour-based clinical assessment of patients with disorders of consciousness (DoC) prompted the employment of functional neuroimaging, neurometabolic, neurophysiological and neurostimulation techniques, to detect brain-based covert markers of awareness. However, uni-modal approaches, consisting in employing just one of those techniques, are usually not sufficient to provide an exhaustive exploration of the neural underpinnings of residual awareness. This systematic review aimed at collecting the evidence from studies employing a multimodal approach, that is, combining more instruments to complement DoC diagnosis, prognosis and better investigating their neural correlates. Following the PRISMA guidelines, records from PubMed, EMBASE and Scopus were screened to select peer-review original articles in which a multi-modal approach was used for the assessment of adult patients with a diagnosis of DoC. Ninety-two observational studies and 32 case reports or case series met the inclusion criteria. Results highlighted a diagnostic and prognostic advantage of multi-modal approaches that involve electroencephalography-based (EEG-based) measurements together with neuroimaging or neurometabolic data or with neurostimulation. Multimodal assessment deepened the knowledge on the neural networks underlying consciousness, by showing correlations between the integrity of the default mode network and the different clinical diagnosis of DoC. However, except for studies using transcranial magnetic stimulation combined with electroencephalography, the integration of more than one technique in most of the cases occurs without an a priori-designed multi-modal diagnostic approach. Our review supports the feasibility and underlines the advantages of a multimodal approach for the diagnosis, prognosis and for the investigation of neural correlates of DoCs.
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Affiliation(s)
- Alessia Gallucci
- Ph.D. Program in Neuroscience, School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
- NeuroMi (Neuroscience Center), University of Milano-Bicocca, Milan, Italy
| | - Erica Varoli
- Neurology Service, Department of Diagnostic and Therapeutic Services, Istituto di Ricovero e Cura a Carattere Scientifico-Istituto Mediterraneo per i Trapianti e Terapie ad Alta Specializzazione (IRCCS ISMETT), Palermo, Italy
| | - Lilia Del Mauro
- Department of Psychology, University of Milano-Bicocca, Milan, Italy
| | - Gabriel Hassan
- Department of Biomedical and Clinical Sciences, University of Milan, Italy
| | - Margherita Rovida
- Department of Psychology, University of Milano-Bicocca, Milan, Italy
| | - Angela Comanducci
- IRCSS Fondazione Don Carlo Gnocchi ONLUS, Milan, Italy
- Università Campus Bio-Medico di Roma, Rome, Italy
| | - Silvia Casarotto
- Department of Biomedical and Clinical Sciences, University of Milan, Italy
- IRCCS Fondazione Don Carlo Gnocchi, Milan, Italy
| | - Vincenzina Lo Re
- Neurology Service, Department of Diagnostic and Therapeutic Services, Istituto di Ricovero e Cura a Carattere Scientifico-Istituto Mediterraneo per i Trapianti e Terapie ad Alta Specializzazione (IRCCS ISMETT), Palermo, Italy
| | - Leonor J Romero Lauro
- NeuroMi (Neuroscience Center), University of Milano-Bicocca, Milan, Italy
- Department of Psychology, University of Milano-Bicocca, Milan, Italy
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McCormick S, Jarvis JM, Terhorst L, Richardson A, Kaseman L, Kesbhat A, Yepuri Y, Beyene E, VonVille H, Bendixen R, Treble-Barna A. Patient-report and caregiver-report measures of rehabilitation service use following acquired brain injury: a systematic review. BMJ Open 2024; 14:e076537. [PMID: 38382949 PMCID: PMC10882343 DOI: 10.1136/bmjopen-2023-076537] [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] [Indexed: 02/23/2024] Open
Abstract
OBJECTIVE To review patient-report/caregiver-report measures of rehabilitation service use following acquired brain injury (ABI). DATA SOURCES Medline, APA PsycINFO, Embase and CINAHL were searched on November 2021 and November 2022. Authors were contacted if measures were not included in manuscripts/appendices. STUDY SELECTION Included articles were empirical research or a research protocol, available in English and described measures of patient report/caregiver report of rehabilitation service use post-ABI via quantitative or qualitative methods. Two reviewers independently screened 5290 records using DistillerSR. Discrepancies were resolved by team adjudication. DATA EXTRACTION Data extraction was piloted with high levels of agreement (k=.94). Data were extracted by a single member with team meetings to seek guidance as needed. Data included administration characteristics (reporter, mode of administration, recall period), psychometric evidence and dimensions assessed (types of services, setting, frequency, duration, intensity, qualitative aspects). DATA SYNTHESIS One hundred and fifty-two measures were identified from 85 quantitative, 56 qualitative and 3 psychometric studies. Psychometric properties were reported for four measures, all of which focused on satisfaction. Most measures inquired about the type of rehabilitation services used, with more than half assessing functional (eg, physical therapy) and behavioural health rehabilitation services, but fewer than half assessing community and academic reintegration (eg, special education, vocational rehabilitation) or cognitive (eg, neuropsychology) services. Fewer than half assessed qualitative aspects (eg, satisfaction). Recall periods ranged from 1 month to 'since the ABI event' or focused on current use. Of measures that could be accessed (n=71), many included a limited checklist of types of services used. Very few measures assessed setting, frequency, intensity or duration. CONCLUSIONS Despite widespread interest, the vast majority of measures have not been validated and are limited in scope. Use of gold-standard psychometric methods to develop and validate a comprehensive patient-report/caregiver-report measure of rehabilitation service use would have wide-ranging implications for improving rehabilitation research in ABI.
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Affiliation(s)
- Sophie McCormick
- Department of Physical Medicine & Rehabilitation, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Jessica M Jarvis
- Department of Physical Medicine & Rehabilitation, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Lauren Terhorst
- Department of Occupational Therapy, SHRS Data Center, School of Health and Rehabilitation Sciences, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Amanda Richardson
- Department of Physical Medicine & Rehabilitation, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Lauren Kaseman
- Department of Physical Medicine & Rehabilitation, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Aboli Kesbhat
- College of Medicine, Drexel University, Philadelphia, Pennsylvania, USA
| | - Yamini Yepuri
- Department of Physical Medicine & Rehabilitation, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Elizabeth Beyene
- Department of Physical Medicine & Rehabilitation, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Helena VonVille
- Health Sciences Library System, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Roxanna Bendixen
- Division of Occupational Therapy, College of Health Professions, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Amery Treble-Barna
- Department of Physical Medicine & Rehabilitation, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
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48
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Young MJ, Fecchio M, Bodien YG, Edlow BL. Covert cortical processing: a diagnosis in search of a definition. Neurosci Conscious 2024; 2024:niad026. [PMID: 38327828 PMCID: PMC10849751 DOI: 10.1093/nc/niad026] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2023] [Revised: 10/22/2023] [Accepted: 12/10/2023] [Indexed: 02/09/2024] Open
Abstract
Historically, clinical evaluation of unresponsive patients following brain injury has relied principally on serial behavioral examination to search for emerging signs of consciousness and track recovery. Advances in neuroimaging and electrophysiologic techniques now enable clinicians to peer into residual brain functions even in the absence of overt behavioral signs. These advances have expanded clinicians' ability to sub-stratify behaviorally unresponsive and seemingly unaware patients following brain injury by querying and classifying covert brain activity made evident through active or passive neuroimaging or electrophysiologic techniques, including functional MRI, electroencephalography (EEG), transcranial magnetic stimulation-EEG, and positron emission tomography. Clinical research has thus reciprocally influenced clinical practice, giving rise to new diagnostic categories including cognitive-motor dissociation (i.e. 'covert consciousness') and covert cortical processing (CCP). While covert consciousness has received extensive attention and study, CCP is relatively less understood. We describe that CCP is an emerging and clinically relevant state of consciousness marked by the presence of intact association cortex responses to environmental stimuli in the absence of behavioral evidence of stimulus processing. CCP is not a monotonic state but rather encapsulates a spectrum of possible association cortex responses from rudimentary to complex and to a range of possible stimuli. In constructing a roadmap for this evolving field, we emphasize that efforts to inform clinicians, philosophers, and researchers of this condition are crucial. Along with strategies to sensitize diagnostic criteria and disorders of consciousness nosology to these vital discoveries, democratizing access to the resources necessary for clinical identification of CCP is an emerging clinical and ethical imperative.
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Affiliation(s)
- Michael J Young
- Center for Neurotechnology and Neurorecovery, Department of Neurology, Massachusetts General Hospital and Harvard Medical School, 101 Merrimac Street, Suite 310, Boston, MA 02114, USA
| | - Matteo Fecchio
- Center for Neurotechnology and Neurorecovery, Department of Neurology, Massachusetts General Hospital and Harvard Medical School, 101 Merrimac Street, Suite 310, Boston, MA 02114, USA
| | - Yelena G Bodien
- Center for Neurotechnology and Neurorecovery, Department of Neurology, Massachusetts General Hospital and Harvard Medical School, 101 Merrimac Street, Suite 310, Boston, MA 02114, USA
- Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Harvard Medical School, 300 1st Ave, Charlestown, Boston, MA 02129, USA
| | - Brian L Edlow
- Center for Neurotechnology and Neurorecovery, Department of Neurology, Massachusetts General Hospital and Harvard Medical School, 101 Merrimac Street, Suite 310, Boston, MA 02114, USA
- Athinoula A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital and Harvard Medical School, 149 13th St, Charlestown, Charlestown, MA 02129, USA
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49
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Farg H, Elnakib A, Gebreil A, Alksas A, van Bogaert E, Mahmoud A, Khalil A, Ghazal M, Abou El-Ghar M, El-Baz A, Contractor S. Diagnostic value of PET imaging in clinically unresponsive patients. Br J Radiol 2024; 97:283-291. [PMID: 38308033 DOI: 10.1093/bjr/tqad040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2023] [Revised: 07/27/2023] [Accepted: 11/21/2023] [Indexed: 02/04/2024] Open
Abstract
Rapid advancements in the critical care management of acute brain injuries have facilitated the survival of numerous patients who may have otherwise succumbed to their injuries. The probability of conscious recovery hinges on the extent of structural brain damage and the level of metabolic and functional cerebral impairment, which remain challenging to assess via laboratory, clinical, or functional tests. Current research settings and guidelines highlight the potential value of fluorodeoxyglucose-PET (FDG-PET) for diagnostic and prognostic purposes, emphasizing its capacity to consistently illustrate a metabolic reduction in cerebral glucose uptake across various disorders of consciousness. Crucially, FDG-PET might be a pivotal tool for differentiating between patients in the minimally conscious state and those in the unresponsive wakefulness syndrome, a persistent clinical challenge. In patients with disorders of consciousness, PET offers utility in evaluating the degree and spread of functional disruption, as well as identifying irreversible neural damage. Further, studies that capture responses to external stimuli can shed light on residual or revived brain functioning. Nevertheless, the validity of these findings in predicting clinical outcomes calls for additional long-term studies with larger patient cohorts suffering from consciousness impairment. Misdiagnosis of conscious illnesses during bedside clinical assessments remains a significant concern. Based on the clinical research settings, current clinical guidelines recommend PET for diagnostic and/or prognostic purposes. This review article discusses the clinical categories of conscious disorders and the diagnostic and prognostic value of PET imaging in clinically unresponsive patients, considering the known limitations of PET imaging in such contexts.
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Affiliation(s)
- Hashim Farg
- Radiology Department, Urology and Nephrology Center, Mansoura University, 35516 Mansoura, Egypt
| | - Ahmed Elnakib
- BioImaging Lab, Bioengineering Department, University of Louisville, Louisville, KY 40292, United States
| | - Ahmad Gebreil
- BioImaging Lab, Bioengineering Department, University of Louisville, Louisville, KY 40292, United States
| | - Ahmed Alksas
- BioImaging Lab, Bioengineering Department, University of Louisville, Louisville, KY 40292, United States
| | - Eric van Bogaert
- Department of Radiology, University of Louisville, Louisville, KY 40202, United States
| | - Ali Mahmoud
- BioImaging Lab, Bioengineering Department, University of Louisville, Louisville, KY 40292, United States
| | - Ashraf Khalil
- College of Technological Innovation, Zayed University, Abu Dhabi 4783, United Arab Emirates
| | - Mohammed Ghazal
- Electrical, Computer, and Biomedical Engineering Department, Abu Dhabi University, Abu Dhabi 59911, United Arab Emirates
| | - Mohamed Abou El-Ghar
- Radiology Department, Urology and Nephrology Center, Mansoura University, 35516 Mansoura, Egypt
| | - Ayman El-Baz
- BioImaging Lab, Bioengineering Department, University of Louisville, Louisville, KY 40292, United States
| | - Sohail Contractor
- Department of Radiology, University of Louisville, Louisville, KY 40202, United States
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50
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Russell ME, Ivanhoe CB, Reed EA. Prognostication and Trajectories of Recovery in Disorders of Consciousness. Phys Med Rehabil Clin N Am 2024; 35:167-173. [PMID: 37993187 DOI: 10.1016/j.pmr.2023.09.001] [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: 11/24/2023]
Abstract
Historically, there has been a pessimistic view regarding outcomes for patients with disorders of consciousness (DoC). There is a paucity of clinical diagnostic tools and prognostic protocols. Guidelines for the care of patients with DoC require behavioral observation, time, resources, and knowledge of the population. Many nonclinical factors such as patient wishes, family perception, and personal finances can indirectly influence long-term outcomes. Prognostic expectations need to be considered but we health-care professional cannot fully appreciate the decisions and influence of those decisions on the person served or on the care providers involved.
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Affiliation(s)
- Mary E Russell
- Physical Medicine and Rehabilitation Department, UT McGovern School of Medicine, TIRR Memorial Hermann-The Woodlands, Houston, TX 77030, USA.
| | - Cindy B Ivanhoe
- Physical Medicine and Rehabilitation Department, UT McGovern School of Medicine, TIRR Memorial Hermann, Houston, TX 77030, USA
| | - Eboni A Reed
- Physical Medicine and Rehabilitation Department, Baylor College of Medicine, Houston, TX 77030, USA
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