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Othman MH, Olsen MH, Hansen KIT, Amiri M, Jensen HR, Nyholm B, Møller K, Kjaergaard J, Kondziella D. Covert Consciousness in Acute Brain Injury Revealed by Automated Pupillometry and Cognitive Paradigms. Neurocrit Care 2024; 41:218-227. [PMID: 38605221 PMCID: PMC11335945 DOI: 10.1007/s12028-024-01983-7] [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: 02/02/2024] [Accepted: 03/12/2024] [Indexed: 04/13/2024]
Abstract
BACKGROUND Identifying covert consciousness in intensive care unit (ICU) patients with coma and other disorders of consciousness (DoC) is crucial for treatment decisions, but sensitive low-cost bedside markers are missing. We investigated whether automated pupillometry combined with passive and active cognitive paradigms can detect residual consciousness in ICU patients with DoC. METHODS We prospectively enrolled clinically low-response or unresponsive patients with traumatic or nontraumatic DoC from ICUs of a tertiary referral center. Age-matched and sex-matched healthy volunteers served as controls. Patients were categorized into clinically unresponsive (coma or unresponsive wakefulness syndrome) or clinically low-responsive (minimally conscious state or better). Using automated pupillometry, we recorded pupillary dilation to passive (visual and auditory stimuli) and active (mental arithmetic) cognitive paradigms, with task-specific success criteria (e.g., ≥ 3 of 5 pupillary dilations on five consecutive mental arithmetic tasks). RESULTS We obtained 699 pupillometry recordings at 178 time points from 91 ICU patients with brain injury (mean age 60 ± 13.8 years, 31% women, and 49.5% nontraumatic brain injuries). Recordings were also obtained from 26 matched controls (59 ± 14.8 years, 38% women). Passive paradigms yielded limited distinctions between patients and controls. However, active paradigms enabled discrimination between different states of consciousness. With mental arithmetic of moderate complexity, ≥ 3 pupillary dilations were seen in 17.8% of clinically unresponsive patients and 50.0% of clinically low-responsive patients (odds ratio 4.56, 95% confidence interval 2.09-10.10; p < 0.001). In comparison, 76.9% healthy controls responded with ≥ 3 pupillary dilations (p = 0.028). Results remained consistent across sensitivity analyses using different thresholds for success. Spearman's rank analysis underscored the robust association between pupillary dilations during mental arithmetic and consciousness levels (rho = 1, p = 0.017). Notably, one behaviorally unresponsive patient demonstrated persistent command-following behavior 2 weeks before overt signs of awareness, suggesting prolonged cognitive motor dissociation. CONCLUSIONS Automated pupillometry combined with mental arithmetic can identify cognitive efforts, and hence covert consciousness, in ICU patients with acute DoC.
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Affiliation(s)
- Marwan H Othman
- Department of Neurology, Rigshospitalet, Copenhagen University Hospital, Inge Lehmanns Vej 8, 2100, Copenhagen, Denmark
| | - Markus Harboe Olsen
- Department of Neuroanesthesiology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Karen Irgens Tanderup Hansen
- Department of Neurology, Rigshospitalet, Copenhagen University Hospital, Inge Lehmanns Vej 8, 2100, Copenhagen, Denmark
- Faculty of Health Science, University of Southern Denmark, Odense, Denmark
| | - Moshgan Amiri
- Department of Neurology, Rigshospitalet, Copenhagen University Hospital, Inge Lehmanns Vej 8, 2100, Copenhagen, Denmark
| | - Helene Ravnholt Jensen
- Department of Neuroanesthesiology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Benjamin Nyholm
- Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Kirsten Møller
- Department of Neuroanesthesiology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Jesper Kjaergaard
- Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Daniel Kondziella
- Department of Neurology, Rigshospitalet, Copenhagen University Hospital, Inge Lehmanns Vej 8, 2100, Copenhagen, Denmark.
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark.
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Grønlund EW, Lindberg U, Fisher PM, Othman MH, Amiri M, Sølling C, Nielsen RD, Capion T, Ciochon UM, Hauerberg J, Sigurdsson ST, Thomsen G, Knudsen GM, Kjaergaard J, Larsen VA, Møller K, Hansen AE, Kondziella D. Arterial Spin Labeling Magnetic Resonance Imaging for Acute Disorders of Consciousness in the Intensive Care Unit. Neurocrit Care 2024:10.1007/s12028-024-02031-0. [PMID: 38918338 DOI: 10.1007/s12028-024-02031-0] [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: 03/05/2024] [Accepted: 05/31/2024] [Indexed: 06/27/2024]
Abstract
BACKGROUND To investigate patients with disorders of consciousness (DoC) for residual awareness, guidelines recommend quantifying glucose brain metabolism using positron emission tomography. However, this is not feasible in the intensive care unit (ICU). Cerebral blood flow (CBF) assessed by arterial spin labeling magnetic resonance imaging (ASL-MRI) could serve as a proxy for brain metabolism and reflect consciousness levels in acute DoC. We hypothesized that ASL-MRI would show compromised CBF in coma and unresponsive wakefulness states (UWS) but relatively preserved CBF in minimally conscious states (MCS) or better. METHODS We consecutively enrolled ICU patients with acute DoC and categorized them as being clinically unresponsive (i.e., coma or UWS [≤ UWS]) or low responsive (i.e., MCS or better [≥ MCS]). ASL-MRI was then acquired on 1.5 T or 3 T. Healthy controls were investigated with both 1.5 T and 3 T ASL-MRI. RESULTS We obtained 84 ASL-MRI scans from 59 participants, comprising 36 scans from 35 patients (11 women [31.4%]; median age 56 years, range 18-82 years; 24 ≤ UWS patients, 12 ≥ MCS patients; 32 nontraumatic brain injuries) and 48 scans from 24 healthy controls (12 women [50%]; median age 50 years, range 21-77 years). In linear mixed-effects models of whole-brain cortical CBF, patients had 16.2 mL/100 g/min lower CBF than healthy controls (p = 0.0041). However, ASL-MRI was unable to discriminate between ≤ UWS and ≥ MCS patients (whole-brain cortical CBF: p = 0.33; best hemisphere cortical CBF: p = 0.41). Numerical differences of regional CBF in the thalamus, amygdala, and brainstem in the two patient groups were statistically nonsignificant. CONCLUSIONS CBF measurement in ICU patients using ASL-MRI is feasible but cannot distinguish between the lower and the upper ends of the acute DoC spectrum. We suggest that pilot testing of diagnostic interventions at the extremes of this spectrum is a time-efficient approach in the continued quest to develop DoC neuroimaging markers in the ICU.
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Affiliation(s)
- Elisabeth Waldemar Grønlund
- Department of Neurology, Copenhagen University Hospital - Rigshospitalet, Blegdamsvej 9, 2100, Copenhagen, Denmark
| | - Ulrich Lindberg
- Functional Imaging Unit, Department of Clinical Physiology and Nuclear Medicine, Copenhagen University Hospital - Rigshospitalet, Glostrup, Denmark
| | - Patrick M Fisher
- Neurobiology Research Unit, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
- Department of Drug Design and Pharmacology, University of Copenhagen, Copenhagen, Denmark
| | - Marwan H Othman
- Department of Neurology, Copenhagen University Hospital - Rigshospitalet, Blegdamsvej 9, 2100, Copenhagen, Denmark
| | - Moshgan Amiri
- Department of Neurology, Copenhagen University Hospital - Rigshospitalet, Blegdamsvej 9, 2100, Copenhagen, Denmark
| | - Christine Sølling
- Department of Neuroanaesthesiology, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Rune Damgaard Nielsen
- Department of Neuroanaesthesiology, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Tenna Capion
- Department of Neurosurgery, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Urszula Maria Ciochon
- Department of Radiology, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - John Hauerberg
- Department of Neurosurgery, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Sigurdur Thor Sigurdsson
- Department of Neuroanaesthesiology, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Gerda Thomsen
- Neurobiology Research Unit, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Gitte Moos Knudsen
- Department of Neurology, Copenhagen University Hospital - Rigshospitalet, Blegdamsvej 9, 2100, Copenhagen, Denmark
- Neurobiology Research Unit, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Jesper Kjaergaard
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
- Department of Cardiology, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Vibeke Andrée Larsen
- Department of Radiology, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Kirsten Møller
- Department of Neuroanaesthesiology, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Adam Espe Hansen
- Department of Radiology, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Daniel Kondziella
- Department of Neurology, Copenhagen University Hospital - Rigshospitalet, Blegdamsvej 9, 2100, Copenhagen, Denmark.
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark.
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Hermann B, Candia‐Rivera D, Sharshar T, Gavaret M, Diehl J, Cariou A, Benghanem S. Aberrant brain-heart coupling is associated with the severity of post cardiac arrest brain injury. Ann Clin Transl Neurol 2024; 11:866-882. [PMID: 38243640 PMCID: PMC11021613 DOI: 10.1002/acn3.52000] [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: 12/05/2023] [Accepted: 12/24/2023] [Indexed: 01/21/2024] Open
Abstract
OBJECTIVE To investigate autonomic nervous system activity measured by brain-heart interactions in comatose patients after cardiac arrest in relation to the severity and prognosis of hypoxic-ischemic brain injury. METHODS Strength and complexity of bidirectional interactions between EEG frequency bands (delta, theta, and alpha) and ECG heart rate variability frequency bands (low frequency, LF and high frequency, HF) were computed using a synthetic data generation model. Primary outcome was the severity of brain injury, assessed by (i) standardized qualitative EEG classification, (ii) somatosensory evoked potentials (N20), and (iii) neuron-specific enolase levels. Secondary outcome was the 3-month neurological status, assessed by the Cerebral Performance Category score [good (1-2) vs. poor outcome (3-4-5)]. RESULTS Between January 2007 and July 2021, 181 patients were admitted to ICU for a resuscitated cardiac arrest. Poor neurological outcome was observed in 134 patients (74%). Qualitative EEG patterns suggesting high severity were associated with decreased LF/HF. Severity of EEG changes were proportional to higher absolute values of brain-to-heart coupling strength (p < 0.02 for all brain-to-heart frequencies) and lower values of alpha-to-HF complexity (p = 0.049). Brain-to-heart coupling strength was significantly higher in patients with bilateral absent N20 and correlated with neuron-specific enolase levels at Day 3. This aberrant brain-to-heart coupling (increased strength and decreased complexity) was also associated with 3-month poor neurological outcome. INTERPRETATION Our results suggest that autonomic dysfunctions may well represent hypoxic-ischemic brain injury post cardiac arrest pathophysiology. These results open avenues for integrative monitoring of autonomic functioning in critical care patients.
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Affiliation(s)
- Bertrand Hermann
- Faculté de MédecineUniversité Paris CitéParisFrance
- Medical Intensive Care UnitHEGP Hospital, Assistance Publique ‐ Hôpitaux de Paris‐Centre (APHP.Centre)ParisFrance
- INSERM UMR 1266, Institut de Psychiatrie et Neurosciences de Paris (IPNP)Université Paris CitéParisFrance
| | - Diego Candia‐Rivera
- Sorbonne Université, Paris Brain Institute (ICM), INRIA, CNRS UMR 722, INSERM U1127, AP‐HP Hôpital Pitié‐SalpêtrièreParisFrance
| | - Tarek Sharshar
- Faculté de MédecineUniversité Paris CitéParisFrance
- INSERM UMR 1266, Institut de Psychiatrie et Neurosciences de Paris (IPNP)Université Paris CitéParisFrance
- GHU Paris Psychiatrie Neurosciences, Service hospitalo‐universitaire de Neuro‐anesthésie réanimationParisFrance
| | - Martine Gavaret
- Faculté de MédecineUniversité Paris CitéParisFrance
- INSERM UMR 1266, Institut de Psychiatrie et Neurosciences de Paris (IPNP)Université Paris CitéParisFrance
- Neurophysiology and Epileptology DepartmentGHU Paris Psychiatrie et NeurosciencesParisFrance
| | - Jean‐Luc Diehl
- Faculté de MédecineUniversité Paris CitéParisFrance
- Medical Intensive Care UnitHEGP Hospital, Assistance Publique ‐ Hôpitaux de Paris‐Centre (APHP.Centre)ParisFrance
- Université Paris Cité, INSERM, Innovative Therapies in HaemostasisParisFrance
- Biosurgical Research Lab (Carpentier Foundation)ParisFrance
| | - Alain Cariou
- Faculté de MédecineUniversité Paris CitéParisFrance
- Medical Intensive Care UnitCochin Hospital, Assistance Publique ‐ Hôpitaux de Paris‐Centre (APHP‐Centre)ParisFrance
- Paris‐Cardiovascular‐Research‐CenterINSERM U970ParisFrance
| | - Sarah Benghanem
- Faculté de MédecineUniversité Paris CitéParisFrance
- INSERM UMR 1266, Institut de Psychiatrie et Neurosciences de Paris (IPNP)Université Paris CitéParisFrance
- Medical Intensive Care UnitCochin Hospital, Assistance Publique ‐ Hôpitaux de Paris‐Centre (APHP‐Centre)ParisFrance
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Othman MH, Møller K, Kjaergaard J, Kondziella D. Detecting signatures of consciousness in acute brain injury after stimulation with apomorphine and methylphenidate: protocol for a placebo-controlled, randomized, cross-over study. BMJ Neurol Open 2024; 6:e000584. [PMID: 38268756 PMCID: PMC10806905 DOI: 10.1136/bmjno-2023-000584] [Citation(s) in RCA: 1] [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: 11/14/2023] [Accepted: 12/04/2023] [Indexed: 01/26/2024] Open
Abstract
Introduction Acute brain injury can lead to states of decreased consciousness, that is, disorder of consciousness (DoC). Detecting signs of consciousness early is vital for DoC management in the intensive care unit (ICU), neurorehabilitation and long-term prognosis. Our primary objective is to investigate the potential of pharmacological stimulant therapies in eliciting signs of consciousness among unresponsive or low-responsive acute DoC patients. Methods In a placebo-controlled, randomised, cross-over setting, we evaluate the effect of methylphenidate and apomorphine in 50 DoC patients with acute traumatic or non-traumatic brain injury admitted to the ICU. Patients are examined before and after administration of the trial drugs using (1) neurobehavioural scales to determine the clinical level of consciousness, (2) automated pupillometry to record pupillary responses as a signature for awareness and (3) near-infrared spectroscopy combined with electroencephalography to record neurovascular coupling as a measure for cortical activity. Primary outcomes include pupillary dilations and increase in cortical activity during passive and active paradigms. Ethics The study has been approved by the ethics committee (Journal-nr: H-21022096) and follows the principles of the Declaration of Helsinki. It is deemed to pose minimal risks and to hold a significant potential to improve treatment options for DoC patients. If the stimulants are shown to enhance cortical modulation of pupillary function and neurovascular coupling, this would warrant a large multicentre trial to evaluate their clinical impact. Dissemination Results will be available on EudraCT, clinicaltrialsregister.eu and published in an international peer-reviewed journal. Trial registration number EudraCT Number: 2021-001453-31.
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Affiliation(s)
- Marwan H Othman
- Department of Neurology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Kirsten Møller
- Department of Neuroanesthesiology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Jesper Kjaergaard
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
- Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Daniel Kondziella
- Department of Neurology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
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Sangare A, Quirins M, Marois C, Valente M, Weiss N, Perez P, Ben Salah A, Munoz-Musat E, Demeret S, Rohaut B, Sitt JD, Eymond C, Naccache L. Pupil dilation response elicited by violations of auditory regularities is a promising but challenging approach to probe consciousness at the bedside. Sci Rep 2023; 13:20331. [PMID: 37989756 PMCID: PMC10663629 DOI: 10.1038/s41598-023-47806-1] [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: 04/17/2023] [Accepted: 11/18/2023] [Indexed: 11/23/2023] Open
Abstract
Pupil dilation response (PDR) has been proposed as a physiological marker of conscious access to a stimulus or its attributes, such as novelty. In a previous study on healthy volunteers, we adapted the auditory "local global" paradigm and showed that violations of global regularity elicited a PDR. Notably without instructions, this global effect was present only in participants who could consciously report violations of global regularities. In the present study, we used a similar approach in 24 non-communicating patients affected with a Disorder of Consciousness (DoC) and compared PDR to ERPs regarding diagnostic and prognostic performance. At the group level, global effect could not be detected in DoC patients. At the individual level, the only patient with a PDR global effect was in a MCS and recovered consciousness at 6 months. Contrasting the most regular trials to the most irregular ones improved PDR's diagnostic and prognostic power in DoC patients. Pupillometry is a promising tool but requires several methodological improvements to enhance the signal-to-noise ratio and make it more robust for probing consciousness and cognition in DoC patients.
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Affiliation(s)
- Aude Sangare
- Assistance Publique - Hôpitaux de Paris, Groupe Hospitalier Pitié-Salpêtrière, Charles Foix, Département de Neurophysiologie, Sorbonne Université, Paris, France.
- INSERM U 1127, PICNIC, Lab, Institut du Cerveau et de la Moelle Épinière, ICM, 75013, Paris, France.
| | - Marion Quirins
- Département de Neurologie, Hôpital Fondation Adolphe de Rothschild, Paris, France
| | - Clémence Marois
- AP-HP.Sorbonne Université, Hôpital Pitié-Salpêtrière, Département de Neurologie, Unité de Médecine Intensive et Réanimation à Orientation Neurologique & Groupe de Recherche Clinique en REanimation et Soins Intensifs du Patient en Insuffisance Respiratoire aiguE (GRC-RESPIRE) Sorbonne Université, Sorbonne Université, Paris, France
| | - Mélanie Valente
- Assistance Publique - Hôpitaux de Paris, Groupe Hospitalier Pitié-Salpêtrière, Charles Foix, Département de Neurophysiologie, Sorbonne Université, Paris, France
- INSERM U 1127, PICNIC, Lab, Institut du Cerveau et de la Moelle Épinière, ICM, 75013, Paris, France
| | - Nicolas Weiss
- AP-HP.Sorbonne Université, Hôpital Pitié-Salpêtrière, Département de Neurologie, Unité de Médecine Intensive et Réanimation à Orientation Neurologique & Groupe de Recherche Clinique en REanimation et Soins Intensifs du Patient en Insuffisance Respiratoire aiguE (GRC-RESPIRE) Sorbonne Université, Sorbonne Université, Paris, France
- Brain Liver Pitié-Salpêtrière (BLIPS) Study Group, INSERM UMR_S 938, Centre de Recherche Saint-Antoine (CRSA), Maladies Métaboliques, Biliaires et Fibro-Inflammatoire du Foie & Institute of Cardiometabolism and Nutrition (ICAN), Paris, France
| | - Pauline Perez
- Anesthesia and Intensive Care Unit, Lyon Medical Intensive Care Unit, Edouard, Herriot Hospital, Hospices Civils de Lyon, 69437, Lyon, France
| | - Amina Ben Salah
- Assistance Publique - Hôpitaux de Paris, Groupe Hospitalier Pitié-Salpêtrière, Charles Foix, Département de Neurophysiologie, Sorbonne Université, Paris, France
- INSERM U 1127, PICNIC, Lab, Institut du Cerveau et de la Moelle Épinière, ICM, 75013, Paris, France
| | - Esteban Munoz-Musat
- INSERM U 1127, PICNIC, Lab, Institut du Cerveau et de la Moelle Épinière, ICM, 75013, Paris, France
| | - Sophie Demeret
- AP-HP.Sorbonne Université, Hôpital Pitié-Salpêtrière, Département de Neurologie, Unité de Médecine Intensive et Réanimation à Orientation Neurologique & Groupe de Recherche Clinique en REanimation et Soins Intensifs du Patient en Insuffisance Respiratoire aiguE (GRC-RESPIRE) Sorbonne Université, Sorbonne Université, Paris, France
| | - Benjamin Rohaut
- Assistance Publique - Hôpitaux de Paris, Groupe Hospitalier Pitié-Salpêtrière, Charles Foix, Département de Neurophysiologie, Sorbonne Université, Paris, France
- INSERM U 1127, PICNIC, Lab, Institut du Cerveau et de la Moelle Épinière, ICM, 75013, Paris, France
| | - Jacobo D Sitt
- INSERM U 1127, PICNIC, Lab, Institut du Cerveau et de la Moelle Épinière, ICM, 75013, Paris, France
| | - Cecile Eymond
- INSERM U 1127, PICNIC, Lab, Institut du Cerveau et de la Moelle Épinière, ICM, 75013, Paris, France
| | - Lionel Naccache
- Assistance Publique - Hôpitaux de Paris, Groupe Hospitalier Pitié-Salpêtrière, Charles Foix, Département de Neurophysiologie, Sorbonne Université, Paris, France.
- INSERM U 1127, PICNIC, Lab, Institut du Cerveau et de la Moelle Épinière, ICM, 75013, Paris, France.
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Kumar A, Ridha M, Claassen J. Prognosis of consciousness disorders in the intensive care unit. Presse Med 2023; 52:104180. [PMID: 37805070 PMCID: PMC10995112 DOI: 10.1016/j.lpm.2023.104180] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2023] [Accepted: 10/03/2023] [Indexed: 10/09/2023] Open
Abstract
Assessments of consciousness are a critical part of prognostic algorithms for critically ill patients suffering from severe brain injuries. There have been significant advances in the field of coma science over the past two decades, providing clinicians with more advanced and precise tools for diagnosing and prognosticating disorders of consciousness (DoC). Advanced neuroimaging and electrophysiological techniques have vastly expanded our understanding of the biological mechanisms underlying consciousness, and have helped identify new states of consciousness. One of these, termed cognitive motor dissociation, can predict functional recovery at 1 year post brain injury, and is present in up to 15-20% of patients with DoC. In this chapter, we review several tools that are used to predict DoC, describing their strengths and limitations, from the neurological examination to advanced imaging and electrophysiologic techniques. We also describe multimodal assessment paradigms that can be used to identify covert consciousness and thus help recognize patients with the potential for future recovery and improve our prognostication practices.
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Affiliation(s)
- Aditya Kumar
- Department of Neurology, Columbia University Medical Center, New York-Presbyterian Hospital, New York, NY, USA
| | - Mohamed Ridha
- Department of Neurology, Columbia University Medical Center, New York-Presbyterian Hospital, New York, NY, USA
| | - Jan Claassen
- Department of Neurology, Columbia University Medical Center, New York-Presbyterian Hospital, New York, NY, USA.
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Pupillary Light Response Deficits in 4-Week-Old Piglets and Adolescent Children after Low-Velocity Head Rotations and Sports-Related Concussions. Biomedicines 2023; 11:biomedicines11020587. [PMID: 36831121 PMCID: PMC9952885 DOI: 10.3390/biomedicines11020587] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2023] [Revised: 02/10/2023] [Accepted: 02/14/2023] [Indexed: 02/18/2023] Open
Abstract
Neurological disorders and traumatic brain injury (TBI) are among the leading causes of death and disability. The pupillary light reflex (PLR) is an emerging diagnostic tool for concussion in humans. We compared PLR obtained with a commercially available pupillometer in the 4 week old piglet model of the adolescent brain subject to rapid nonimpact head rotation (RNR), and in human adolescents with and without sports-related concussion (SRC). The 95% PLR reference ranges (RR, for maximum and minimum pupil diameter, latency, and average and peak constriction velocities) were established in healthy piglets (N = 13), and response reliability was validated in nine additional healthy piglets. PLR assessments were obtained in female piglets allocated to anesthetized sham (N = 10), single (sRNR, N = 13), and repeated (rRNR, N = 14) sagittal low-velocity RNR at pre-injury, as well as days 1, 4, and 7 post injury, and evaluated against RRs. In parallel, we established human PLR RRs in healthy adolescents (both sexes, N = 167) and compared healthy PLR to values obtained <28 days from a SRC (N = 177). In piglets, maximum and minimum diameter deficits were greater in rRNR than sRNR. Alterations peaked on day 1 post sRNR and rRNR, and remained altered at day 4 and 7. In SRC adolescents, the proportion of adolescents within the RR was significantly lower for maximum pupil diameter only (85.8%). We show that PLR deficits may persist in humans and piglets after low-velocity head rotations. Differences in timing of assessment after injury, developmental response to injury, and the number and magnitude of impacts may contribute to the differences observed between species. We conclude that PLR is a feasible, quantifiable involuntary physiological metric of neurological dysfunction in pigs, as well as humans. Healthy PLR porcine and human reference ranges established can be used for neurofunctional assessments after TBI or hypoxic exposures (e.g., stroke, apnea, or cardiac arrest).
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Understanding, detecting, and stimulating consciousness recovery in the ICU. Acta Neurochir (Wien) 2022; 165:809-828. [PMID: 36242637 DOI: 10.1007/s00701-022-05378-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Accepted: 08/07/2022] [Indexed: 11/01/2022]
Abstract
Coma is a medical and socioeconomic emergency. Although underfunded, research on coma and disorders of consciousness has made impressive progress. Lesion-network-mapping studies have delineated the precise brainstem regions that consistently produce coma when damaged. Functional neuroimaging has revealed how mechanisms like "communication through coherence" and "inhibition by gating" work in synergy to enable cortico-cortical processing and how this information transfer is disrupted in brain injury. On the cellular level, break-down of intracellular communication between the layer 5 pyramidal cell soma and the apical dendritic part impairs dendritic information integration, with up-stream effects on microcircuits in local neuronal populations and on large-scale fronto-parietal networks, which correlates with loss of consciousness. A breakthrough in clinical concepts occurred when fMRI, and later EEG, studies revealed that 15% of clinically unresponsive patients in acute and chronic settings are in fact awake and aware, as shown by their command following abilities revealed by brain activation during motor and locomotion imagery tasks. This condition is now termed "cognitive motor dissociation." Furthermore, epidemiological data on coma were literally non-existent until recently because of difficulties related to case ascertainment with traditional methods, but crowdsourcing of family observations enabled the first estimates of how frequent coma is in the general population (pooled annual incidence of 201 coma cases per 100,000 population in the UK and the USA). Diagnostic guidelines on coma and disorders of consciousness by the American Academy of Neurology and the European Academy of Neurology provide ambitious clinical frameworks to accommodate these achievements. As for therapy, a broad range of medical and non-medical treatment options is now being tested in increasingly larger trials; in particular, amantadine and transcranial direct current stimulation appear promising in this regard. Major international initiatives like the Curing Coma Campaign aim to raise awareness for coma and disorders of consciousness in the public, with the ultimate goal to make more brain-injured patients recover consciousness after a coma. To highlight all these accomplishments, this paper provides a comprehensive overview of recent progress and future challenges related to understanding, detecting, and stimulating consciousness recovery in the ICU.
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Arora Y, Dutta A. Human-in-the-Loop Optimization of Transcranial Electrical Stimulation at the Point of Care: A Computational Perspective. Brain Sci 2022; 12:1294. [PMID: 36291228 PMCID: PMC9599464 DOI: 10.3390/brainsci12101294] [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: 08/04/2022] [Revised: 09/05/2022] [Accepted: 09/18/2022] [Indexed: 11/17/2022] Open
Abstract
Individual differences in the responsiveness of the brain to transcranial electrical stimulation (tES) are increasingly demonstrated by the large variability in the effects of tES. Anatomically detailed computational brain models have been developed to address this variability; however, static brain models are not “realistic” in accounting for the dynamic state of the brain. Therefore, human-in-the-loop optimization at the point of care is proposed in this perspective article based on systems analysis of the neurovascular effects of tES. First, modal analysis was conducted using a physiologically detailed neurovascular model that found stable modes in the 0 Hz to 0.05 Hz range for the pathway for vessel response through the smooth muscle cells, measured with functional near-infrared spectroscopy (fNIRS). During tES, the transient sensations can have arousal effects on the hemodynamics, so we present a healthy case series for black-box modeling of fNIRS−pupillometry of short-duration tDCS effects. The block exogeneity test rejected the claim that tDCS is not a one-step Granger cause of the fNIRS total hemoglobin changes (HbT) and pupil dilation changes (p < 0.05). Moreover, grey-box modeling using fNIRS of the tDCS effects in chronic stroke showed the HbT response to be significantly different (paired-samples t-test, p < 0.05) between the ipsilesional and contralesional hemispheres for primary motor cortex tDCS and cerebellar tDCS, which was subserved by the smooth muscle cells. Here, our opinion is that various physiological pathways subserving the effects of tES can lead to state−trait variability, which can be challenging for clinical translation. Therefore, we conducted a case study on human-in-the-loop optimization using our reduced-dimensions model and a stochastic, derivative-free covariance matrix adaptation evolution strategy. We conclude from our computational analysis that human-in-the-loop optimization of the effects of tES at the point of care merits investigation in future studies for reducing inter-subject and intra-subject variability in neuromodulation.
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Affiliation(s)
- Yashika Arora
- Neuroimaging and Neurospectroscopy Lab, National Brain Research Centre, Gurgaon 122052, India
| | - Anirban Dutta
- Neuroengineering and Informatics for Rehabilitation and Simulation-Based Learning (NIRSlearn), University of Lincoln, Lincoln LN6 7TS, UK
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Mat B, Sanz L, Arzi A, Boly M, Laureys S, Gosseries O. New behavioral signs of consciousness in patients with severe brain injuries. Semin Neurol 2022; 42:259-272. [PMID: 35738292 DOI: 10.1055/a-1883-0861] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Affiliation(s)
- Beril Mat
- Neurology, University of Wisconsin-Madison, Madison, United States.,Coma Science Group, University of Liege, Liege, Belgium
| | - Leandro Sanz
- Coma Science Group, University of Liege, Liege, Belgium
| | - Anat Arzi
- The Hebrew University of Jerusalem Department of Cognitive and Brain Sciences, Jerusalem, Israel
| | - Melanie Boly
- Neurology, University of Wisconsin-Madison, Madison, United States.,Psychiatry, University of Wisconsin-Madison, Madison, United States
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11
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Aubinet C, Schnakers C, Majerus S. Language Assessment in Patients with Disorders of Consciousness. Semin Neurol 2022; 42:273-282. [PMID: 36100226 DOI: 10.1055/s-0042-1755561] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
Abstract
The assessment of residual language abilities in patients with disorders of consciousness (DoC) after severe brain injury is particularly challenging due to their limited behavioral repertoire. Moreover, associated language impairment such as receptive aphasia may lead to an underestimation of actual consciousness levels. In this review, we examine past research on the assessment of residual language processing in DoC patients, and we discuss currently available tools for identifying language-specific abilities and their prognostic value. We first highlight the need for validated and sensitive bedside behavioral assessment tools for residual language abilities in DoC patients. As regards neuroimaging and electrophysiological methods, the tasks involving higher level linguistic commands appear to be the most informative about level of consciousness and have the best prognostic value. Neuroimaging methods should be combined with the most appropriate behavioral tools in multimodal assessment protocols to assess receptive language abilities in DoC patients in the most complete and sensitive manner.
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Affiliation(s)
- Charlène Aubinet
- Coma Science Group, GIGA Consciousness, University of Liège, Liège, Belgium.,Centre du Cerveau, University Hospital of Liège, Liège, Belgium.,Psychology and Neuroscience of Cognition Research Unit, University of Liège, Liège, Belgium
| | - Caroline Schnakers
- Research Institute, Casa Colina Hospital and Centers for Healthcare, Pomona, California
| | - Steve Majerus
- Psychology and Neuroscience of Cognition Research Unit, University of Liège, Liège, Belgium
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12
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Severe bradycardia in a teenager as the initial manifestation for Guillain Barré syndrome: a case report. BMC Pediatr 2022; 22:152. [PMID: 35317762 PMCID: PMC8938645 DOI: 10.1186/s12887-022-03165-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2021] [Accepted: 02/16/2022] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Guillain-Barré syndrome is the most common cause of flaccid paralysis, with multiple known clinical variants. Autonomic dysfunction, although frequently reported in the clinical course, is often overlooked in the pediatric population and is usually not the initial presenting symptom in this age group CASE PRESENTATION: We present the case of a previously healthy 17-year-old who arrived at the Emergency Department complaining of gastrointestinal symptoms associated with lipothymia. An initial electrocardiogram (ECG) showed sustained sinus bradycardia subsequently associated with arterial hypertension. Structural and inflammatory cardiac pathology were ruled out, as well as auriculoventricular conduction block and posterior reversible encephalopathy syndrome. On the ninth day after initial symptoms, the patient presented sensory and motor nerve disturbances with the cerebrospinal fluid analysis showing a clear albumin-cytologic dissociation, consistent with an atypical presentation of GBS with autonomic dysfunction. Immunoglobulin therapy was administered, developing subsequent aseptic meningitis, that required discontinuation of previous therapy and treatment with plasmapheresis. Clinical improvement was achieved with full motor function recovery. CONCLUSION This case illustrates a Guillain-Barré syndrome variant in which autonomic dysfunction preceded neurologic deficit, a finding uncommon in children, emphasizing this as an important differential diagnosis for severe bradycardia in pediatric patients.
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13
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Aubinet C, Chatelle C, Gosseries O, Carrière M, Laureys S, Majerus S. Residual implicit and explicit language abilities in patients with disorders of consciousness: A systematic review. Neurosci Biobehav Rev 2021; 132:391-409. [PMID: 34864003 DOI: 10.1016/j.neubiorev.2021.12.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2021] [Revised: 11/13/2021] [Accepted: 12/01/2021] [Indexed: 01/14/2023]
Abstract
Language assessment in post-comatose patients is difficult due to their limited behavioral repertoire; yet associated language deficits might lead to an underestimation of consciousness levels in unresponsive wakefulness syndrome (UWS) or minimally conscious state (MCS; -/+) diagnoses. We present a systematic review of studies from 2002 assessing residual language abilities with neuroimaging, electrophysiological or behavioral measures in patients with severe brain injury. Eighty-five articles including a total of 2278 patients were assessed for quality. The median percentages of patients showing residual implicit language abilities (i.e., cortical responses to specific words/sentences) were 33 % for UWS, 50 % for MCS- and 78 % for MCS + patients, whereas explicit language abilities (i.e., command-following using brain-computer interfaces) were reported in 20 % of UWS, 33 % of MCS- and 50 % of MCS + patients. Cortical responses to verbal stimuli increased along with consciousness levels and the progressive recovery of consciousness after a coma was paralleled by the reappearance of both implicit and explicit language processing. This review highlights the importance of language assessment in patients with disorders of consciousness.
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Affiliation(s)
- Charlène Aubinet
- Coma Science Group, GIGA Consciousness, University of Liège, Belgium; Centre du Cerveau, University Hospital of Liège, Belgium.
| | - Camille Chatelle
- Coma Science Group, GIGA Consciousness, University of Liège, Belgium; Centre du Cerveau, University Hospital of Liège, Belgium
| | - Olivia Gosseries
- Coma Science Group, GIGA Consciousness, University of Liège, Belgium; Centre du Cerveau, University Hospital of Liège, Belgium; Fund for Scientific Research, FNRS, Belgium
| | - Manon Carrière
- Coma Science Group, GIGA Consciousness, University of Liège, Belgium; Centre du Cerveau, University Hospital of Liège, Belgium
| | - Steven Laureys
- Coma Science Group, GIGA Consciousness, University of Liège, Belgium; Centre du Cerveau, University Hospital of Liège, Belgium; Fund for Scientific Research, FNRS, Belgium
| | - Steve Majerus
- Fund for Scientific Research, FNRS, Belgium; Psychology and Neuroscience of Cognition Research Unit, University of Liège, Belgium.
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Bouchereau E, Sharshar T, Legouy C. Delayed awakening in neurocritical care. Rev Neurol (Paris) 2021; 178:21-33. [PMID: 34392974 DOI: 10.1016/j.neurol.2021.06.001] [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] [Received: 05/27/2021] [Revised: 06/22/2021] [Accepted: 06/23/2021] [Indexed: 02/07/2023]
Abstract
Delayed awakening is defined as a persistent disorder of arousal or consciousness 48 to 72h after sedation interruption in critically ill patients. Delayed awakening is either a component of coma or delirium. It results in longer hospital stays and increased mortality. It is therefore a diagnostic, therapeutic and prognostic emergency. In severe brain injured patients, delayed awakening may be related to the primary neurological injury or to secondary systemic insults related to organ failure associated with intensive care. In the present review, we propose diagnostic, therapeutic and prognostic algorithms for managing delayed awaking in neuro-ICU brain injured patients.
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Affiliation(s)
- E Bouchereau
- G.H.U Paris Psychiatry & Neurosciences, department of Neurocritical care, Service d'Anesthésie-Réanimation Neurochirurgicale, 1, rue Cabanis, 75674 Paris Cedex 14, France; INSERM U1266, FHU NeuroVasc, Institut de Psychiatrie et Neuroscience de Paris, Paris, France
| | - T Sharshar
- G.H.U Paris Psychiatry & Neurosciences, department of Neurocritical care, Service d'Anesthésie-Réanimation Neurochirurgicale, 1, rue Cabanis, 75674 Paris Cedex 14, France; INSERM U1266, FHU NeuroVasc, Institut de Psychiatrie et Neuroscience de Paris, Paris, France.
| | - C Legouy
- G.H.U Paris Psychiatry & Neurosciences, department of Neurocritical care, Service d'Anesthésie-Réanimation Neurochirurgicale, 1, rue Cabanis, 75674 Paris Cedex 14, France
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15
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Kondziella D, Menon DK, Helbok R, Naccache L, Othman MH, Rass V, Rohaut B, Diringer MN, Stevens RD. A Precision Medicine Framework for Classifying Patients with Disorders of Consciousness: Advanced Classification of Consciousness Endotypes (ACCESS). Neurocrit Care 2021; 35:27-36. [PMID: 34236621 DOI: 10.1007/s12028-021-01246-9] [Citation(s) in RCA: 39] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2020] [Accepted: 03/30/2021] [Indexed: 12/25/2022]
Abstract
BACKGROUND Consciousness in patients with brain injury is traditionally assessed based on semiological evaluation at the bedside. This classification is limited because of low granularity, ill-defined and rigid nomenclatures incompatible with the highly fluctuating nature of consciousness, failure to identify specific brain states like cognitive motor dissociation, and neglect for underlying biological mechanisms. Here, the authors present a pragmatic framework based on consciousness endotypes that combines clinical phenomenology with all essential physiological and biological data, emphasizing recovery trajectories, therapeutic potentials and clinical feasibility. METHODS The Neurocritical Care Society's Curing Coma Campaign identified an international group of experts who convened in a series of online meetings between May and November 2020 to discuss and propose a novel framework for classifying consciousness. RESULTS The expert group proposes Advanced Classification of Consciousness Endotypes (ACCESS), a tiered multidimensional framework reflecting increasing complexity and an aspiration to consider emerging and future approaches. Tier 1 is based on clinical phenotypes and structural imaging. Tier 2 adds functional measures including EEG, PET and functional MRI, that can be summarized using the Arousal, Volition, Cognition and Mechanisms (AVCM) score (where "Volition" signifies volitional motor responses). Finally, Tier 3 reflects dynamic changes over time with a (theoretically infinite) number of physiologically distinct states to outline consciousness recovery and identify opportunities for therapeutic interventions. CONCLUSIONS Whereas Tiers 1 and 2 propose an approach for low-resource settings and state-of-the-art expertise at leading academic centers, respectively, Tier 3 is a visionary multidimensional consciousness paradigm driven by continuous incorporation of new knowledge while addressing the Curing Coma Campaign's aspirational goals.
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Affiliation(s)
- Daniel Kondziella
- Department of Neurology, Rigshospitalet, Copenhagen University Hospital, Inge Lehmanns Vej 8, 2100, Copenhagen, Denmark. .,Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark.
| | - David K Menon
- Division of Anaesthesia, University of Cambridge, Cambridge, CB2 0NU, UK.
| | - Raimund Helbok
- Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - Lionel Naccache
- PICNIC Lab Team, INSERM, U 1127, CNRS UMR 7225, Faculté de Médecine de Sorbonne Université, UMR S 1127 Institut du Cerveau et de la Moelle épinière, ICM, Hôpital Pitié-Salpêtrière, Paris, France.,APHP, Departments of Neurology and of Clinical Neurophysiology, Hôpital de la Salpêtriere, Paris, France
| | - Marwan H Othman
- Department of Neurology, Rigshospitalet, Copenhagen University Hospital, Inge Lehmanns Vej 8, 2100, Copenhagen, Denmark
| | - Verena Rass
- Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - Benjamin Rohaut
- Sorbonne Université, Faculté de Médecine Pitié-Salpêtrière, Paris, France.,Brain institute - ICM, Sorbonne Université, Inserm U1127, CNRS UMR 7225, Hôpital Pitié-Salpêtrière, Paris, France.,Department of Neurology, Neuro ICU, Groupe Hospitalier Universitaire APHP-Sorbonne Université, site Pitié-Salpêtrière, Paris, France
| | | | - Robert D Stevens
- Departments of Anesthesiology, Critical Care Medicine, Neurology, and Neurosurgery, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
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16
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Olsen MH, Jensen HR, Ebdrup SR, Topp NH, Strange DG, Møller K, Kondziella D. Automated pupillometry and the FOUR score - what is the diagnostic benefit in neurointensive care? Acta Neurochir (Wien) 2020; 162:1639-1645. [PMID: 32383011 PMCID: PMC7223804 DOI: 10.1007/s00701-020-04381-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2019] [Accepted: 04/29/2020] [Indexed: 12/02/2022]
Abstract
Introduction The Glasgow Coma Scale (GCS) and visual inspection of pupillary function are routine measures to monitor patients with impaired consciousness and predict their outcome in the neurointensive care unit (neuro-ICU). Our aim was to compare more recent measures, i.e. FOUR score and automated pupillometry, to standard monitoring with the GCS and visual inspection of pupils. Methods Supervised trained nursing staff examined a consecutive sample of patients admitted to the neuro-ICU of a tertiary referral centre using GCS and FOUR score and assessing pupillary function first by visual inspection and then by automated pupillometry. Clinical outcome was evaluated 6 months after admission using the Glasgow Outcome Scale-Extended. Results Fifty-six consecutive patients (median age 63 years) were assessed a total of 234 times. Of the 36 patients with at least one GCS score of 3, 13 had a favourable outcome. All seven patients with at least one FOUR score of ≤ 3 had an unfavourable outcome, which was best predicted by a low “brainstem” sub-score. Compared to automated pupillometry, visual assessment underestimated pupillary diameters (median difference, 0.4 mm; P = 0.006). Automated pupillometry detected a preserved pupillary light reflex in 10 patients, in whom visual inspection had missed pupillary constriction. Discussion Training of nursing staff to implement frequent monitoring of patients in the neuro-ICU with FOUR score and automated pupillometry is feasible. Both measures provide additional clinical information compared to the GCS and visual assessment of pupillary function, most importantly a more granular classification of patients with low levels of consciousness by the FOUR score.
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Affiliation(s)
- Markus Harboe Olsen
- Department of Neuroanaesthesiology, The Neuroscience Center, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark.
| | - Helene Ravnholt Jensen
- Department of Neuroanaesthesiology, The Neuroscience Center, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Søren Røddik Ebdrup
- Department of Neuroanaesthesiology, The Neuroscience Center, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Nina Hvid Topp
- Department of Neuroanaesthesiology, The Neuroscience Center, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Ditte Gry Strange
- Department of Neuroanaesthesiology, The Neuroscience Center, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Kirsten Møller
- Department of Neuroanaesthesiology, The Neuroscience Center, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
- Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Daniel Kondziella
- Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
- Department of Neurology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
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Rasulo FA, Togni T, Romagnoli S. Essential Noninvasive Multimodality Neuromonitoring for the Critically Ill Patient. Crit Care 2020; 24:100. [PMID: 32204723 PMCID: PMC7092614 DOI: 10.1186/s13054-020-2781-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
This article is one of ten reviews selected from the Annual Update in Intensive Care and Emergency Medicine 2020. Other selected articles can be found online at https://www.biomedcentral.com/collections/annualupdate2020. Further information about the Annual Update in Intensive Care and Emergency Medicine is available from http://www.springer.com/series/8901.
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Affiliation(s)
- Frank A Rasulo
- Division of Anesthesiology, Intensive Care & Emergency Medicine, University of Brescia at Spedali Civili Hospital, Brescia, Italy.
| | - Tommaso Togni
- Division of Anesthesiology, Intensive Care & Emergency Medicine, University of Brescia at Spedali Civili Hospital, Brescia, Italy
| | - Stefano Romagnoli
- Department of Health Science, University of Florence, Florence, Italy
- Department of Anesthesiology and Intensive Care, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy
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Kondziella D, Bender A, Diserens K, van Erp W, Estraneo A, Formisano R, Laureys S, Naccache L, Ozturk S, Rohaut B, Sitt JD, Stender J, Tiainen M, Rossetti AO, Gosseries O, Chatelle C. European Academy of Neurology guideline on the diagnosis of coma and other disorders of consciousness. Eur J Neurol 2020; 27:741-756. [PMID: 32090418 DOI: 10.1111/ene.14151] [Citation(s) in RCA: 325] [Impact Index Per Article: 81.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2019] [Accepted: 01/09/2020] [Indexed: 12/20/2022]
Abstract
BACKGROUND AND PURPOSE Patients with acquired brain injury and acute or prolonged disorders of consciousness (DoC) are challenging. Evidence to support diagnostic decisions on coma and other DoC is limited but accumulating. This guideline provides the state-of-the-art evidence regarding the diagnosis of DoC, summarizing data from bedside examination techniques, functional neuroimaging and electroencephalography (EEG). METHODS Sixteen members of the European Academy of Neurology (EAN) Scientific Panel on Coma and Chronic Disorders of Consciousness, representing 10 European countries, reviewed the scientific evidence for the evaluation of coma and other DoC using standard bibliographic measures. Recommendations followed the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system. The guideline was endorsed by the EAN. RESULTS Besides a comprehensive neurological examination, the following suggestions are made: probe for voluntary eye movements using a mirror; repeat clinical assessments in the subacute and chronic setting, using the Coma Recovery Scale - Revised; use the Full Outline of Unresponsiveness score instead of the Glasgow Coma Scale in the acute setting; obtain clinical standard EEG; search for sleep patterns on EEG, particularly rapid eye movement sleep and slow-wave sleep; and, whenever feasible, consider positron emission tomography, resting state functional magnetic resonance imaging (fMRI), active fMRI or EEG paradigms and quantitative analysis of high-density EEG to complement behavioral assessment in patients without command following at the bedside. CONCLUSIONS Standardized clinical evaluation, EEG-based techniques and functional neuroimaging should be integrated for multimodal evaluation of patients with DoC. The state of consciousness should be classified according to the highest level revealed by any of these three approaches.
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Affiliation(s)
- D Kondziella
- Department of Neurology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark.,Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark.,Department of Neurosciences, Norwegian University of Science and Technology, Trondheim, Norway
| | - A Bender
- Department of Neurology, Ludwig-Maximilians-Universität München, Munich, Germany.,Therapiezentrum Burgau, Burgau, Germany
| | - K Diserens
- Department of Clinical Neurosciences, Centre Hospitalier Universitaire Vaudois and University of Lausanne, Lausanne, Switzerland
| | - W van Erp
- Coma Science Group, GIGA Consciousness, University and University Hospital of Liège, Liège, Belgium.,Department of Primary Care, Radboud University Medical Center, Nijmegen, The Netherlands
| | - A Estraneo
- Neurology Unit, Santa Maria della Pietà General Hospital, Nola, Italy.,IRCCS Fondazione don Carlo Gnocchi ONLUS, Florence, Italy
| | - R Formisano
- Post-Coma Unit, Neurorehabilitation Hospital and Research Institution, Santa Lucia Foundation, Rome, Italy
| | - S Laureys
- Coma Science Group, GIGA Consciousness, University and University Hospital of Liège, Liège, Belgium
| | - L Naccache
- Department of Neurology, AP-HP, Groupe hospitalier Pitié-Salpêtrière, Paris, France.,Sorbonne Université, UPMC Univ Paris 06, Faculté de Médecine Pitié-Salpêtrière, Paris, France
| | - S Ozturk
- Department of Neurology, Faculty of Medicine, Selcuk University, Konya, Turkey
| | - B Rohaut
- Department of Neurology, AP-HP, Groupe hospitalier Pitié-Salpêtrière, Paris, France.,Sorbonne Université, UPMC Univ Paris 06, Faculté de Médecine Pitié-Salpêtrière, Paris, France.,Neuro-ICU, Department of Neurology, Columbia University, New York, NY, USA
| | - J D Sitt
- Sorbonne Université, UPMC Univ Paris 06, Faculté de Médecine Pitié-Salpêtrière, Paris, France
| | - J Stender
- Department of Neurosurgery, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - M Tiainen
- Department of Neurology, Helsinki University Hospital, Helsinki, Finland
| | - A O Rossetti
- Department of Clinical Neurosciences, Centre Hospitalier Universitaire Vaudois and University of Lausanne, Lausanne, Switzerland
| | - O Gosseries
- Coma Science Group, GIGA Consciousness, University and University Hospital of Liège, Liège, Belgium
| | - C Chatelle
- Coma Science Group, GIGA Consciousness, University and University Hospital of Liège, Liège, Belgium.,Laboratory for NeuroImaging of Coma and Consciousness - Department of Neurology, Harvard Medical School, Massachusetts General Hospital, Boston, MA, USA
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