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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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Piedade GS, Assumpcao de Monaco B, Guest JD, Cordeiro JG. Review of spinal cord stimulation for disorders of consciousness. Curr Opin Neurol 2023; 36:507-515. [PMID: 37889524 DOI: 10.1097/wco.0000000000001222] [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: 10/28/2023]
Abstract
PURPOSE OF REVIEW High-cervical spinal cord stimulation can alter cortical activity and cerebral metabolism. These effects are potentially beneficial for disorders of consciousness. A better understanding of the effects of clinical application of stimulation is needed. We aimed to evaluate the existing literature to determine the state of available knowledge. We performed a literature review of clinical studies assessing cervical spinal cord epidural stimulation for disorders of consciousness. Only peer-reviewed articles reporting preoperative and postoperative clinical status were included. RECENT FINDINGS Nineteen studies were included. A total of 532 cases were reported, and 255 patients were considered responsive (47.9%). Considering only studies published after the definition of minimally conscious state (MCS) as an entity, 402 individuals in unresponsive wakefulness syndrome (UWS) and 113 in MCS were reported. Responsiveness to SCS was reported in 170 UWS patients (42.3%) and in 78 MCS cases (69.0%), although the criteria for responsiveness and outcome measures varied among publications. SUMMARY Cervical SCS yielded encouraging results in patients with disorders of consciousness and seems to be more effective in MCS. More extensive investigation is needed to understand its potential role in clinical practice.
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Affiliation(s)
| | | | - James D Guest
- Department of Neurosurgery, Jackson Memorial Hospital, University of Miami Miller School of Medicine, Miami
- The Miami Project to Cure Paralysis, Miller School of Medicine, Miami, Florida, USA
| | - Joacir Graciolli Cordeiro
- Department of Neurosurgery, Jackson Memorial Hospital, University of Miami Miller School of Medicine, Miami
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Chudy D, Deletis V, Paradžik V, Dubroja I, Marčinković P, Orešković D, Chudy H, Raguž M. Deep brain stimulation in disorders of consciousness: 10 years of a single center experience. Sci Rep 2023; 13:19491. [PMID: 37945710 PMCID: PMC10636144 DOI: 10.1038/s41598-023-46300-y] [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: 05/20/2023] [Accepted: 10/30/2023] [Indexed: 11/12/2023] Open
Abstract
Disorders of consciousness (DoC), namely unresponsive wakefulness syndrome (UWS) and minimally conscious state (MCS), represent severe conditions with significant consequences for patients and their families. Several studies have reported the regaining of consciousness in such patients using deep brain stimulation (DBS) of subcortical structures or brainstem nuclei. Our study aims to present the 10 years' experience of a single center using DBS as a therapy on a cohort of patients with DoC. Eighty Three consecutive patients were evaluated between 2011 and 2022; entry criteria consisted of neurophysiological and neurological evaluations and neuroimaging examinations. Out of 83, 36 patients were considered candidates for DBS implantation, and 32 patients were implanted: 27 patients had UWS, and five had MCS. The stimulation target was the centromedian-parafascicular complex in the left hemisphere in hypoxic brain lesion or the one better preserved in patients with traumatic brain injury. The level of consciousness was improved in seven patients. Three out of five MCS patients emerged to full awareness, with the ability to interact and communicate. Two of them can live largely independently. Four out of 27 UWS patients showed consciousness improvement with two patients emerging to full awareness, and the other two reaching MCS. In patients with DoC lasting longer than 12 months following traumatic brain injury or 6 months following anoxic-ischemic brain lesion, spontaneous recovery is rare. Thus, DBS of certain thalamic nuclei could be recommended as a treatment option for patients who meet neurological, neurophysiological and neuroimaging criteria, especially in earlier phases, before occurrence of irreversible musculoskeletal changes. Furthermore, we emphasize the importance of cooperation between centers worldwide in studies on the potentials of DBS in treating patients with DoC.
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Affiliation(s)
- Darko Chudy
- Department of Neurosurgery, Dubrava University Hospital, Zagreb, Croatia.
- Department of Surgery, School of Medicine, University of Zagreb, Zagreb, Croatia.
| | - Vedran Deletis
- Department of Neurosurgery, Dubrava University Hospital, Zagreb, Croatia
- Albert Einstein College of Medicine, New York, USA
| | - Veronika Paradžik
- Department of Neurosurgery, Dubrava University Hospital, Zagreb, Croatia
| | - Ivan Dubroja
- Brain Trauma Unit, Specialty Hospital for Medical Rehabilitation, Krapinske Toplice, Croatia
| | - Petar Marčinković
- Department of Neurosurgery, Dubrava University Hospital, Zagreb, Croatia
| | - Darko Orešković
- Department of Neurosurgery, Dubrava University Hospital, Zagreb, Croatia
| | - Hana Chudy
- Department of Neurology, Dubrava University Hospital, Zagreb, Croatia
| | - Marina Raguž
- Department of Neurosurgery, Dubrava University Hospital, Zagreb, Croatia
- School of Medicine, Catholic University of Croatia, Zagreb, Croatia
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4
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Yang Y, He Q, Dang Y, Xia X, Xu X, Chen X, Zhao J, He J. Long-term functional outcomes improved with deep brain stimulation in patients with disorders of consciousness. Stroke Vasc Neurol 2023; 8:368-378. [PMID: 36882201 PMCID: PMC10647871 DOI: 10.1136/svn-2022-001998] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2022] [Accepted: 01/26/2023] [Indexed: 03/09/2023] Open
Abstract
BACKGROUND Deep brain stimulation (DBS) has been preliminarily applied to treat patients with disorders of consciousness (DoCs). The study aimed to determine whether DBS was effective for treating patients with DoC and identify factors related to patients' outcomes. METHODS Data from 365 patients with DoCs who were consecutively admitted from 15 July 2011 to 31 December 2021 were retrospectively analysed. Multivariate regression and subgroup analysis were performed to adjust for potential confounders. The primary outcome was improvement in consciousness at 1 year. RESULTS An overall improvement in consciousness at 1 year was achieved in 32.4% (12/37) of the DBS group compared with 4.3% (14/328) of the conservative group. After full adjustment, DBS significantly improved consciousness at 1 year (adjusted OR 11.90, 95% CI 3.65-38.46, p<0.001). There was a significant treatment×follow up interaction (H=14.99, p<0.001). DBS had significantly better effects in patients with minimally conscious state (MCS) compared with patients with vegetative state/unresponsive wakefulness syndrome (p for interaction <0.001). A nomogram based on age, state of consciousness, pathogeny and duration of DoCs indicated excellent predictive performance (c-index=0.882). CONCLUSIONS DBS was associated with better outcomes in patients with DoC, and the effect was likely to be significantly greater in patients with MCS. DBS should be cautiously evaluated by nomogram preoperatively, and randomised controlled trials are still needed.
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Affiliation(s)
- Yi Yang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- Translational Medicine Center, Chinese Institute for Brain Research, Beijing, China
- Beijing Institute of Brain Disorders, Capital Medical University, Beijing, China
| | - Qiheng He
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yuanyuan Dang
- Department of Neurosurgery, PLA General Hospital, Beijing, China
| | - Xiaoyu Xia
- Department of Neurosurgery, PLA General Hospital, Beijing, China
| | - Xin Xu
- Department of Neurosurgery, PLA General Hospital, Beijing, China
| | - Xueling Chen
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Jizong Zhao
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- Academician Office, China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Jianghong He
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
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5
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Shu Z, Wu J, Li H, Liu J, Lu J, Lin J, Liang S, Wu J, Han J, Yu N. fNIRS-based functional connectivity signifies recovery in patients with disorders of consciousness after DBS treatment. Clin Neurophysiol 2023; 147:60-68. [PMID: 36702043 DOI: 10.1016/j.clinph.2022.12.011] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Revised: 11/20/2022] [Accepted: 12/12/2022] [Indexed: 01/17/2023]
Abstract
OBJECTIVE While deep brain stimulation (DBS) has proved effective for certain patients with disorders of consciousness (DOC), the working neural mechanism is not clear, the response varies for patients, and the assessment is inadequate. This paper aims to quantify the DBS-induced changes of consciousness in DOC patients at the neural functional level. METHODS Ten DOC patients were included for DBS surgery. The DBS target was the right centromedian-parafascicular (CM-pf) nuclei for four patients and the bilateral CM-pf nuclei for six patients. Functional near-infrared spectroscopy (fNIRS) was taken to measure the neural activation of patients, in parallel with Coma Recovery Scale-Revised (CRS-R), before the DBS surgery and one month after. The fNIRS signals were recorded from the frontal, parietal, and occipital lobes. Functional connectivity analysis quantified the communication between brain regions, area communication strength, and global communication efficiency. Linear regression analysis was conducted between the changes of indices based on functional connectivity analysis and the changes of the CRS-R index. RESULTS Patients with trauma (n = 4) exhibited a greater increase of CRS-R scores after DBS treatment compared with patients with hemorrhage (n = 4) and brainstem infarction (n = 2). Global communication efficiency changed consistently with the CRS-R index (slope = 57.384, p < 0.05, R2=0.483). No significant relationship was found between the changes of area communication strength of six brain lobes and the changes of the CRS-R index. CONCLUSIONS The cause of DOC is essential for the outcome of DBS treatment, and brain communication efficiency is a promising functional marker for DOC recovery. SIGNIFICANCE fNIRS-based functional connectivity analysis on brain network signifies changes of consciousness in DOC patients after DBS treatment.
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Affiliation(s)
- Zhilin Shu
- College of Artificial Intelligence, Nankai University, Tianjin 300350, China; Tianjin Key Laboratory of Intelligent Robotics, Nankai University, Tianjin 300350, China
| | - Jingchao Wu
- Department of Neurosurgery, Tianjin Huanhu Hospital, Tianjin 300350, China
| | - Haitao Li
- Department of Neurosurgery, Tianjin Huanhu Hospital, Tianjin 300350, China
| | - Jinrui Liu
- College of Artificial Intelligence, Nankai University, Tianjin 300350, China; Tianjin Key Laboratory of Intelligent Robotics, Nankai University, Tianjin 300350, China
| | - Jiewei Lu
- College of Artificial Intelligence, Nankai University, Tianjin 300350, China; Tianjin Key Laboratory of Intelligent Robotics, Nankai University, Tianjin 300350, China
| | - Jianeng Lin
- College of Artificial Intelligence, Nankai University, Tianjin 300350, China; Tianjin Key Laboratory of Intelligent Robotics, Nankai University, Tianjin 300350, China
| | - Siquan Liang
- Department of Neurosurgery, Tianjin Huanhu Hospital, Tianjin 300350, China.
| | - Jialing Wu
- Department of Neurology, Tianjin Huanhu Hospital, Tianjin 300350, China; Laboratory of Cerebral Vascular and Neurodegenerative Diseases, Tianjin Neurosurgical Institute, Tianjin Huanhu Hospital, Tianjin 300350, China.
| | - Jianda Han
- College of Artificial Intelligence, Nankai University, Tianjin 300350, China; Tianjin Key Laboratory of Intelligent Robotics, Nankai University, Tianjin 300350, China.
| | - Ningbo Yu
- College of Artificial Intelligence, Nankai University, Tianjin 300350, China; Tianjin Key Laboratory of Intelligent Robotics, Nankai University, Tianjin 300350, China.
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6
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Arnts H, Coolen SE, Fernandes FW, Schuurman R, Krauss JK, Groenewegen HJ, van den Munckhof P. The intralaminar thalamus: a review of its role as a target in functional neurosurgery. Brain Commun 2023; 5:fcad003. [PMID: 37292456 PMCID: PMC10244065 DOI: 10.1093/braincomms/fcad003] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Revised: 10/06/2022] [Accepted: 01/03/2023] [Indexed: 09/29/2023] Open
Abstract
The intralaminar thalamus, in particular the centromedian-parafascicular complex, forms a strategic node between ascending information from the spinal cord and brainstem and forebrain circuitry that involves the cerebral cortex and basal ganglia. A large body of evidence shows that this functionally heterogeneous region regulates information transmission in different cortical circuits, and is involved in a variety of functions, including cognition, arousal, consciousness and processing of pain signals. Not surprisingly, the intralaminar thalamus has been a target area for (radio)surgical ablation and deep brain stimulation (DBS) in different neurological and psychiatric disorders. Historically, ablation and stimulation of the intralaminar thalamus have been explored in patients with pain, epilepsy and Tourette syndrome. Moreover, DBS has been used as an experimental treatment for disorders of consciousness and a variety of movement disorders. In this review, we provide a comprehensive analysis of the underlying mechanisms of stimulation and ablation of the intralaminar nuclei, historical clinical evidence, and more recent (experimental) studies in animals and humans to define the present and future role of the intralaminar thalamus as a target in the treatment of neurological and psychiatric disorders.
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Affiliation(s)
- Hisse Arnts
- Department of Neurosurgery, Amsterdam University Medical Centers, location Academic Medical Center, Amsterdam, The Netherlands
- Department of Neurosurgery, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Stan E Coolen
- Department of Neurosurgery, Amsterdam University Medical Centers, location Academic Medical Center, Amsterdam, The Netherlands
| | | | - Rick Schuurman
- Department of Neurosurgery, Amsterdam University Medical Centers, location Academic Medical Center, Amsterdam, The Netherlands
| | - Joachim K Krauss
- Department of Neurosurgery, Hannover Medical School, Hannover, Germany
| | - Henk J Groenewegen
- Department of Anatomy and Neurosciences, Neuroscience Campus Amsterdam, Amsterdam University Medical Centers, location VU University Medical Center, Amsterdam, The Netherlands
| | - Pepijn van den Munckhof
- Department of Neurosurgery, Amsterdam University Medical Centers, location Academic Medical Center, Amsterdam, The Netherlands
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7
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Dang Y, Wang Y, Xia X, Yang Y, Bai Y, Zhang J, He J. Deep brain stimulation improves electroencephalogram functional connectivity of patients with minimally conscious state. CNS Neurosci Ther 2022; 29:344-353. [PMID: 36377433 PMCID: PMC9804046 DOI: 10.1111/cns.14009] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2022] [Revised: 09/20/2022] [Accepted: 10/12/2022] [Indexed: 11/16/2022] Open
Abstract
AIM Deep brain stimulation (DBS) is a potential neuromodulatory therapy that enhances recovery from disorders of consciousness, especially minimally conscious state (MCS). This study measured the effects of DBS on the brain and explored the underlying mechanisms of DBS on MCS. METHODS Nine patients with MCS were recruited for this study. The neuromodulation effects of 100 Hz DBS were explored via cross-control experiments. Coma Recovery Scale-Revised (CRS-R) and EEG were recorded, and corresponding functional connectivity and network parameters were calculated. RESULTS Our results showed that 100 Hz DBS could improve the functional connectivity of the whole, local and local-local brain regions, while no significant change in EEG functional connectivity was observed in sham DBS. The whole brain's network parameters (clustering coefficient, path length, and small world characteristic) were significantly improved. In addition, a significant increase in the CRS-R and functional connectivity of three MCS patients who received 100 Hz DBS for 6 months were observed. CONCLUSION This study showed that DBS improved EEG functional connectivity and brain networks, indicating that the long-term use of DBS could improve the level of consciousness of MCS patients.
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Affiliation(s)
- Yuanyuan Dang
- Medical School of Chinese PLABeijingChina,Department of Neurosurgerythe First Medical Center of Chinese PLA General HospitalBeijingChina
| | - Yong Wang
- Zhuhai UM Science and Technology Research InstituteZhuhaiChina
| | - Xiaoyu Xia
- Department of Neurosurgerythe Seventh Medical Center of Chinese PLA General HospitalBeijingChina
| | - Yi Yang
- Department of Neurosurgery, Beijing Tiantan HospitalCapital Medical UniversityBeijingChina
| | - Yang Bai
- Department of Basic Medical Science, School of MedicineHangzhou Normal UniversityHangzhouChina
| | - Jianning Zhang
- Medical School of Chinese PLABeijingChina,Department of Neurosurgerythe First Medical Center of Chinese PLA General HospitalBeijingChina
| | - Jianghong He
- Department of Neurosurgery, Beijing Tiantan HospitalCapital Medical UniversityBeijingChina
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8
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Understanding, detecting, and stimulating consciousness recovery in the ICU. Acta Neurochir (Wien) 2022; 165:809-828. [PMID: 36242637 DOI: 10.1007/s00701-022-05378-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Accepted: 08/07/2022] [Indexed: 11/01/2022]
Abstract
Coma is a medical and socioeconomic emergency. Although underfunded, research on coma and disorders of consciousness has made impressive progress. Lesion-network-mapping studies have delineated the precise brainstem regions that consistently produce coma when damaged. Functional neuroimaging has revealed how mechanisms like "communication through coherence" and "inhibition by gating" work in synergy to enable cortico-cortical processing and how this information transfer is disrupted in brain injury. On the cellular level, break-down of intracellular communication between the layer 5 pyramidal cell soma and the apical dendritic part impairs dendritic information integration, with up-stream effects on microcircuits in local neuronal populations and on large-scale fronto-parietal networks, which correlates with loss of consciousness. A breakthrough in clinical concepts occurred when fMRI, and later EEG, studies revealed that 15% of clinically unresponsive patients in acute and chronic settings are in fact awake and aware, as shown by their command following abilities revealed by brain activation during motor and locomotion imagery tasks. This condition is now termed "cognitive motor dissociation." Furthermore, epidemiological data on coma were literally non-existent until recently because of difficulties related to case ascertainment with traditional methods, but crowdsourcing of family observations enabled the first estimates of how frequent coma is in the general population (pooled annual incidence of 201 coma cases per 100,000 population in the UK and the USA). Diagnostic guidelines on coma and disorders of consciousness by the American Academy of Neurology and the European Academy of Neurology provide ambitious clinical frameworks to accommodate these achievements. As for therapy, a broad range of medical and non-medical treatment options is now being tested in increasingly larger trials; in particular, amantadine and transcranial direct current stimulation appear promising in this regard. Major international initiatives like the Curing Coma Campaign aim to raise awareness for coma and disorders of consciousness in the public, with the ultimate goal to make more brain-injured patients recover consciousness after a coma. To highlight all these accomplishments, this paper provides a comprehensive overview of recent progress and future challenges related to understanding, detecting, and stimulating consciousness recovery in the ICU.
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9
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Aronson JP, Katnani HA, Huguenard A, Mulvaney G, Bader ER, Yang JC, Eskandar EN. Phasic stimulation in the nucleus accumbens enhances learning after traumatic brain injury. Cereb Cortex Commun 2022; 3:tgac016. [PMID: 35529519 PMCID: PMC9070350 DOI: 10.1093/texcom/tgac016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2021] [Revised: 03/31/2022] [Accepted: 04/04/2022] [Indexed: 11/13/2022] Open
Abstract
Traumatic brain injury (TBI) is a significant cause of morbidity and mortality worldwide. Despite improvements in survival, treatments that improve functional outcome remain lacking. There is, therefore, a pressing need to develop novel treatments to improve functional recovery. Here, we investigated task-matched deep-brain stimulation of the nucleus accumbens (NAc) to augment reinforcement learning in a rodent model of TBI. We demonstrate that task-matched deep brain stimulation (DBS) of the NAc can enhance learning following TBI. We further demonstrate that animals receiving DBS exhibited greater behavioral improvement and enhanced neural proliferation. Treated animals recovered to an uninjured behavioral baseline and showed retention of improved performance even after stimulation was stopped. These results provide encouraging early evidence for the potential of NAc DBS to improve functional outcomes following TBI and that its effects may be broad, with alterations in neurogenesis and synaptogenesis.
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Affiliation(s)
- Joshua P Aronson
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
- Section of Neurosurgery, Department of Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
| | - Husam A Katnani
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Anna Huguenard
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Graham Mulvaney
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Edward R Bader
- Department of Neurological Surgery, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Jimmy C Yang
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Emad N Eskandar
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
- Department of Neurological Surgery, Albert Einstein College of Medicine, Bronx, NY, USA
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10
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Elias GJB, Loh A, Gwun D, Pancholi A, Boutet A, Neudorfer C, Germann J, Namasivayam A, Gramer R, Paff M, Lozano AM. Deep brain stimulation of the brainstem. Brain 2021; 144:712-723. [PMID: 33313788 DOI: 10.1093/brain/awaa374] [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] [Received: 07/03/2020] [Revised: 07/31/2020] [Accepted: 08/17/2020] [Indexed: 01/02/2023] Open
Abstract
Deep brain stimulation (DBS) of the subthalamic nucleus, pallidum, and thalamus is an established therapy for various movement disorders. Limbic targets have also been increasingly explored for their application to neuropsychiatric and cognitive disorders. The brainstem constitutes another DBS substrate, although the existing literature on the indications for and the effects of brainstem stimulation remains comparatively sparse. The objective of this review was to provide a comprehensive overview of the pertinent anatomy, indications, and reported stimulation-induced acute and long-term effects of existing white and grey matter brainstem DBS targets. We systematically searched the published literature, reviewing clinical trial articles pertaining to DBS brainstem targets. Overall, 164 studies describing brainstem DBS were identified. These studies encompassed 10 discrete structures: periaqueductal/periventricular grey (n = 63), pedunculopontine nucleus (n = 48), ventral tegmental area (n = 22), substantia nigra (n = 9), mesencephalic reticular formation (n = 7), medial forebrain bundle (n = 8), superior cerebellar peduncles (n = 3), red nucleus (n = 3), parabrachial complex (n = 2), and locus coeruleus (n = 1). Indications for brainstem DBS varied widely and included central neuropathic pain, axial symptoms of movement disorders, headache, depression, and vegetative state. The most promising results for brainstem DBS have come from targeting the pedunculopontine nucleus for relief of axial motor deficits, periaqueductal/periventricular grey for the management of central neuropathic pain, and ventral tegmental area for treatment of cluster headaches. Brainstem DBS has also acutely elicited numerous motor, limbic, and autonomic effects. Further work involving larger, controlled trials is necessary to better establish the therapeutic potential of DBS in this complex area.
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Affiliation(s)
- Gavin J B Elias
- Division of Neurosurgery, Department of Surgery, University Health Network and University of Toronto, Toronto, Canada
| | - Aaron Loh
- Division of Neurosurgery, Department of Surgery, University Health Network and University of Toronto, Toronto, Canada
| | - Dave Gwun
- Division of Neurosurgery, Department of Surgery, University Health Network and University of Toronto, Toronto, Canada
| | - Aditya Pancholi
- Division of Neurosurgery, Department of Surgery, University Health Network and University of Toronto, Toronto, Canada
| | - Alexandre Boutet
- Division of Neurosurgery, Department of Surgery, University Health Network and University of Toronto, Toronto, Canada.,Joint Department of Medical Imaging, University of Toronto, Toronto, Canada
| | - Clemens Neudorfer
- Division of Neurosurgery, Department of Surgery, University Health Network and University of Toronto, Toronto, Canada
| | - Jürgen Germann
- Division of Neurosurgery, Department of Surgery, University Health Network and University of Toronto, Toronto, Canada
| | - Andrew Namasivayam
- Division of Neurosurgery, Department of Surgery, University Health Network and University of Toronto, Toronto, Canada
| | - Robert Gramer
- Division of Neurosurgery, Department of Surgery, University Health Network and University of Toronto, Toronto, Canada
| | - Michelle Paff
- Division of Neurosurgery, Department of Surgery, University Health Network and University of Toronto, Toronto, Canada
| | - Andres M Lozano
- Division of Neurosurgery, Department of Surgery, University Health Network and University of Toronto, Toronto, Canada
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11
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Therapies to Restore Consciousness in Patients with Severe Brain Injuries: A Gap Analysis and Future Directions. Neurocrit Care 2021; 35:68-85. [PMID: 34236624 PMCID: PMC8266715 DOI: 10.1007/s12028-021-01227-y] [Citation(s) in RCA: 53] [Impact Index Per Article: 17.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2021] [Accepted: 03/04/2021] [Indexed: 02/06/2023]
Abstract
Background/Objective For patients with disorders of consciousness (DoC) and their families, the search for new therapies has been a source of hope and frustration. Almost all clinical trials in patients with DoC have been limited by small sample sizes, lack of placebo groups, and use of heterogeneous outcome measures. As a result, few therapies have strong evidence to support their use; amantadine is the only therapy recommended by current clinical guidelines, specifically for patients with DoC caused by severe traumatic brain injury. To foster and advance development of consciousness-promoting therapies for patients with DoC, the Curing Coma Campaign convened a Coma Science Work Group to perform a gap analysis. Methods We consider five classes of therapies: (1) pharmacologic; (2) electromagnetic; (3) mechanical; (4) sensory; and (5) regenerative. For each class of therapy, we summarize the state of the science, identify gaps in knowledge, and suggest future directions for therapy development. Results Knowledge gaps in all five therapeutic classes can be attributed to the lack of: (1) a unifying conceptual framework for evaluating therapeutic mechanisms of action; (2) large-scale randomized controlled trials; and (3) pharmacodynamic biomarkers that measure subclinical therapeutic effects in early-phase trials. To address these gaps, we propose a precision medicine approach in which clinical trials selectively enroll patients based upon their physiological receptivity to targeted therapies, and therapeutic effects are measured by complementary behavioral, neuroimaging, and electrophysiologic endpoints. Conclusions This personalized approach can be realized through rigorous clinical trial design and international collaboration, both of which will be essential for advancing the development of new therapies and ultimately improving the lives of patients with DoC. Supplementary Information The online version contains supplementary material available at 10.1007/s12028-021-01227-y.
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Lemaire JJ, Pontier B, Chaix R, El Ouadih Y, Khalil T, Sinardet D, Achim V, Postelnicu A, Coste J, Germain V, Sarret C, Sontheimer A. Neural correlates of consciousness and related disorders: From phenotypic descriptors of behavioral and relative consciousness to cortico-subcortical circuitry. Neurochirurgie 2021; 68:212-222. [PMID: 34051246 DOI: 10.1016/j.neuchi.2021.05.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Revised: 04/13/2021] [Accepted: 05/09/2021] [Indexed: 01/01/2023]
Abstract
We report a review of medical aspects of the consciousness. The behavioral dimension, phenotypic descriptors, relative consciousness and neural correlates of consciousness and related disorders were addressed successively in a holistic and chronological approach. Consciousness is relative, specific to each individual across time and space. Historically defined as the perception of the self and the environment, it cannot be separated from behaviors, entailing an idea of conscious behavior with metapractic and metagnostic aspects. Observation of spontaneous and evoked overt behavior distinguishes three main types of disorder of consciousness (DoC): coma, vegetative state or unresponsive wakefulness, and minimally conscious or relationally impoverished state. Modern functional exploration techniques, such as imaging, increase the understanding of DoCs and consciousness. Whether consciousness is a superior function and/or an instrumental function is discussed. Neural correlates can be subdivided into two wakefulness pathways (superior thalamic cholinergic and inferior extra-thalamic), and cortico-subcortical circuitry. The deep brain structures are those described in the well-known sensorimotor, associative and limbic loops, as illustrated in the mesolimbic model of DoC. The cortices can be segregated into several overlapping networks: (1) a global workspace including thalamo-cortical loops; (2) the default mode network (DMN) and related intrinsic connectivity networks (i.e., central executive, medial DMN and salience networks); (3) a 3-fold network comprising the fronto-parietal control system and its dorsal and ventral attentional sub-networks, the fronto-parietal executive control network, and the cingulo-opercular salience network; (4) the internal and external cortices, respectively medial, turned toward the self, and lateral, turned toward the environment. The network dynamics is the reflection of consciousness, notably anticorrelations such as the decrease in activity of the posterior cingulate-precuneus regions during attentional tasks. Thanks to recent advances in DoC pathophysiology, further significative therapeutic progress is expected, taking into account the societal context. This depends notably on the dissemination of medical knowledge and its transfer to a wider public.
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Affiliation(s)
- J-J Lemaire
- Service de neurochirurgie, CHU Clermont-Ferrand, Clermont-Ferrand, France; Institut Pascal, université Clermont Auvergne CNRS SIGMA, Clermont-Ferrand, France.
| | - B Pontier
- Service de neurochirurgie, CHU Clermont-Ferrand, Clermont-Ferrand, France; Institut Pascal, université Clermont Auvergne CNRS SIGMA, Clermont-Ferrand, France
| | - R Chaix
- Service de neurochirurgie, CHU Clermont-Ferrand, Clermont-Ferrand, France
| | - Y El Ouadih
- Service de neurochirurgie, CHU Clermont-Ferrand, Clermont-Ferrand, France
| | - T Khalil
- Service de neurochirurgie, CHU Clermont-Ferrand, Clermont-Ferrand, France; Institut Pascal, université Clermont Auvergne CNRS SIGMA, Clermont-Ferrand, France
| | - D Sinardet
- Service de neurochirurgie, CHU Clermont-Ferrand, Clermont-Ferrand, France
| | - V Achim
- Service de neurochirurgie, CHU Clermont-Ferrand, Clermont-Ferrand, France
| | - A Postelnicu
- Service de neurochirurgie, CHU Clermont-Ferrand, Clermont-Ferrand, France
| | - J Coste
- Service de neurochirurgie, CHU Clermont-Ferrand, Clermont-Ferrand, France; Institut Pascal, université Clermont Auvergne CNRS SIGMA, Clermont-Ferrand, France
| | - V Germain
- Service de neurochirurgie, CHU Clermont-Ferrand, Clermont-Ferrand, France; Institut Pascal, université Clermont Auvergne CNRS SIGMA, Clermont-Ferrand, France
| | - C Sarret
- Institut Pascal, université Clermont Auvergne CNRS SIGMA, Clermont-Ferrand, France
| | - A Sontheimer
- Service de neurochirurgie, CHU Clermont-Ferrand, Clermont-Ferrand, France; Institut Pascal, université Clermont Auvergne CNRS SIGMA, Clermont-Ferrand, France
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Abstract
Background: Reviving patients with prolonged disorders of consciousness (DOCs) has always been focused and challenging in medical research. Owing to the limited effectiveness of available medicine, recent research has increasingly turned towards neuromodulatory therapies, involving the stimulation of neural circuits. We summarised the progression of research regarding neuromodulatory therapies in the field of DOCs, compared the differences among different studies, in an attempt to explore optimal stimulation patterns and parameters, and analyzed the major limitations of the relevant studies to facilitate future research. Methods: We performed a search in the PubMed database, using the concepts of DOCs and neuromodulation. Inclusion criteria were: articles in English, published after 2002, and reporting clinical trials of neuromodulatory therapies in human patients with DOCs. Results: Overall, 187 published articles met the search criteria, and 60 articles met the inclusion criteria. There are differences among these studies regarding the clinical efficacies of neurostimulation techniques for patients with DOCs, and large-sample studies are still lacking. Conclusions: Neuromodulatory techniques were used as trial therapies for DOCs wherein their curative effects were controversial. The difficulties in detecting residual consciousness, the confounding effect between the natural course of the disease and therapeutic effect, and the heterogeneity across patients are the major limitations. Large-sample, well-designed studies, and innovations for both treatment and assessment are anticipated in future research.
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Structural changes in brains of patients with disorders of consciousness treated with deep brain stimulation. Sci Rep 2021; 11:4401. [PMID: 33623134 PMCID: PMC7902623 DOI: 10.1038/s41598-021-83873-y] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2020] [Accepted: 02/09/2021] [Indexed: 11/09/2022] Open
Abstract
Disorders of consciousness (DOC) are one of the major consequences after anoxic or traumatic brain injury. So far, several studies have described the regaining of consciousness in DOC patients using deep brain stimulation (DBS). However, these studies often lack detailed data on the structural and functional cerebral changes after such treatment. The aim of this study was to conduct a volumetric analysis of specific cortical and subcortical structures to determine the impact of DBS after functional recovery of DOC patients. Five DOC patients underwent unilateral DBS electrode implantation into the centromedian parafascicular complex of the thalamic intralaminar nuclei. Consciousness recovery was confirmed using the Rappaport Disability Rating and the Coma/Near Coma scale. Brain MRI volumetric measurements were done prior to the procedure, then approximately a year after, and finally 7 years after the implementation of the electrode. The volumetric analysis included changes in regional cortical volumes and thickness, as well as in subcortical structures. Limbic cortices (parahippocampal and cingulate gyrus) and paralimbic cortices (insula) regions showed a significant volume increase and presented a trend of regional cortical thickness increase 1 and 7 years after DBS. The volumes of related subcortical structures, namely the caudate, the hippocampus as well as the amygdala, were significantly increased 1 and 7 years after DBS, while the putamen and nucleus accumbens presented with volume increase. Volume increase after DBS could be a result of direct DBS effects, or a result of functional recovery. Our findings are in accordance with the results of very few human studies connecting DBS and brain volume increase. Which mechanisms are behind the observed brain changes and whether structural changes are caused by consciousness recovery or DBS in patients with DOC is still a matter of debate.
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Kundu B, Brock AA, Englot DJ, Butson CR, Rolston JD. Deep brain stimulation for the treatment of disorders of consciousness and cognition in traumatic brain injury patients: a review. Neurosurg Focus 2019; 45:E14. [PMID: 30064315 DOI: 10.3171/2018.5.focus18168] [Citation(s) in RCA: 48] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Traumatic brain injury (TBI) is a looming epidemic, growing most rapidly in the elderly population. Some of the most devastating sequelae of TBI are related to depressed levels of consciousness (e.g., coma, minimally conscious state) or deficits in executive function. To date, pharmacological and rehabilitative therapies to treat these sequelae are limited. Deep brain stimulation (DBS) has been used to treat a number of pathologies, including Parkinson disease, essential tremor, and epilepsy. Animal and clinical research shows that targets addressing depressed levels of consciousness include components of the ascending reticular activating system and areas of the thalamus. Targets for improving executive function are more varied and include areas that modulate attention and memory, such as the frontal and prefrontal cortex, fornix, nucleus accumbens, internal capsule, thalamus, and some brainstem nuclei. The authors review the literature addressing the use of DBS to treat higher-order cognitive dysfunction and disorders of consciousness in TBI patients, while also offering suggestions on directions for future research.
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Affiliation(s)
| | | | - Dario J Englot
- 2Department of Neurosurgery, Vanderbilt University Medical Center, Nashville, Tennessee
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16
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Bourdillon P, Hermann B, Sitt JD, Naccache L. Electromagnetic Brain Stimulation in Patients With Disorders of Consciousness. Front Neurosci 2019; 13:223. [PMID: 30936822 PMCID: PMC6432925 DOI: 10.3389/fnins.2019.00223] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2018] [Accepted: 02/26/2019] [Indexed: 12/27/2022] Open
Abstract
Severe brain injury is a common cause of coma. In some cases, despite vigilance improvement, disorders of consciousness (DoC) persist. Several states of impaired consciousness have been defined, according to whether the patient exhibits only reflexive behaviors as in the vegetative state/unresponsive wakefulness syndrome (VS/UWS) or purposeful behaviors distinct from reflexes as in the minimally conscious state (MCS). Recently, this clinical distinction has been enriched by electrophysiological and neuroimaging data resulting from a better understanding of the physiopathology of DoC. However, therapeutic options, especially pharmacological ones, remain very limited. In this context, electroceuticals, a new category of therapeutic agents which act by targeting the neural circuits with electromagnetic stimulations, started to develop in the field of DoC. We performed a systematic review of the studies evaluating therapeutics relying on the direct or indirect electro-magnetic stimulation of the brain in DoC patients. Current evidence seems to support the efficacy of deep brain stimulation (DBS) and non-invasive brain stimulation (NIBS) on consciousness in some of these patients. However, while the latter is non-invasive and well tolerated, the former is associated with potential major side effects. We propose that all chronic DoC patients should be given the possibility to benefit from NIBS, and that transcranial direct current stimulation (tDCS) should be preferred over repetitive transcranial magnetic stimulation (rTMS), based on the literature and its simple use. Surgical techniques less invasive than DBS, such as vagus nerve stimulation (VNS) might represent a good compromise between efficacy and invasiveness but still need to be further investigated.
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Affiliation(s)
- Pierre Bourdillon
- Department of Neurosurgery, Adolphe de Rothschild Foundation, Paris, France.,Sorbonne Université, Faculté de Médecine Pitié-Salpêtrière, Paris, France.,Institut du Cerveau et de la Moelle Épinière, ICM, PICNIC Lab, Paris, France.,Inserm U 1127, Paris, France.,CNRS, UMR 7225, Paris, France
| | - Bertrand Hermann
- Sorbonne Université, Faculté de Médecine Pitié-Salpêtrière, Paris, France.,Institut du Cerveau et de la Moelle Épinière, ICM, PICNIC Lab, Paris, France.,Inserm U 1127, Paris, France.,CNRS, UMR 7225, Paris, France.,Department of Neurology, Neuro ICU, Groupe Hospitalier Pitié-Salpêtrière, AP-HP, Paris, France
| | - Jacobo D Sitt
- Institut du Cerveau et de la Moelle Épinière, ICM, PICNIC Lab, Paris, France.,Inserm U 1127, Paris, France.,CNRS, UMR 7225, Paris, France
| | - Lionel Naccache
- Sorbonne Université, Faculté de Médecine Pitié-Salpêtrière, Paris, France.,Institut du Cerveau et de la Moelle Épinière, ICM, PICNIC Lab, Paris, France.,Inserm U 1127, Paris, France.,CNRS, UMR 7225, Paris, France.,Department of Neurophysiology, Groupe Hospitalier Pitié-Salpêtrière, AP-HP, Paris, France
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Rezaei Haddad A, Lythe V, Green AL. Deep Brain Stimulation for Recovery of Consciousness in Minimally Conscious Patients After Traumatic Brain Injury: A Systematic Review. Neuromodulation 2019; 22:373-379. [DOI: 10.1111/ner.12944] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2018] [Revised: 01/05/2019] [Accepted: 02/06/2019] [Indexed: 10/27/2022]
Affiliation(s)
- Ali Rezaei Haddad
- Medical Sciences Divisional Office University of Oxford, John Radcliffe Hospital Oxford UK
- Neurosurgical Department Oxford University Hospitals Oxford UK
| | - Vanessa Lythe
- Green Templeton College, University of Oxford Oxford UK
| | - Alexander L. Green
- Neurosurgical Department Oxford University Hospitals Oxford UK
- Nuffield Department of Surgical Sciences University of Oxford Oxford UK
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Lemaire J, Sontheimer A, Pereira B, Coste J, Rosenberg S, Sarret C, Coll G, Gabrillargues J, Jean B, Gillart T, Coste A, Roche B, Kelly A, Pontier B, Feschet F. Deep brain stimulation in five patients with severe disorders of consciousness. Ann Clin Transl Neurol 2018; 5:1372-1384. [PMID: 30480031 PMCID: PMC6243378 DOI: 10.1002/acn3.648] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2018] [Revised: 08/07/2018] [Accepted: 08/22/2018] [Indexed: 02/03/2023] Open
Abstract
OBJECTIVE The efficacy of deep brain stimulation in disorders of consciousness remains inconclusive. We investigated bilateral 30-Hz low-frequency stimulation designed to overdrive neuronal activity by dual pallido-thalamic targeting, using the Coma Recovery Scale Revised (CRS-R) to assess conscious behavior. METHODS We conducted a prospective, single center, observational 11-month pilot study comprising four phases: baseline (2 months); surgery and titration (1 month); blind, random, crossover, 1.5-month ON and OFF periods; and unblinded, 5-month stimulation ON. Five adult patients were included: one unresponsive-wakefulness-syndrome male (traumatic brain injury); and four patients in a minimally conscious state, one male (traumatic brain injury) and three females (two hemorrhagic strokes and one traumatic brain injury). Primary outcome measures focused on CRS-R scores. Secondary outcome measures focused notably on baseline brain metabolism and variation in activity (stimulation ON - baseline) using normalized fluorodeoxyglucose positron emission tomography maps. Statistical analysis used random-effect models. RESULTS The two male patients (one minimally conscious and one unresponsive wakefulness syndrome) showed improved mean CRS-R scores (stimulation ON vs. baseline), in auditory, visual and oromotor/verbal subscores, and visual subscores respectively. The metabolism of the medial cortices (low at baseline in all five patients) increased specifically in the two responders. INTERPRETATION Our findings show there were robust but limited individual clinical benefits, mainly in visual and auditory processes. Overall modifications seem linked to the modulation of thalamo-cortico-basal and tegmental loops activating default mode network cortices. Specifically, in the two responders there was an increase in medial cortex activity related to internal awareness.
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Affiliation(s)
- Jean‐Jacques Lemaire
- Service de NeurochirurgieCHU Clermont‐FerrandClermont‐FerrandF‐63000France
- Université Clermont AuvergneCNRS, SIGMA Clermont, Institut PascalClermont‐FerrandF‐63000France
| | - Anna Sontheimer
- Service de NeurochirurgieCHU Clermont‐FerrandClermont‐FerrandF‐63000France
- Université Clermont AuvergneCNRS, SIGMA Clermont, Institut PascalClermont‐FerrandF‐63000France
| | - Bruno Pereira
- Unité de Biostatistiques (Délégation Recherche Clinique & Innovation)CHU Clermont‐FerrandClermont‐FerrandF‐63000France
| | - Jérôme Coste
- Service de NeurochirurgieCHU Clermont‐FerrandClermont‐FerrandF‐63000France
- Université Clermont AuvergneCNRS, SIGMA Clermont, Institut PascalClermont‐FerrandF‐63000France
| | - Sarah Rosenberg
- Université Clermont AuvergneCNRS, SIGMA Clermont, Institut PascalClermont‐FerrandF‐63000France
| | - Catherine Sarret
- Université Clermont AuvergneCNRS, SIGMA Clermont, Institut PascalClermont‐FerrandF‐63000France
| | - Guillaume Coll
- Service de NeurochirurgieCHU Clermont‐FerrandClermont‐FerrandF‐63000France
- Université Clermont AuvergneCNRS, SIGMA Clermont, Institut PascalClermont‐FerrandF‐63000France
| | - Jean Gabrillargues
- Université Clermont AuvergneCNRS, SIGMA Clermont, Institut PascalClermont‐FerrandF‐63000France
- Service de RadiologieCHU Clermont‐FerrandClermont‐FerrandF‐63000France
| | - Betty Jean
- Service de RadiologieCHU Clermont‐FerrandClermont‐FerrandF‐63000France
| | - Thierry Gillart
- Département d'Anesthésie RéanimationCHU Clermont‐FerrandClermont‐FerrandF‐63000France
| | - Aurélien Coste
- Service de NeurochirurgieCHU Clermont‐FerrandClermont‐FerrandF‐63000France
| | - Basile Roche
- Université Clermont AuvergneCNRS, SIGMA Clermont, Institut PascalClermont‐FerrandF‐63000France
| | - Antony Kelly
- Service de Médecine NucléaireCentre Jean PerrinClermont‐FerrandF‐63000France
| | - Bénédicte Pontier
- Service de NeurochirurgieCHU Clermont‐FerrandClermont‐FerrandF‐63000France
- Université Clermont AuvergneCNRS, SIGMA Clermont, Institut PascalClermont‐FerrandF‐63000France
| | - Fabien Feschet
- Université Clermont AuvergneCNRS, SIGMA Clermont, Institut PascalClermont‐FerrandF‐63000France
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Xia X, Yang Y, Guo Y, Bai Y, Dang Y, Xu R, He J. Current Status of Neuromodulatory Therapies for Disorders of Consciousness. Neurosci Bull 2018; 34:615-625. [PMID: 29916112 DOI: 10.1007/s12264-018-0244-4] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2018] [Accepted: 04/25/2018] [Indexed: 11/26/2022] Open
Abstract
Treatment for disorders of consciousness (DOCs) is still a Gordian knot. Evidence-based guidelines on the treatment of DOC patients are not currently available, while neuromodulation techniques are seen as a potential treatment. Multiple neuromodulation therapies have been applied. This article reviews the most relevant studies in the literature in order to describe a clear picture of the current state of neuromodulation therapies that could be used to treat DOC patients. Both invasive and non-invasive brain stimulation is discussed. Significant behavioral improvements in prolonged DOCs under neuromodulation therapies are rare. The efficacy of various such therapies remains a matter of debate. Further clinical investigations of existing techniques in larger samples properly controlling for spontaneous recovery are needed, and new approaches are awaited.
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Affiliation(s)
- Xiaoyu Xia
- Department of Neurosurgery, PLA Army General Hospital, Beijing, 100700, China
| | - Yi Yang
- Department of Neurosurgery, PLA Army General Hospital, Beijing, 100700, China
| | - Yongkun Guo
- Department of Neurosurgery, Zhengzhou Central Hospital Affiliated to Zhengzhou University, Zhengzhou, 450007, China
| | - Yang Bai
- International Vegetative State and Consciousness Science Institute, Hangzhou Normal University, Hangzhou, 311121, China
| | - Yuanyuan Dang
- Department of Neurosurgery, PLA Army General Hospital, Beijing, 100700, China
| | - Ruxiang Xu
- Department of Neurosurgery, PLA Army General Hospital, Beijing, 100700, China
| | - Jianghong He
- Department of Neurosurgery, PLA Army General Hospital, Beijing, 100700, China.
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Abstract
PURPOSE OF REVIEW Very few options exist for patients who survive severe traumatic brain injury but fail to fully recover and develop a disorder of consciousness (e.g. vegetative state, minimally conscious state). RECENT FINDINGS Among pharmacological approaches, Amantadine has shown the ability to accelerate functional recovery. Although with very low frequency, Zolpidem has shown the ability to improve the level of consciousness transiently and, possibly, also in a sustained fashion. Among neuromodulatory approaches, transcranial direct current stimulation has been shown to transiently improve behavioral responsiveness, but mostly in minimally conscious patients. New evidence for thalamic deep brain stimulation calls into question its cost/benefit trade-off. SUMMARY The growing understanding of the biology of disorders of consciousness has led to a renaissance in the development of therapeutic interventions for patients with disorders of consciousness. High-quality evidence is emerging for pharmacological (i.e. Amantadine) and neurostimulatory (i.e. transcranial direct current stimulation) interventions, although further studies are needed to delineate preconditions, optimal dosages, and timing of administration. Other exciting new approaches (e.g. low intensity focused ultrasound) still await systematic assessment. A crucial future direction should be the use of neuroimaging measures of functional and structural impairment as a means of tailoring patient-specific interventions.
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Cortés N, Andrade V, Maccioni RB. Behavioral and Neuropsychiatric Disorders in Alzheimer’s Disease. J Alzheimers Dis 2018; 63:899-910. [DOI: 10.3233/jad-180005] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Affiliation(s)
- Nicole Cortés
- International Center for Biomedicine (ICC), Santiago, Chile
- Laboratory of Cellular and Molecular Neurosciences, Faculty of Sciences, University of Chile, Santiago, Chile
| | - Víctor Andrade
- International Center for Biomedicine (ICC), Santiago, Chile
- Laboratory of Cellular and Molecular Neurosciences, Faculty of Sciences, University of Chile, Santiago, Chile
| | - Ricardo B. Maccioni
- International Center for Biomedicine (ICC), Santiago, Chile
- Laboratory of Cellular and Molecular Neurosciences, Faculty of Sciences, University of Chile, Santiago, Chile
- Department of Neurological Sciences, Faculty of Medicine, East Campus, University of Chile, Santiago, Chile
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Ragazzoni A, Cincotta M, Giovannelli F, Cruse D, Young GB, Miniussi C, Rossi S. Clinical neurophysiology of prolonged disorders of consciousness: From diagnostic stimulation to therapeutic neuromodulation. Clin Neurophysiol 2017; 128:1629-1646. [DOI: 10.1016/j.clinph.2017.06.037] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2017] [Revised: 05/17/2017] [Accepted: 06/15/2017] [Indexed: 10/19/2022]
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Vanhoecke J, Hariz M. Deep brain stimulation for disorders of consciousness: Systematic review of cases and ethics. Brain Stimul 2017; 10:1013-1023. [PMID: 28966051 DOI: 10.1016/j.brs.2017.08.006] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2017] [Revised: 07/24/2017] [Accepted: 08/21/2017] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND A treatment for patients suffering from prolonged severely altered consciousness is not available. The success of Deep Brain Stimulation (DBS) in diseases such as Parkinson's, dystonia and essential tremor provided a renewed impetus for its application in Disorders of Consciousness (DoC). OBJECTIVE To evaluate the rationale for DBS in patients with DoC, through systematic review of literature containing clinical data and ethical considerations. METHODS Articles from PubMed, Embase, Medline and Web of Science were systematically reviewed. RESULTS The outcomes of 78 individual patients reported in 19 articles from 1968 onwards were pooled and elements of ethical discussions were compared. There is no clear clinical evidence that DBS is a treatment for DoC that can restore both consciousness and the ability to communicate. In patients who benefitted, the outcome of DBS is often confounded by the time frame of spontaneous recovery from DoC. Difficult ethical considerations remain, such as the risk of increasing self-awareness of own limitations, without improving overall wellbeing, and the issues of proxy consent. CONCLUSION DBS is far from being evident as a possible future therapeutic avenue for patients with DoC. Double-blind studies are lacking, and many clinical and ethical issues have to be addressed. In the rare cases when DBS for patients with DoC is considered, this needs to be evaluated meticulously on a case by case basis, with comprehensive overall outcome measures including psychological and quality-of-life assessments, and with the guidance of an ethical and interdisciplinary panel, especially in relation to proxy consent.
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Affiliation(s)
- Jonathan Vanhoecke
- Unit of Functional Neurosurgery, Institute of Neurology, University College London, Queen Square, WC1N 3BG, London, UK.
| | - Marwan Hariz
- Unit of Functional Neurosurgery, Institute of Neurology, University College London, Queen Square, WC1N 3BG, London, UK; Department of Clinical Neuroscience, Umeå University, SE-901 87, Umeå, Sweden.
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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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Chudy D, Deletis V, Almahariq F, Marčinković P, Škrlin J, Paradžik V. Deep brain stimulation for the early treatment of the minimally conscious state and vegetative state: experience in 14 patients. J Neurosurg 2017. [PMID: 28621620 DOI: 10.3171/2016.10.jns161071] [Citation(s) in RCA: 44] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE An effective treatment of patients in a minimally conscious state (MCS) or vegetative state (VS) caused by hypoxic encephalopathy or traumatic brain injury (TBI) is not yet available. Deep brain stimulation (DBS) of the thalamic reticular nuclei has been attempted as a therapeutic procedure mainly in patients with TBI. The purpose of this study was to investigate the therapeutic use of DBS for patients in VS or MCS. METHODS Fourteen of 49 patients in VS or MCS qualified for inclusion in this study and underwent DBS. Of these 14 patients, 4 were in MCS and 10 were in VS. The etiology of VS or MCS was TBI in 4 cases and hypoxic encephalopathy due to cardiac arrest in 10. The selection criteria for DBS, evaluating the status of the cerebral cortex and thalamocortical reticular formation, included: neurological evaluation, electrophysiological evaluation, and the results of positron emission tomography (PET) and MRI examinations. The target for DBS was the centromedian-parafascicular (CM-pf) complex. The duration of follow-up ranged from 38 to 60 months. RESULTS Two MCS patients regained consciousness and regained their ability to walk, speak fluently, and live independently. One MCS patient reached the level of consciousness, but was still in a wheelchair at the time the article was written. One VS patient (who had suffered a cerebral ischemic lesion) improved to the level of consciousness and currently responds to simple commands. Three VS patients died of respiratory infection, sepsis, or cerebrovascular insult (1 of each). The other 7 patients remained without substantial improvement of consciousness. CONCLUSIONS Spontaneous recovery from MCS/VS to the level of consciousness with no or minimal need for assistance in everyday life is very rare. Therefore, if a patient in VS or MCS fulfills the selection criteria (presence of somatosensory evoked potentials from upper extremities, motor and brainstem auditory evoked potentials, with cerebral glucose metabolism affected not more than the level of hypometabolism, which is judged using PET), DBS could be a treatment option.
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Affiliation(s)
- Darko Chudy
- 1Department of Neurosurgery.,2Croatian Institute for Brain Research, University of Zagreb, School of Medicine, Zagreb
| | - Vedran Deletis
- 3University of Split, School of Medicine, Split, Croatia; and.,4Albert Einstein College of Medicine, New York, New York
| | | | | | - Jasenka Škrlin
- 5Center for Clinical Microbiology and Hospital Infections, and
| | - Veronika Paradžik
- 6Center for Physical Medicine and Rehabilitation, University Hospital Dubrava, Zagreb
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26
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Mattogno PP, Barbagallo G, Iacopino G, Pappalardo G, LA Rocca G, Signorelli F, Zhong J, Visocchi M. Recovery from Chronic Diseases of Consciousness: State of the Art in Neuromodulation for Persistent Vegetative State and Minimally Conscious State. ACTA NEUROCHIRURGICA. SUPPLEMENT 2017; 124:19-25. [PMID: 28120048 DOI: 10.1007/978-3-319-39546-3_4] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Chronic diseases of consciousness (CDC) can still be considered a challenging frontier for modern medicine, probably because of their not completely understood physiopathological mechanisms. Following encouraging evidence on cerebral hemodynamics, some authors have hypothesized a role for neuromodulation in the treatment of CDC patients. In the past 40 years, spinal cord stimulation (SCS) and deep brain stimulation (DBS) have been used experimentally for the treatment of patients in a severe altered state of consciousness, with some interesting but not conclusive results. The present review summarizes the data currently available in the literature on this particular and debated topic. On these grounds, further clinical studies are needed to better understand the altered dynamics of neuronal network circuits in CDC patients as a step towards novel therapeutic strategies.
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Affiliation(s)
- Pier Paolo Mattogno
- Neurosurgery, Catholic University Medical School, Rome, Italy. .,Neurosurgery - A, Gemelli Hospital, Largo A. Gemelli, 8, Rome, 00168, Italy.
| | - Giuseppe Barbagallo
- Division of Neurosurgery, Department of Neurosciences, Policlinico "G. Rodolico" University Hospital, Catania, Italy
| | - Gerardo Iacopino
- Department of Experimental Biomedicine and Clinical Neurosciences, School of Medicine, Neurosurgical Clinic, University of Palermo, Palermo, Italy
| | | | | | | | - Jun Zhong
- Department of Neurosurgery, XinHua Hospital, Shanghai JiaoTong University School of Medicine, Shanghai, 200092, China
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Yamamoto T, Watanabe M, Obuchi T, Kobayashi K, Oshima H, Fukaya C, Yoshino A. Spinal Cord Stimulation for Vegetative State and Minimally Conscious State: Changes in Consciousness Level and Motor Function. ACTA NEUROCHIRURGICA. SUPPLEMENT 2017; 124:37-42. [PMID: 28120050 DOI: 10.1007/978-3-319-39546-3_6] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/04/2022]
Abstract
Twenty-one vegetative state (VS) patients and 10 minimally conscious state (MCS) patients were treated by spinal cord stimulation (SCS) following an electrophysiological evaluation 3 months or more after the onset of brain injury.A flexible four-contact cylindrical electrode was inserted into the epidural space of the cervical vertebrae, and placed at cervical levels C2-C4. Five-hertz stimulation was applied for 5 min every 30 min during the daytime at an intensity that produced muscle twitches of the upper extremities.Both the fifth wave in the auditory brainstem response (ABR) and N20 in the somatosensory evoked potential (SEP) were detected in 8 of the 21 VS patients and 9 of the 10 MCS patients. Of the 3 VS patients and 7 MCS patients who recovered following SCS therapy, all showed a preserved fifth wave in the ABR and N20 in the SEP, and all had received SCS therapy within 9 months after the onset of brain injury. Although the 3 patients who recovered from VS remained in a bedridden state, all 7 patients who recovered from MCS were able to emerge from the bedridden state within 12 months after the start of SCS.Five-hertz cervical SCS caused increased cerebral blood flow (CBF) and induced muscle twitches of the upper extremities, and MCS patients showed a remarkable recovery of consciousness and motor function in the upper extremities compared with the lower extremities. This SCS method could be a new neuromodulation and neurorehabilitation technique, and MCS patients may be good candidates for SCS therapy.
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Affiliation(s)
- Takamitsu Yamamoto
- Divisions of Applied System Neuroscience, Department of Neurological Surgery, Nihon University School of Medicine, 30-1 Ohyaguchi Kamimachi, Itabashi-ku, Tokyo, 173-8610, Japan.
| | - Mitsuru Watanabe
- Divisions of Applied System Neuroscience, Department of Neurological Surgery, Nihon University School of Medicine, 30-1 Ohyaguchi Kamimachi, Itabashi-ku, Tokyo, 173-8610, Japan
| | - Toshiki Obuchi
- Divisions of Applied System Neuroscience, Department of Neurological Surgery, Nihon University School of Medicine, 30-1 Ohyaguchi Kamimachi, Itabashi-ku, Tokyo, 173-8610, Japan
| | - Kazutaka Kobayashi
- Divisions of Applied System Neuroscience, Department of Neurological Surgery, Nihon University School of Medicine, 30-1 Ohyaguchi Kamimachi, Itabashi-ku, Tokyo, 173-8610, Japan
| | - Hideki Oshima
- Divisions of Applied System Neuroscience, Department of Neurological Surgery, Nihon University School of Medicine, 30-1 Ohyaguchi Kamimachi, Itabashi-ku, Tokyo, 173-8610, Japan
| | - Chikashi Fukaya
- Divisions of Applied System Neuroscience, Department of Neurological Surgery, Nihon University School of Medicine, 30-1 Ohyaguchi Kamimachi, Itabashi-ku, Tokyo, 173-8610, Japan
| | - Atsuo Yoshino
- Divisions of Applied System Neuroscience, Department of Neurological Surgery, Nihon University School of Medicine, 30-1 Ohyaguchi Kamimachi, Itabashi-ku, Tokyo, 173-8610, Japan
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Zheng ZS, Reggente N, Lutkenhoff E, Owen AM, Monti MM. Disentangling disorders of consciousness: Insights from diffusion tensor imaging and machine learning. Hum Brain Mapp 2016; 38:431-443. [PMID: 27622575 DOI: 10.1002/hbm.23370] [Citation(s) in RCA: 52] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2016] [Revised: 07/27/2016] [Accepted: 08/25/2016] [Indexed: 11/07/2022] Open
Abstract
Previous studies have suggested that disorders of consciousness (DOC) after severe brain injury may result from disconnections of the thalamo-cortical system. However, thalamo-cortical connectivity differences between vegetative state (VS), minimally conscious state minus (MCS-, i.e., low-level behavior such as visual pursuit), and minimally conscious state plus (MCS+, i.e., high-level behavior such as language processing) remain unclear. Probabilistic tractography in a sample of 25 DOC patients was employed to assess whether structural connectivity in various thalamo-cortical circuits could differentiate between VS, MCS-, and MCS+ patients. First, the thalamus was individually segmented into seven clusters based on patterns of cortical connectivity and tested for univariate differences across groups. Second, reconstructed whole-brain thalamic tracks were used as features in a multivariate searchlight analysis to identify regions along the tracks that were most informative in distinguishing among groups. At the univariate level, it was found that VS patients displayed reduced connectivity in most thalamo-cortical circuits of interest, including frontal, temporal, and sensorimotor connections, as compared with MCS+, but showed more pulvinar-occipital connections when compared with MCS-. Moreover, MCS- exhibited significantly less thalamo-premotor and thalamo-temporal connectivity than MCS+. At the multivariate level, it was found that thalamic tracks reaching frontal, parietal, and sensorimotor regions, could discriminate, up to 100% accuracy, across each pairwise group comparison. Together, these findings highlight the role of thalamo-cortical connections in patients' behavioral profile and level of consciousness. Diffusion tensor imaging combined with machine learning algorithms could thus potentially facilitate diagnostic distinctions in DOC and shed light on the neural correlates of consciousness. Hum Brain Mapp 38:431-443, 2017. © 2016 Wiley Periodicals, Inc.
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Affiliation(s)
- Zhong S Zheng
- Department of Psychology, University of California Los Angeles, Los Angeles, California
| | - Nicco Reggente
- Department of Psychology, University of California Los Angeles, Los Angeles, California
| | - Evan Lutkenhoff
- Department of Psychology, University of California Los Angeles, Los Angeles, California
| | - Adrian M Owen
- The Brain and Mind Institute, University of Western Ontario, London, Ontario, Canada
| | - Martin M Monti
- Department of Psychology, University of California Los Angeles, Los Angeles, California.,Department of Neurosurgery, University of California Los Angeles, Los Angeles, California
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McMillan TM, Greenwood RJ. Models of rehabilitation programmes for the brain- injured adult. II: model services and suggestions for change in the UK. Clin Rehabil 2016. [DOI: 10.1177/026921559300700411] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- TM McMillan
- Wolfson Medical Rehabilitation Centre, London — Top Grade Clinical Psychologist, Wolfson Medical Rehabilitation Centre, Atkinson Morley's Hospital, Copse Hill, Wimbledon, London SW20 ONE, UK
| | - RJ Greenwood
- St Bartholomew's and Homerton Hospitals and Homerton Regional Neurological Rehabilitation Unit, London
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30
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Central thalamic deep brain stimulation to support anterior forebrain mesocircuit function in the severely injured brain. J Neural Transm (Vienna) 2016; 123:797-806. [PMID: 27113938 DOI: 10.1007/s00702-016-1547-0] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2016] [Accepted: 04/02/2016] [Indexed: 10/21/2022]
Abstract
This integrative review frames a general rationale for the use of central thalamic deep brain stimulation (CT-DBS) to support arousal regulation mechanisms in the severely injured brain. The organizing role of the anterior forebrain mesocircuit in recovery mechanisms following widespread deafferentation produced by multi-focal structural brain injuries is emphasized. The mesocircuit model provides the conceptual foundation for the key role of the central thalamus as a privileged node for neuromodulation to support forebrain arousal regulation. In this context, cellular mechanisms arising at the neocortical, striatal, and thalamic population level are considered in the assessment of an individual patient's capacity for harboring underlying reserve that could be recruited for further recovery. Recent preclinical studies and pilot clinical results are compared to frame the detailed rationale for CT-DBS. Application of CT-DBS across the range of outcomes following severe-to-moderate brain injuries is discussed with the aim of improving consciousness and cognition in patients with non-progressive brain injuries.
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31
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Gummadavelli A, Kundishora AJ, Willie JT, Andrews JP, Gerrard JL, Spencer DD, Blumenfeld H. Neurostimulation to improve level of consciousness in patients with epilepsy. Neurosurg Focus 2016; 38:E10. [PMID: 26030698 DOI: 10.3171/2015.3.focus1535] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
When drug-resistant epilepsy is poorly localized or surgical resection is contraindicated, current neurostimulation strategies such as deep brain stimulation and vagal nerve stimulation can palliate the frequency or severity of seizures. However, despite medical and neuromodulatory therapy, a significant proportion of patients continue to experience disabling seizures that impair awareness, causing disability and risking injury or sudden unexplained death. We propose a novel strategy in which neuromodulation is used not only to reduce seizures but also to ameliorate impaired consciousness when the patient is in the ictal and postictal states. Improving or preventing alterations in level of consciousness may have an effect on morbidity (e.g., accidents, drownings, falls), risk for death, and quality of life. Recent studies may have elucidated underlying networks and mechanisms of impaired consciousness and yield potential novel targets for neuromodulation. The feasibility, benefits, and pitfalls of potential deep brain stimulation targets are illustrated in human and animal studies involving minimally conscious/vegetative states, movement disorders, depth of anesthesia, sleep-wake regulation, and epilepsy. We review evidence that viable therapeutic targets for impaired consciousness associated with seizures may be provided by key nodes of the consciousness system in the brainstem reticular activating system, hypothalamus, basal ganglia, thalamus, and basal forebrain.
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Affiliation(s)
| | | | - Jon T Willie
- 2Departments of Neurosurgery and Neurology, Emory University School of Medicine, Atlanta, Georgia
| | | | | | | | - Hal Blumenfeld
- Departments of 1Neurosurgery.,3Neurology, and.,4Neurobiology, Yale University School of Medicine, New Haven, Connecticut; and
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32
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Magrassi L, Maggioni G, Pistarini C, Di Perri C, Bastianello S, Zippo AG, Iotti GA, Biella GEM, Imberti R. Results of a prospective study (CATS) on the effects of thalamic stimulation in minimally conscious and vegetative state patients. J Neurosurg 2016; 125:972-981. [PMID: 26745476 DOI: 10.3171/2015.7.jns15700] [Citation(s) in RCA: 49] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Deep brain stimulation of the thalamus was introduced more than 40 years ago with the objective of improving the performance and attention of patients in a vegetative or minimally conscious state. Here, the authors report the results of the Cortical Activation by Thalamic Stimulation (CATS) study, a prospective multiinstitutional study on the effects of bilateral chronic stimulation of the anterior intralaminar thalamic nuclei and adjacent paralaminar regions in patients affected by a disorder of consciousness. METHODS The authors evaluated the clinical and radiological data of 29 patients in a vegetative state (unresponsive wakefulness syndrome) and 11 in a minimally conscious state that lasted for more than 6 months. Of these patients, 5 were selected for bilateral stereotactic implantation of deep brain stimulating electrodes into their thalamus. A definitive consensus for surgery was obtained for 3 of the selected patients. All 3 patients (2 in a vegetative state and 1 in a minimally conscious state) underwent implantation of bilateral thalamic electrodes and submitted to chronic stimulation for a minimum of 18 months and a maximum of 48 months. RESULTS In each case, there was an increase in desynchronization and the power spectrum of electroencephalograms, and improvement in the Coma Recovery Scale-Revised scores was found. Furthermore, the severity of limb spasticity and the number and severity of pathological movements were reduced. However, none of these patients returned to a fully conscious state. CONCLUSIONS Despite the limited number of patients studied, the authors confirmed that bilateral thalamic stimulation can improve the clinical status of patients affected by a disorder of consciousness, even though this stimulation did not induce persistent, clinically evident conscious behavior in the patients. Clinical trial registration no.: NCT01027572 ( ClinicalTrials.gov ).
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Affiliation(s)
- Lorenzo Magrassi
- Neurochirurgia Dipartimento di Scienze Clinico-Chirurgiche, Diagnostiche e Pediatriche, University of Pavia-Fondazione IRCCS Policlinico S. Matteo, Pavia
| | - Giorgio Maggioni
- Neurorehabilitation Unit, Salvatore Maugeri Foundation IRCCS, Scientific Institute of Pavia
| | - Caterina Pistarini
- Neurorehabilitation Unit, Salvatore Maugeri Foundation IRCCS, Scientific Institute of Pavia
| | - Carol Di Perri
- Neuroradiology Unit, Neurological Institute IRCCS Fondazione C. Mondino, Pavia, Italy.,Coma Science Group, Cyclotoron Research Center, University of Liege, Belgium
| | - Stefano Bastianello
- Neuroradiology Unit, Neurological Institute IRCCS Fondazione C. Mondino, Pavia, Italy
| | - Antonio G Zippo
- Istituto di Bioimmagini e Fisiologia Molecolare, CNR, Segrate; and
| | | | | | - Roberto Imberti
- Rianimazione 2° and.,Phase I Clinical Trial Unit and Experimental Therapy, Fondazione IRCCS Policlinico S. Matteo, Pavia, Italy
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33
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Li S, Zaninotto AL, Neville IS, Paiva WS, Nunn D, Fregni F. Clinical utility of brain stimulation modalities following traumatic brain injury: current evidence. Neuropsychiatr Dis Treat 2015; 11:1573-86. [PMID: 26170670 PMCID: PMC4494620 DOI: 10.2147/ndt.s65816] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
Traumatic brain injury (TBI) remains the main cause of disability and a major public health problem worldwide. This review focuses on the neurophysiology of TBI, and the rationale and current state of evidence of clinical application of brain stimulation to promote TBI recovery, particularly on consciousness, cognitive function, motor impairments, and psychiatric conditions. We discuss the mechanisms of different brain stimulation techniques including major noninvasive and invasive stimulations. Thus far, most noninvasive brain stimulation interventions have been nontargeted and focused on the chronic phase of recovery after TBI. In the acute stages, there is limited available evidence of the efficacy and safety of brain stimulation to improve functional outcomes. Comparing the studies across different techniques, transcranial direct current stimulation is the intervention that currently has the higher number of properly designed clinical trials, though total number is still small. We recognize the need for larger studies with target neuroplasticity modulation to fully explore the benefits of brain stimulation to effect TBI recovery during different stages of recovery.
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Affiliation(s)
- Shasha Li
- Department of Rehabilitation Medicine, West China Hospital, Sichuan University, Chengdu, Sichuan, People's Republic of China ; Spaulding Neuromodulation Center, Harvard Medical School, Boston, MA, USA
| | - Ana Luiza Zaninotto
- Spaulding Neuromodulation Center, Harvard Medical School, Boston, MA, USA ; Division of Psychology, Hospital das Clínicas, University of São Paulo, São Paulo, Brazil
| | - Iuri Santana Neville
- Division of Neurosurgery, University of São Paulo Medical School, São Paulo, São Paulo, Brazil
| | - Wellingson Silva Paiva
- Division of Neurosurgery, University of São Paulo Medical School, São Paulo, São Paulo, Brazil
| | - Danuza Nunn
- Spaulding Neuromodulation Center, Harvard Medical School, Boston, MA, USA
| | - Felipe Fregni
- Spaulding Neuromodulation Center, Harvard Medical School, Boston, MA, USA
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Abstract
Traumatic brain injury (TBI) remains a significant public health problem and is a leading cause of death and disability in many countries. Durable treatments for neurological function deficits following TBI have been elusive, as there are currently no FDA-approved therapeutic modalities for mitigating the consequences of TBI. Neurostimulation strategies using various forms of electrical stimulation have recently been applied to treat functional deficits in animal models and clinical stroke trials. The results from these studies suggest that neurostimulation may augment improvements in both motor and cognitive deficits after brain injury. Several studies have taken this approach in animal models of TBI, showing both behavioral enhancement and biological evidence of recovery. There have been only a few studies using deep brain stimulation (DBS) in human TBI patients, and future studies are warranted to validate the feasibility of this technique in the clinical treatment of TBI. In this review, the authors summarize insights from studies employing neurostimulation techniques in the setting of brain injury. Moreover, they relate these findings to the future prospect of using DBS to ameliorate motor and cognitive deficits following TBI.
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Affiliation(s)
- Samuel S Shin
- Department of Neurological Surgery, University of Pittsburgh, Pennsylvania
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35
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Electrical modulation of neuronal networks in brain-injured patients with disorders of consciousness: A systematic review. ACTA ACUST UNITED AC 2014; 33:88-97. [DOI: 10.1016/j.annfar.2013.11.007] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
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36
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Hariz M, Blomstedt P, Zrinzo L. Future of brain stimulation: new targets, new indications, new technology. Mov Disord 2013; 28:1784-92. [PMID: 24123327 DOI: 10.1002/mds.25665] [Citation(s) in RCA: 103] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2013] [Revised: 06/27/2013] [Accepted: 08/09/2013] [Indexed: 01/15/2023] Open
Abstract
In the last quarter of a century, DBS has become an established neurosurgical treatment for Parkinson's disease (PD), dystonia, and tremors. Improved understanding of brain circuitries and their involvement in various neurological and psychiatric illnesses, coupled with the safety of DBS and its exquisite role as a tool for ethical study of the human brain, have unlocked new opportunities for this technology, both for future therapies and in research. Serendipitous discoveries and advances in structural and functional imaging are providing abundant "new" brain targets for an ever-increasing number of pathologies, leading to investigations of DBS in diverse neurological, psychiatric, behavioral, and cognitive conditions. Trials and "proof of concept" studies of DBS are underway in pain, epilepsy, tinnitus, OCD, depression, and Gilles de la Tourette syndrome, as well as in eating disorders, addiction, cognitive decline, consciousness, and autonomic states. In parallel, ongoing technological development will provide pulse generators with longer battery longevity, segmental electrode designs allowing a current steering, and the possibility to deliver "on-demand" stimulation based on closed-loop concepts. The future of brain stimulation is certainly promising, especially for movement disorders-that will remain the main indication for DBS for the foreseeable future-and probably for some psychiatric disorders. However, brain stimulation as a technique may be at risk of gliding down a slippery slope: Some reports indicate a disturbing trend with suggestions that future DBS may be proposed for enhancement of memory in healthy people, or as a tool for "treatment" of "antisocial behavior" and for improving "morality."
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Affiliation(s)
- Marwan Hariz
- Unit of Functional Neurosurgery, UCL Institute of Neurology, London, UK; Department of Clinical Neuroscience, Umeå University, Umeå, Sweden
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37
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Cossu G. Therapeutic options to enhance coma arousal after traumatic brain injury: state of the art of current treatments to improve coma recovery. Br J Neurosurg 2013; 28:187-98. [PMID: 24090192 DOI: 10.3109/02688697.2013.841845] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Traumatic brain injury is a leading cause of death and disability. Optimizing the recovery from coma is a priority in seeking to improve patients' functional outcomes. Standards of care have not been established: pharmacological interventions, right median nerve and sensory stimulation, dorsal column stimulation (DCS), deep brain stimulation, transcranial magnetic stimulation, hyperbaric oxygen therapy and cell transplantation have all been utilized with contrasting results. The aim of this review is to clarify the indications for the various techniques and to guide the clinical practice towards an earlier coma arousal. A systematic bibliographic search was undertaken using the principal search engines (Pubmed, Embase, Ovid and Cochrane databases) to locate the most pertinent studies. Traumatic injury is a highly individualized process, and subsequent impairments are dependent on multiple factors: this heterogeneity influences and determines therapeutic responses to the various interventions.
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Affiliation(s)
- Giulia Cossu
- Azienda Ospedaliera Universitaria San Luigi Gonzaga , Orbassano, Turin , Italy
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38
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Robison RA, Taghva A, Liu CY, Apuzzo ML. Surgery of the Mind, Mood, and Conscious State: An Idea in Evolution. World Neurosurg 2013; 80:S2-26. [PMID: 23916496 DOI: 10.1016/j.wneu.2013.08.002] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2012] [Accepted: 03/15/2012] [Indexed: 10/26/2022]
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França NR, Toniolo EF, Franciosi AC, Alves AS, de Andrade DC, Fonoff ET, Britto LR, Dale CS. Antinociception induced by motor cortex stimulation: Somatotopy of behavioral response and profile of neuronal activation. Behav Brain Res 2013; 250:211-21. [DOI: 10.1016/j.bbr.2013.05.019] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2013] [Revised: 04/24/2013] [Accepted: 05/10/2013] [Indexed: 12/18/2022]
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Central thalamic deep brain stimulation for support of forebrain arousal regulation in the minimally conscious state. HANDBOOK OF CLINICAL NEUROLOGY 2013; 116:295-306. [PMID: 24112903 DOI: 10.1016/b978-0-444-53497-2.00024-3] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
This chapter considers the use of central thalamic deep brain stimulation (CT/DBS) to support arousal regulation mechanisms in the minimally conscious state (MCS). CT/DBS for selected patients in a MCS is first placed in the historical context of prior efforts to use thalamic electrical brain stimulation to treat the unconscious clinical conditions of coma and vegetative state. These previous studies and a proof of concept result from a single-subject study of a patient in a MCS are reviewed against the background of new population data providing benchmarks of the natural history of vegetative and MCSs. The conceptual foundations for CT/DBS in selected patients in a MCS are then presented with consideration of both circuit and cellular mechanisms underlying recovery of consciousness identified from empirical studies. Directions for developing future generalizable criteria for CT/DBS that focus on the integrity of necessary brain systems and behavioral profiles in patients in a MCS that may optimally response to support of arousal regulation mechanisms are proposed.
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Schiff ND. Moving toward a generalizable application of central thalamic deep brain stimulation for support of forebrain arousal regulation in the severely injured brain. Ann N Y Acad Sci 2012; 1265:56-68. [PMID: 22834729 DOI: 10.1111/j.1749-6632.2012.06712.x] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
This review considers the challenges ahead for developing a generalizable strategy for the use of central thalamic deep brain stimulation (CT/DBS) to support arousal regulation mechanisms in the severely injured brain. Historical efforts to apply CT/DBS to patients with severe brain injuries and a proof-of-concept result from a single-subject study are discussed. Circuit and cellular mechanisms underlying the recovery of consciousness are considered for their relevance to the application of CT/DBS, to improve consciousness and cognition in nonprogressive brain injuries. Finally, directions for development, and testing of generalizable criteria for CT/DBS are suggested, which aim to identify neuronal substrates and behavioral profiles that may optimally benefit from support of arousal regulation mechanisms.
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Affiliation(s)
- Nicholas D Schiff
- Department of Neurology and Neuroscience, Weill Cornell Medical College, New York, USA.
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Erickson KM, Cole DJ. Anesthetic considerations for awake craniotomy for epilepsy and functional neurosurgery. Anesthesiol Clin 2012; 30:241-268. [PMID: 22901609 DOI: 10.1016/j.anclin.2012.05.002] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
The two most common neurosurgical procedures that call for an awake patient include epilepsy surgery and functional neurosurgery. Monitoring patients in the awake state allows more aggressive resection of epileptogenic foci in functionally important brain regions. Careful patient selection and preparation combined with attentive monitoring and anticipation of events are fundamental to a smooth awake procedure. Current pharmacologic agents and techniques at the neuroanesthesiologist's disposal facilitate an increasing number of procedures performed in awake patients.
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Affiliation(s)
- Kirstin M Erickson
- Department of Anesthesiology, Mayo Clinic College of Medicine, 200 First Street SE, Rochester, MN 55901, USA.
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Giacino J, Fins JJ, Machado A, Schiff ND. Central thalamic deep brain stimulation to promote recovery from chronic posttraumatic minimally conscious state: challenges and opportunities. Neuromodulation 2012; 15:339-49. [PMID: 22624587 DOI: 10.1111/j.1525-1403.2012.00458.x] [Citation(s) in RCA: 70] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND Central thalamic deep brain stimulation (CT-DBS) may have therapeutic potential to improve behavioral functioning in patients with severe traumatic brain injury (TBI), but its use remains experimental. Current research suggests that the central thalamus plays a critical role in modulating arousal during tasks requiring sustained attention, working memory, and motor function. The aim of the current article is to review the methodology used in the CT-DBS protocol developed by our group, outline the challenges we encountered and offer suggestions for future DBS trials in this population. RATIONAL FOR CT-DBS IN TBI: CT-DBS may therefore be able to stimulate these functions by eliciting action potentials that excite thalamocortical and thalamostriatal pathways. Because patients in chronic minimally conscious state (MCS) have a very low probability of regaining functional independence, yet often have significant sparing of cortical connectivity, they may represent a particularly appropriate target group for CT-DBS. PIlOT STUDY RESULTS: We have conducted a series of single-subject studies of CT-DBS in patients with chronic posttraumatic MCS, with 24-month follow-up. Outcomes were measured using the Coma Recovery Scale-Revised as well as a battery of secondary outcome measures to capture more granular changes. Findings from our index case suggest that CT-DBS can significantly increase functional communication, motor performance, feeding, and object naming in the DBS on state, with performance in some domains remaining above baseline even after DBS was turned off. CONCLUSIONS The use of CT-DBS in patients in MCS, however, presents challenges at almost every step, including during surgical planning, outcome measurement, and postoperative care. Additionally, given the difficulties of obtaining informed consent from patients in MCS and the experimental nature of the treatment, a robust, scientifically rooted ethical framework is resented for pursuing this line of work.
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Affiliation(s)
- Joseph Giacino
- Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Boston, MA 02114, USA.
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Yamamoto T, Katayama Y, Obuchi T, Kobayashi K, Oshima H, Fukaya C. Deep brain stimulation and spinal cord stimulation for vegetative state and minimally conscious state. World Neurosurg 2012; 80:S30.e1-9. [PMID: 22543046 DOI: 10.1016/j.wneu.2012.04.010] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2011] [Revised: 03/13/2012] [Accepted: 04/19/2012] [Indexed: 10/28/2022]
Abstract
OBJECTIVE On the basis of the findings of the electrophysiological evaluation of vegetative state (VS) and minimally conscious state (MCS), the effect of deep brain stimulation (DBS) was examined according to long-term follow-up results. The results of spinal cord stimulation (SCS) on MCS was also examined and compared with that of DBS. METHODS One hundred seven patients in VS and 21 patients in MCS were evaluated neurologically and electrophysiologically over 3 months after the onset of brain injury. Among the 107 VS patients, 21 were treated by DBS. Among the 21 MCS patients, 5 were treated by DBS and 10 by SCS. RESULTS Eight of the 21 patients recovered from VS and were able to follow verbal instructions. These eight patients showed desynchronization on continuous electroencephalographic frequency analysis. The Vth wave of the auditory brainstem response and N20 of somatosensory evoked potential were recorded even with a prolonged latency, and pain-related P250 was recorded with an amplitude of more than 7 μV. In addition, DBS and SCS induced a marked functional recovery in MCS patients who satisfied the electrophysiological inclusion criteria. CONCLUSION DBS for VS and MCS patients and SCS for MCS patients may be useful, when the candidates are selected on the basis of the electrophysiological inclusion criteria. Only 16 (14.9%) of the 107 VS patients and 15 (71.4%) of the 21 MCS patients satisfied the electrophysiological inclusion criteria.
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Affiliation(s)
- Takamitsu Yamamoto
- Division of Applied System Neuroscience, Nihon University School of Medicine, Tokyo, Japan.
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The vegetative and minimally conscious states: a review of the literature and preliminary survey of prevalence in Ireland. Ir J Med Sci 2012; 182:7-15. [PMID: 22528253 DOI: 10.1007/s11845-012-0825-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2011] [Accepted: 04/09/2012] [Indexed: 10/28/2022]
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Robison RA, Taghva A, Liu CY, Apuzzo MLJ. Surgery of the mind, mood, and conscious state: an idea in evolution. World Neurosurg 2012; 77:662-86. [PMID: 22446082 DOI: 10.1016/j.wneu.2012.03.005] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2012] [Accepted: 03/15/2012] [Indexed: 11/25/2022]
Abstract
Since the beginning of recorded history, humans have sought a physical means of altering disordered behavior and consciousness. This quest has spawned numerous innovations in neurosurgery and the neurosciences, from the earliest prehistoric attempts at trepanation to the electrocortical and anatomic localization of cerebral function that emerged in the 19th century. At the start of the 20th century, the overwhelming social impact of psychiatric illness intersected with the novel but imperfect understanding of frontal lobe function, establishing a decades-long venture into the modern origin of psychosurgery, the prefrontal lobotomy. The subsequent social and ethical ramifications of the widespread overuse of transorbital lobotomies drove psychosurgery to near extinction. However, as the pharmacologic treatment of psychiatric illness was established, numerous concomitant technical and neuroscientific innovations permitted the incremental development of a new paradigm of treating the disordered mind. In this article, we retrospectively examine these early origins of psychosurgery and then look to the recent past, present, and future for emerging trends in surgery of the psyche. Recent decades have seen a revolution in minimalism, noninvasive imaging, and functional manipulation of the human cerebrum that have created new opportunities and treatment modalities for disorders of the human mind and mood. Early contemporary efforts were directed at focal lesioning of abnormal pathways, but deep-brain stimulation now aims to reversibly alter and modulate those neurologic activities responsible for not only psychiatric disorders, but also to modulate and even to augment consciousness, memory, and other elements of cerebral function. As new tools become available, the social and medical impact of psychosurgery promises to revolutionize not only neurosurgery, but also humans' capability for positively impacting life and society.
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Affiliation(s)
- R Aaron Robison
- Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California, USA.
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Sankar T, Tierney TS, Hamani C. Novel applications of deep brain stimulation. Surg Neurol Int 2012; 3:S26-33. [PMID: 22826807 PMCID: PMC3400483 DOI: 10.4103/2152-7806.91607] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2011] [Accepted: 12/20/2011] [Indexed: 11/11/2022] Open
Abstract
The success of deep brain stimulation (DBS) surgery in treating medically refractory symptoms of some movement disorders has inspired further investigation into a wide variety of other treatment-resistant conditions. These range from disorders of gait, mood, and memory to problems as diverse as obesity, consciousness, and addiction. We review the emerging indications, rationale, and outcomes for some of the most promising new applications of DBS in the treatment of postural instability associated with Parkinson's disease, depression, obsessive–compulsive disorder, obesity, substance abuse, epilepsy, Alzheimer′s-type dementia, and traumatic brain injury. These studies reveal some of the excitement in a field at the edge of a rapidly expanding frontier. Much work still remains to be done on basic mechanism of DBS, optimal target and patient selection, and long-term durability of this technology in treating new indications.
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Affiliation(s)
- Tejas Sankar
- Department of Neurosurgery, Toronto Western Hospital, Toronto, Ontario, Canada
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YAMAMOTO T, KATAYAMA Y, OBUCHI T, KOBAYASHI K, OSHIMA H, FUKAYA C. Spinal Cord Stimulation for Treatment of Patients in the Minimally Conscious State. Neurol Med Chir (Tokyo) 2012; 52:475-81. [PMID: 22850495 DOI: 10.2176/nmc.52.475] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
- Takamitsu YAMAMOTO
- Division of Applied System Neuroscience, Department of Neurological Surgery, Nihon University School of Medicine
| | - Yoichi KATAYAMA
- Division of Neurosurgery, Department of Neurological Surgery, Nihon University School of Medicine
| | - Toshiki OBUCHI
- Division of Neurosurgery, Department of Neurological Surgery, Nihon University School of Medicine
| | - Kazutaka KOBAYASHI
- Division of Neurosurgery, Department of Neurological Surgery, Nihon University School of Medicine
| | - Hideki OSHIMA
- Division of Neurosurgery, Department of Neurological Surgery, Nihon University School of Medicine
| | - Chikashi FUKAYA
- Division of Applied System Neuroscience, Department of Neurological Surgery, Nihon University School of Medicine
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Oluigbo CO, Salma A, Rezai AR. Deep Brain Stimulation for Neurological Disorders. IEEE Rev Biomed Eng 2012; 5:88-99. [DOI: 10.1109/rbme.2012.2197745] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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50
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Clauss RP. Neurotransmitters in disorders of consciousness and brain damage. Med Hypotheses 2011; 77:209-13. [PMID: 21549512 DOI: 10.1016/j.mehy.2011.04.014] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2011] [Revised: 03/30/2011] [Accepted: 04/08/2011] [Indexed: 01/17/2023]
Abstract
Restorations from disorders of consciousness such as the minimally conscious state and the vegetative state have been achieved spontaneously or by pharmacological agents such as zolpidem, baclofen, dopaminergic agents and tricyclic antidepressants in some patients. Other restoration methods have included electric and magnetic nerve stimulation, oxygen, Kreb's cycle constituent substitution and axonal re-growth. Although apparently unrelated, these methods all influence neurotransmitter availability or production within the brain. This review proposes depleted neurotransmitter function as a cause for long term brain suppression and disorders of consciousness. It unifies fundamentally different treatment approaches and explores the restoration of neurotransmitter function as a common theme to improve brain function after brain damage.
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Affiliation(s)
- R P Clauss
- Nuclear Medicine Department, Royal Surrey County Hospital, Guildford, Surrey GU27XX, UK.
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