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Bagetta G, Bano D, Scuteri D. Basic, Translational, and Clinical Research on Dementia. Int J Mol Sci 2024; 25:6861. [PMID: 38999974 PMCID: PMC11241002 DOI: 10.3390/ijms25136861] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2024] [Accepted: 06/20/2024] [Indexed: 07/14/2024] Open
Abstract
The global impact of dementia is an increasing area of concern and, according to the Alzheimer's Disease International (ADI) World Alzheimer Report 2021, up to 90% of dementia patients in low- and middle-income countries are not diagnosed [...].
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Affiliation(s)
- Giacinto Bagetta
- Department of Pharmacy, Health Science and Nutrition, University of Calabria, 87036 Rende, Italy
| | - Daniele Bano
- German Center for Neurodegenerative Diseases (DZNE), 53127 Bonn, Germany
| | - Damiana Scuteri
- Department of Health Sciences, University "Magna Graecia" of Catanzaro, 88100 Catanzaro, Italy
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2
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Riganello F, Tonin P, Soddu A. I Feel! Therefore, I Am from Pain to Consciousness in DOC Patients. Int J Mol Sci 2023; 24:11825. [PMID: 37511583 PMCID: PMC10380260 DOI: 10.3390/ijms241411825] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2023] [Revised: 07/13/2023] [Accepted: 07/20/2023] [Indexed: 07/30/2023] Open
Abstract
Pain assessment and management in patients with disorders of consciousness (DOC) is a challenging and important aspect of care, with implications for detecting consciousness and promoting recovery. This narrative review explores the role of pain in consciousness, the challenges of pain assessment, pharmacological treatment in DOC, and the implications of pain assessment when detecting changes in consciousness. The review discusses the Nociception Coma Scale and its revised version, which are behavioral scales used to assess pain in DOC patients, and the challenges and controversies surrounding the appropriate pharmacological treatment of pain in these patients. Moreover, we highlight recent evidence suggesting that an accurate pain assessment may predict changes in the level of consciousness in unresponsive wakefulness syndrome/vegetative state patients, underscoring the importance of ongoing pain management in these patients.
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Affiliation(s)
- Francesco Riganello
- Research in Advanced Neurorehabilitation, S. Anna Institute, 88900 Crotone, Italy
| | - Paolo Tonin
- Research in Advanced Neurorehabilitation, S. Anna Institute, 88900 Crotone, Italy
| | - Andrea Soddu
- Physics, and Astronomy Department, Western Institute for Neuroscience, University of Western Ontario, London, ON N6A 3K7, Canada
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3
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Milano BA, Moutoussis M, Convertino L. The neurobiology of functional neurological disorders characterised by impaired awareness. Front Psychiatry 2023; 14:1122865. [PMID: 37009094 PMCID: PMC10060839 DOI: 10.3389/fpsyt.2023.1122865] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2022] [Accepted: 02/24/2023] [Indexed: 03/18/2023] Open
Abstract
We review the neurobiology of Functional Neurological Disorders (FND), i.e., neurological disorders not explained by currently identifiable histopathological processes, in order to focus on those characterised by impaired awareness (functionally impaired awareness disorders, FIAD), and especially, on the paradigmatic case of Resignation Syndrome (RS). We thus provide an improved more integrated theory of FIAD, able to guide both research priorities and the diagnostic formulation of FIAD. We systematically address the diverse spectrum of clinical presentations of FND with impaired awareness, and offer a new framework for understanding FIAD. We find that unraveling the historical development of neurobiological theory of FIAD is of paramount importance for its current understanding. Then, we integrate contemporary clinical material in order to contextualise the neurobiology of FIAD within social, cultural, and psychological perspectives. We thus review neuro-computational insights in FND in general, to arrive at a more coherent account of FIAD. FIAD may be based on maladaptive predictive coding, shaped by stress, attention, uncertainty, and, ultimately, neurally encoded beliefs and their updates. We also critically appraise arguments in support of and against such Bayesian models. Finally, we discuss implications of our theoretical account and provide pointers towards an improved clinical diagnostic formulation of FIAD. We suggest directions for future research towards a more unified theory on which future interventions and management strategies could be based, as effective treatments and clinical trial evidence remain limited.
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Affiliation(s)
- Beatrice Annunziata Milano
- Institute of Life Sciences, Sant'Anna School of Advanced Studies, Pisa, Italy
- Faculty of Medicine and Surgery, University of Pisa, Pisa, Italy
| | - Michael Moutoussis
- Wellcome Centre for Human Neuroimaging, University College London, London, United Kingdom
- Max Planck UCL Centre for Computational Psychiatry and Ageing Research, University College London, London, United Kingdom
- National Hospital of Neurology and Neurosurgery (UCLH), London, United Kingdom
| | - Laura Convertino
- Wellcome Centre for Human Neuroimaging, University College London, London, United Kingdom
- National Hospital of Neurology and Neurosurgery (UCLH), London, United Kingdom
- Institute of Cognitive Neuroscience, University College London, London, United Kingdom
- *Correspondence: Laura Convertino,
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4
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Lavezzi S, Bargellesi S, Cassio A, DE Tanti A, Gatta G, Hakiki B, Lombardi F, Montis A, Posteraro F, Scarponi F, Taricco M, Boldrini P, Cecchi F. Redefining a minimal rehabilitation assessment protocol for severe acquired brain injuries. Eur J Phys Rehabil Med 2022; 58:584-591. [PMID: 35666492 PMCID: PMC9980564 DOI: 10.23736/s1973-9087.22.07451-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND The assessment of patients with severe Acquired Brain Injury (sABI) is mandatory in every phase and setting of care, and requires a multidimensional and interdisciplinary approach, to develop the individual rehabilitation project, and monitor long-term functional outcomes. In 2001 the Italian Society of Physical and Rehabilitation Medicine (SIMFER) published the minimal assessment protocol for traumatic sABI, providing a comprehensive, standardized functional assessment based on the International Classification of Functioning, Disability and Health (ICF), 2001. In 2007, a new protocol was published, extended to all sABI patients (PMGCA). In 2019, the SIMFER appointed a working group to provide a revised, updated version: the PMGCA2020. AIM The purpose of this study was to describe the minimal assessment protocol to be applied at every stage and setting of the care process of patients with sABI. METHODS The working group, including one neurologist and 11 physiatrists experts in sABI rehabilitation, performed a review of the international recommendations for sABI assessment focusing on the following key words: "sABI assessment," "sABI rehabilitation," "sABI prognostic factors," "sABI rehabilitation assessment," "sABI outcome," in MEDLINE. Revision and integration proposals by each member were written and motivated, discussed and voted. RESULTS The PMGCA2020 is addressed to sABI adult patients. It investigates the main clinical problems of sABI at any time of the rehabilitation pathway. It includes a demographic/anamnestic section, a clinical/functional assessment section and an outcome measures section following the ICF model of functioning and the model of the construction of the rehabilitation project. CONCLUSIONS The PMGCA2020 provides an updated tool for the multidimensional rehabilitation assessment of sABI patients, at any stage of the rehabilitation pathway. Further studies will allow the validation of this minimum set of variables paving the way to an assessment standardization of patients with sABI in the rehabilitation settings. CLINICAL REHABILITATION IMPACT This minimum set of variables, defining patient's functioning and clinical status and outcomes, at every stage and setting of the care process to provide a framework for the standardization of the clinical evaluation of patients with sABI in rehabilitation settings.
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Affiliation(s)
- Susanna Lavezzi
- Severe Brain Injury Rehabilitation Unit, Department of Neuroscience and Rehabilitation, S. Anna University Hospital, Ferrara, Italy
| | | | - Anna Cassio
- Physical and Rehabilitation Medicine, AUSL Piacenza, Piacenza, Italy
| | | | - Giordano Gatta
- Italian Society of Physical and Rehabilitation Medicine (SIMFER), Ravenna, Italy
| | - Bahia Hakiki
- IRCCS Don Carlo Gnocchi Foundation, Florence, Italy -
| | - Francesco Lombardi
- Department of Intensive Neurorehabilitation, Correggio Hospital, ASL Reggio Emilia, Reggio Emilia, Italy
| | - Andrea Montis
- Rehabilitation Medicine Unit, Ospedale Civile di Baggiovara, Modena University Hospital, Modena, Italy
| | - Federico Posteraro
- Department of Rehabilitation, Versilia Hospital, AUSL Toscana Nord Ovest, Camaiore, Lucca, Italy
| | - Federico Scarponi
- Department of Rehabilitation, San Giovanni Battista Hospital, ASL 3, Foligno, Perugia, Italy
| | - Mariangela Taricco
- Italian Society of Physical and Rehabilitation Medicine (SIMFER), Bologna, Italy
| | - Paolo Boldrini
- Italian Society of Physical and Rehabilitation Medicine (SIMFER), Rome, Italy.,European Society of Physical and Rehabilitation Medicine (ESPRM), Rotterdam, the Netherlands
| | - Francesca Cecchi
- IRCCS Don Carlo Gnocchi Foundation, Florence, Italy.,Department of Clinical and Experimental Medicine, University of Florence, Florence, Italy
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5
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Pain Perception in Disorder of Consciousness: A Scoping Review on Current Knowledge, Clinical Applications, and Future Perspective. Brain Sci 2021; 11:brainsci11050665. [PMID: 34065349 PMCID: PMC8161058 DOI: 10.3390/brainsci11050665] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2021] [Revised: 05/05/2021] [Accepted: 05/19/2021] [Indexed: 01/18/2023] Open
Abstract
Pain perception in individuals with prolonged disorders of consciousness (PDOC) is still a matter of debate. Advanced neuroimaging studies suggest some cortical activations even in patients with unresponsive wakefulness syndrome (UWS) compared to those with a minimally conscious state (MCS). Therefore, pain perception has to be considered even in individuals with UWS. However, advanced neuroimaging assessment can be challenging to conduct, and its findings are sometimes difficult to be interpreted. Conversely, multichannel electroencephalography (EEG) and laser-evoked potentials (LEPs) can be carried out quickly and are more adaptable to the clinical needs. In this scoping review, we dealt with the neurophysiological basis underpinning pain in PDOC, pointing out how pain perception assessment in these individuals might help in reducing the misdiagnosis rate. The available literature data suggest that patients with UWS show a more severe functional connectivity breakdown among the pain-related brain areas compared to individuals in MCS, pointing out that pain perception increases with the level of consciousness. However, there are noteworthy exceptions, because some UWS patients show pain-related cortical activations that partially overlap those observed in MCS individuals. This suggests that some patients with UWS may have residual brain functional connectivity supporting the somatosensory, affective, and cognitive aspects of pain processing (i.e., a conscious experience of the unpleasantness of pain), rather than only being able to show autonomic responses to potentially harmful stimuli. Therefore, the significance of the neurophysiological approach to pain perception in PDOC seems to be clear, and despite some methodological caveats (including intensity of stimulation, multimodal paradigms, and active vs. passive stimulation protocols), remain to be solved. To summarize, an accurate clinical and neurophysiological assessment should always be performed for a better understanding of pain perception neurophysiological underpinnings, a more precise differential diagnosis at the level of individual cases as well as group comparisons, and patient-tailored management.
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6
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Abstract
PURPOSE OF REVIEW The purpose of this review is to describe ethical and legal issues that arise in the management of patients with disorders of consciousness ranging from the minimally conscious state to the coma state, as well as brain death. RECENT FINDINGS The recent literature highlights dilemmas created by diagnostic and prognostic uncertainties in patients with disorders of consciousness. The discussion also reveals the challenges experienced by the disability community, which includes individuals with severe brain injury who are classified as having a disorder of consciousness. We review current guidelines for management of patients with disorders of consciousness including discussions around diagnosis, prognosis, consideration of neuropalliation, and decisions around life sustaining medical treatment. SUMMARY In the setting of uncertainty, this review describes the utility of applying a disability rights perspective and shared decision-making process to approach medical decision-making for patients with disorders of consciousness. We outline approaches to identifying surrogate decision makers, standards for decision-making and decision-making processes, specifically addressing the concept of futility as a less useful framework for making decisions. We also highlight special considerations for research, innovative and controversial care, brain death, organ donation, and child abuse and neglect.
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Affiliation(s)
- Lauren Rissman
- Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, IL
- Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Erin Talati Paquette
- Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, IL
- Northwestern University Feinberg School of Medicine, Chicago, IL
- Northwestern University Pritzker School of Law (by courtesy), Chicago, IL
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7
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Zilio F, Gomez-Pilar J, Cao S, Zhang J, Zang D, Qi Z, Tan J, Hiromi T, Wu X, Fogel S, Huang Z, Hohmann MR, Fomina T, Synofzik M, Grosse-Wentrup M, Owen AM, Northoff G. Are intrinsic neural timescales related to sensory processing? Evidence from abnormal behavioral states. Neuroimage 2020; 226:117579. [PMID: 33221441 DOI: 10.1016/j.neuroimage.2020.117579] [Citation(s) in RCA: 50] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Revised: 10/15/2020] [Accepted: 11/12/2020] [Indexed: 12/11/2022] Open
Abstract
The brain exhibits a complex temporal structure which translates into a hierarchy of distinct neural timescales. An open question is how these intrinsic timescales are related to sensory or motor information processing and whether these dynamics have common patterns in different behavioral states. We address these questions by investigating the brain's intrinsic timescales in healthy controls, motor (amyotrophic lateral sclerosis, locked-in syndrome), sensory (anesthesia, unresponsive wakefulness syndrome), and progressive reduction of sensory processing (from awake states over N1, N2, N3). We employed a combination of measures from EEG resting-state data: auto-correlation window (ACW), power spectral density (PSD), and power-law exponent (PLE). Prolonged neural timescales accompanied by a shift towards slower frequencies were observed in the conditions with sensory deficits, but not in conditions with motor deficits. Our results establish that the spontaneous activity's intrinsic neural timescale is related to the neural capacity that specifically supports sensory rather than motor information processing in the healthy brain.
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Affiliation(s)
- Federico Zilio
- Department of Philosophy, Sociology, Education and Applied Psychology, University of Padova, Padua, Italy.
| | - Javier Gomez-Pilar
- Biomedical Engineering Group, University of Valladolid, Valladolid, Spain; Centro de Investigación Biomédica en Red en Bioingeniería, Biomateriales y Nanomedicina (CIBER-BBN), Valladolid, Spain
| | - Shumei Cao
- Department of Anesthesiology, Huashan Hospital, Fudan University, Shanghai, China
| | - Jun Zhang
- Department of Anesthesiology, Huashan Hospital, Fudan University, Shanghai, China
| | - Di Zang
- Department of Neurosurgery, Huashan Hospital, Fudan University, Shanghai, China
| | - Zengxin Qi
- Department of Neurosurgery, Huashan Hospital, Fudan University, Shanghai, China
| | - Jiaxing Tan
- Department of Neurosurgery, Huashan Hospital, Fudan University, Shanghai, China
| | - Tanigawa Hiromi
- Department of Neurosurgery, Huashan Hospital, Fudan University, Shanghai, China
| | - Xuehai Wu
- Department of Neurosurgery, Huashan Hospital, Fudan University, Shanghai, China
| | - Stuart Fogel
- The Brain and Mind Institute, Department of Physiology and Pharmacology and the Department of Psychology, University of Western Ontario, Canada
| | - Zirui Huang
- Center for Consciousness Science, Department of Anesthesiology, University of Michigan Medical School, Ann Arbor, MI, United States
| | - Matthias R Hohmann
- Department for Empirical Inference, Max Planck Institute for Intelligent Systems, Tübingen, Germany
| | - Tatiana Fomina
- Department for Empirical Inference, Max Planck Institute for Intelligent Systems, Tübingen, Germany
| | - Matthis Synofzik
- Department of Neurology, Hertie Institute for Clinical Brain Research, Tübingen, Germany
| | - Moritz Grosse-Wentrup
- Research Group Neuroinformatics, Faculty of Computer Science, University of Vienna, Austria
| | - Adrian M Owen
- The Brain and Mind Institute, Department of Physiology and Pharmacology and the Department of Psychology, University of Western Ontario, Canada
| | - Georg Northoff
- Institute of Mental Health Research, University of Ottawa, Ottawa, Canada
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8
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Governo R, Eden-Green B, Dawes T, Mavridou I, Giles J, Rosten C, Rennie-Taylor J, Nduka C. Evaluation of facial electromyographic pain responses in healthy participants. Pain Manag 2020; 10:399-410. [PMID: 33073690 DOI: 10.2217/pmt-2020-0005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
Aim: Assessing pain perception through self-reports may not be possible in some patients, for example, sedated. Our group considered if facial electromyography (fEMG) could provide a useful alternative, by testing on healthy participants subjected to experimental pain. Materials & methods: Activity of four facial muscles was recorded using fEMG alongside self-reported pain scores and physiological parameters. Results: The pain stimulus elicited significant activity on all facial muscles of interest as well as increases in heart rate. Activity from two of the facial muscles correlated significantly against pain intensity. Conclusion: Pain perception can be assessed through fEMG on healthy participants. We believe that this model would be valuable to clinicians that need to diagnose pain perception in circumstances where verbal reporting is not possible.
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Affiliation(s)
- Ricardo Governo
- Brighton & Sussex Medical School, University of Sussex, Brighton, BN1 9PX, UK
| | - Ben Eden-Green
- Department of Anaesthesia, Queen Victoria Hospital NHS Foundation Trust, East Grinstead, RH19 3DZ, UK
| | - Thomas Dawes
- Department of Anaesthesia, Queen Victoria Hospital NHS Foundation Trust, East Grinstead, RH19 3DZ, UK
| | | | - Julian Giles
- Department of Anaesthesia, Queen Victoria Hospital NHS Foundation Trust, East Grinstead, RH19 3DZ, UK
| | - Claire Rosten
- School of Health Sciences, University of Brighton, Brighton, BN1 9PH, UK
| | - Joe Rennie-Taylor
- School of Applied Social Science, University of Brighton, Brighton, BN1 9PH, UK
| | - Charles Nduka
- Department of Plastic Surgery & Burns, Queen Victoria Hospital NHS Foundation Trust, East Grinstead, RH19 3DZ, UK
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9
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Nardone R, Sebastianelli L, Brigo F, Golaszewski S, Trinka E, Pucks-Faes E, Saltuari L, Versace V. Effects of intrathecal baclofen therapy in subjects with disorders of consciousness: a reappraisal. J Neural Transm (Vienna) 2020; 127:1209-1215. [PMID: 32710152 DOI: 10.1007/s00702-020-02233-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2020] [Accepted: 07/14/2020] [Indexed: 01/16/2023]
Abstract
Baclofen is a structural analogue of gamma-amino-butyric acid (GABA), which reduces spastic hypertonia of striated muscle due to a mechanism of GABAB-ergic inhibition of mono- and polysynaptic reflexes at the spinal level. There are reports of patients with severe disorders of consciousness that presented a substantial improvement following intrathecal baclofen (ITB) administration for severe spasticity. The neural mechanisms underlying the clinical recovery after ITB have not yet been clarified. Baclofen could modulate sleep-wake cycles that may be dysregulated and thus interfere with alertness and awareness. The diminished proprioceptive and nociceptive sensory inputs may relieve thalamo-cortical neural networks involved in maintaining the consciousness of the self and the world. ITB treatment might also promote the recovery of an impaired GABAergic cortical tone, restoring the balance between excitatory and inhibitory cortical activity. Furthermore, glutamatergic synapses are directly or indirectly modulated by GABAB-ergic receptors. Neurophysiological techniques (such as transcranial magnetic stimulation, electroencephalography, or the combination of both) can be helpful to explore the effects of intrathecal or oral baclofen on the modulation of neural cortical circuits in humans with disorders of consciousness.
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Affiliation(s)
- Raffaele Nardone
- Department of Neurology, Hospital of Merano (SABES-ASDAA), Merano-Meran, Italy. .,Department of Neurology, Christian Doppler Klinik, Paracelsus Medical University, Salzburg, Austria. .,Spinal Cord Injury and Tissue Regeneration Center, Salzburg, Austria. .,Karl Landsteiner Institut für Neurorehabilitation und Raumfahrtneurologie, Salzburg, Austria.
| | - Luca Sebastianelli
- Department of Neurorehabilitation, Hospital of Vipiteno, Vipiteno, Italy.,Research Unit for Neurorehabilitation South Tyrol, Bolzano, Italy
| | - Francesco Brigo
- Department of Neurology, Hospital of Merano (SABES-ASDAA), Merano-Meran, Italy.,Department of Neuroscience, Biomedicine and Movement Science, University of Verona, Verona, Italy
| | - Stefan Golaszewski
- Department of Neurology, Christian Doppler Klinik, Paracelsus Medical University, Salzburg, Austria.,Karl Landsteiner Institut für Neurorehabilitation und Raumfahrtneurologie, Salzburg, Austria
| | - Eugen Trinka
- Department of Neurology, Christian Doppler Klinik, Paracelsus Medical University, Salzburg, Austria.,Centre for Cognitive Neurosciences Salzburg, Salzburg, Austria.,University for Medical Informatics and Health Technology, UMIT, Hall in Tirol, Austria
| | | | - Leopold Saltuari
- Department of Neurorehabilitation, Hospital of Vipiteno, Vipiteno, Italy.,Research Unit for Neurorehabilitation South Tyrol, Bolzano, Italy
| | - Viviana Versace
- Department of Neurology, Hospital of Merano (SABES-ASDAA), Merano-Meran, Italy.,Research Unit for Neurorehabilitation South Tyrol, Bolzano, Italy
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10
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Rudas J, Martínez D, Castellanos G, Demertzi A, Martial C, Carriére M, Aubinet C, Soddu A, Laureys S, Gómez F. Time-Delay Latency of Resting-State Blood Oxygen Level-Dependent Signal Related to the Level of Consciousness in Patients with Severe Consciousness Impairment. Brain Connect 2020; 10:83-94. [DOI: 10.1089/brain.2019.0716] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Affiliation(s)
- Jorge Rudas
- Institute of Biotechnology, Universidad Nacional de Colombia, Bogotá, Colombia
| | - Darwin Martínez
- Department of Computer Science, Universidad Nacional de Colombia, Bogotá, Colombia
- Department of Computer Science, Universidad Central de Colombia, Bogotá, Colombia
| | - Gabriel Castellanos
- Department of Physiological Sciences, Facultad de Medicina, Pontificia Universidad Javeriana, Bogotá, Colombia
| | - Athena Demertzi
- Physiology of Cognition Research Lab, GIGA-Consciousness, GIGA Institute, University of Liege, Liège, Belgium
| | - Charlotte Martial
- Coma Science Group, GIGA Consciousness, University of Liège, Liège, Belgium
| | - Manon Carriére
- Coma Science Group, GIGA Consciousness, University of Liège, Liège, Belgium
| | - Charlène Aubinet
- Coma Science Group, GIGA Consciousness, University of Liège, Liège, Belgium
| | - Andrea Soddu
- Department of Physics and Astronomy, University of Western Ontario, London, Ontario
| | - Steven Laureys
- Coma Science Group, GIGA Consciousness, University of Liège, Liège, Belgium
| | - Francisco Gómez
- Department of Mathematics, Universidad Nacional de Colombia, Bogotá, Colombia
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11
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Billeri L, Filoni S, Russo EF, Portaro S, Militi D, Calabrò RS, Naro A. Toward Improving Diagnostic Strategies in Chronic Disorders of Consciousness: An Overview on the (Re-)Emergent Role of Neurophysiology. Brain Sci 2020; 10:brainsci10010042. [PMID: 31936844 PMCID: PMC7016627 DOI: 10.3390/brainsci10010042] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2019] [Revised: 01/03/2020] [Accepted: 01/08/2020] [Indexed: 12/13/2022] Open
Abstract
The differential diagnosis of patients with Disorder of Consciousness (DoC), in particular in the chronic phase, is significantly difficult. Actually, about 40% of patients with unresponsive wakefulness syndrome (UWS) and the minimally conscious state (MCS) are misdiagnosed. Indeed, only advanced paraclinical approaches, including advanced EEG analyses, can allow achieving a more reliable diagnosis, that is, discovering residual traces of awareness in patients with UWS (namely, functional Locked-In Syndrome (fLIS)). These approaches aim at capturing the residual brain network models, at rest or that may be activated in response to relevant stimuli, which may be appropriate for awareness to emerge (despite their insufficiency to generate purposeful motor behaviors). For this, different brain network models have been studied in patients with DoC by using sensory stimuli (i.e., passive tasks), probing response to commands (i.e., active tasks), and during resting-state. Since it can be difficult for patients with DoC to perform even simple active tasks, this scoping review aims at summarizing the current, innovative neurophysiological examination methods in resting state/passive modality to differentiate and prognosticate patients with DoC. We conclude that the electrophysiologically-based diagnostic procedures represent an important resource for diagnosis, prognosis, and, therefore, management of patients with DoC, using advance passive and resting state paradigm analyses for the patients who lie in the “greyzones” between MCS, UWS, and fLIS.
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Affiliation(s)
- Luana Billeri
- IRCCS Centro Neurolesi Bonino Pulejo, 98124 Messina, Italy; (L.B.); (S.P.); (A.N.)
| | - Serena Filoni
- Padre Pio Foundation and Rehabilitation Centers, San Giovanni Rotondo, 71013 Foggia, Italy;
- Correspondence: (S.F.); (R.S.C.); Tel.: +39-090-6012-8166 (R.S.C.)
| | | | - Simona Portaro
- IRCCS Centro Neurolesi Bonino Pulejo, 98124 Messina, Italy; (L.B.); (S.P.); (A.N.)
| | | | - Rocco Salvatore Calabrò
- IRCCS Centro Neurolesi Bonino Pulejo, 98124 Messina, Italy; (L.B.); (S.P.); (A.N.)
- Correspondence: (S.F.); (R.S.C.); Tel.: +39-090-6012-8166 (R.S.C.)
| | - Antonino Naro
- IRCCS Centro Neurolesi Bonino Pulejo, 98124 Messina, Italy; (L.B.); (S.P.); (A.N.)
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12
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Riganello F, Larroque SK, Di Perri C, Prada V, Sannita WG, Laureys S. Measures of CNS-Autonomic Interaction and Responsiveness in Disorder of Consciousness. Front Neurosci 2019; 13:530. [PMID: 31293365 PMCID: PMC6598458 DOI: 10.3389/fnins.2019.00530] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2018] [Accepted: 05/08/2019] [Indexed: 12/25/2022] Open
Abstract
Neuroimaging studies have demonstrated functional interactions between autonomic (ANS) and brain (CNS) structures involved in higher brain functions, including attention and conscious processes. These interactions have been described by the Central Autonomic Network (CAN), a concept model based on the brain-heart two-way integrated interaction. Heart rate variability (HRV) measures proved reliable as non-invasive descriptors of the ANS-CNS function setup and are thought to reflect higher brain functions. Autonomic function, ANS-mediated responsiveness and the ANS-CNS interaction qualify as possible independent indicators for clinical functional assessment and prognosis in Disorders of Consciousness (DoC). HRV has proved helpful to investigate residual responsiveness in DoC and predict clinical recovery. Variability due to internal (e.g., homeostatic and circadian processes) and environmental factors remains a key independent variable and systematic research with this regard is warranted. The interest in bidirectional ANS-CNS interactions in a variety of physiopathological conditions is growing, however, these interactions have not been extensively investigated in DoC. In this brief review we illustrate the potentiality of brain-heart investigation by means of HRV analysis in assessing patients with DoC. The authors' opinion is that this easy, inexpensive and non-invasive approach may provide useful information in the clinical assessment of this challenging patient population.
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Affiliation(s)
- Francesco Riganello
- Coma Science Group, GIGA-Consciousness, GIGA Institute, University Hospital of Liège, Liège, Belgium
- S. Anna Institute, Research in Advanced Neurorehabilitation, Crotone, Italy
| | - Stephen Karl Larroque
- Coma Science Group, GIGA-Consciousness, GIGA Institute, University Hospital of Liège, Liège, Belgium
| | - Carol Di Perri
- Coma Science Group, GIGA-Consciousness, GIGA Institute, University Hospital of Liège, Liège, Belgium
- Centre for Clinical Brain Sciences, The University of Edinburgh, Edinburgh, United Kingdom
| | - Valeria Prada
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, and Maternal/Child Sciences, Polyclinic Hospital San Martino IRCCS, University of Genoa, Genoa, Italy
| | - Walter G. Sannita
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, and Maternal/Child Sciences, Polyclinic Hospital San Martino IRCCS, University of Genoa, Genoa, Italy
| | - Steven Laureys
- Coma Science Group, GIGA-Consciousness, GIGA Institute, University Hospital of Liège, Liège, Belgium
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13
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Wade DT. Using best interests meetings for people in a prolonged disorder of consciousness to improve clinical and ethical management. JOURNAL OF MEDICAL ETHICS 2018; 44:336-342. [PMID: 28912289 DOI: 10.1136/medethics-2017-104244] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/27/2017] [Revised: 07/14/2017] [Accepted: 07/18/2017] [Indexed: 06/07/2023]
Abstract
Current management of people with prolonged disorders of consciousness is failing patients, families and society. The causes include a general lack of concern, knowledge and expertise; a legal and professional framework which impedes timely and appropriate decision-making and/or enactment of the decision; and the exclusive focus on the patient, with no legitimate means to consider the broader consequences of healthcare decisions. This article argues that a clinical pathway based on the principles of (a) the English Mental Capacity Act 2005 and (b) using time-limited treatment trials could greatly improve patient management and reduce stress on families. There needs to be early and continuing use of formal best interests meetings, starting between 7 and 21 days after onset of unconsciousness (from any cause, including progressive disorders). The treatment options need to evolve as the clinical state and prognosis becomes more certain. A formal discussion of treatment withdrawal should occur when the upper bound of predicted recovery falls below a level the patient would have considered acceptable, and it should always be discussed when the condition is considered permanent. Any decision to stop treatment should be contingent on a formal second opinion from an independent expert who should review the clinical situation and expected prognosis, but not the best interests decision. The article also asks how, if at all, the adverse effects on the family and the resource implications of long-term care of people left in a prolonged state of unconsciousness should be incorporated in the process.
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14
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Tobaldini E, Toschi-Dias E, Trimarchi PD, Brena N, Comanducci A, Casarotto S, Montano N, Devalle G. Cardiac autonomic responses to nociceptive stimuli in patients with chronic disorders of consciousness. Clin Neurophysiol 2018; 129:1083-1089. [DOI: 10.1016/j.clinph.2018.01.068] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2017] [Revised: 12/07/2017] [Accepted: 01/06/2018] [Indexed: 11/15/2022]
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15
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Naro A, Bramanti P, Bramanti A, Calabrò RS. Assessing pain in patients with chronic disorders of consciousness: Are we heading in the right direction? Conscious Cogn 2017; 55:148-155. [PMID: 28865377 DOI: 10.1016/j.concog.2017.08.009] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2016] [Revised: 08/16/2017] [Accepted: 08/18/2017] [Indexed: 01/03/2023]
Abstract
The deterioration of sensory-motor integration within the pain matrix in patients with chronic Disorders of Consciousness (DoC) is one of the principal mechanisms responsible for non-conscious pain perception. The present study aimed to assess whether the variability in the inter-peak interval (IPI) between the N2 and P2 components of laser evoked potentials (LEP) could represent an objective marker of the behavioral responsiveness to nociceptive stimulation, as measured by the Nociception Coma Scale-Revised (NCS-R), and regardless of the sensory part of pain processing. We found that only IPI variability showed a significant correlation with NCS-R score, independently of the stimulation intensity (that influences the sensory part of pain processing). It was thus concluded that IPI variability might represent an objective measure of pain processing, which may help clinicians in the development of effective pain management strategies.
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Affiliation(s)
- Antonino Naro
- IRCCS Centro Neurolesi "Bonino-Pulejo", Messina, Italy
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