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Gatto LAM, Demartini Z, Telles JPM, Figueiredo EG. Does amantadine improve cognitive recovery in severe disorders of consciousness after aneurysmal subarachnoid hemorrhage? A double-blind placebo-controlled study. Clin Neurol Neurosurg 2024; 237:108135. [PMID: 38330801 DOI: 10.1016/j.clineuro.2024.108135] [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: 01/01/2024] [Revised: 01/22/2024] [Accepted: 01/24/2024] [Indexed: 02/10/2024]
Abstract
BACKGROUND Severe disorders of consciousness (sDoC) are a common sequela of aneurysmal subarachnoid hemorrhages (aSAH), and amantadine has been used to improve cognitive recovery after traumatic brain injury. OBJECTIVE This study evaluated the effect of amantadine treatment on consciousness in patients with sDoC secondary to aSAH. METHODS This double-center, randomized, prospective, cohort study included patients ≥ 18 years old with sDoC after aSAH from February 2020 to September 2023. Individual patient data of patients were pooled to determine the effect of amantadine, in comparison to placebo. The primary outcomes at 3 and 6 months after the ictus were evaluated using the modified Rankin scale (mRS) and Glasgow outcome scale (GOS). In addition to all-cause mortality, secondary endpoints were assessed weekly during intervention by scores on Rappaport's Disability Rating Scale (RDRS) and Coma Recovery Scale-Revised (CRSR). RESULTS Overall, 37 patients with sDoC and initial Glasgow Coma Scale (GCS) varying between 3 and 11 were recruited and randomized to amantadine (test group, n = 20) or placebo (control group, n = 17). The average age was 59.5 years (28 to 81 year-old), 24 (65%) were women, and the mean GCS at the beginning of intervention was 7.1. Most patients evolved to vasospasm (81%), with ischemia in 73% of them. The intervention was started between 30 to 180 days after the ictus, and administered for 6 weeks, with progressively higher doses. Neither epidemiological characteristics nor considerations regarding the treatment of the aneurysm and its complications differed between both arms. Overall mortality was 10.8% (4 deaths). During the study, four patients had potential adverse drug effects: two presented seizures, one had paralytic ileus, and another evolved with tachycardia; the medication was not suspended, only the dose was not increased. At data opening, 2 were taking amantadine and 2 placebo. CONCLUSION Despite some good results associated with amantadine in the literature, this study did not find statistically significant positive effects in cognitive recovery in patients with delayed post-aSAH sDoC. Further large randomized clinical trials in patients' subgroups are needed to better define its effectiveness and clarify any therapeutic window where it can be advantageous.
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Affiliation(s)
| | - Zeferino Demartini
- Department of Neurosurgery, Hospital de Clinicas - Universidade Federal do Paraná, Curitiba, PR, Brazil
| | - João Paulo Mota Telles
- Department of Neurology, Hospital das Clinicas, Universidade de São Paulo, São Paulo, SP, Brazil
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2
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Murtaugh B, Morrissey AM, Fager S, Knight HE, Rushing J, Weaver J. Music, occupational, physical, and speech therapy interventions for patients in disorders of consciousness: An umbrella review. NeuroRehabilitation 2024; 54:109-127. [PMID: 38277314 DOI: 10.3233/nre-230149] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2024]
Abstract
BACKGROUND Current clinical guidelines recommend that a multidisciplinary team inclusive of allied healthcare practitioners deliver assessment and intervention for disorders of consciousness. Allied health professionals include music, occupational, physical, and speech therapists. These allied health clinicians are challenged to select interventions due to a lack of evidence-based recommendations regarding rehabilitation interventions that support recovery of consciousness. This umbrella review synthesizes available systematic reviews (SRs) that describe occupational, speech and language, physical and/or musical therapeutic interventions for people with disorders of consciousness. OBJECTIVES Identify and summarize evidence from systematic reviews (SRs) that examine allied healthcare interventions for patients with disorders of consciousness. Additionally, this umbrella review aims to evaluate the impact of allied health interventions on recovery of consciousness, methodological quality and risk of bias for the included systematic reviews. METHODS An umbrella review was completed. The review was reported according to the Preferred Reporting Items for Overview of Reviews (PRIOR) guidance. Five academic databases (PubMed, CINAHL, PsycInfo, Web of Science, and the Cochrane Library) were searched for SRs and/or meta-analyses of allied health (i.e., music, occupational, physical, and speech therapy) interventions for disorders of consciousness. For included studies, data were extracted and quality of the SRs appraised using the A Measurement Tool to Assess Systematic Reviews (AMSTAR) 2 checklist. Data extracted from each SR identified the authors and years of primary studies, interventions, comparators, and outcomes related to recovery of consciousness (i.e., neurobehavioral/cognitive), functional status, physiological response pain, and adverse events. Rehabilitation interventions were categorized and described. RESULTS Fifteen SRs were included and three of these reviews conducted meta-analyses. Identified rehabilitation interventions included: 1) sensory stimulation, 2) median nerve stimulation, 3) communication/environmental control through assistive technology, 4) mobilization, and 5) music-based therapy. SRs were published between 2002 and 2022 and included 2286 participants. Using the AMSTAR 2, the quality of reviews was critically low (k = 6), low (k = 3), moderate (k = 4), and high (k = 2). SRs within this umbrella review demonstrated significant heterogeneity in research methods and use of outcome measures to evaluate the recovery of consciousness within the primary studies. These factors influenced the ability to conduct meta-analyses. CONCLUSIONS Sensory stimulation, median nerve stimulation, music therapy and mobilization are all interventions that demonstrate some level of benefit, but current SRs fail to prove benefit through high-level quality evidence. There is an indisputable need for continued rehabilitation research to expand options for treatment modalities and to ensure that the interventions being applied to DoC rehabilitation are evidence-based to improve consciousness and recovery.
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Affiliation(s)
- Brooke Murtaugh
- Department of Rehabilitation Programs, Madonna Rehabilitation Hospitals, Lincoln, NE, USA
| | - Ann-Marie Morrissey
- School of Allied Health, Ageing Research Centre, Health Research Institute, University of Limerick, Limerick, Ireland
| | - Susan Fager
- Communication Center, Madonna Rehabilitation Hospitals, Lincoln, NE, USA
| | - Heather E Knight
- Department of Physical Therapy, School of Pharmacy & Health Professions, Creighton University, Omaha, NE, USA
| | - Jess Rushing
- Colorado State University, Fort Collins, CO, USA
| | - Jennifer Weaver
- Department of Occupational Therapy, College of Health and Human Sciences, Colorado State University, Fort Collins, CO, USA
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3
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Seifi A, Hassannezhad S, Mosaddeghi-Heris R, Haji Kamanaj Olia A, Adib A, Hafeez S, Barthol C. Consciousness Recovery in Traumatic Brain Injury: A Systematic Review Comparing Modafinil and Amantadine. Clin Neuropharmacol 2023; 46:229-238. [PMID: 37962310 DOI: 10.1097/wnf.0000000000000577] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2023]
Abstract
OBJECTIVES Acute traumatic brain injury is one of the most common causes of death and disability. Reduction in the level of consciousness is a significant complication that can impact morbidity. Glasgow Coma Scale (GCS) is the most widely used method of assessing the level of consciousness. Neurostimulants such as amantadine and modafinil are common pharmacologic agents that increase GCS in patients with brain trauma. This study aimed to compare the effectiveness of these 2 drugs. METHODS This systematic review obtained articles from Google Scholar, PubMed, Scopus, Embase, and MEDLINE databases. Extensive searches were conducted separately by 4 individuals in 3 stages. Ultimately, 16 clinical trials, cohort studies, case reports, and case series articles were obtained after reading the title, abstract, and full text and considering the exclusion criteria. The data of the final article were entered into the analysis table. This study was registered with PROSPERO (registration number CRD42022334409) and conducted in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. RESULTS Amantadine seems to be associated with a higher overall response rate. In contrast, modafinil is associated with the most remarkable change in GCS score during treatment. However, the number of clinical trials with high quality and sample size has not been satisfactory to compare the effectiveness of these 2 drugs and their potential side effects. CONCLUSIONS The authors recommend additional double-blind clinical trials are needed to be conducted with a larger sample size, comparing amantadine with modafinil to delineate the efficacy and adverse effects, both short and long term.
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Affiliation(s)
- Ali Seifi
- Department of Neurosurgery, UT Health, San Antonio, TX
| | - Sina Hassannezhad
- Neurosciences Research Center (NSRC), Tabriz University of Medical Sciences, Tabriz, Iran
| | - Reza Mosaddeghi-Heris
- Neurosciences Research Center (NSRC), Tabriz University of Medical Sciences, Tabriz, Iran
| | | | - Ali Adib
- Neurosciences Research Center (NSRC), Tabriz University of Medical Sciences, Tabriz, Iran
| | - Shaheryar Hafeez
- Division of Neuro Critical Care, Department of Critical Care Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Colleen Barthol
- Department of Pharmacotherapy and Pharmacy Services, University Health System of San Antonio, San Antonio, TX
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4
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Dutysheva EA, Mikhaylova ER, Trestsova MA, Andreev AI, Apushkin DY, Utepova IA, Serebrennikova PO, Akhremenko EA, Aksenov ND, Bon’ EI, Zimatkin SM, Chupakhin ON, Margulis BA, Guzhova IV, Lazarev VF. Combination of a Chaperone Synthesis Inducer and an Inhibitor of GAPDH Aggregation for Rehabilitation after Traumatic Brain Injury: A Pilot Study. Pharmaceutics 2022; 15:pharmaceutics15010007. [PMID: 36678636 PMCID: PMC9867013 DOI: 10.3390/pharmaceutics15010007] [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: 11/09/2022] [Revised: 12/12/2022] [Accepted: 12/14/2022] [Indexed: 12/24/2022] Open
Abstract
The recovery period after traumatic brain injury (TBI) is often complicated by secondary damage that may last for days or even months after trauma. Two proteins, Hsp70 and glyceraldehyde-3-phosphate dehydrogenase (GAPDH), were recently described as modulating post-traumatic processes, and in this study, we test them as targets for combination therapy using an inhibitor of GAPDH aggregation (derivative of hydrocortisone RX624) and an inducer of Hsp70 synthesis (the pyrrolylazine derivative PQ-29). The protective effect of the combination on C6 rat glioblastoma cells treated with the cerebrospinal fluid of traumatized animals resulted in an increase in the cell index and in a reduced level of apoptosis. Using a rat weight drop model of TBI, we found that the combined use of both drugs prevented memory impairment and motor deficits, as well as a reduction of neurons and accumulation of GAPDH aggregates in brain tissue. In conclusion, we developed and tested a new approach to the treatment of TBI based on influencing distinct molecular mechanisms in brain cells.
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Affiliation(s)
| | - Elena R. Mikhaylova
- Institute of Cytology of the Russian Academy of Sciences, 194064 St. Petersburg, Russia
| | - Maria A. Trestsova
- Department of Organic and Biomolecular Chemistry, Ural Federal University, 620002 Ekaterinburg, Russia
| | - Alexander I. Andreev
- Laboratory of Experimental Pharmacology, Perm State University, 614990 Perm, Russia
- Perm State Pharmaceutical Academy, 614990 Perm, Russia
| | - Danila Yu. Apushkin
- Laboratory of Experimental Pharmacology, Perm State University, 614990 Perm, Russia
- Perm State Pharmaceutical Academy, 614990 Perm, Russia
| | - Irina A. Utepova
- Department of Organic and Biomolecular Chemistry, Ural Federal University, 620002 Ekaterinburg, Russia
- Postovsky Institute of Organic Synthesis, Ural Branch, The Russian Academy of Sciences, 620108 Ekaterinburg, Russia
| | - Polina O. Serebrennikova
- Department of Organic and Biomolecular Chemistry, Ural Federal University, 620002 Ekaterinburg, Russia
| | | | - Nikolay D. Aksenov
- Institute of Cytology of the Russian Academy of Sciences, 194064 St. Petersburg, Russia
| | - Elizaveta I. Bon’
- Department of Histology, Cytology and Embryology, Grodno State Medical University, 230009 Grodno, Belarus
| | - Sergey M. Zimatkin
- Department of Histology, Cytology and Embryology, Grodno State Medical University, 230009 Grodno, Belarus
| | - Oleg N. Chupakhin
- Department of Organic and Biomolecular Chemistry, Ural Federal University, 620002 Ekaterinburg, Russia
- Postovsky Institute of Organic Synthesis, Ural Branch, The Russian Academy of Sciences, 620108 Ekaterinburg, Russia
| | - Boris A. Margulis
- Institute of Cytology of the Russian Academy of Sciences, 194064 St. Petersburg, Russia
| | - Irina V. Guzhova
- Institute of Cytology of the Russian Academy of Sciences, 194064 St. Petersburg, Russia
| | - Vladimir F. Lazarev
- Institute of Cytology of the Russian Academy of Sciences, 194064 St. Petersburg, Russia
- Correspondence: ; Tel.: +7-931-233-1811
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5
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Hadgu RM, Borghol A, Gillard C, Wilson C, Elqess Mossa S, McKay M, Jastram C, Onor IO. Evaluation of Outcomes in Patients Receiving Amantadine to Improve Alertness After Traumatic Brain Injury. Hosp Pharm 2021; 56:486-494. [PMID: 34720150 DOI: 10.1177/0018578720920803] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background: Amantadine has been used off-label to improve alertness after traumatic brain injury (TBI). The goal of this study is to assess the mean change at 72 hours and in course of therapy (COT) Glasgow Coma Scale (GCS) score after amantadine initiation and to correlate the change in GCS score with participation in physical therapy (PT) and occupational therapy (OT) among patients with TBI receiving amantadine during the first hospitalization. Methods: This single-center, retrospective, cohort study included patients ≥18 years old hospitalized for a TBI from August 2012 to February 2018 and received ≥1 dose of amantadine to increase alertness. The primary endpoint is the mean change in 72-hour GCS score after amantadine initiation. The secondary endpoint is the mean change in COT GCS score after amantadine initiation and the correlation between the change in GCS score and percent PT and OT participation at 72 hours and during the COT. Results: Seventy-nine patients were included. The mean age of patients was 41 years, and 79.8% of the patients were men. The mean change in 72-hour GCS score was +0.75 (95% confidence interval [CI] = 0.09-1.42, P = .027), and the mean change in COT GCS score was +2.29 (95% CI = 1.68-2.90, P < .001). There was no significant correlation between the increase in GCS score and percent PT/OT session participation at 72 hours and during the COT, r = -0.15 (P = .24) and r = -0.02 (P = .74), respectively. The percent PT/OT session participation at 72-hour post-amantadine initiation was 61.3% compared with 65.9% during the COT. Conclusion: There were small but statistically significant increases in the mean change at 72 hours and in COT GCS score; however, they were not correlated with percent PT/OT participation. Other studies are needed to determine the appropriate time and GCS score to initiate amantadine along with the optimal dose in the inpatient setting.
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Affiliation(s)
- Rim M Hadgu
- Xavier University of Louisiana, New Orleans, USA.,Midwestern University, Glendale, AZ, USA
| | - Amne Borghol
- Xavier University of Louisiana, New Orleans, USA
| | | | | | | | - Megan McKay
- Xavier University of Louisiana, New Orleans, USA
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6
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Li J, Zhang P, Liu Y, Wu S, Yi X, Zhang S, Wang C, Liu M. Early amantadine treatment reduces the risk of death in patients with large hemisphere infarctions:a Chinese hospital-based study. BMC Neurol 2021; 21:419. [PMID: 34711177 PMCID: PMC8554877 DOI: 10.1186/s12883-021-02444-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2020] [Accepted: 10/12/2021] [Indexed: 02/08/2023] Open
Abstract
Background Amantadine hydrochloride is one of the most frequently prescribed drugs for patients with severe traumatic brain injury in restoring consciousness and accelerating the pace of functional recovery. However, there is a paucity of studies on the effectiveness of amantadine in patients with severe stroke especially large hemisphere infarction (LHI). The present study aimed to investigate whether amantadine treatment is associated with better clinical outcomes in conservatively treated LHI patients. Methods We retrospectively collected conservatively treated LHI patients according to inclusion/exclusion criteria. The patients were divided into two groups based on the treatment regimen, whether they did receive amantadine hydrochloride in addition to standard therapy (ST) or not. The primary outcomes were in-hospital death, 3-month mortality, and unfavorable outcome (defined as modified Rankin Scale score of 4 to 6). All outcomes were compared between the two groups before and after propensity score matching (PSM). Multivariate logistic regression was performed to identify the association between early amantadine hydrochloride treatment and clinical outcomes in LHI patients. Results Thirty-one LHI patients treated with amantadine combined with ST and 127 patients treated with ST were enrolled. Amantadine group had a shorter prehospital delay (median: 2 vs. 10 h), a higher baseline NIHSS score (21.71 ± 4.76 vs. 17.49 ± 5.84), and a higher rate of dominant hemisphere involvement (67.74% vs. 45.67%). After PSM, amantadine treatment significantly reduced the risk of in-hospital death (7.41% vs. 31.11%, p=0.019) and 3-month mortality (25.93% vs. 55.56%, p=0.008). Amantadine treatment yielded a significant decrease in death in-hospital (before PSM: OR 0.143, 95% CI 0.034 to 0.605; after PSM: OR 0.113, 95% CI 0.020 to 0.635) and 3-month mortality (before PSM: OR 0.214, 95% CI 0.077 to 0.598; after PSM: OR 0.176, 95% CI 0.053 to 0.586) in unmatched and matched multivariate analyses. Conclusion The results of our study provide initial evidence that early amantadine treatment was associated with a decrease in death in conservatively treated LHI patients. Considering the limitations of observational study, randomized controlled trials with a large sample size may help provide a clearer picture of the utility of amantadine in LHI patients. Supplementary Information The online version contains supplementary material available at 10.1186/s12883-021-02444-w.
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Affiliation(s)
- Jie Li
- Department of Neurology, People's Hospital of Deyang City, No.173, North Taishan Road, Deyang, 618000, Sichuan Province, PR China.,Center of Cerebrovascular Diseases, Department of Neurology, West China Hospital, Sichuan University, No. 37 GuoXue Xiang, Chengdu, Sichuan Province, 610041, PR China
| | - Ping Zhang
- Department of Neurology, People's Hospital of Deyang City, No.173, North Taishan Road, Deyang, 618000, Sichuan Province, PR China
| | - Yingying Liu
- Department of Neurology, People's Hospital of Deyang City, No.173, North Taishan Road, Deyang, 618000, Sichuan Province, PR China
| | - Simiao Wu
- Center of Cerebrovascular Diseases, Department of Neurology, West China Hospital, Sichuan University, No. 37 GuoXue Xiang, Chengdu, Sichuan Province, 610041, PR China
| | - Xingyang Yi
- Department of Neurology, People's Hospital of Deyang City, No.173, North Taishan Road, Deyang, 618000, Sichuan Province, PR China
| | - Shihong Zhang
- Center of Cerebrovascular Diseases, Department of Neurology, West China Hospital, Sichuan University, No. 37 GuoXue Xiang, Chengdu, Sichuan Province, 610041, PR China
| | - Chun Wang
- Department of Neurology, People's Hospital of Deyang City, No.173, North Taishan Road, Deyang, 618000, Sichuan Province, PR China.
| | - Ming Liu
- Center of Cerebrovascular Diseases, Department of Neurology, West China Hospital, Sichuan University, No. 37 GuoXue Xiang, Chengdu, Sichuan Province, 610041, PR China.
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7
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Feller D, Vinante C, Trentin F, Innocenti T. The effectiveness of median nerve electrical stimulation in patients with disorders of consciousness: a systematic review. Brain Inj 2021; 35:385-394. [PMID: 33617359 DOI: 10.1080/02699052.2021.1887522] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
OBJECTIVE To examine the effectiveness of median nerve electrical stimulation on consciousness level in subjects with disorders of consciousness. METHODS Electronic databases PubMed, EMBASE, CENTRAL, and PEDro, as well as manual search and gray literature were searched from inception until May 2019. We included only randomized controlled trials. Two reviewers independently conducted the search strategy, study selection, data extraction, risk of bias assessment, and evidence judgment quality. RESULTS Five studies met the inclusion criteria. Overall, no clear conclusion can be drawn about the intervention's effectiveness on the level of consciousness. One study reported a benefit of the intervention on the number of hospitalization days in the intensive care unit. Furthermore, another study reported a higher percentage of patients who regained consciousness six months from the event in the experimental group. CONCLUSION Due to the limited number of studies that met the inclusion criteria and overall high risk of bias, it is impossible to draw a definitive conclusion. The results of this systematic review should be used to improve future research in this field.
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Affiliation(s)
- Daniel Feller
- Provincial Agency for Health of the Autonomous Province of Trento, Trento, Italy
| | - Caterina Vinante
- Provincial Agency for Health of the Autonomous Province of Trento, Trento, Italy
| | - Francesca Trentin
- Provincial Agency for Health of the Autonomous Province of Trento, Trento, Italy
| | - Tiziano Innocenti
- Department of Health Science, Faculty of Science, Vrije Universiteit Amsterdam, Amsterdam Movement Sciences, The Netherlands
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8
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Zhang R, Zhang L, Guo Y, Shi L, Gao J, Wang X, Hu Y. Effects of High-Definition Transcranial Direct-Current Stimulation on Resting-State Functional Connectivity in Patients With Disorders of Consciousness. Front Hum Neurosci 2020; 14:560586. [PMID: 33100996 PMCID: PMC7546763 DOI: 10.3389/fnhum.2020.560586] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2020] [Accepted: 08/26/2020] [Indexed: 12/23/2022] Open
Abstract
Recently a positive treatment effect on disorders of consciousness (DOCs) with high-definition transcranial direct-current stimulation (HD-tDCS) has been reported; however, the neural modulation mechanisms of this treatment’s efficacy need further investigation. To better understand the processing of HD-tDCS interventions, a long-lasting HD-tDCS protocol was applied to 15 unresponsive wakefulness syndrome (UWS) patients and 20 minimally conscious states (MCS) patients in this study. Ten minutes of resting-state electroencephalograms (EEGs) were recorded from the patients, and the coma recovery scale-revised scores (CRS-Rs) were assessed for each patient from four time-points (T0, T1, T2, and T3). Brain networks were constructed by calculating the EEG spectral connectivity using the debiased weighted phase lag index (dwPLI) and then quantified the network information transmission efficiency by graph theory. We found that there was an increasing trend in local and global information processing of beta and gamma bands in resting-state functional brain networks during the 14 days of HD-tDCS modulation for MCS patients. Furthermore, the increased functional connectivity not only occurred in the local brain area surrounding the stimulation position but was also present across more global brain areas. Our results suggest that long-lasting HD-tDCS on the precuneus may facilitate information processing among neural populations in MCS patients.
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Affiliation(s)
- Rui Zhang
- School of Electrical Engineering, Zhengzhou University, Zhengzhou, China.,Henan Key Laboratory of Brain Science and Brain-Computer Interface Technology, Zhengzhou, China
| | - Lipeng Zhang
- School of Electrical Engineering, Zhengzhou University, Zhengzhou, China.,Henan Key Laboratory of Brain Science and Brain-Computer Interface Technology, Zhengzhou, China
| | - Yongkun Guo
- The Fifth Affiliated Hospital of Zhengzhou University, Zhengzhou, China.,Department of Neurosurgery, Zhengzhou Central Hospital Affiliated to Zhengzhou University, Zhengzhou, China
| | - Li Shi
- Department of Automation, Tsinghua University, Beijing, China.,Beijing National Research Center for Information Science and Technology, Beijing, China
| | - Jinfeng Gao
- School of Electrical Engineering, Zhengzhou University, Zhengzhou, China.,Henan Key Laboratory of Brain Science and Brain-Computer Interface Technology, Zhengzhou, China
| | - Xinjun Wang
- The Fifth Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Yuxia Hu
- School of Electrical Engineering, Zhengzhou University, Zhengzhou, China.,Henan Key Laboratory of Brain Science and Brain-Computer Interface Technology, Zhengzhou, China
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9
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Tang H, Zhu Q, Li W, Qin S, Gong Y, Wang H, Shioda S, Li S, Huang J, Liu B, Fang Y, Liu Y, Wang S, Guo Y, Xia Q, Guo Y, Xu Z. Neurophysiology and Treatment of Disorders of Consciousness Induced by Traumatic Brain Injury: Orexin Signaling as a Potential Therapeutic Target. Curr Pharm Des 2020; 25:4208-4220. [PMID: 31663471 DOI: 10.2174/1381612825666191029101830] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2019] [Accepted: 10/21/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND Traumatic brain injury (TBI) can cause disorders of consciousness (DOC) by impairing the neuronal circuits of the ascending reticular activating system (ARAS) structures, including the hypothalamus, which are responsible for the maintenance of the wakefulness and awareness. However, the effectiveness of drugs targeting ARAS activation is still inadequate, and novel therapeutic modalities are urgently needed. METHODS The goal of this work is to describe the neural loops of wakefulness, and explain how these elements participate in DOC, with emphasis on the identification of potential new therapeutic options for DOC induced by TBI. RESULTS Hypothalamus has been identified as a sleep/wake center, and its anterior and posterior regions have diverse roles in the regulation of the sleep/wake function. In particular, the posterior hypothalamus (PH) possesses several types of neurons, including the orexin neurons in the lateral hypothalamus (LH) with widespread projections to other wakefulness-related regions of the brain. Orexins have been known to affect feeding and appetite, and recently their profound effect on sleep disorders and DOC has been identified. Orexin antagonists are used for the treatment of insomnia, and orexin agonists can be used for narcolepsy. Additionally, several studies demonstrated that the agonists of orexin might be effective in the treatment of DOC, providing novel therapeutic opportunities in this field. CONCLUSION The hypothalamic-centered orexin has been adopted as the point of entry into the system of consciousness control, and modulators of orexin signaling opened several therapeutic opportunities for the treatment of DOC.
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Affiliation(s)
- Huiling Tang
- Acupuncture Research Center, Tianjin University of Traditional Chinese Medicine, Tianjin, China
| | - Qiumei Zhu
- Acupuncture Research Center, Tianjin University of Traditional Chinese Medicine, Tianjin, China
| | - Wei Li
- Acupuncture Research Center, Tianjin University of Traditional Chinese Medicine, Tianjin, China
| | - Siru Qin
- Acupuncture Research Center, Tianjin University of Traditional Chinese Medicine, Tianjin, China
| | - Yinan Gong
- Acupuncture Research Center, Tianjin University of Traditional Chinese Medicine, Tianjin, China
| | - Hong Wang
- Acu-moxibustion and Tuina Department, Tianjin University of Traditional Chinese Medicine, Tianjin, China
| | - Seiji Shioda
- Peptide Drug Innovation, Global Research Center for Innovative Life Science, Hoshi University School of Pharmacy and Pharmaceutical Sciences, 2-4-41 Ebara, Shinagawa, Tokyo 142-8501, Japan
| | - Shanshan Li
- Acupuncture Research Center, Tianjin University of Traditional Chinese Medicine, Tianjin, China
| | - Jin Huang
- Acupuncture Research Center, Tianjin University of Traditional Chinese Medicine, Tianjin, China
| | - Baohu Liu
- Department of Rehabilitation, Wangjing Hospital, China Academy of Chinese Medical Sciences, Beijing, China
| | - Yuxin Fang
- Acupuncture Research Center, Tianjin University of Traditional Chinese Medicine, Tianjin, China.,Acu-moxibustion and Tuina Department, Tianjin University of Traditional Chinese Medicine, Tianjin, China
| | - Yangyang Liu
- Acupuncture Research Center, Tianjin University of Traditional Chinese Medicine, Tianjin, China.,Acu-moxibustion and Tuina Department, Tianjin University of Traditional Chinese Medicine, Tianjin, China
| | - Shenjun Wang
- Acupuncture Research Center, Tianjin University of Traditional Chinese Medicine, Tianjin, China.,Acu-moxibustion and Tuina Department, Tianjin University of Traditional Chinese Medicine, Tianjin, China
| | - Yongming Guo
- Acupuncture Research Center, Tianjin University of Traditional Chinese Medicine, Tianjin, China.,Acu-moxibustion and Tuina Department, Tianjin University of Traditional Chinese Medicine, Tianjin, China
| | - Qing Xia
- Acu-moxibustion and Tuina Department, Tianjin University of Traditional Chinese Medicine, Tianjin, China
| | - Yi Guo
- Acupuncture Research Center, Tianjin University of Traditional Chinese Medicine, Tianjin, China.,College of Traditional Chinese Medicine, Tianjin University of Traditional Chinese Medicine, Tianjin, China
| | - Zhifang Xu
- Acupuncture Research Center, Tianjin University of Traditional Chinese Medicine, Tianjin, China.,Acu-moxibustion and Tuina Department, Tianjin University of Traditional Chinese Medicine, Tianjin, China
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10
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Wang X, Guo Y, Zhang Y, Li J, Gao Z, Li Y, Zhou T, Zhang H, He J, Cong F. Combined Behavioral and Mismatch Negativity Evidence for the Effects of Long-Lasting High-Definition tDCS in Disorders of Consciousness: A Pilot Study. Front Neurosci 2020; 14:381. [PMID: 32410950 PMCID: PMC7198816 DOI: 10.3389/fnins.2020.00381] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2019] [Accepted: 03/27/2020] [Indexed: 11/17/2022] Open
Abstract
Objective To evaluate the effects of long-term High-definition transcranial direct current stimulation (HD-tDCS) over precuneus on the level of consciousness (LOC) and the relationship between Mismatch negativity (MMN) and the LOC over the therapy period in patients with Disorders of consciousness (DOCs). Methods We employed a with-in group repeated measures design with an anode HD-tDCS protocol (2 mA, 20 min, the precuneus) on 11 (2 vegetative state and nine minimally conscious state) patients with DOCs. MMN and Coma Recovery Scale-Revised (CRS-R) scores were measured at four time points: before the treatment of HD-tDCS (T0), after a single session of HD-tDCS (T1), after the treatment of 7 days (T2) and 14 days (T3). A frequency-deviant oddball paradigm with two deviation magnitudes (standard stimulus: 1000 Hz, small deviant stimuli: 1050 Hz, large deviant stimuli: 1200 Hz) was adopted to elicit MMN. Results Significant improvements of CRS-R score were found after 7-day (T2) and 14-day (T3) treatment compared with baseline (T0). Regarding the MMN, significant improvements of MMN amplitudes were observed after a single session of stimulation (T1), 7-day (T2) and 14-day treatment (T3) compared with baseline (T0). Additionally, there were significant negative correlations between CRS-R scores and MMN amplitudes elicited by both large and small deviant stimuli. Conclusion Long-term HD-tDCS over precuneus might improve signs of consciousness in patients with DOCs as measured by CRS-R total scores, and MMN could be an assistant assessment in the course of tDCS treatment.
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Affiliation(s)
- Xiaoyu Wang
- School of Biomedical Engineering, Faculty of Electronic Information and Electrical Engineering, Dalian University of Technology, Dalian, China
| | - Yongkun Guo
- Department of Neurosurgery, Zhengzhou Central Hospital, Zhengzhou, China.,Department of Neurosurgery, The Fifth Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Yunge Zhang
- School of Biomedical Engineering, Faculty of Electronic Information and Electrical Engineering, Dalian University of Technology, Dalian, China
| | - Jinju Li
- Department of Neurosurgery, Zhengzhou Central Hospital, Zhengzhou, China
| | - Zhongqi Gao
- School of Biomedical Engineering, Faculty of Electronic Information and Electrical Engineering, Dalian University of Technology, Dalian, China
| | - Yingxin Li
- School of Biomedical Engineering, Faculty of Electronic Information and Electrical Engineering, Dalian University of Technology, Dalian, China
| | - Tianlin Zhou
- School of Biomedical Engineering, Faculty of Electronic Information and Electrical Engineering, Dalian University of Technology, Dalian, China
| | - Hui Zhang
- Department of Neurosurgery, Zhengzhou Central Hospital, Zhengzhou, China
| | - Jianghong He
- Department of Neurosurgery, People's Liberation Army General Hospital, Beijing, China
| | - Fengyu Cong
- School of Biomedical Engineering, Faculty of Electronic Information and Electrical Engineering, Dalian University of Technology, Dalian, China.,Faculty of Information Technology, University of Jyväskylä, Jyväskylä, Finland
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11
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Sensory stimulation to improve arousal in comatose patients after traumatic brain injury: a systematic review of the literature. Neurol Sci 2020; 41:2367-2376. [PMID: 32323082 DOI: 10.1007/s10072-020-04410-9] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2019] [Accepted: 04/11/2020] [Indexed: 01/14/2023]
Abstract
BACKGROUND No standard rehabilitative treatment for coma arousal after traumatic brain injury (TBI) exists. Based on our clinical experience, we hypothesized that sensory stimulation (SS) is a promising protocol to improve outcomes in these patients. METHODS We performed a literature review on the progress of sensory stimulation to enhance coma arousal after traumatic brain injury. We searched the databases on Medline, Embase, and Cochrane to gain access to relevant publications using the key words "traumatic brain injury," "disorders of consciousness," "sensory stimulation," and "coma scale." RESULTS We included all original studies published in English with patients presenting severe disorders of consciousness due to traumatic brain injury who had received SS and whose behavioral/neural responses had been measured. We compared data on ten selected studies and analyzed the SS effects in comatose patient outcomes after TBI. Our review outlines the role of SS in patients with TBI and provides guidance for its implementation in the clinical practice. CONCLUSIONS The literature suggests the SS program improves coma arousal after TBI. However, high-quality clinical trials are needed to establish standard SS protocols.
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12
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Li S, Dong X, Sun W, Zhao N, Yu G, Shuai L. Effects of transcranial direct current stimulation on patients with disorders of consciousness after traumatic brain injury: study protocol for a randomized, double-blind controlled trial. Trials 2019; 20:596. [PMID: 31623656 PMCID: PMC6796458 DOI: 10.1186/s13063-019-3680-1] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2019] [Accepted: 08/24/2019] [Indexed: 12/31/2022] Open
Abstract
Background Disorders of consciousness (DOC) after traumatic brain injury (TBI) raise the mortality of patients, restrict the rehabilitation of patients with TBI, and increase the physical and economic burden that TBI imposes on patients and their families. Thus, treatment to promote early awakening in DOC after TBI is of vital importance. Various treatments have been reported, but there is no advanced evidence base to support them. Transcranial direct current stimulation (tDCS) has shown great potential in promoting neuroelectrochemical effects. This protocol is for a double-blind, randomized, controlled, clinical trial aiming to research the effects and safety of conventional rehabilitation combined with tDCS therapy in patients with DOC after TBI. Methods/design Eighty patients with DOC after TBI will be randomized into one of two groups receiving conventional rehabilitation combined with sham tDCS or conventional rehabilitation combined with active tDCS. The intervention period in each of the two groups will last 4 weeks (20 min per day, 6 days per week). Primary outcomes (Glasgow Outcome Scale (GOS)) will be measured at baseline and the end of every week from the first to the fourth week. Secondary outcomes will be measured at baseline and the end of the fourth week. Adverse events and untoward effects will be measured during each treatment. Discussion Patients with central nervous system lesions have received tDCS as a painless, non-invasive, easily applied and effective therapy for several decades, and there has been some evidence in recent years showing partial improvement on the level of consciousness of partial patients with DOC. However, reports mainly focus on the patients in a minimally conscious state (MCS), and there is a lack of large-sample clinical trials. This protocol presents an objective design for a randomized controlled trial that aims to study the effectiveness of conventional rehabilitation combined with tDCS therapy for DOC after TBI, to evaluate its safety, and to explore effective and economical therapeutic methods. Trial registration Chinese Clinical Trial Registry, ChiCTR1800014808. Registered on 7 February 2018. Electronic supplementary material The online version of this article (10.1186/s13063-019-3680-1) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Shilin Li
- Department of Rehabilitation Medicine, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi Province, 330006, People's Republic of China.,First Clinical Medical School, Nanchang University, Nanchang, Jiangxi Province, 330006, People's Republic of China
| | - Xiangli Dong
- Department of Psychosomatic Medicine, The Second Affiliated Hospital of Nanchang University, Nanchang, Jiangxi Province, 330006, People's Republic of China
| | - Weiming Sun
- Department of Rehabilitation Medicine, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi Province, 330006, People's Republic of China. .,First Clinical Medical School, Nanchang University, Nanchang, Jiangxi Province, 330006, People's Republic of China.
| | - Na Zhao
- Department of Rehabilitation Medicine, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi Province, 330006, People's Republic of China.,First Clinical Medical School, Nanchang University, Nanchang, Jiangxi Province, 330006, People's Republic of China
| | - Guohua Yu
- Department of Rehabilitation Medicine, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi Province, 330006, People's Republic of China.,First Clinical Medical School, Nanchang University, Nanchang, Jiangxi Province, 330006, People's Republic of China
| | - Lang Shuai
- Department of Rehabilitation Medicine, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi Province, 330006, People's Republic of China.,First Clinical Medical School, Nanchang University, Nanchang, Jiangxi Province, 330006, People's Republic of China
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13
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Walsh H, Fleming J, Silvestre Edo C, Bernabeu Guitart M, Murillo N. Occupational performance and multisensory stimulation during post-traumatic amnesia: An observational and randomized controlled trial protocol. Can J Occup Ther 2019; 86:326-337. [PMID: 31088143 DOI: 10.1177/0008417419834420] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND. Occupational performance (OP) and interventions during post-traumatic amnesia (PTA) following traumatic brain injury are poorly understood. PURPOSE. This study aims to describe a study protocol to (a) track person factors of OP throughout PTA and (b) assess the feasibility of a randomized controlled trial (RCT) protocol comparing an occupation-based multisensory stimulation and environmental enrichment intervention with usual care during PTA. METHOD. A prospective observational study will be conducted with an embedded Phase II RCT with 30 participants in PTA. Participants will be randomly assigned to group and regularly assessed on PTA and OP measures. Feasibility aspects will be recorded in a logbook. All measures will be repeated at PTA resolution and 1 month later, with a follow-up questionnaire completed at 6 months postinjury. FINDINGS. Observational data will be analyzed using correlations. Feasibility will be examined descriptively, and group comparisons will be conducted to determine effect size. IMPLICATIONS. Results will provide a broader understanding of OP during PTA and inform future trials.
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14
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Guo Y, Bai Y, Xia X, Li J, Wang X, Dai Y, Dang Y, He J, Liu C, Zhang H. Effects of Long-Lasting High-Definition Transcranial Direct Current Stimulation in Chronic Disorders of Consciousness: A Pilot Study. Front Neurosci 2019; 13:412. [PMID: 31114475 PMCID: PMC6502996 DOI: 10.3389/fnins.2019.00412] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2019] [Accepted: 04/11/2019] [Indexed: 11/23/2022] Open
Abstract
Transcranial direct current stimulation (tDCS) recently was shown to benefit rehabilitation of patients with disorders of consciousness (DOC). However, high-Definition tDCS (HD-tDCS) has not been applied in DOC. In this study, we tried to use HD-tDCS protocol (2 mA, 20 min, the precuneus, and sustaining 14 days) to rehabilitate 11 patients with DOC. Electroencephalography (EEG) and Coma Recovery Scale–Revised (CRS-R) scores were recorded at before (T0), after a single session (T1), after 7 days’ (T2), and 14 days’ HD-tDCS (T3) to assess the modulation effects. EEG coherence was measured to evaluate functional connectivity during the experiment. It showed that 9 patients’ scores increased compared with the baseline. The central-parietal coherence significantly decreased in the delta band in patients with DOC. EEG coherence might be useful for assessing the effect of HD-tDCS in patients with DOC. Long-lasting HD-tDCS over the precuneus is promising for the treatment of patients with DOC.
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Affiliation(s)
- Yongkun Guo
- Department of Neurosurgery, Zhengzhou Central Hospital Affiliated to Zhengzhou University, Zhengzhou, China
| | - Yang Bai
- International Vegetative State and Consciousness Science Institute, Hangzhou Normal University, Hangzhou, China.,Department of Basic Medical Science, School of Medicine, Hangzhou Normal University, Hangzhou, China
| | - Xiaoyu Xia
- Department of Neurosurgery, PLA Army General Hospital, Beijing, China
| | - Jinju Li
- Department of Neurosurgery, Zhengzhou Central Hospital Affiliated to Zhengzhou University, Zhengzhou, China
| | - Xiaoli Wang
- Department of Neurosurgery, Zhengzhou Central Hospital Affiliated to Zhengzhou University, Zhengzhou, China
| | - Yiwu Dai
- Department of Neurosurgery, PLA Army General Hospital, Beijing, China
| | - Yuanyuan Dang
- Department of Neurosurgery, PLA Army General Hospital, Beijing, China
| | - Jianghong He
- Department of Neurosurgery, PLA Army General Hospital, Beijing, China
| | - Chunying Liu
- Department of Neurosurgery, Zhengzhou Central Hospital Affiliated to Zhengzhou University, Zhengzhou, China
| | - Hui Zhang
- Department of Neurosurgery, Zhengzhou Central Hospital Affiliated to Zhengzhou University, Zhengzhou, China
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15
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Barra ME, Izzy S, Sarro-Schwartz A, Hirschberg RE, Mazwi N, Edlow BL. Stimulant Therapy in Acute Traumatic Brain Injury: Prescribing Patterns and Adverse Event Rates at 2 Level 1 Trauma Centers. J Intensive Care Med 2019; 35:1196-1202. [PMID: 30966863 DOI: 10.1177/0885066619841603] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND/OBJECTIVE Pharmacological stimulant therapies are routinely administered to promote recovery in patients with subacute and chronic disorders of consciousness (DoC). However, utilization rates and adverse drug event (ADE) rates of stimulant therapies in patients with acute DoC are unknown. We aimed to determine the frequency of stimulant use and associated ADEs in intensive care unit (ICU) patients with acute DoC caused by traumatic brain injury (TBI). METHODS We retrospectively identified patients with TBI admitted to the ICU at 2 level 1 trauma centers between 2015 and 2018. Patients were included if they were stimulant naive at baseline and received amantadine, methylphenidate, or modafinil during ICU admission. Stimulant dose reduction or discontinuation during ICU admission was considered a surrogate marker of an ADE. Targeted chart review was performed to identify reasons for dose reduction or discontinuation. RESULTS Forty-eight of 608 patients with TBI received pharmacological stimulant therapy (7.9%) during the study period. Most patients were diagnosed with severe TBI at presentation (60.4%), although stimulants were also administered to patients with moderate (14.6%) and mild (25.0%) TBI. The median time of stimulant initiation was 11 days post-injury (range: 2-28 days). Median Glasgow Coma Scale score at the time of stimulant initiation was 9 (range: 4-15). Amantadine was the most commonly prescribed stimulant (85.4%) followed by modafinil (14.6%). Seven (14.6%) patients required stimulant dose reduction or discontinuation during ICU admission. The most common ADE resulting in therapy modification was delirium/agitation (n = 2), followed by insomnia (n = 1), anxiety (n = 1), and rash (n = 1); the reason for therapy modification was undocumented in 2 patients. CONCLUSIONS Pharmacological stimulant therapy is infrequently prescribed but well tolerated in ICU patients with acute TBI at level 1 trauma centers. These retrospective observations provide the basis for prospective studies to evaluate the safety, optimal dose range, and efficacy of stimulant therapies in this population.
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Affiliation(s)
- Megan E Barra
- Department of Pharmacy, 2348Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Saef Izzy
- Department of Neurology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Aliyah Sarro-Schwartz
- Department of Neurology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Ronald E Hirschberg
- Department of Physical Medicine and Rehabilitation, 2348Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Nicole Mazwi
- Department of Physical Medicine and Rehabilitation, 2348Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Brian L Edlow
- Department of Neurology, Center for Neurotechnology and Neurorecovery, 2348Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.,Athinoula A. Martinos Center for Biomedical Imaging, 2348Massachusetts General Hospital, Charlestown, MA, USA
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16
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Bian H, Huang L, Li B, Hu Q, Liang X, Tang J, Zhang JH. The arousal effect of hyperbaric oxygen through orexin/hypocretin an upregulation on ketamine/ethanol-induced unconsciousness in male rats. J Neurosci Res 2019; 98:201-211. [PMID: 30895638 DOI: 10.1002/jnr.24414] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2018] [Revised: 02/01/2019] [Accepted: 03/01/2019] [Indexed: 01/18/2023]
Abstract
Approaches that facilitate the recovery from coma would have enormous impacts on patient outcomes and medical economics. Orexin-producing neurons release orexins (also known as hypocretins) energy-dependently to maintain arousal. Hyperbaric oxygen (HBO) could increase ATP levels by preserving mitochondrial function. We investigated, for the first time, the arousal effects of HBO and orexins mechanisms in a rat model of unconsciousness induced by ketamine or ethanol. A total of 120 Sprague-Dawley male rats were used in this study. Unconsciousness was induced either by intraperitoneal injection of ketamine or ethanol. The HBO treatment (100% O2 at 3 ATA) was administered immediately after unconsciousness induction for 1 hr. SB334867, orexin-1 receptor (OX1R) inhibitor, or JNJ10397049, orexin-2 receptor (OX2R) inhibitor was administered 30 min intraperitoneally before unconsciousness induction. Loss of righting reflex test (LORR) and Garcia test were used to evaluate the unconsciousness duration and neurological deficits after recovering from unconsciousness, respectively. Enzyme-linked immunosorbent assay was used to measure brain tissue ATP and orexin A levels. Ketamine or ethanol injection resulted in LORR immediately and neurological deficits 6 hr after unconsciousness induction. HBO treatment significantly reduced the LORR duration, improved Garcia scores and unregulated ATP and orexin A levels in the brain tissue. Administration of OX1R inhibitor or OX2 R inhibitor abolished arousal and neurological benefits of HBO. In conclusion, HBO exerted arousal-promoting effects on unconscious rats induced by ketamine or ethanol. The underlying mechanism was via, at least in part, ATP/orexin A upregulation. HBO may be a practical clinical approach to accelerate unconsciousness recovery in patients.
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Affiliation(s)
- Hetao Bian
- Division of Physiology, Department of Basic Sciences, School of Medicine, Loma Linda University, Loma Linda, California.,Department of Neurology, Jining First People's Hospital, Jining, China.,Mental Health Center of Wuhan University Renmin Hospital, Wuhan, China
| | - Lei Huang
- Division of Physiology, Department of Basic Sciences, School of Medicine, Loma Linda University, Loma Linda, California.,Department of Neurosurgery, School of Medicine, Loma Linda University, Loma Linda, California
| | - Bo Li
- Division of Physiology, Department of Basic Sciences, School of Medicine, Loma Linda University, Loma Linda, California
| | - Qin Hu
- Division of Physiology, Department of Basic Sciences, School of Medicine, Loma Linda University, Loma Linda, California
| | - Xiping Liang
- Division of Physiology, Department of Basic Sciences, School of Medicine, Loma Linda University, Loma Linda, California
| | - Jiping Tang
- Division of Physiology, Department of Basic Sciences, School of Medicine, Loma Linda University, Loma Linda, California
| | - John H Zhang
- Division of Physiology, Department of Basic Sciences, School of Medicine, Loma Linda University, Loma Linda, California.,Department of Neurosurgery, School of Medicine, Loma Linda University, Loma Linda, California.,Department of Anesthesiology, School of Medicine, Loma Linda University, Loma Linda, California
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17
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Bancalari E, Rabinstein A, Machiavello F, Desmaison A. Accelerated emergence from a nontraumatic minimally conscious state with levodopa/carbidopa. Neurol Clin Pract 2018; 8:541-542. [DOI: 10.1212/cpj.0000000000000508] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2018] [Accepted: 07/16/2018] [Indexed: 11/15/2022]
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18
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Cheng L, Cortese D, Monti MM, Wang F, Riganello F, Arcuri F, Di H, Schnakers C. Do Sensory Stimulation Programs Have an Impact on Consciousness Recovery? Front Neurol 2018; 9:826. [PMID: 30333789 PMCID: PMC6176776 DOI: 10.3389/fneur.2018.00826] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2018] [Accepted: 09/13/2018] [Indexed: 11/13/2022] Open
Abstract
Objectives: Considering sensory stimulation programs (SSP) as a treatment for disorders of consciousness is still debated today. Previous studies investigating its efficacy were affected by various biases among which small sample size and spontaneous recovery. In this study, treatment-related changes were assessed using time-series design in patients with disorders of consciousness (i.e., vegetative state-VS and minimally conscious state-MCS). Methods: A withdrawal design (ABAB) was used. During B phases, patients underwent a SSP (3 days a week, including auditory, visual, tactile, olfactory, and gustatory stimulation). The program was not applied during A phases. To assess behavioral changes, the Coma Recovery Scale-Revised (CRS-R) was administered by an independent rater on a weekly basis, across all phases. Each phase lasted 4 weeks. In a subset of patients, resting state functional magnetic resonance imaging (fMRI) data were collected at the end of each phase. Results: Twenty nine patients (48 ± 19 years old; 15 traumatic; 21 > a year post-injury; 11 VS and 18 MCS) were included in our study. Higher CRS-R total scores (medium effect size) as well as higher arousal and oromotor subscores were observed in the B phases (treatment) as compared to A phases (no treatment), in the MCS group but not in the VS group. In the three patients who underwent fMRI analyses, a modulation of metabolic activity related to treatment was observed in middle frontal gyrus, superior temporal gyrus as well as ventro-anterior thalamic nucleus. Conclusion: Our results suggest that SSP may not be sufficient to restore consciousness. SSP might nevertheless lead to improved behavioral responsiveness in MCS patients. Our results show higher CRS-R total scores when treatment is applied, and more exactly, increased arousal and oromotor functions.
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Affiliation(s)
- Lijuan Cheng
- International Vegetative State and Consciousness Science Institute, Hangzhou Normal University, Hangzhou, China
| | - Daniela Cortese
- Research in Advanced Neurorehabilitation, S. Anna Institute, Crotone, Italy
| | - Martin M. Monti
- Department of Psychology, University of California, Los Angeles, Los Angeles, CA, United States
- Department of Neurosurgery, David Geffen School of Medicine at UCLA, Los Angeles, CA, United States
| | - Fuyan Wang
- International Vegetative State and Consciousness Science Institute, Hangzhou Normal University, Hangzhou, China
| | | | - Francesco Arcuri
- Research in Advanced Neurorehabilitation, S. Anna Institute, Crotone, Italy
| | - Haibo Di
- International Vegetative State and Consciousness Science Institute, Hangzhou Normal University, Hangzhou, China
| | - Caroline Schnakers
- Research Institute, Casa Colina Hospital and Centers for Healthcare, Pomona, CA, United States
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19
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Li Y, Luo X, Wan M, Li J, Wang H, Wei D, Feng H. The effectiveness of non-invasive brain stimulation on arousal and alertness in patients in coma or persistent vegetative state after traumatic brain injury: Protocol of systematic review and network meta-analysis. Medicine (Baltimore) 2018; 97:e12321. [PMID: 30212977 PMCID: PMC6155968 DOI: 10.1097/md.0000000000012321] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2018] [Accepted: 08/21/2018] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Traumatic brain injury is a leading cause of death and disability worldwide. The survivors usually suffer from disorders of consciousness, especially coma state and persistent vegetative state. For these patients, there is no standard treatment for them, but non-invasive brain stimulations are considered as relatively more acceptable treatments. However, the knowledge regarding the relative effectiveness and the rank of the effectiveness of the non-invasive brain stimulations is limited. Thus, in this study, we aim to conduct a systematic review and network meta-analysis to evaluate the effect of non-invasive train stimulations on arousal and alertness in patients in a coma or persistent vegetative state after traumatic brain injury. METHODS AND ANALYSIS A comprehensive search strategy will be performed in the relevant databases (MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP), Chinese Biomedical Literature Database, China National Knowledge Infrastructure, Wan Fang Data). The random or quasi-random controlled trails focusing on the effectiveness of the non-invasive brain stimulations will be included. The risk of bias for the included studies will be appraised using the Cochrane collaboration tool for assessing risk of bias. The standard pairwise meta-analysis and a Bayesian network meta-analysis will be conducted. ETHICS AND DISSEMINATION This research is a systematic review and network meta-analysis. Thus, there is no requirement of ethical approval and patient informed consent. PROSPERO REGISTRATION NUMBER CRD42018104945.
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Affiliation(s)
- Yabin Li
- Department of Neurological Rehabilitation, Rehabilitation Central Hospital of Gansu Province
| | - Xianggui Luo
- The First Clinical Medical College of Lanzhou University, Lanzhou, China
| | - Miao Wan
- The First Clinical Medical College of Lanzhou University, Lanzhou, China
| | - Jiao Li
- Department of Neurological Rehabilitation, Rehabilitation Central Hospital of Gansu Province
| | - Hongxia Wang
- Department of Neurological Rehabilitation, Rehabilitation Central Hospital of Gansu Province
| | - Dang Wei
- Department of Public Health Sciences, Karolinska Institute, Stockholm, Sweden
| | - Haixia Feng
- Department of Neurological Rehabilitation, Rehabilitation Central Hospital of Gansu Province
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20
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Dong XY, Feng Z. Wake-promoting effects of vagus nerve stimulation after traumatic brain injury: upregulation of orexin-A and orexin receptor type 1 expression in the prefrontal cortex. Neural Regen Res 2018; 13:244-251. [PMID: 29557373 PMCID: PMC5879895 DOI: 10.4103/1673-5374.226395] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Orexins, produced in the lateral hypothalamus, are important neuropeptides that participate in the sleep/wake cycle, and their expression coincides with the projection area of the vagus nerve in the brain. Vagus nerve stimulation has been shown to decrease the amounts of daytime sleep and rapid eye movement in epilepsy patients with traumatic brain injury. In the present study, we investigated whether vagus nerve stimulation promotes wakefulness and affects orexin expression. A rat model of traumatic brain injury was established using the free fall drop method. In the stimulated group, rats with traumatic brain injury received vagus nerve stimulation (frequency, 30 Hz; current, 1.0 mA; pulse width, 0.5 ms; total stimulation time, 15 minutes). In the antagonist group, rats with traumatic brain injury were intracerebroventricularly injected with the orexin receptor type 1 (OX1R) antagonist SB334867 and received vagus nerve stimulation. Changes in consciousness were observed after stimulation in each group. Enzyme-linked immunosorbent assay, western blot assay and immunohistochemistry were used to assess the levels of orexin-A and OX1R expression in the prefrontal cortex. In the stimulated group, consciousness was substantially improved, orexin-A protein expression gradually increased within 24 hours after injury and OX1R expression reached a peak at 12 hours, compared with rats subjected to traumatic brain injury only. In the antagonist group, the wake-promoting effect of vagus nerve stimulation was diminished, and orexin-A and OX1R expression were decreased, compared with that of the stimulated group. Taken together, our findings suggest that vagus nerve stimulation promotes the recovery of consciousness in comatose rats after traumatic brain injury. The upregulation of orexin-A and OX1R expression in the prefrontal cortex might be involved in the wake-promoting effects of vagus nerve stimulation.
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Affiliation(s)
- Xiao-Yang Dong
- Department of Rehabilitation Medicine, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi Province, China
| | - Zhen Feng
- Department of Rehabilitation Medicine, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi Province, China
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21
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Lehnerer SM, Scheibe F, Buchert R, Kliesch S, Meisel A. Awakening with amantadine from a persistent vegetative state after subarachnoid haemorrhage. BMJ Case Rep 2017; 2017:bcr-2017-220305. [PMID: 28739616 PMCID: PMC5614270 DOI: 10.1136/bcr-2017-220305] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
We report the case of a 36-year-old woman with a subarachnoid haemorrhage (SAH) caused by a rupture of a right-sided middle cerebral artery aneurysm and subsequent malignant infarction of the right hemisphere leading to a persistent vegetative state and severe spastic tetraparesis with recurrent myocloni. Nine months after disease onset, the patient was transferred to our department for diagnostic and therapeutic re-evaluation. The poor clinical condition could not be explained by the brain lesion caused by the SAH or infarction. Moreover, glucose metabolism was normal in brain regions not affected by SAH and infarction as shown by positron emission tomography with 18F-fluorodeoxyglucose. We terminated baclofen and reduced antiepileptics known to impair vigilance and cognitive functions. However, only after starting amantadine treatment we observed a stunning awakening of the patient fully orientated within days. Our findings warrant trials to investigate amantadine in the treatment of unresponsive wakefulness syndromes due to acute central nervous system diseases.
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Affiliation(s)
- Sophie Mirabell Lehnerer
- Department of Experimental Neurology, NeuroCure Clinical Research Center, and Department of Neurology, Charite´-University Medicine Berlin, Berlin, Germany
| | - Franziska Scheibe
- Department of Experimental Neurology, NeuroCure Clinical Research Center, and Department of Neurology, Charite´-University Medicine Berlin, Berlin, Germany
| | - Ralph Buchert
- Department of Nuclear Medicine, Charite´-University Medicine Berlin, Berlin, Germany
| | - Stefan Kliesch
- Department of Neuroradiology, Charite´-University Medicine Berlin, Berlin, Germany
| | - Andreas Meisel
- Department of Experimental Neurology, NeuroCure Clinical Research Center, and Department of Neurology, Charite´-University Medicine Berlin, Berlin, Germany
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Wu X, Zhang C, Feng J, Mao Q, Gao G, Jiang J. Right median nerve electrical stimulation for acute traumatic coma (the Asia Coma Electrical Stimulation trial): study protocol for a randomised controlled trial. Trials 2017; 18:311. [PMID: 28693604 PMCID: PMC5504835 DOI: 10.1186/s13063-017-2045-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2016] [Accepted: 06/08/2017] [Indexed: 11/24/2022] Open
Abstract
Background Traumatic brain injury (TBI) has become the most common cause of death and disability in persons between 15 and 30 years of age, and about 10–15% of patients affected by TBI will end up in a coma. Coma caused by TBI presents a significant challenge to neuroscientists. Right median nerve electrical stimulation has been reported as a simple, inexpensive, non-invasive technique to speed recovery and improve outcomes for traumatic comatose patients. Methods/design This multicentre, prospective, randomised (1:1) controlled trial aims to demonstrate the efficacy and safety of electrical right median nerve stimulation (RMNS) in both accelerating emergence from coma and promoting long-term outcomes. This trial aims to enrol 380 TBI comatose patients to partake in either an electrical stimulation group or a non-stimulation group. Patients assigned to the stimulation group will receive RMNS in addition to standard treatment at an amplitude of 15–20 mA with a pulse width of 300 μs at 40 Hz ON for 20 s and OFF for 40 s. The electrical treatment will last for 8 h per day for 2 weeks. The primary endpoint will be the percentage of patients regaining consciousness 6 months after injury. The secondary endpoints will be Extended Glasgow Outcome Scale, Coma Recovery Scale-Revised and Disability Rating Scale scores at 28 days, 3 months and 6 months after injury; Glasgow Coma Scale, Glasgow Coma Scale Motor Part and Full Outline of Unresponsiveness scale scores on day 1 and day 7 after enrolment and 28 days, 3 months and 6 months after injury; duration of unconsciousness and mechanical ventilation; length of intensive care unit and hospital stays; and incidence of adverse events. Discussion Right median nerve electrical stimulation has been used as a safe, inexpensive, non-invasive therapy for neuroresuscitation of coma patients for more than two decades, yet no trial has robustly proven the efficacy and safety of this treatment. The Asia Coma Electrical Stimulation (ACES) trial has the following novel features compared with other major RMNS trials: (1) the ACES trial is an Asian multicentre randomised controlled trial; (2) RMNS therapy starts at an early stage 7–14 days after the injury; and (3) various assessment scales are used to evaluate the condition of patients. We hope the ACES trial will lead to optimal use of right median nerve electrical treatment. Trial registration ClinicalTrials.gov, NCT02645578. Registered on 23 December 2015. Electronic supplementary material The online version of this article (doi:10.1186/s13063-017-2045-x) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Xiang Wu
- Department of Neurosurgery, Renji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, China
| | - Chao Zhang
- Department of Neurosurgery, Renji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, China
| | - Junfeng Feng
- Department of Neurosurgery, Renji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, China
| | - Qing Mao
- Department of Neurosurgery, Renji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, China
| | - Guoyi Gao
- Department of Neurosurgery, Renji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, China.
| | - Jiyao Jiang
- Department of Neurosurgery, Renji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, China
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A Narrative Review of Pharmacologic and Non-pharmacologic Interventions for Disorders of Consciousness Following Brain Injury in the Pediatric Population. CURRENT PHYSICAL MEDICINE AND REHABILITATION REPORTS 2016; 4:56-70. [PMID: 27280064 DOI: 10.1007/s40141-016-0108-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Traumatic brain injury (TBI) is the most common cause of long-term disability in the United States. A significant proportion of children who experience a TBI will have moderate or severe injuries, which includes a period of decreased responsiveness. Both pharmacological and non-pharmacological modalities are used for treating disorders of consciousness after TBI in children. However, the evidence supporting the use of potential therapies is relatively scant, even in adults, and overall, there is a paucity of study in pediatrics. The goal of this review is to describe the state of the science for use of pharmacologic and non-pharmacologic interventions for disorders of consciousness in the pediatric population.
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Pallesen H, Buhl I, Roenn-Smidt H. Early rehabilitation and participation in focus – a Danish perspective on patients with severe acquired brain injury. EUROPEAN JOURNAL OF PHYSIOTHERAPY 2016. [DOI: 10.1080/21679169.2016.1189594] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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ZHONG YINGJUN, FENG ZHEN, WANG LIANG, WEI TIANQI. Wake-promoting actions of median nerve stimulation in TBI-induced coma: An investigation of orexin-A and orexin receptor 1 in the hypothalamic region. Mol Med Rep 2015; 12:4441-4447. [DOI: 10.3892/mmr.2015.3898] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2014] [Accepted: 05/08/2015] [Indexed: 11/06/2022] Open
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Lei J, Wang L, Gao G, Cooper E, Jiang J. Right Median Nerve Electrical Stimulation for Acute Traumatic Coma Patients. J Neurotrauma 2015; 32:1584-9. [PMID: 25664378 DOI: 10.1089/neu.2014.3768] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
The right median nerve as a peripheral portal to the central nervous system can be electrically stimulated to help coma arousal after traumatic brain injury (TBI). The present study set out to examine the efficacy and safety of right median nerve electrical stimulation (RMNS) in a cohort of 437 comatose patients after severe TBI from August 2005 to December 2011. The patients were enrolled 2 weeks after their injury and assigned to the RMNS group (n=221) receiving electrical stimulation for 2 weeks or the control group (n = 216) treated by standard management according to the date of birth in the month. The baseline data were similar. After the 2-week treatment, the RMNS-treated patients demonstrated a more rapid increase of the mean Glasgow Coma Score, although statistical significance was not reached (8.43 ± 4.98 vs. 7.47 ± 5.37, p = 0.0532). The follow-up data at 6-month post-injury showed a significantly higher proportion of patients who regained consciousness (59.8% vs. 46.2%, p = 0.0073). There was a lower proportion of vegetative persons in the RMNS group than in the control group (17.6% vs. 22.0%, p = 0.0012). For persons regaining consciousness, the functional independence measurement (FIM) score was higher among the RMNS group patients (91.45 ± 8.65 vs. 76.23 ± 11.02, p < 0.001). There were no unique complications associated with the RMNS treatment. The current study, although with some limitations, showed that RMNS may serve as an easy, effective, and noninvasive technique to promote the recovery of traumatic coma in the early phase.
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Affiliation(s)
- Jin Lei
- 1 Department of Neurosurgery, Renji Hospital, Shanghai Jiaotong University School of Medicine , Shanghai, China .,2 Shanghai Institute of Head Trauma , Shanghai, China
| | - Lei Wang
- 1 Department of Neurosurgery, Renji Hospital, Shanghai Jiaotong University School of Medicine , Shanghai, China .,2 Shanghai Institute of Head Trauma , Shanghai, China
| | - Guoyi Gao
- 1 Department of Neurosurgery, Renji Hospital, Shanghai Jiaotong University School of Medicine , Shanghai, China .,2 Shanghai Institute of Head Trauma , Shanghai, China
| | - Edwin Cooper
- 3 Department of Neurological Surgery, University of Virginia Health System , Charlottesville, Virginia
| | - Jiyao Jiang
- 1 Department of Neurosurgery, Renji Hospital, Shanghai Jiaotong University School of Medicine , Shanghai, China .,2 Shanghai Institute of Head Trauma , Shanghai, China
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