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Liuzzi P, Cassioli T, Secci S, Hakiki B, Scarpino M, Burali R, di Palma A, Toci T, Grippo A, Cecchi F, Frosini A, Mannini A. A neurophysiological profiling of the heartbeat-evoked potential in severe acquired brain injuries: A focus on unconsciousness. Eur J Neurosci 2024; 60:4201-4216. [PMID: 38797841 DOI: 10.1111/ejn.16394] [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: 09/18/2023] [Revised: 04/26/2024] [Accepted: 05/01/2024] [Indexed: 05/29/2024]
Abstract
Unconsciousness in severe acquired brain injury (sABI) patients occurs with different cognitive and neural profiles. Perturbational approaches, which enable the estimation of proxies for brain reorganization, have added a new avenue for investigating the non-behavioural diagnosis of consciousness. In this prospective observational study, we conducted a comparative analysis of the topological patterns of heartbeat-evoked potentials (HEP) between patients experiencing a prolonged disorder of consciousness (pDoC) and patients emerging from a minimally consciousness state (eMCS). A total of 219 sABI patients were enrolled, each undergoing a synchronous EEG-ECG resting-state recording, together with a standardized consciousness diagnosis. A number of graph metrics were computed before/after the HEP (Before/After) using the R-peak on the ECG signal. The peak value of the global field power of the HEP was found to be significantly higher in eMCS patients with no difference in latency. Power spectrum was not able to discriminate consciousness neither Before nor After. Node assortativity and global efficiency were found to vary with different trends at unconsciousness. Lastly, the Perturbational Complexity Index of the HEP was found to be significantly higher in eMCS patients compared with pDoC. Given that cortical elaboration of peripheral inputs may serve as a non-behavioural determinant of consciousness, we have devised a low-cost and translatable technique capable of estimating causal proxies of brain functionality with an endogenous, non-invasive stimulus. Thus, we present an effective means to enhance consciousness assessment by incorporating the interaction between the autonomic nervous system (ANS) and central nervous system (CNS) into the loop.
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Affiliation(s)
- Piergiuseppe Liuzzi
- IRCCS Fondazione Don Carlo Gnocchi ONLUS, Florence, Italy
- Istituto di BioRobotica, Scuola Superiore Sant'Anna, Pisa, Italy
| | | | - Sara Secci
- IRCCS Fondazione Don Carlo Gnocchi ONLUS, Florence, Italy
| | - Bahia Hakiki
- IRCCS Fondazione Don Carlo Gnocchi ONLUS, Florence, Italy
- Dipartimento di Medicina Sperimentale e Clinica, Università di Firenze, Florence, Italy
| | | | - Rachele Burali
- IRCCS Fondazione Don Carlo Gnocchi ONLUS, Florence, Italy
| | | | - Tanita Toci
- IRCCS Fondazione Don Carlo Gnocchi ONLUS, Florence, Italy
| | | | - Francesca Cecchi
- IRCCS Fondazione Don Carlo Gnocchi ONLUS, Florence, Italy
- Dipartimento di Medicina Sperimentale e Clinica, Università di Firenze, Florence, Italy
| | - Andrea Frosini
- IRCCS Fondazione Don Carlo Gnocchi ONLUS, Florence, Italy
- Dipartimento di Matematica Ulisse Dini, Università di Firenze, Florence, Italy
| | - Andrea Mannini
- IRCCS Fondazione Don Carlo Gnocchi ONLUS, Florence, Italy
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Secci S, Liuzzi P, Hakiki B, Burali R, Draghi F, Romoli AM, di Palma A, Scarpino M, Grippo A, Cecchi F, Frosini A, Mannini A. Low-density EEG-based Functional Connectivity Discriminates Minimally Conscious State plus from minus. Clin Neurophysiol 2024; 163:197-208. [PMID: 38761713 DOI: 10.1016/j.clinph.2024.04.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Revised: 04/03/2024] [Accepted: 04/18/2024] [Indexed: 05/20/2024]
Abstract
OBJECTIVE Within the continuum of consciousness, patients in a Minimally Conscious State (MCS) may exhibit high-level behavioral responses (MCS+) or may not (MCS-). The evaluation of residual consciousness and related classification is crucial to propose tailored rehabilitation and pharmacological treatments, considering the inherent differences among groups in diagnosis and prognosis. Currently, differential diagnosis relies on behavioral assessments posing a relevant risk of misdiagnosis. In this context, EEG offers a non-invasive approach to model the brain as a complex network. The search for discriminating features could reveal whether behavioral responses in post-comatose patients have a defined physiological background. Additionally, it is essential to determine whether the standard behavioral assessment for quantifying responsiveness holds physiological significance. METHODS In this prospective observational study, we investigated whether low-density EEG-based graph metrics could discriminate MCS+/- patients by enrolling 57 MCS patients (MCS-: 30; males: 28). At admission to intensive rehabilitation, 30 min resting-state closed-eyes EEG recordings were performed together with consciousness diagnosis following international guidelines. After EEG preprocessing, graphs' metrics were estimated using different connectivity measures, at multiple connection densities and frequency bands (α,θ,δ). Metrics were also provided to cross-validated Machine Learning (ML) models with outcome MCS+/-. RESULTS A lower level of brain activity integration was found in the MCS- group in the α band. Instead, in the δ band MCS- group presented an higher level of clustering (weighted clustering coefficient) respect to MCS+. The best-performing solution in discriminating MCS+/- through the use of ML was an Elastic-Net regularized logistic regression with a cross-validation accuracy of 79% (sensitivity and specificity of 74% and 85% respectively). CONCLUSION Despite tackling the MCS+/- differential diagnosis is highly challenging, a daily-routine low-density EEG might allow to differentiate across these differently responsive brain networks. SIGNIFICANCE Graph-theoretical features are shown to discriminate between these two neurophysiologically similar conditions, and may thus support the clinical diagnosis.
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Affiliation(s)
- Sara Secci
- IRCCS Fondazione Don Carlo Gnocchi, via di Scandicci 269, Firenze, FI, Italy
| | - Piergiuseppe Liuzzi
- IRCCS Fondazione Don Carlo Gnocchi, via di Scandicci 269, Firenze, FI, Italy; Scuola Superiore Sant'Anna, BioRobotics Institute, Viale Rinaldo Piaggio 34, Pontedera, PI, Italy
| | - Bahia Hakiki
- IRCCS Fondazione Don Carlo Gnocchi, via di Scandicci 269, Firenze, FI, Italy; Dipartimento di Medicina Sperimentale e Clinica, Largo Brambilla 3, FI, Italy.
| | - Rachele Burali
- IRCCS Fondazione Don Carlo Gnocchi, via di Scandicci 269, Firenze, FI, Italy
| | - Francesca Draghi
- IRCCS Fondazione Don Carlo Gnocchi, via di Scandicci 269, Firenze, FI, Italy
| | - Anna Maria Romoli
- IRCCS Fondazione Don Carlo Gnocchi, via di Scandicci 269, Firenze, FI, Italy
| | - Azzurra di Palma
- Dipartimento di Matematica e Informatica, Università di Firenze, Viale Morgagni 65, FI, Italy
| | - Maenia Scarpino
- IRCCS Fondazione Don Carlo Gnocchi, via di Scandicci 269, Firenze, FI, Italy
| | - Antonello Grippo
- IRCCS Fondazione Don Carlo Gnocchi, via di Scandicci 269, Firenze, FI, Italy
| | - Francesca Cecchi
- IRCCS Fondazione Don Carlo Gnocchi, via di Scandicci 269, Firenze, FI, Italy; Dipartimento di Medicina Sperimentale e Clinica, Largo Brambilla 3, FI, Italy
| | - Andrea Frosini
- Dipartimento di Matematica e Informatica, Università di Firenze, Viale Morgagni 65, FI, Italy
| | - Andrea Mannini
- IRCCS Fondazione Don Carlo Gnocchi, via di Scandicci 269, Firenze, FI, Italy
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Draghi F, Pancani S, De Nisco A, Romoli AM, Maccanti D, Burali R, Grippo A, Macchi C, Cecchi F, Hakiki B. Implications of the Consciousness State on Decannulation in Patients With a Prolonged Disorder of Consciousness. Arch Phys Med Rehabil 2024:S0003-9993(24)00994-8. [PMID: 38734048 DOI: 10.1016/j.apmr.2024.05.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2023] [Revised: 05/02/2024] [Accepted: 05/02/2024] [Indexed: 05/13/2024]
Abstract
OBJECTIVE To prospectively investigate the evolution of the consciousness state and the cannula-weaning progression in patients with prolonged disorders of consciousness. DESIGN Nonconcurrent cohort study. SETTING A rehabilitation unit. PARTICIPANTS Adult patients (N=144) with prolonged disorders of consciousness after a severe acquired brain injury admitted between June 2020 and September 2022. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES Consciousness state was assessed by repeated Coma Recovery Scale-Revised (CRS-R) questionnaire administration at admission and weekly afterward. The dates of the first improvement of consciousness state and the achievement of decannulation were recorded. Decannulation followed an internal protocol of multiprofessional rehabilitation. RESULTS One hundred forty-four patients were included: age, 69 years; 64 (44.4%) with hemorrhagic etiology; time post onset, 40 days, CRS-R score at admission, 9, median length of stay, 90 days. Seventy-three (50.7%) patients were decannulated. They showed a significantly higher CRS-R (P<.001) and states of consciousness (P<.001) at admission, at the first improvement of the consciousness state (P=.003), and at discharge (P<.001); a lower severity in the Cumulative Illness Rating Scale at admission (P=.01); and a lower rate of pulmonary infections with recurrence (P=.021), compared with nondecannulated patients. Almost all decannulated patients (97.3%) improved their consciousness before decannulation. Consciousness states at decannulation were as follows: unresponsive wakefulness syndrome, 0 (0%); minimally conscious state (MCS) minus, 4 (5.5%); MCS plus, 7 (9.6%); and emergence from MCS, 62 (84.9%). Kaplan-Meier analysis showed a significant divergence between the curves with a higher probability of decannulation in patients who improved consciousness (P<.001). CONCLUSIONS This study showed that the presence of signs of consciousness, even subtle, is a necessary condition for decannulation, suggesting that consciousness may influence some of the components implied in the decannulation process.
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Affiliation(s)
- Francesca Draghi
- Istituto di Ricovero e Cura a Carattere Scientifico Fondazione Don Carlo Gnocchi Onlus, Florence
| | - Silvia Pancani
- Istituto di Ricovero e Cura a Carattere Scientifico Fondazione Don Carlo Gnocchi Onlus, Florence.
| | - Agnese De Nisco
- Istituto di Ricovero e Cura a Carattere Scientifico Fondazione Don Carlo Gnocchi Onlus, Florence
| | - Anna Maria Romoli
- Istituto di Ricovero e Cura a Carattere Scientifico Fondazione Don Carlo Gnocchi Onlus, Florence
| | - Daniela Maccanti
- Istituto di Ricovero e Cura a Carattere Scientifico Fondazione Don Carlo Gnocchi Onlus, Florence
| | - Rachele Burali
- Istituto di Ricovero e Cura a Carattere Scientifico Fondazione Don Carlo Gnocchi Onlus, Florence
| | - Antonello Grippo
- Istituto di Ricovero e Cura a Carattere Scientifico Fondazione Don Carlo Gnocchi Onlus, Florence
| | - Claudio Macchi
- Istituto di Ricovero e Cura a Carattere Scientifico Fondazione Don Carlo Gnocchi Onlus, Florence; Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Francesca Cecchi
- Istituto di Ricovero e Cura a Carattere Scientifico Fondazione Don Carlo Gnocchi Onlus, Florence; Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Bahia Hakiki
- Istituto di Ricovero e Cura a Carattere Scientifico Fondazione Don Carlo Gnocchi Onlus, Florence; Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
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Mazzeo S, Pancani S, Sodero A, Castagnoli C, Politi AM, Barnabè M, Ciullini F, Baccini M, Grippo A, Hakiki B, Macchi C, Cecchi F. Depressive Symptoms Moderate the Association Between Functional Level at Admission to Intensive Post-Stroke Rehabilitation and Effectiveness of the Intervention. J Geriatr Psychiatry Neurol 2024; 37:222-233. [PMID: 37828783 DOI: 10.1177/08919887231204543] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/14/2023]
Abstract
INTRODUCTION Previous studies showed that depression acts as an independent factor in functional recovery after stroke. In a prospective cohort of patients admitted to intensive inpatient rehabilitation after a stroke, we aimed to test depression as a moderator of the relationship between the functional level at admission and the effectiveness of rehabilitation at discharge. METHODS All patients admitted to within 30 days from an ischemic or hemorrhagic stroke to 4 intensive rehabilitation units were prospectively screened for eligibility to a multicenter prospective observational study. Enrolled patients underwent an evidence-based rehabilitation pathway. We used clinical data collected at admission (T0) and discharge (T1). The outcome was the effectiveness of recovery at T1 on the modified Barthel Index (proportion of achieved over potential functional improvement). Moderation analysis was performed by using the PROCESS macro for SPSS using the bootstrapping procedure. RESULTS Of 278 evaluated patients, 234 were eligible and consented to enrolment; 81 patients were able to answer to the Hospital Anxiety and Depression Scale (HADS) and were included in this analysis. The relationship between the functional status at admission and rehabilitation effectiveness was significant only in persons with fewer depressive symptoms; depression (HADS cut-off score: 5.9) moderated this relationship (P = .047), independent from age and neurological impairment. CONCLUSIONS Our results suggest that depression moderates between the functional status at admission and the functional recovery after post-stroke rehabilitation. This approach facilitates the identification of subgroups of individuals who may respond differently to stroke rehabilitation based on depression.
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Affiliation(s)
- Salvatore Mazzeo
- IRCCS Fondazione Don Carlo Gnocchi onlus, Florence, Italy
- Department of Neuroscience, Psychology, Drug Research and Child Health (NEUROFARBA), University of Florence, Azienda Ospedaliera-Universitaria Careggi, Florence, Italy
| | - Silvia Pancani
- IRCCS Fondazione Don Carlo Gnocchi onlus, Florence, Italy
| | - Alessandro Sodero
- IRCCS Fondazione Don Carlo Gnocchi onlus, Florence, Italy
- Department of Neuroscience, Psychology, Drug Research and Child Health (NEUROFARBA), University of Florence, Azienda Ospedaliera-Universitaria Careggi, Florence, Italy
| | | | | | - Monica Barnabè
- IRCCS Fondazione Don Carlo Gnocchi onlus, Florence, Italy
| | | | - Marco Baccini
- IRCCS Fondazione Don Carlo Gnocchi onlus, Florence, Italy
| | | | - Bahia Hakiki
- IRCCS Fondazione Don Carlo Gnocchi onlus, Florence, Italy
| | - Claudio Macchi
- IRCCS Fondazione Don Carlo Gnocchi onlus, Florence, Italy
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Francesca Cecchi
- IRCCS Fondazione Don Carlo Gnocchi onlus, Florence, Italy
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
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Hirsch KG, Tamura T, Ristagno G, Sekhon MS. Wolf Creek XVII Part 8: Neuroprotection. Resusc Plus 2024; 17:100556. [PMID: 38328750 PMCID: PMC10847936 DOI: 10.1016/j.resplu.2024.100556] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/09/2024] Open
Abstract
Introduction Post-cardiac arrest brain injury (PCABI) is the primary determinant of clinical outcomes for patients who achieve return of spontaneous circulation after cardiac arrest (CA). There are limited neuroprotective therapies available to mitigate the acute pathophysiology of PCABI. Methods Neuroprotection was one of six focus topics for the Wolf Creek XVII Conference held on June 14-17, 2023 in Ann Arbor, Michigan, USA. Conference invitees included international thought leaders and scientists in the field of CA resuscitation from academia and industry. Participants submitted via online survey knowledge gaps, barriers to translation, and research priorities for each focus topic. Expert panels used the survey results and their own perspectives and insights to create and present a preliminary unranked list for each category that was debated, revised and ranked by all attendees to identify the top 5 for each category. Results Top 5 knowledge gaps included developing therapies for neuroprotection; improving understanding of the pathophysiology, mechanisms, and natural history of PCABI; deploying precision medicine approaches; optimizing resuscitation and CPR quality; and determining optimal timing for and duration of interventions. Top 5 barriers to translation included patient heterogeneity; nihilism & lack of knowledge about cardiac arrest; challenges with the translational pipeline; absence of mechanistic biomarkers; and inaccurate neuro-triage and neuroprognostication. Top 5 research priorities focused on translational research and trial optimization; addressing patient heterogeneity and individualized interventions; improving understanding of pathophysiology and mechanisms; developing mechanistic and outcome biomarkers across post-CA time course; and improving implementation of science and technology. Conclusion This overview can serve as a guide to transform the care and outcome of patients with PCABI. Addressing these topics has the potential to improve both research and clinical care in the field of neuroprotection for PCABI.
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Affiliation(s)
- Karen G. Hirsch
- Department of Neurology, Stanford University, Stanford, CA, United States
| | - Tomoyoshi Tamura
- Department of Emergency and Critical Care Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Giuseppe Ristagno
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Mypinder S. Sekhon
- Division of Critical Care Medicine and Department of Medicine, University of British Columbia, Vancouver, Canada
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Liuzzi P, Mannini A, Hakiki B, Campagnini S, Romoli AM, Draghi F, Burali R, Scarpino M, Cecchi F, Grippo A. Brain microstate spatio-temporal dynamics as a candidate endotype of consciousness. Neuroimage Clin 2023; 41:103540. [PMID: 38101096 PMCID: PMC10727951 DOI: 10.1016/j.nicl.2023.103540] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2023] [Revised: 10/02/2023] [Accepted: 11/09/2023] [Indexed: 12/17/2023]
Abstract
Consciousness can be defined as a phenomenological experience continuously evolving. Current research showed how conscious mental activity can be subdivided into a series of atomic brain states converging to a discrete spatiotemporal pattern of global neuronal firing. Using the high temporal resolution of EEG recordings in patients with a severe Acquired Brain Injury (sABI) admitted to an Intensive Rehabilitation Unit (IRU), we detected a novel endotype of consciousness from the spatiotemporal brain dynamics identified via microstate analysis. Also, we investigated whether microstate features were associated with common neurophysiological alterations. Finally, the prognostic information comprised in such descriptors was analysed in a sub-cohort of patients with prolonged Disorder of Consciousness (pDoC). Occurrence of frontally-oriented microstates (C microstate), likelihood of maintaining such brain state or transitioning to the C topography and complexity were found to be indicators of consciousness presence and levels. Features of left-right asymmetric microstates and transitions toward them were found to be negatively correlated with antero-posterior brain reorganization and EEG symmetry. Substantial differences in microstates' sequence complexity and presence of C topography were found between groups of patients with alpha dominant background, cortical reactivity and antero-posterior gradient. Also, transitioning from left-right to antero-posterior microstates was found to be an independent predictor of consciousness recovery, stronger than consciousness levels at IRU's admission. In conclusions, global brain dynamics measured with scale-free estimators can be considered an indicator of consciousness presence and a candidate marker of short-term recovery in patients with a pDoC.
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Affiliation(s)
- Piergiuseppe Liuzzi
- IRCCS Don Carlo Gnocchi ONLUS, Firenze, Italy; Istituto di BioRobotica, Scuola Superiore Sant'Anna, Pontedera, Italy
| | | | | | | | | | | | | | | | - Francesca Cecchi
- IRCCS Don Carlo Gnocchi ONLUS, Firenze, Italy; Dipartimento di Medicina Sperimentale e Clinica, Università di Firenze, Firenze, Italy
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Liuzzi P, Hakiki B, Draghi F, Romoli AM, Burali R, Scarpino M, Cecchi F, Grippo A, Mannini A. EEG fractal dimensions predict high-level behavioral responses in minimally conscious patients. J Neural Eng 2023; 20:046038. [PMID: 37494926 DOI: 10.1088/1741-2552/aceaac] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Accepted: 07/26/2023] [Indexed: 07/28/2023]
Abstract
Objective.Brain-injured patients may enter a state of minimal or inconsistent awareness termed minimally conscious state (MCS). Such patient may (MCS+) or may not (MCS-) exhibit high-level behavioral responses, and the two groups retain two inherently different rehabilitative paths and expected outcomes. We hypothesized that brain complexity may be treated as a proxy of high-level cognition and thus could be used as a neural correlate of consciousness.Approach.In this prospective observational study, 68 MCS patients (MCS-: 30; women: 31) were included (median [IQR] age 69 [20]; time post-onset 83 [28]). At admission to intensive rehabilitation, 30 min resting-state closed-eyes recordings were performed together with consciousness diagnosis following international guidelines. The width of the multifractal singularity spectrum (MSS) was computed for each channel time series and entered nested cross-validated interpretable machine learning models targeting the differential diagnosis of MCS±.Main results.Frontal MSS widths (p< 0.05), as well as the ones deriving from the left centro-temporal network (C3:p= 0.018, T3:p= 0.017; T5:p= 0.003) were found to be significantly higher in the MCS+ cohort. The best performing solution was found to be the K-nearest neighbor model with an aggregated test accuracy of 75.5% (median [IQR] AuROC for 100 executions 0.88 [0.02]). Coherently, the electrodes with highest Shapley values were found to be Fz and Cz, with four out the first five ranked features belonging to the fronto-central network.Significance.MCS+ is a frequent condition associated with a notably better prognosis than the MCS-. High fractality in the left centro-temporal network results coherent with neurological networks involved in the language function, proper of MCS+ patients. Using EEG-based interpretable algorithm to complement differential diagnosis of consciousness may improve rehabilitation pathways and communications with caregivers.
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Affiliation(s)
- Piergiuseppe Liuzzi
- IRCCS Fondazione Don Carlo Gnocchi ONLUS, Via di Scandicci 269, Firenze, FI, Italy
- The Biorobotics Institute, Scuola Superiore Sant'Anna Istituto di BioRobotica, Viale Rinaldo Piaggio 34, Pontedera, PI, Italy
| | - Bahia Hakiki
- IRCCS Fondazione Don Carlo Gnocchi ONLUS, Via di Scandicci 269, Firenze, FI, Italy
| | - Francesca Draghi
- IRCCS Fondazione Don Carlo Gnocchi ONLUS, Via di Scandicci 269, Firenze, FI, Italy
| | - Anna Maria Romoli
- IRCCS Fondazione Don Carlo Gnocchi ONLUS, Via di Scandicci 269, Firenze, FI, Italy
| | - Rachele Burali
- IRCCS Fondazione Don Carlo Gnocchi ONLUS, Via di Scandicci 269, Firenze, FI, Italy
| | - Maenia Scarpino
- IRCCS Fondazione Don Carlo Gnocchi ONLUS, Via di Scandicci 269, Firenze, FI, Italy
| | - Francesca Cecchi
- IRCCS Fondazione Don Carlo Gnocchi ONLUS, Via di Scandicci 269, Firenze, FI, Italy
- Department of Experimental and Clinical Medicine, University of Florence, Largo Brambilla 3, Florence, 50143 FI, Italy
| | - Antonello Grippo
- IRCCS Fondazione Don Carlo Gnocchi ONLUS, Via di Scandicci 269, Firenze, FI, Italy
| | - Andrea Mannini
- IRCCS Fondazione Don Carlo Gnocchi ONLUS, Via di Scandicci 269, Firenze, FI, Italy
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Gheri CF, Scalfi L, Biffi B, Pancani S, Madiai S, Di Vincenzo O, Ghaderi M, Celoni R, Dalladonna M, Draghi F, Maccanti D, Macchi C, Romoli AM, Cecchi F, Hakiki B, Luisi MLE. Relationship between Nutritional Risk, Clinical and Demographic Characteristics, and Pressure Ulcers in Patients with Severe Acquired Brain Injuries Attending a Rehabilitative Program. Nutrients 2023; 15:3336. [PMID: 37571274 PMCID: PMC10421108 DOI: 10.3390/nu15153336] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2023] [Revised: 07/19/2023] [Accepted: 07/25/2023] [Indexed: 08/13/2023] Open
Abstract
Preliminary evidence in the literature suggests a high prevalence of malnutrition (undernutrition) in patients with severe acquired brain injuries (sABI), with an expected negative impact on clinical outcomes and pressure ulcers (PUs) in particular. In a retrospective cohort study on patients discharged from intensive care units (ICU) and admitted to an intensive rehabilitation unit (IRU), the risk of malnutrition was systematically assessed, in addition to standard clinical procedures (including PUs evaluation), using two different tools: the Malnutrition Universal Screening Tool (MUST) and the Controlling Nutritional Status (CONUT) tool. Eighty-eight patients were included in the analysis. A high proportion (79.5%) of patients with sABI suffered from PUs, being older and more frequently men, with a longer ICU stay between the event and admission to IRU, and a greater MUST score. At discharge, when compared to patients whose PUs had healed, those with persisting PUs were more often men and had the worst cognitive performance at admission. As for nutritional risk, the baseline CONUT score was identified as an independent negative predictor of PUs at discharge by the logistic regression model. In conclusion, the assessment of nutritional risk using simple standard tools may be useful in the clinical evaluation of sABI patients with PUs.
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Affiliation(s)
- Chiara Francesca Gheri
- IRCCS Fondazione Don Carlo Gnocchi ONLUS Firenze, 50143 Florence, Italy (S.P.); (M.G.); (R.C.); (M.D.); (F.D.); (D.M.); (C.M.); (A.M.R.); (F.C.); (B.H.); (M.L.E.L.)
| | - Luca Scalfi
- Human Nutrition and Dietetics, Department of Public Health, Federico II University, 80131 Naples, Italy; (L.S.); (O.D.V.)
- Santa Maria del Pozzo Private Hospital, Somma Vesuviana, 80049 Naples, Italy
| | - Barbara Biffi
- IRCCS Fondazione Don Carlo Gnocchi ONLUS Firenze, 50143 Florence, Italy (S.P.); (M.G.); (R.C.); (M.D.); (F.D.); (D.M.); (C.M.); (A.M.R.); (F.C.); (B.H.); (M.L.E.L.)
| | - Silvia Pancani
- IRCCS Fondazione Don Carlo Gnocchi ONLUS Firenze, 50143 Florence, Italy (S.P.); (M.G.); (R.C.); (M.D.); (F.D.); (D.M.); (C.M.); (A.M.R.); (F.C.); (B.H.); (M.L.E.L.)
| | - Sara Madiai
- IRCCS Fondazione Don Carlo Gnocchi ONLUS Firenze, 50143 Florence, Italy (S.P.); (M.G.); (R.C.); (M.D.); (F.D.); (D.M.); (C.M.); (A.M.R.); (F.C.); (B.H.); (M.L.E.L.)
| | - Olivia Di Vincenzo
- Human Nutrition and Dietetics, Department of Public Health, Federico II University, 80131 Naples, Italy; (L.S.); (O.D.V.)
| | - Michele Ghaderi
- IRCCS Fondazione Don Carlo Gnocchi ONLUS Firenze, 50143 Florence, Italy (S.P.); (M.G.); (R.C.); (M.D.); (F.D.); (D.M.); (C.M.); (A.M.R.); (F.C.); (B.H.); (M.L.E.L.)
| | - Rebecca Celoni
- IRCCS Fondazione Don Carlo Gnocchi ONLUS Firenze, 50143 Florence, Italy (S.P.); (M.G.); (R.C.); (M.D.); (F.D.); (D.M.); (C.M.); (A.M.R.); (F.C.); (B.H.); (M.L.E.L.)
| | - Mara Dalladonna
- IRCCS Fondazione Don Carlo Gnocchi ONLUS Firenze, 50143 Florence, Italy (S.P.); (M.G.); (R.C.); (M.D.); (F.D.); (D.M.); (C.M.); (A.M.R.); (F.C.); (B.H.); (M.L.E.L.)
| | - Francesca Draghi
- IRCCS Fondazione Don Carlo Gnocchi ONLUS Firenze, 50143 Florence, Italy (S.P.); (M.G.); (R.C.); (M.D.); (F.D.); (D.M.); (C.M.); (A.M.R.); (F.C.); (B.H.); (M.L.E.L.)
| | - Daniela Maccanti
- IRCCS Fondazione Don Carlo Gnocchi ONLUS Firenze, 50143 Florence, Italy (S.P.); (M.G.); (R.C.); (M.D.); (F.D.); (D.M.); (C.M.); (A.M.R.); (F.C.); (B.H.); (M.L.E.L.)
| | - Claudio Macchi
- IRCCS Fondazione Don Carlo Gnocchi ONLUS Firenze, 50143 Florence, Italy (S.P.); (M.G.); (R.C.); (M.D.); (F.D.); (D.M.); (C.M.); (A.M.R.); (F.C.); (B.H.); (M.L.E.L.)
- Department of Experimental and Clinical Medicine, University of Florence, Largo Brambilla, 50134 Florence, Italy
| | - Anna Maria Romoli
- IRCCS Fondazione Don Carlo Gnocchi ONLUS Firenze, 50143 Florence, Italy (S.P.); (M.G.); (R.C.); (M.D.); (F.D.); (D.M.); (C.M.); (A.M.R.); (F.C.); (B.H.); (M.L.E.L.)
| | - Francesca Cecchi
- IRCCS Fondazione Don Carlo Gnocchi ONLUS Firenze, 50143 Florence, Italy (S.P.); (M.G.); (R.C.); (M.D.); (F.D.); (D.M.); (C.M.); (A.M.R.); (F.C.); (B.H.); (M.L.E.L.)
- Department of Experimental and Clinical Medicine, University of Florence, Largo Brambilla, 50134 Florence, Italy
| | - Bahia Hakiki
- IRCCS Fondazione Don Carlo Gnocchi ONLUS Firenze, 50143 Florence, Italy (S.P.); (M.G.); (R.C.); (M.D.); (F.D.); (D.M.); (C.M.); (A.M.R.); (F.C.); (B.H.); (M.L.E.L.)
| | - Maria Luisa Eliana Luisi
- IRCCS Fondazione Don Carlo Gnocchi ONLUS Firenze, 50143 Florence, Italy (S.P.); (M.G.); (R.C.); (M.D.); (F.D.); (D.M.); (C.M.); (A.M.R.); (F.C.); (B.H.); (M.L.E.L.)
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Liuzzi P, Hakiki B, Scarpino M, Burali R, Maiorelli A, Draghi F, Romoli AM, Grippo A, Cecchi F, Mannini A. Neural coding of autonomic functions in different states of consciousness. J Neuroeng Rehabil 2023; 20:96. [PMID: 37491259 PMCID: PMC10369699 DOI: 10.1186/s12984-023-01216-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2023] [Accepted: 07/10/2023] [Indexed: 07/27/2023] Open
Abstract
Detecting signs of residual neural activity in patients with altered states of consciousness is a crucial issue for the customization of neurorehabilitation treatments and clinical decision-making. With this large observational prospective study, we propose an innovative approach to detect residual signs of consciousness via the assessment of the amount of autonomic information coded within the brain. The latter was estimated by computing the mutual information (MI) between preprocessed EEG and ECG signals, to be then compared across consciousness groups, together with the absolute power and an international qualitative labeling. One-hundred seventy-four patients (73 females, 42%) were included in the study (median age of 65 years [IQR = 20], MCS +: 29, MCS -: 23, UWS: 29). Electroencephalography (EEG) information content was found to be mostly related to the coding of electrocardiography (ECG) activity, i.e., with higher MI (p < 0.05), in Unresponsive Wakefulness Syndrome and Minimally Consciousness State minus (MCS -). EEG-ECG MI, besides clearly discriminating patients in an MCS - and +, significantly differed between lesioned areas (sides) in a subgroup of unilateral hemorrhagic patients. Crucially, such an accessible and non-invasive measure of residual consciousness signs was robust across electrodes and patient groups. Consequently, exiting from a strictly neuro-centric consciousness detection approach may be the key to provide complementary insights for the objective assessment of patients' consciousness levels and for the patient-specific planning of rehabilitative interventions.
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Affiliation(s)
- Piergiuseppe Liuzzi
- Sant’Anna School of Advanced Studies, The BioRobotics Institute, Viale Rinaldo Piaggio 69, 56025 Pontedera, PI Italy
- IRCSS Fondazione Don Carlo Gnocchi ONLUS, Via di Scandicci 269, FI 50143 Florence, Italy
| | - Bahia Hakiki
- IRCSS Fondazione Don Carlo Gnocchi ONLUS, Via di Scandicci 269, FI 50143 Florence, Italy
| | - Maenia Scarpino
- IRCSS Fondazione Don Carlo Gnocchi ONLUS, Via di Scandicci 269, FI 50143 Florence, Italy
| | - Rachele Burali
- IRCSS Fondazione Don Carlo Gnocchi ONLUS, Via di Scandicci 269, FI 50143 Florence, Italy
| | - Antonio Maiorelli
- IRCSS Fondazione Don Carlo Gnocchi ONLUS, Via di Scandicci 269, FI 50143 Florence, Italy
| | - Francesca Draghi
- IRCSS Fondazione Don Carlo Gnocchi ONLUS, Via di Scandicci 269, FI 50143 Florence, Italy
| | - Anna Maria Romoli
- IRCSS Fondazione Don Carlo Gnocchi ONLUS, Via di Scandicci 269, FI 50143 Florence, Italy
| | - Antonello Grippo
- IRCSS Fondazione Don Carlo Gnocchi ONLUS, Via di Scandicci 269, FI 50143 Florence, Italy
| | - Francesca Cecchi
- IRCSS Fondazione Don Carlo Gnocchi ONLUS, Via di Scandicci 269, FI 50143 Florence, Italy
- Department of Experimental and Clinical Medicine, University of Florence, Largo Brambilla 3, 50143 Florence, FI Italy
| | - Andrea Mannini
- IRCSS Fondazione Don Carlo Gnocchi ONLUS, Via di Scandicci 269, FI 50143 Florence, Italy
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Liuzzi P, Campagnini S, Hakiki B, Burali R, Scarpino M, Macchi C, Cecchi F, Mannini A, Grippo A. Heart rate variability for the evaluation of patients with disorders of consciousness. Clin Neurophysiol 2023; 150:31-39. [PMID: 37002978 DOI: 10.1016/j.clinph.2023.03.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2022] [Revised: 12/12/2022] [Accepted: 03/03/2023] [Indexed: 04/03/2023]
Abstract
OBJECTIVE Clinical responsiveness of patients with a Disorder of Consciousness (DoC) correlates to sympathetic/parasympathetic homeostatic balance. Heart Rate Variability (HRV) metrics result in non-invasive proxies of modulation capabilities of visceral states. In this work, our aim was to evaluate whether HRV measures could improve the differential diagnosis between Unresponsive Wakefulness Syndrome (UWS) and Minimally Conscious State (MCS) with respect to multivariate models based on standard clinical electroencephalography (EEG) labeling only in a rehabilitation setting. METHODS A prospective observational study was performed consecutively enrolling 82 DoC patients. Polygraphic recordings were performed. HRV-metrics and EEG descriptors derived from the American Clinical Neurophysiology Society's Standardized Critical Care terminology were included. Descriptors entered univariate and then multivariate logistic regressions with the target set to the UWS/MCS diagnosis. RESULTS HRV measures resulted significantly different between UWS and MCS patients, with higher values being associated with better consciousness levels. Specifically, adding HRV-related metrics to ACNS EEG descriptors increased the Nagelkerke R2 from 0.350 (only EEG descriptors) to 0.565 (HRV-EEG combination) with the outcome set to the consciousness diagnosis. CONCLUSIONS HRV changes across the lowest states of consciousness. Rapid changes in heart rate, occurring in better consciousness levels, confirm the mutual correlation between visceral state functioning patterns and consciousness alterations. SIGNIFICANCE Quantitative analysis of heart rate in patients with a DoC paves the way for the implementation of low-cost pipelines supporting medical decisions within multimodal consciousness assessments.
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Affiliation(s)
- Piergiuseppe Liuzzi
- IRCCS Fondazione Don Carlo Gnocchi, Firenze, Via di Scandicci 269, Italy; Scuola Superiore Sant'Anna, Istituto di BioRobotica, Pontedera, Viale Rinaldo Piaggio 34, Italy
| | - Silvia Campagnini
- IRCCS Fondazione Don Carlo Gnocchi, Firenze, Via di Scandicci 269, Italy; Scuola Superiore Sant'Anna, Istituto di BioRobotica, Pontedera, Viale Rinaldo Piaggio 34, Italy
| | - Bahia Hakiki
- IRCCS Fondazione Don Carlo Gnocchi, Firenze, Via di Scandicci 269, Italy.
| | - Rachele Burali
- IRCCS Fondazione Don Carlo Gnocchi, Firenze, Via di Scandicci 269, Italy
| | - Maenia Scarpino
- IRCCS Fondazione Don Carlo Gnocchi, Firenze, Via di Scandicci 269, Italy
| | - Claudio Macchi
- IRCCS Fondazione Don Carlo Gnocchi, Firenze, Via di Scandicci 269, Italy; Università di Firenze, Dipartimento di Medicina Sperimentale e Clinica, Firenze, Largo Brambilla 3, Italy
| | - Francesca Cecchi
- IRCCS Fondazione Don Carlo Gnocchi, Firenze, Via di Scandicci 269, Italy; Università di Firenze, Dipartimento di Medicina Sperimentale e Clinica, Firenze, Largo Brambilla 3, Italy
| | - Andrea Mannini
- IRCCS Fondazione Don Carlo Gnocchi, Firenze, Via di Scandicci 269, Italy
| | - Antonello Grippo
- IRCCS Fondazione Don Carlo Gnocchi, Firenze, Via di Scandicci 269, Italy
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Liuzzi P, Grippo A, Draghi F, Hakiki B, Macchi C, Cecchi F, Mannini A. Can Respiration Complexity Help the Diagnosis of Disorders of Consciousness in Rehabilitation? Diagnostics (Basel) 2023; 13:diagnostics13030507. [PMID: 36766612 PMCID: PMC9914359 DOI: 10.3390/diagnostics13030507] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Revised: 01/23/2023] [Accepted: 01/27/2023] [Indexed: 01/31/2023] Open
Abstract
BACKGROUND Autonomic Nervous System (ANS) activity, as cardiac, respiratory and electrodermal activity, has been shown to provide specific information on different consciousness states. Respiration rates (RRs) are considered indicators of ANS activity and breathing patterns are currently already included in the evaluation of patients in critical care. OBJECTIVE The aim of this work was to derive a proxy of autonomic functions via the RR variability and compare its diagnostic capability with known neurophysiological biomarkers of consciousness. METHODS In a cohort of sub-acute patients with brain injury during post-acute rehabilitation, polygraphy (ECG, EEG) recordings were collected. The EEG was labeled via descriptors based on American Clinical Neurophysiology Society terminology and the respiration variability was extracted by computing the Approximate Entropy (ApEN) of the ECG-derived respiration signal. Competing logistic regressions were applied to evaluate the improvement in model performances introduced by the RR ApEN. RESULTS Higher RR complexity was significantly associated with higher consciousness levels and improved diagnostic models' performances in contrast to the ones built with only electroencephalographic descriptors. CONCLUSIONS Adding a quantitative, instrumentally based complexity measure of RR variability to multimodal consciousness assessment protocols may improve diagnostic accuracy based only on electroencephalographic descriptors. Overall, this study promotes the integration of biomarkers derived from the central and the autonomous nervous system for the most comprehensive diagnosis of consciousness in a rehabilitation setting.
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Affiliation(s)
- Piergiuseppe Liuzzi
- IRCCS Fondazione Don Carlo Gnocchi ONLUS, Via di Scandicci 269, 50143 Firenze, Italy
- Istituto di BioRobotica, Scuola Superiore Sant’Anna, Viale Rinaldo Piaggio 34, 56025 Pontedera, Italy
| | - Antonello Grippo
- IRCCS Fondazione Don Carlo Gnocchi ONLUS, Via di Scandicci 269, 50143 Firenze, Italy
| | - Francesca Draghi
- IRCCS Fondazione Don Carlo Gnocchi ONLUS, Via di Scandicci 269, 50143 Firenze, Italy
| | - Bahia Hakiki
- IRCCS Fondazione Don Carlo Gnocchi ONLUS, Via di Scandicci 269, 50143 Firenze, Italy
- Correspondence: ; Tel.: +39-333-401-8388
| | - Claudio Macchi
- IRCCS Fondazione Don Carlo Gnocchi ONLUS, Via di Scandicci 269, 50143 Firenze, Italy
- Dipartimento di Medicina Sperimentale e Clinica, Universita di Firenze, Largo Brambilla 3, 50134 Firenze, Italy
| | - Francesca Cecchi
- IRCCS Fondazione Don Carlo Gnocchi ONLUS, Via di Scandicci 269, 50143 Firenze, Italy
- Istituto di BioRobotica, Scuola Superiore Sant’Anna, Viale Rinaldo Piaggio 34, 56025 Pontedera, Italy
- Dipartimento di Medicina Sperimentale e Clinica, Universita di Firenze, Largo Brambilla 3, 50134 Firenze, Italy
| | - Andrea Mannini
- IRCCS Fondazione Don Carlo Gnocchi ONLUS, Via di Scandicci 269, 50143 Firenze, Italy
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The Impact of Cerebral Amyloid Angiopathy on Functional Outcome of Patients Affected by Spontaneous Intracerebral Hemorrhage Discharged from Intensive Inpatient Rehabilitation: A Cohort Study. Diagnostics (Basel) 2022; 12:diagnostics12102458. [PMID: 36292146 PMCID: PMC9600668 DOI: 10.3390/diagnostics12102458] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2022] [Revised: 09/19/2022] [Accepted: 09/29/2022] [Indexed: 11/19/2022] Open
Abstract
Background: Sporadic CAA is recognized as a major cause of sICH and sABI. Even if intensive rehabilitation is recommended to maximize functional recovery after sICH, no data are available on whether CAA may affect rehabilitation outcomes. In this observational prospective study, to explore the impact of CAA on rehabilitation results, functional outcomes after intensive rehabilitation have been compared between patients affected by sICH with and without a diagnosis of CAA. Methods: All adults affected by sABI due to sICH and admitted to the IRU of IRCCS-Don-Gnocchi-Foundation were consecutively enrolled for 12 months. Demographic and clinical data were recorded upon admission and discharge. Results: Among 102 sICH patients (age: 66 (IQR = 16), 53% female), 13% were diagnosed as probable/possible-CAA. TPO and functional assessment were comparable upon admission, but CAA patients were significantly older (p = 0.001). After a comparable LOS, CAA patients presented higher care burden (ERBI: p = 0.025), poorer functional recovery (FIM: p = 0.02) and lower levels of global independence (GOSE > 4: p = 0.03). In multivariate analysis, CAA was significantly correlated with a lower FIM (p = 0.019) and a lower likelihood of reaching GOS-E > 4, (p = 0.041) at discharge, independently from age. Conclusions: CAA seems to be independently associated with poorer rehabilitation outcomes, suggesting the importance of improving knowledge about CAA to better predict rehabilitation outcomes.
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