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Onami S, Tran D, Koh-Pham C, Shih W, Chi B, Peng J, Shavlik D, Singh P, Giacino J. Coma Recovery Scale-Revised Predicts Disability Rating Scale in Acute Rehabilitation of Severe Traumatic Brain Injury. Arch Phys Med Rehabil 2023; 104:1054-1061. [PMID: 36736600 PMCID: PMC10404472 DOI: 10.1016/j.apmr.2023.01.007] [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: 05/26/2022] [Revised: 12/19/2022] [Accepted: 01/04/2023] [Indexed: 02/03/2023]
Abstract
OBJECTIVE To explore the prognostic value of the Coma Recovery Scale-Revised (CRS-R) in predicting disability outcomes in patients with severe traumatic brain injury using the Disability Rating Scale (DRS). DESIGN Secondary analysis including linear and logistic regressions were performed. SETTING Data were collected in a previous clinical trial. PARTICIPANTS One hundred eighty-four participants across 3 countries (N=184). MAIN OUTCOME MEASURES Disability Rating Scales. RESULTS Analyses showed an inverse relation between CRS-R scores obtained at baseline and change in DRS scores at 6 weeks. Similarly, changes in CRS-R scores between baseline and 4 weeks were also found to have an inverse relation to change in DRS scores at 6 weeks. CONCLUSIONS This study generates a tool that can be used to predict the probability that a patient with severe traumatic brain injury lands in 1 of 3 disability categories. The CRS-R may be useful in prognostication of disability in patients with severe traumatic brain injury.
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Affiliation(s)
- Susan Onami
- Physical Medicine & Rehabilitation, Loma Linda University, Loma Linda, CA
| | - Duc Tran
- Physical Medicine & Rehabilitation, Loma Linda University, Loma Linda, CA
| | - Christine Koh-Pham
- Physical Medicine & Rehabilitation, Loma Linda University, Loma Linda, CA.
| | - Wendy Shih
- Research Consulting Group, Loma Linda University School of Public Health, Loma Linda, CA
| | - Bradley Chi
- Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY
| | - Jiahao Peng
- Research Consulting Group, Loma Linda University School of Public Health, Loma Linda, CA
| | - David Shavlik
- Research Consulting Group, Loma Linda University School of Public Health, Loma Linda, CA
| | - Pramil Singh
- Research Consulting Group, Loma Linda University School of Public Health, Loma Linda, CA
| | - Joseph Giacino
- Physical Medicine & Rehabilitation, Spaulding Rehabilitation Hospital, Charleston, MA
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Quiñones-Ossa GA, Durango-Espinosa YA, Janjua T, Moscote-Salazar LR, Agrawal A. Persistent vegetative state: an overview. EGYPTIAN JOURNAL OF NEUROSURGERY 2021. [DOI: 10.1186/s41984-021-00111-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Disorder of consciousness diagnosis, especially when is classified as persistent vegetative state (without misestimating the other diagnosis classifications), in the intensive care is an important diagnosis to evaluate and treat. Persistent vegetative state diagnosis is a challenge in the daily clinical practice because the diagnosis is made mainly based upon the clinical history and the patient behavior observation. There are some specific criteria for this diagnosis, and this could be very tricky when the physician is not well trained.
Main body
We made a literature review regarding the persistent vegetative state diagnosis, clinical features, management, prognosis, and daily medical practice challenges while considering the bioethical issues and the family perspective about the patient status. The objective of this overview is to provide updated information regarding this clinical state’s features while considering the current medical literature available.
Conclusions
Regardless of the currently available guidelines and literature, there is still a lot of what we do not know about the persistent vegetative state. There is a lack of evidence regarding the optimal diagnosis and even more, about how to expect a natural history of this disorder of consciousness. It is important to recall that the patients (despite of their altered mental state diagnosis) should always be treated to avoid some of the intensive care unit long-stance complications.
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Wang J, Hu X, Hu Z, Sun Z, Laureys S, Di H. The misdiagnosis of prolonged disorders of consciousness by a clinical consensus compared with repeated coma-recovery scale-revised assessment. BMC Neurol 2020; 20:343. [PMID: 32919461 PMCID: PMC7488705 DOI: 10.1186/s12883-020-01924-9] [Citation(s) in RCA: 46] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2019] [Accepted: 09/08/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Previous studies have shown that a single Coma-Recovery Scale-Revision (CRS-R) assessment can identify high rates of misdiagnosis by clinical consensus. The aim of this study was to investigate the proportion of misdiagnosis by clinical consensus compared to repeated behavior-scale assessments in patients with prolonged disorders of consciousness (DOC). METHODS Patients with prolonged DOC during hospitalization were screened by clinicians, and the clinicians formed a clinical-consensus diagnosis. Trained professionals used the CRS-R to evaluate the consciousness levels of the enrolled patients repeatedly (≥5 times) within a week. Based on the repeated evaluation results, the enrolled patients with prolonged DOC were divided into unresponsive wakefulness syndrome (UWS), minimally conscious state (MCS), and emergence from MCS (EMCS). Finally, the relationship between the results of the CRS-R and the clinical consensus were analyzed. RESULTS In this study, 137 patients with a clinical-consensus diagnosis of prolonged DOC were enrolled. It was found that 24.7% of patients with clinical UWS were actually in MCS after a single CRS-R behavior evaluation, while the repeated CRS-R evaluation results showed that the proportion of misdiagnosis of MCS was 38.2%. A total of 16.7% of EMCS patients were misdiagnosed with clinical MCS, and 1.1% of EMCS patients were misdiagnosed with clinical UWS. CONCLUSIONS The rate of the misdiagnosis by clinical consensus is still relatively high. Therefore, clinicians should be aware of the importance of the bedside CRS-R behavior assessment and should apply the CRS-R tool in daily procedures. TRIAL REGISTRATION ClinicalTrials.gov ID: NCT04139239 ; Registered 24 October 2019 - Retrospectively registered.
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Affiliation(s)
- Jing Wang
- International Unresponsive Wakefulness Syndrome and Consciousness Science Institute, Hangzhou Normal University, Hangzhou, 310036 China
| | - Xiaohua Hu
- Rehabilitation Center for Brain Damage, Wujing Hospital of Hangzhou City, Hangzhou, China
| | - Zhouyao Hu
- International Unresponsive Wakefulness Syndrome and Consciousness Science Institute, Hangzhou Normal University, Hangzhou, 310036 China
| | - Ziwei Sun
- International Unresponsive Wakefulness Syndrome and Consciousness Science Institute, Hangzhou Normal University, Hangzhou, 310036 China
| | - Steven Laureys
- Coma Science Group, GIGA Consciousness, University and University Hospital of Liège, Liège, Belgium
| | - Haibo Di
- International Unresponsive Wakefulness Syndrome and Consciousness Science Institute, Hangzhou Normal University, Hangzhou, 310036 China
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Wang J, Wang J, Hu X, Xu L, Tian J, Li J, Fang D, Huang W, Sun Y, He M, Laureys S, Di H. The Initiation of Swallowing Can Indicate the Prognosis of Disorders of Consciousness: A Self-Controlled Study. Front Neurol 2019; 10:1184. [PMID: 31798516 PMCID: PMC6868083 DOI: 10.3389/fneur.2019.01184] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2019] [Accepted: 10/24/2019] [Indexed: 11/23/2022] Open
Abstract
Objective: To detect the initiation of swallowing in patients with disorders of consciousness (DOC) as well as the relationship between the initiation of swallowing and the prognosis of DOC patients. Methods: Nineteen DOC patients were included in this study, and a self-controlled trial compared five different stimuli. The five different stimuli were as follows: (1) one command, as recommended by the Coma Recovery Scale-Revised (CRS-R), which was "open your mouth"; (2) placing a spoon in front of the patient's mouth without a command; (3) placing a spoon filled with water in front of the patient's mouth without a command; (4) one command-"there is a spoon; open your mouth"-with a spoon in front of the patient's mouth; (5) one command, "there is a spoon with water; open your mouth," with a spoon filled with water in front of the patient's mouth. All 19 patients were given these five stimuli randomly, and any one of the commands was presented four times to a patient, one at a time, at 15-s intervals. The sensitivity and specificity of the initiation of swallowing in detecting conscious awareness were determined. Results: None of the patients responded to the first four stimuli. However, six patients showed initiated swallowing toward the fifth stimulus. Among those six, five patients showed improvement in their consciousness state 6 months later. The sensitivity and specificity of the initiation of swallowing for DOC patients was 83.33% [95% CIs (36%, 100%)] and 92.31% [95% CIs (64%, 100%)], respectively. Conclusions: The initiation of swallowing can be an early indication of conscious behavior and can likely provide evidence of conscious awareness. Clinical Trial Registration: www.ClinicalTrials.gov, identifier: NCT03508336; Date of registration: 2018/4/16.
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Affiliation(s)
- Jianan Wang
- International Unresponsive Wakefulness Syndrome and Consciousness Science Institute, Hangzhou Normal University, Hangzhou, China
| | - Jing Wang
- International Unresponsive Wakefulness Syndrome and Consciousness Science Institute, Hangzhou Normal University, Hangzhou, China
| | - Xiaohua Hu
- Rehabilitation Center for Brain Damage, Wujing Hospital of Hangzhou City, Hangzhou, China
| | - Lingqi Xu
- International Unresponsive Wakefulness Syndrome and Consciousness Science Institute, Hangzhou Normal University, Hangzhou, China
| | - Jinna Tian
- International Unresponsive Wakefulness Syndrome and Consciousness Science Institute, Hangzhou Normal University, Hangzhou, China
| | - Jiayin Li
- International Unresponsive Wakefulness Syndrome and Consciousness Science Institute, Hangzhou Normal University, Hangzhou, China
| | - Danruo Fang
- International Unresponsive Wakefulness Syndrome and Consciousness Science Institute, Hangzhou Normal University, Hangzhou, China
| | - Wangshan Huang
- International Unresponsive Wakefulness Syndrome and Consciousness Science Institute, Hangzhou Normal University, Hangzhou, China
| | - Yuxiao Sun
- International Unresponsive Wakefulness Syndrome and Consciousness Science Institute, Hangzhou Normal University, Hangzhou, China
| | - Minhui He
- International Unresponsive Wakefulness Syndrome and Consciousness Science Institute, Hangzhou Normal University, Hangzhou, China
| | - Steven Laureys
- GIGA, GIGA-Consciousness, Coma Science Group, Neurology Department, University Hospital of Liege, University of Liège, Liège, Belgium
| | - Haibo Di
- International Unresponsive Wakefulness Syndrome and Consciousness Science Institute, Hangzhou Normal University, Hangzhou, China
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Zhang Y, Wang J, Schnakers C, He M, Luo H, Cheng L, Wang F, Nie Y, Huang W, Hu X, Laureys S, Di H. Validation of the Chinese version of the Coma Recovery Scale-Revised (CRS-R). Brain Inj 2019; 33:529-533. [PMID: 30663434 DOI: 10.1080/02699052.2019.1566832] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
PRIMARY OBJECTIVE This study aims to validate the Chinese version of the Coma Recovery Scale-Revised (CRS-R). METHODS One hundred sixty-nine patients were assessed with both the CRS-R and the Glasgow Coma Scale (GCS), diagnosed as being in unresponsive wakefulness syndrome (UWS, formerly known as vegetative state), minimally conscious state (MCS), or emergence from MCS (EMCS). A subgroup of 50 patients has been assessed twice by the same rater, within 24 h. Patient outcome was documented six months after assessment. RESULTS The internal consistency for the CRS-R total score was excellent (Cronbach's α = 0.84). Good test-retest reliability was obtained for CRS-R total score and subscale scores (intra-class correlation coefficient [ICC] = 0.87 and ICC = 0.66-0.84, respectively). Inter-rater reliability was high (ICC = 0.719; p < 0.01). Concurrent validity was good between CRS-R total scale and GCS total scale. Diagnostic validity was excellent compared with GCS (emerged from UWS: 24%; emerged from MCS: 28%). When considering patient outcome, diagnostic validity was good. In addition, false-positive rates have been detected for both diagnoses. CONCLUSION The Chinese version of the CRS-R is a reliable and sensitive tool and can discriminate patients in UWS, MCS, and EMCS successfully.
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Affiliation(s)
- Ying Zhang
- a International Vegetative State and Consciousness Science Institute, Hangzhou Normal University , Hangzhou , Zhejiang , China.,b The Affiliated Hospital of Hangzhou Normal University , Hangzhou Normal University , Hangzhou , Zhejiang , China
| | - Jing Wang
- a International Vegetative State and Consciousness Science Institute, Hangzhou Normal University , Hangzhou , Zhejiang , China
| | - Caroline Schnakers
- c Research Institute , Casa Colina Hospital and Centers for Healthcare , Pomona , CA , USA.,d Department of Psychiatry , University of California , Los Angeles , CA , USA
| | - Minhui He
- a International Vegetative State and Consciousness Science Institute, Hangzhou Normal University , Hangzhou , Zhejiang , China.,b The Affiliated Hospital of Hangzhou Normal University , Hangzhou Normal University , Hangzhou , Zhejiang , China
| | - Hong Luo
- b The Affiliated Hospital of Hangzhou Normal University , Hangzhou Normal University , Hangzhou , Zhejiang , China
| | - Lijuan Cheng
- a International Vegetative State and Consciousness Science Institute, Hangzhou Normal University , Hangzhou , Zhejiang , China.,e Hangzhou Normal University Qianjiang College , Hangzhou , Zhejiang , China
| | - Fuyan Wang
- a International Vegetative State and Consciousness Science Institute, Hangzhou Normal University , Hangzhou , Zhejiang , China.,b The Affiliated Hospital of Hangzhou Normal University , Hangzhou Normal University , Hangzhou , Zhejiang , China
| | - Yunzhi Nie
- a International Vegetative State and Consciousness Science Institute, Hangzhou Normal University , Hangzhou , Zhejiang , China.,f Ningbo NO.7 Hospital , Ningbo , Zhejiang , China
| | - Wangshan Huang
- a International Vegetative State and Consciousness Science Institute, Hangzhou Normal University , Hangzhou , Zhejiang , China
| | - Xiaohua Hu
- g Department of Rehabilitation , Hangzhou Wujing Hospital , Hangzhou , China
| | - Steven Laureys
- h GIGA, GIGA-Consciousness, Coma Science Group, University & Neurology Department , Hospital of Liege , Liege , Belgium
| | - Haibo Di
- a International Vegetative State and Consciousness Science Institute, Hangzhou Normal University , Hangzhou , Zhejiang , China
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Riganello F, Larroque SK, Bahri MA, Heine L, Martial C, Carrière M, Charland-Verville V, Aubinet C, Vanhaudenhuyse A, Chatelle C, Laureys S, Di Perri C. A Heartbeat Away From Consciousness: Heart Rate Variability Entropy Can Discriminate Disorders of Consciousness and Is Correlated With Resting-State fMRI Brain Connectivity of the Central Autonomic Network. Front Neurol 2018; 9:769. [PMID: 30258400 PMCID: PMC6145008 DOI: 10.3389/fneur.2018.00769] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2018] [Accepted: 08/24/2018] [Indexed: 12/20/2022] Open
Abstract
Background: Disorders of consciousness are challenging to diagnose, with inconsistent behavioral responses, motor and cognitive disabilities, leading to approximately 40% misdiagnoses. Heart rate variability (HRV) reflects the complexity of the heart-brain two-way dynamic interactions. HRV entropy analysis quantifies the unpredictability and complexity of the heart rate beats intervals. We here investigate the complexity index (CI), a score of HRV complexity by aggregating the non-linear multi-scale entropies over a range of time scales, and its discriminative power in chronic patients with unresponsive wakefulness syndrome (UWS) and minimally conscious state (MCS), and its relation to brain functional connectivity. Methods: We investigated the CI in short (CIs) and long (CIl) time scales in 14 UWS and 16 MCS sedated. CI for MCS and UWS groups were compared using a Mann-Whitney exact test. Spearman's correlation tests were conducted between the Coma Recovery Scale-revised (CRS-R) and both CI. Discriminative power of both CI was assessed with One-R machine learning model. Correlation between CI and brain connectivity (detected with functional magnetic resonance imagery using seed-based and hypothesis-free intrinsic connectivity) was investigated using a linear regression in a subgroup of 10 UWS and 11 MCS patients with sufficient image quality. Results: Higher CIs and CIl values were observed in MCS compared to UWS. Positive correlations were found between CRS-R and both CI. The One-R classifier selected CIl as the best discriminator between UWS and MCS with 90% accuracy, 7% false positive and 13% false negative rates after a 10-fold cross-validation test. Positive correlations were observed between both CI and the recovery of functional connectivity of brain areas belonging to the central autonomic networks (CAN). Conclusion: CI of MCS compared to UWS patients has high discriminative power and low false negative rate at one third of the estimated human assessors' misdiagnosis, providing an easy, inexpensive and non-invasive diagnostic tool. CI reflects functional connectivity changes in the CAN, suggesting that CI can provide an indirect way to screen and monitor connectivity changes in this neural system. Future studies should assess the extent of CI's predictive power in a larger cohort of patients and prognostic power in acute patients.
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Affiliation(s)
- Francesco Riganello
- Coma Science Group, GIGA-Consciousness, University & Hospital of Liege, Liege, Belgium
- Research in Advanced NeuroRehabilitation, Istituto S. Anna, Crotone, Italy
| | - Stephen Karl Larroque
- Coma Science Group, GIGA-Consciousness, University & Hospital of Liege, Liege, Belgium
| | - Mohamed Ali Bahri
- GIGA-Cyclotron Research Center in vivo Imaging, University of Liege, Liege, Belgium
| | - Lizette Heine
- Centre de Recherche en Neurosciences, Inserm U1028 - CNRS UMR5292, University of Lyon 1, Bron, France
| | - Charlotte Martial
- Coma Science Group, GIGA-Consciousness, University & Hospital of Liege, Liege, Belgium
| | - Manon Carrière
- Coma Science Group, GIGA-Consciousness, University & Hospital of Liege, Liege, Belgium
| | | | - Charlène Aubinet
- Coma Science Group, GIGA-Consciousness, University & Hospital of Liege, Liege, Belgium
| | - Audrey Vanhaudenhuyse
- Sensation & Perception Research Group, GIGA-Consciousness, University & Hospital of Liege, Liege, Belgium
| | - Camille Chatelle
- Coma Science Group, GIGA-Consciousness, University & Hospital of Liege, Liege, Belgium
| | - Steven Laureys
- Coma Science Group, GIGA-Consciousness, University & Hospital of Liege, Liege, Belgium
| | - Carol Di Perri
- Coma Science Group, GIGA-Consciousness, University & Hospital of Liege, Liege, Belgium
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, United Kingdom
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Devalle G, Castiglioni P, Arienti C, Abbate C, Mazzucchi A, Agnello L, Merati G. Cardio-respiratory autonomic responses to nociceptive stimuli in patients with disorders of consciousness. PLoS One 2018; 13:e0201921. [PMID: 30208114 PMCID: PMC6135369 DOI: 10.1371/journal.pone.0201921] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2018] [Accepted: 07/24/2018] [Indexed: 12/26/2022] Open
Abstract
The autonomic response to pain might discriminate among consciousness disorders. Therefore, aim of this study was to describe differences between minimally conscious state (MCS) and unresponsive wakefulness syndrome (UWS) patients in their autonomic response to a nociceptive stimulus. ECG, respiration, finger blood pressure (BP) and total peripheral resistances (TPR) were continuously recorded before, during and after a standardized noxious stimulus in 20 adult brain-injured patients, 14 in UWS and 6 in MCS. Occurrence of fast autonomic responses synchronous with the stimulus was detected by visual inspection of the tracings; short-term (<20 s) and long-term (between 20s and 50 s from the stimulus) responses were evaluated by beat-by-beat quantitative analysis. The noxious stimulus elicited fast responses in both groups, but only MCS patients showed a significant short-term response in TPR and long-term response in HR. Thus, short- and long-term cardiovascular responses to pain might integrate neuro-behavioural assessments to discriminate between MCS and UWS.
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Affiliation(s)
- Guya Devalle
- Vegetative State Unit, IRCCS Fondazione Don Carlo Gnocchi, Milan, Italy
| | | | - Chiara Arienti
- Vegetative State Unit, IRCCS Fondazione Don Carlo Gnocchi, Milan, Italy
| | - Carlo Abbate
- Geriatric Unit, Fondazione IRCCS Ca’ Granda, Ospedale Maggiore Policlinico, Milan, Italy
| | - Anna Mazzucchi
- Rete Gravi Cerebrolesioni Acquisite, IRCCS Fondazione Don Carlo Gnocchi, Santa Maria dei Servi, Parma, Italy
| | - Luca Agnello
- Department of Biomedical Sciences for Health, University of Milan, Milan, Italy
| | - Giampiero Merati
- Department of Biomedical Sciences for Health, University of Milan, Milan, Italy
- Center of Sports Medicine, IRCCS Fondazione Don Carlo Gnocchi, Milan, Italy
- * E-mail:
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Rupawala M, Dehghani H, Lucas SJE, Tino P, Cruse D. Shining a Light on Awareness: A Review of Functional Near-Infrared Spectroscopy for Prolonged Disorders of Consciousness. Front Neurol 2018; 9:350. [PMID: 29872420 PMCID: PMC5972220 DOI: 10.3389/fneur.2018.00350] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2017] [Accepted: 04/30/2018] [Indexed: 12/19/2022] Open
Abstract
Qualitative clinical assessments of the recovery of awareness after severe brain injury require an assessor to differentiate purposeful behavior from spontaneous behavior. As many such behaviors are minimal and inconsistent, behavioral assessments are susceptible to diagnostic errors. Advanced neuroimaging tools can bypass behavioral responsiveness and reveal evidence of covert awareness and cognition within the brains of some patients, thus providing a means for more accurate diagnoses, more accurate prognoses, and, in some instances, facilitated communication. The majority of reports to date have employed the neuroimaging methods of functional magnetic resonance imaging, positron emission tomography, and electroencephalography (EEG). However, each neuroimaging method has its own advantages and disadvantages (e.g., signal resolution, accessibility, etc.). Here, we describe a burgeoning technique of non-invasive optical neuroimaging—functional near-infrared spectroscopy (fNIRS)—and review its potential to address the clinical challenges of prolonged disorders of consciousness. We also outline the potential for simultaneous EEG to complement the fNIRS signal and suggest the future directions of research that are required in order to realize its clinical potential.
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Affiliation(s)
- Mohammed Rupawala
- Centre for Doctoral Training in Physical Sciences for Health, University of Birmingham, Birmingham, United Kingdom
| | - Hamid Dehghani
- Centre for Doctoral Training in Physical Sciences for Health, University of Birmingham, Birmingham, United Kingdom.,School of Computer Science, University of Birmingham, Birmingham, United Kingdom
| | - Samuel J E Lucas
- School of Sport, Exercise and Rehabilitation Sciences, University of Birmingham, Birmingham, United Kingdom
| | - Peter Tino
- School of Computer Science, University of Birmingham, Birmingham, United Kingdom
| | - Damian Cruse
- School of Psychology, University of Birmingham, Birmingham, United Kingdom
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9
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Riganello F, Macrì S, Alleva E, Petrini C, Soddu A, Leòn-Carriòn J, Dolce G. Pain Perception in Unresponsive Wakefulness Syndrome May Challenge the Interruption of Artificial Nutrition and Hydration: Neuroethics in Action. Front Neurol 2016; 7:202. [PMID: 27899911 PMCID: PMC5110539 DOI: 10.3389/fneur.2016.00202] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2016] [Accepted: 11/01/2016] [Indexed: 12/23/2022] Open
Affiliation(s)
| | - Simone Macrì
- Section of Behavioral Neuroscience, Department of Cell Biology and Neuroscience, Istituto Superiore di Sanità, Rome, Italy
| | - Enrico Alleva
- Section of Behavioral Neuroscience, Department of Cell Biology and Neuroscience, Istituto Superiore di Sanità, Rome, Italy
| | - Carlo Petrini
- Office of the President, Bioethics Unit, Istituto Superiore di Sanità, Rome, Italy
| | - Andrea Soddu
- Department of Physics and Astronomy, Brain and Mind Institute, The University of Western Ontario, London, ON, Canada
| | - Josè Leòn-Carriòn
- Human Neuropsychology Laboratory, Department of Experimental Psychology, School of Psychology, University of Seville, Seville, Spain
| | - Giuliano Dolce
- Research in Advanced Neurorehabilitation, Istituto S. Anna, Crotone, Italy
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10
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Thonnard M, Wannez S, Keen S, Brédart S, Bruno MA, Gosseries O, Demertzi A, Thibaut A, Chatelle C, Charland-Verville V, Heine L, Habbal D, Laureys S, Vanhaudenhuyse A. Detection of visual pursuit in patients in minimally conscious state: A matter of stimuli and visual plane? Brain Inj 2014; 28:1164-70. [DOI: 10.3109/02699052.2014.920521] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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11
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Fingelkurts AA, Fingelkurts AA, Bagnato S, Boccagni C, Galardi G. Prognostic Value of Resting-State Electroencephalography Structure in Disentangling Vegetative and Minimally Conscious States. Neurorehabil Neural Repair 2013; 27:345-54. [DOI: 10.1177/1545968312469836] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background. Patients in a vegetative state pose problems in diagnosis, prognosis, and treatment. Currently, no prognostic markers predict the chance of recovery, which has serious consequences, especially in end-of-life decision making. Objective. We aimed to assess an objective measurement of prognosis using advanced electroencephalography (EEG). Methods. EEG data (19 channels) were collected in 14 patients who were diagnosed to be persistently vegetative based on repeated clinical evaluations at 3 months following brain damage. EEG structure parameters (amplitude, duration, and variability within quasi-stationary segments, as well as the spatial synchrony between such segments and the strength of this synchrony) were used to predict recovery of consciousness 3 months later. Results. The number and strength of cortical functional connections between EEG segments were higher in patients who recovered consciousness ( P < .05 to P < .001) compared with those who did not recover. Linear regression analysis confirms that EEG structure parameters are capable of predicting ( P = .0025) recovery of consciousness 6 months postinjury, whereas the same analysis failed to significantly predict patient outcome based on aspects of their clinical history alone ( P = .629) or conventional EEG spectrum power ( P = .473). Conclusions. The result of this preliminary study demonstrates that structural strategy of EEG analysis is better suited for providing prognosis of consciousness recovery than existing methods of clinical assessment and of conventional EEG. Our results may be a starting point for developing reliable prognosticators in patients who are in a vegetative state, with the potential to improve their day-to-day management, quality of life, and access to early interventions.
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Affiliation(s)
| | | | - Sergio Bagnato
- Neurorehabilitation Unit, Rehabilitation Department, Fondazione Istituto “San Raffaele–G. Giglio,” Cefalu, Palermo, Italy
| | - Cristina Boccagni
- Neurorehabilitation Unit, Rehabilitation Department, Fondazione Istituto “San Raffaele–G. Giglio,” Cefalu, Palermo, Italy
| | - Giuseppe Galardi
- Neurorehabilitation Unit, Rehabilitation Department, Fondazione Istituto “San Raffaele–G. Giglio,” Cefalu, Palermo, Italy
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12
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Fingelkurts AA, Fingelkurts AA, Bagnato S, Boccagni C, Galardi G. The value of spontaneous EEG oscillations in distinguishing patients in vegetative and minimally conscious states. SUPPLEMENTS TO CLINICAL NEUROPHYSIOLOGY 2013; 62:81-99. [PMID: 24053033 DOI: 10.1016/b978-0-7020-5307-8.00005-3] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVE The value of spontaneous electroencephalography (EEG) oscillations in distinguishing patients in vegetative state (VS) and minimally conscious states (MCS) was studied. METHODS We quantified dynamic repertoire of EEG oscillations in resting condition with closed eyes in patients in VS and MCS. The exact composition of EEG oscillations was assessed by the probability-classification analysis of short-term EEG spectral patterns. RESULTS The probability of delta, theta, and slow-alpha oscillations occurrence was smaller for patients in MCS than for VS. Additionally, only patients in MCS demonstrated fast-alpha oscillation occurrence. Depending on the type and composition of EEG oscillations, the probability of their occurrence was either etiology dependent or independent. The probability of EEG oscillations occurrence differentiated brain injuries with different etiologies. CONCLUSIONS Spontaneous EEG oscillations have a potential value in distinguishing patients in VS and MCS. SIGNIFICANCE This work may have implications for clinical care, rehabilitative programs, and medical-legal decisions in patients with impaired consciousness states following coma due to acute brain injuries. HIGHLIGHTS The probability of delta, theta, and slow-alpha oscillations occurrence was smaller and the probability of fast-alpha oscillations occurrence was higher for patients in MCS than for patients in VS. The probability of EEG oscillations occurrence differentiated brain injuries with different etiologies. Spontaneous EEG has a potential value in distinguishing patients in VS and MCS.
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Tighe B, Mainwaring J. The bioethical experiences of student dietitians on their final clinical placement. J Hum Nutr Diet 2012. [DOI: 10.1111/jhn.12007] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Affiliation(s)
- B. Tighe
- Department of Physiotherapy and Dietetics; Coventry University; Coventry UK
| | - J. Mainwaring
- Department of Physiotherapy and Dietetics; Coventry University; Coventry UK
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Geppert CMA, Andrews MR, Druyan ME. Ethical Issues in Artificial Nutrition and Hydration: A Review. JPEN J Parenter Enteral Nutr 2009; 34:79-88. [DOI: 10.1177/0148607109347209] [Citation(s) in RCA: 53] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Cynthia M. A. Geppert
- From New Mexico Veteran's Affairs Health Care System and University of New Mexico School of Medicine, Albuquerque, New Mexico; El Paso VA Health Care System, El Paso, Texas; and Broad Spectrum Communications, Clarendon Hills, Illinois
| | - Maria R. Andrews
- From New Mexico Veteran's Affairs Health Care System and University of New Mexico School of Medicine, Albuquerque, New Mexico; El Paso VA Health Care System, El Paso, Texas; and Broad Spectrum Communications, Clarendon Hills, Illinois
| | - Mary Ellen Druyan
- From New Mexico Veteran's Affairs Health Care System and University of New Mexico School of Medicine, Albuquerque, New Mexico; El Paso VA Health Care System, El Paso, Texas; and Broad Spectrum Communications, Clarendon Hills, Illinois
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L’alimentation artificielle et l’hydratation chez la personne en état végétatif chronique : soin, traitement ou acharnement thérapeutique ? MEDECINE PALLIATIVE 2008. [DOI: 10.1016/j.medpal.2008.01.003] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Guidelines for Quality Management of Apallic Syndrome / Vegetative State. Eur J Trauma Emerg Surg 2007; 33:268-92. [PMID: 26814491 DOI: 10.1007/s00068-007-6138-1] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2006] [Accepted: 08/13/2006] [Indexed: 01/02/2023]
Abstract
INTRODUCTION Epidemiology in Europe shows constantly increasing figures for the apallic syndrome (AS)/vegetative state (VS) as a consequence of advanced rescue, emergency services, intensive care treatment after acute brain damage and high-standard activating home nursing for completely dependent end-stage cases secondary to progressive neurological disease. Management of patients in irreversible permanent AS/VS has been the subject of sustained scientific and moral-legal debate over the past decade. METHODS A task force on guidelines for quality management of AS/VS was set up under the auspices of the Scientific Panel Neurotraumatology of the European Federation of Neurological Societies to address key issues relating to AS/VS prevalence and quality management. Collection and analysis of scientific data on class II (III) evidence from the literature and recommendations based on the best practice as resulting from the task force members' expertise are in accordance with EFNS Guidance regulations. FINDINGS The overall incidence of new AS/VS full stage cases all etiology is 0.5-2/100.000 population per year. About one third are traumatic and two thirds non traumatic cases. Increasing figures for hypoxic brain damage and progressive neurological disease have been noticed. The main conceptual criticism is based on the assessment and diagnosis of all different AS/VS stages based solely on behavioural findings without knowing the exact or uniform pathogenesis or neuropathological findings and the uncertainty of clinical assessment due to varying inclusion criteria. No special diagnostics, no specific medical management can be recommended for class II or III AS treatment and rehabilitation. This is why sine qua non diagnostics of the clinical features and appropriate treatment of AS/VS patients of "AS full, remission, defect and end stages" require further professional training and expertise for doctors and rehabilitation personnel. INTERPRETATION Management of AS aims at the social reintegration of patients or has to guarantee humanistic active nursing if treatment fails. Outcome depends on the cause and duration of AS/VS as well as patient's age. There is no single AS/VS specific laboratory investigation, no specific regimen or stimulating intervention to be recommended for improving higher cerebral functioning. Quality management requires at least 3 years of advanced training and permanent education to gain approval of qualification for AS/VS treatment and expertise. Sine qua non areas covering AS/VS institutions for early and long-term rehabilitation are required on a population base (prevalence of 2/100.000/year) to quicken functional restoration and to prevent or treat complications. Caring homes are needed for respectful humane nursing including basal sensor-motor stimulating techniques. Passive euthanasia is considered an act of mercy by physicians in terms of withholding treatment; however, ethical and legal issues with regard to withdrawal of nutrition and hydration and end of life discussions raise deep concerns. The aim of the guideline is to provide management guidance (on the best medical evidence class II and III or task force expertise) for neurologists, neurosurgeons, other physicians working with AS/VS patients, neurorehabilitation personnel, patients, next-of-kin, and health authorities.
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Abstract
The vegetative state and the minimally conscious state are disorders of consciousness that can be acute and reversible or chronic and irreversible. Diffuse lesions of the thalami, cortical neurons, or the white-matter tracts that connect them cause the vegetative state, which is wakefulness without awareness. Functional imaging with PET and functional MRI shows activation of primary cortical areas with stimulation, but not of secondary areas or distributed neural networks that would indicate awareness. Vegetative state has a poor prognosis for recovery of awareness when present for more than a year in traumatic cases and for 3 months in non-traumatic cases. Patients in minimally conscious state are poorly responsive to stimuli, but show intermittent awareness behaviours. Indeed, findings of preliminary functional imaging studies suggest that some patients could have substantially intact awareness. The outcomes of minimally conscious state are variable. Stimulation treatments have been disappointing in vegetative state but occasionally improve minimally conscious state. Treatment decisions for patients in vegetative state or minimally conscious state should follow established ethical and legal principles and accepted practice guidelines of professional medical specialty societies.
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Abstract
The concept of death has evolved as technology has progressed. This has forced medicine and society to redefine its ancient cardiorespiratory centred diagnosis to a neurocentric diagnosis of death. The apparent consensus about the definition of death has not yet appeased all controversy. Ethical, moral and religious concerns continue to surface and include a prevailing malaise about possible expansions of the definition of death to encompass the vegetative state or about the feared bias of formulating criteria so as to facilitate organ transplantation.
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Affiliation(s)
- Steven Laureys
- Cyclotron Research Centre and Neurology Department, Université de Liège, Sart Tilman-B30, 4000 Liège, Belgium.
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