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Toplutaş E, Aydın F, Hanoğlu L. EEG Microstate Analysis in Patients with Disorders of Consciousness and Its Clinical Significance. Brain Topogr 2024; 37:377-387. [PMID: 36735192 DOI: 10.1007/s10548-023-00939-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Accepted: 01/19/2023] [Indexed: 02/04/2023]
Abstract
Disorders of Consciousness are divided into two major categories such as vegetative and minimally conscious states. Objective measures that allow correct identification of patients with vegetative and minimally conscious state are needed. EEG microstate analysis is a promising approach that we believe has the potential to be effective in examining the resting state activities of the brain in different stages of consciousness by allowing the proper identification of vegetative and minimally conscious patients. As a result, we try to identify clinical evaluation scales and microstate characteristics with resting state EEGs from individuals with disorders of consciousness. Our prospective observational study included 28 individuals with a disorder of consciousness. Control group included 18 healthy subjects with proper EEG data. We made clinical evaluations using patient behavior scales. We also analyzed the EEGs using microstate analysis. In our study, microstate D coverage differed substantially between vegetative and minimally conscious state patients. Also, there was a strong connection between microstate D characteristics and clinical scale scores. Consequently, we have demonstrated that the most accurate parameter for representing consciousness level is microstate D. Microstate analysis appears to be a strong option for future use in the diagnosis, follow-up, and treatment response of patients with Disorders of Consciousness.
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Affiliation(s)
- Eren Toplutaş
- Department of Neurology, Istanbul Eyupsultan Public Hospital, Istanbul, Turkey.
- Program of Neuroscience Ph.D., Graduate School of Health Sciences,, Istanbul Medipol University, Istanbul, Turkey.
| | - Fatma Aydın
- Program of Neuroscience Ph.D., Graduate School of Health Sciences,, Istanbul Medipol University, Istanbul, Turkey
| | - Lütfü Hanoğlu
- Department of Neurology, School of Medicine, Istanbul Medipol University, Istanbul, Turkey
- Neuroimaging and Neuromodulation Lab, Clinical Electrophysiology, REMER, Istanbul Medipol University, Istanbul, Turkey
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2
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Pisano F, Bilotta F. Verbal Glasgow Coma Scale as predictor of persistent disorder of consciousness: Insights for improving accuracy and reliability in clinical practice. Clin Neurol Neurosurg 2024; 240:108274. [PMID: 38583299 DOI: 10.1016/j.clineuro.2024.108274] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2024] [Revised: 03/20/2024] [Accepted: 04/01/2024] [Indexed: 04/09/2024]
Abstract
This brief report discusses the relationship between verbal function, disorders of consciousness, and neurological follow-up after acute brain injury. It provides valuable insights for improving the accuracy and reliability of Verbal Glasgow Coma Scale scoring in clinical practice. The report addresses the need for standardized training and underlines the importance of physiological stabilization before assessment. Clarity in communication, recognition of non-verbal cues, and serial assessments are emphasized as critical factors to reduce the Verbal Glasgow Coma Scale inconsistencies. It also promotes interdisciplinary collaboration and cultural sensitivity to refine the Verbal Glasgow Coma Scale evaluation, improving the prediction of long-term neurological outcomes after acute brain injury and optimizing effective rehabilitation programs. Possible strategies to implement in the routine clinical practice the provided tips are discussed.
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Affiliation(s)
- Francesca Pisano
- Department of Cognitive Sciences, Psychology, Education and Cultural Studies, University of Messina, Messina 98121, Italy; Department of Anesthesiology, Critical Care and Pain Medicine, Policlinico Umberto I, "Sapienza" University of Rome, Rome 00161, Italy.
| | - Federico Bilotta
- Department of Anesthesiology, Critical Care and Pain Medicine, Policlinico Umberto I, "Sapienza" University of Rome, Rome 00161, Italy
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Bai Y, Yang L, Meng X, Huang Y, Wang Q, Gong A, Feng Z, Ziemann U. Breakdown of effective information flow in disorders of consciousness: Insights from TMS-EEG. Brain Stimul 2024:S1935-861X(24)00069-X. [PMID: 38641169 DOI: 10.1016/j.brs.2024.04.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2023] [Revised: 03/29/2024] [Accepted: 04/15/2024] [Indexed: 04/21/2024] Open
Abstract
BACKGROUND The complexity of the neurophysiological mechanisms underlying human consciousness is widely acknowledged, with information processing and flow originating in cortex conceived as a core mechanism of consciousness emergence. Combination of transcranial magnetic stimulation and electroencephalography (TMS-EEG) is considered as a promising technique to understand the effective information flow associated with consciousness. OBJECTIVES To investigate information flow with TMS-EEG and its relationship to different consciousness states. METHODS We applied an effective information flow analysis by combining time-varying multivariate adaptive autoregressive model and adaptive directed transfer function on TMS-EEG data of frontal, motor and parietal cortex in patients with disorder of consciousness (DOC), including 14 vegetative state/unresponsive wakefulness syndrome (VS/UWS) patients, 21 minimally conscious state (MCS) patients, and 22 healthy subjects. RESULTS TMS in DOC patients, particularly VS/UWS, induced a significantly weaker effective information flow compared to healthy subjects. The bidirectional directed information flow was lost in DOC patients with TMS of frontal, motor and parietal cortex. The interactive ROI rate of the information flow network induced by TMS of frontal and parietal cortex was significantly lower in VS/UWS than in MCS. The interactive ROI rate correlated with DOC clinical scales. CONCLUSIONS TMS-EEG revealed a physiologically relevant correlation between TMS-induced information flow and levels of consciousness. This suggests that breakdown of effective cortical information flow serves as a viable marker of human consciousness. SIGNIFICANCE Findings offer a unique perspective on the relevance of information flow in DOC, thus providing a novel way of understanding the physiological basis of human consciousness.
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Affiliation(s)
- Yang Bai
- Center of Disorders of Consciousness Rehabilitation, Affiliated Rehabilitation Hospital, Jiangxi Medical College, Nanchang University, Nanchang, 330006, Jiangxi, China; Rehabilitation Medicine Clinical Research Center of Jiangxi Province, 330006, Jiangxi, China; Department of Neurology & Stroke, University of Tübingen, Tübingen, Germany; Hertie Institute for Clinical Brain Research, University of Tübingen, Tübingen, Germany
| | - Li Yang
- Center of Disorders of Consciousness Rehabilitation, Affiliated Rehabilitation Hospital, Jiangxi Medical College, Nanchang University, Nanchang, 330006, Jiangxi, China; Rehabilitation Medicine Clinical Research Center of Jiangxi Province, 330006, Jiangxi, China
| | - Xiangqiang Meng
- Center of Disorders of Consciousness Rehabilitation, Affiliated Rehabilitation Hospital, Jiangxi Medical College, Nanchang University, Nanchang, 330006, Jiangxi, China; Rehabilitation Medicine Clinical Research Center of Jiangxi Province, 330006, Jiangxi, China
| | - Ying Huang
- Center of Disorders of Consciousness Rehabilitation, Affiliated Rehabilitation Hospital, Jiangxi Medical College, Nanchang University, Nanchang, 330006, Jiangxi, China; Rehabilitation Medicine Clinical Research Center of Jiangxi Province, 330006, Jiangxi, China
| | - Qijun Wang
- Center for Cognition and Brain Disorders, The Affiliated Hospital of Hangzhou Normal University, Hangzhou, China
| | - Anjuan Gong
- Center for Cognition and Brain Disorders, The Affiliated Hospital of Hangzhou Normal University, Hangzhou, China
| | - Zhen Feng
- Center of Disorders of Consciousness Rehabilitation, Affiliated Rehabilitation Hospital, Jiangxi Medical College, Nanchang University, Nanchang, 330006, Jiangxi, China; Rehabilitation Medicine Clinical Research Center of Jiangxi Province, 330006, Jiangxi, China
| | - Ulf Ziemann
- Department of Neurology & Stroke, University of Tübingen, Tübingen, Germany; Hertie Institute for Clinical Brain Research, University of Tübingen, Tübingen, Germany.
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Yang H, Wu H, Kong L, Luo W, Xie Q, Pan J, Quan W, Hu L, Li D, Wu X, Liang H, Qin P. Precise detection of awareness in disorders of consciousness using deep learning framework. Neuroimage 2024; 290:120580. [PMID: 38508294 DOI: 10.1016/j.neuroimage.2024.120580] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2024] [Revised: 03/14/2024] [Accepted: 03/16/2024] [Indexed: 03/22/2024] Open
Abstract
Diagnosis of disorders of consciousness (DOC) remains a formidable challenge. Deep learning methods have been widely applied in general neurological and psychiatry disorders, while limited in DOC domain. Considering the successful use of resting-state functional MRI (rs-fMRI) for evaluating patients with DOC, this study seeks to explore the conjunction of deep learning techniques and rs-fMRI in precisely detecting awareness in DOC. We initiated our research with a benchmark dataset comprising 140 participants, including 76 unresponsive wakefulness syndrome (UWS), 25 minimally conscious state (MCS), and 39 Controls, from three independent sites. We developed a cascade 3D EfficientNet-B3-based deep learning framework tailored for discriminating MCS from UWS patients, referred to as "DeepDOC", and compared its performance against five state-of-the-art machine learning models. We also included an independent dataset consists of 11 DOC patients to test whether our model could identify patients with cognitive motor dissociation (CMD), in which DOC patients were behaviorally diagnosed unconscious but could be detected conscious by brain computer interface (BCI) method. Our results demonstrate that DeepDOC outperforms the five machine learning models, achieving an area under curve (AUC) value of 0.927 and accuracy of 0.861 for distinguishing MCS from UWS patients. More importantly, DeepDOC excels in CMD identification, achieving an AUC of 1 and accuracy of 0.909. Using gradient-weighted class activation mapping algorithm, we found that the posterior cortex, encompassing the visual cortex, posterior middle temporal gyrus, posterior cingulate cortex, precuneus, and cerebellum, as making a more substantial contribution to classification compared to other brain regions. This research offers a convenient and accurate method for detecting covert awareness in patients with MCS and CMD using rs-fMRI data.
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Affiliation(s)
- Huan Yang
- Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou 510080, China; Medical Big Data Center, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou 510080, China; Guangdong Provincial Key Laboratory of Artificial Intelligence in Medical Image Analysis and Application, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Guangzhou 510080, China
| | - Hang Wu
- Key Laboratory of Brain, Cognition and Education Sciences, Ministry of Education; Institute for Brain Research and Rehabilitation, and Guangdong Key Laboratory of Mental Health and Cognitive Science, South China Normal University, Guangzhou 510631, China
| | - Lingcong Kong
- Medical Big Data Center, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou 510080, China; Guangdong Provincial Key Laboratory of Artificial Intelligence in Medical Image Analysis and Application, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Guangzhou 510080, China
| | - Wen Luo
- The First Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou 528199, China
| | - Qiuyou Xie
- Joint Research Center for disorders of consciousness, Department of Rehabilitation, Zhujiang Hospital, School of Rehabilitation Sciences, Southern Medical University, Guangzhou 510220, China
| | - Jiahui Pan
- School of Software, South China Normal University, Foshan 528225, China; Pazhou Lab, Guangzhou 510330, China
| | - Wuxiu Quan
- Medical Big Data Center, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou 510080, China; Guangdong Provincial Key Laboratory of Artificial Intelligence in Medical Image Analysis and Application, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Guangzhou 510080, China
| | - Lianting Hu
- Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou 510080, China; Medical Big Data Center, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou 510080, China; Guangdong Provincial Key Laboratory of Artificial Intelligence in Medical Image Analysis and Application, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Guangzhou 510080, China
| | - Dantong Li
- Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou 510080, China; Medical Big Data Center, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou 510080, China; Guangdong Provincial Key Laboratory of Artificial Intelligence in Medical Image Analysis and Application, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Guangzhou 510080, China
| | - Xuehai Wu
- Pazhou Lab, Guangzhou 510330, China; Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai 200433, China; Shanghai Clinical Medical Center of Neurosurgery, Shanghai Key laboratory of Brain Function Restoration and Neural Regeneration, Neurosurgical Institute of Fudan University, Shanghai 200433, China; State Key Laboratory of Medical Neurobiology and MOE Frontiers Center for Brain Science, School of Basic Medical Sciences and Institutes of Brain Science, Fudan University, Shanghai 200433, China
| | - Huiying Liang
- Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou 510080, China; Medical Big Data Center, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou 510080, China; Guangdong Provincial Key Laboratory of Artificial Intelligence in Medical Image Analysis and Application, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Guangzhou 510080, China.
| | - Pengmin Qin
- Pazhou Lab, Guangzhou 510330, China; Key Laboratory of Brain, Cognition and Education Sciences, Ministry of Education; School of Psychology, Center for Studies of Psychological Application, and Guangdong Key Laboratory of Mental Health and Cognitive Science, South China Normal University, Guangzhou 510631, China.
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Ge Q, Lu H, Geng X, Chen X, Liu X, Sun H, Guo Z, Sun J, Qi F, Niu X, Wang A, He J, Sun W, Xu L. Serum metabolism alteration behind different etiology, diagnosis, and prognosis of disorders of consciousness. Chin Neurosurg J 2024; 10:12. [PMID: 38594757 PMCID: PMC11003070 DOI: 10.1186/s41016-024-00365-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2023] [Accepted: 03/26/2024] [Indexed: 04/11/2024] Open
Abstract
BACKGROUND Patients with disorders of consciousness (DoC) exhibit varied revival outcomes based on different etiologies and diagnoses, the mechanisms of which remain largely unknown. The fluctuating clinical presentations in DoC pose challenges in accurately assessing consciousness levels and prognoses, often leading to misdiagnoses. There is an urgent need for a deeper understanding of the physiological changes in DoC and the development of objective diagnostic and prognostic biomarkers to improve treatment guidance. METHODS To explore biomarkers and understand the biological processes, we conducted a comprehensive untargeted metabolomic analysis on serum samples from 48 patients with DoC. Patients were categorized based on etiology (TBI vs. non-TBI), CRS-R scores, and prognosis. Advanced analytical techniques, including PCA and OPLS-DA models, were employed to identify differential metabolites. RESULTS Our analysis revealed a distinct separation in metabolomic profiles among the different groups. The primary differential metabolites distinguishing patients with varying etiologies were predominantly phospholipids, with a notable decrease in glycerophospholipids observed in the TBI group. Patients with higher CRS-R scores exhibited a pattern of impaired carbohydrate metabolism coupled with enhanced lipid metabolism. Notably, serum concentrations of both LysoPE and PE were reduced in patients with improved outcomes, suggesting their potential as prognostic biomarkers. CONCLUSIONS Our study underscores the critical role of phospholipid metabolism in the brain's metabolic alterations in patients with DoC. It identifies key biomarkers for diagnosis and prognosis, offering insights that could lead to novel therapeutic targets. These findings highlight the value of metabolomic profiling in understanding and potentially treating DoC.
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Affiliation(s)
- Qianqian Ge
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Hezhen Lu
- China-Japan Union Hospital of Jilin University, Changchun, China
- Core Instrument Facility, Institute of Basic Medical Sciences, Chinese Academy of Medical Sciences, School of Basic Medicine, Peking Union Medical College, Beijing, China
| | - Xiaoli Geng
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Xueling Chen
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Xiaoyan Liu
- Core Instrument Facility, Institute of Basic Medical Sciences, Chinese Academy of Medical Sciences, School of Basic Medicine, Peking Union Medical College, Beijing, China
| | - Haidan Sun
- Core Instrument Facility, Institute of Basic Medical Sciences, Chinese Academy of Medical Sciences, School of Basic Medicine, Peking Union Medical College, Beijing, China
| | - Zhengguang Guo
- Core Instrument Facility, Institute of Basic Medical Sciences, Chinese Academy of Medical Sciences, School of Basic Medicine, Peking Union Medical College, Beijing, China
| | - Jiameng Sun
- Core Instrument Facility, Institute of Basic Medical Sciences, Chinese Academy of Medical Sciences, School of Basic Medicine, Peking Union Medical College, Beijing, China
| | - Feng Qi
- Core Instrument Facility, Institute of Basic Medical Sciences, Chinese Academy of Medical Sciences, School of Basic Medicine, Peking Union Medical College, Beijing, China
| | - Xia Niu
- Core Instrument Facility, Institute of Basic Medical Sciences, Chinese Academy of Medical Sciences, School of Basic Medicine, Peking Union Medical College, Beijing, China
| | - Aiwei Wang
- Core Instrument Facility, Institute of Basic Medical Sciences, Chinese Academy of Medical Sciences, School of Basic Medicine, Peking Union Medical College, Beijing, China
| | - Jianghong He
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases (NCRC-ND), Beijing, China
| | - Wei Sun
- Core Instrument Facility, Institute of Basic Medical Sciences, Chinese Academy of Medical Sciences, School of Basic Medicine, Peking Union Medical College, Beijing, China.
| | - Long Xu
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.
- China National Clinical Research Center for Neurological Diseases (NCRC-ND), Beijing, China.
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Colomer C, Llorens R, Navarro MD, Noé E, Ferri J. Neurobehavioral Progress and Signs of Transition in Children With Prolonged Disorders of Consciousness: A Retrospective Longitudinal Study With the Coma Recovery Scale-Revised. Pediatr Neurol 2024; 155:187-192. [PMID: 38677241 DOI: 10.1016/j.pediatrneurol.2024.03.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Revised: 05/05/2023] [Accepted: 03/31/2024] [Indexed: 04/29/2024]
Abstract
BACKGROUND Research on disorders of consciousness in children is scarce and includes disparate and barely comparable participants and assessment instruments and therefore provides inconclusive information on the clinical progress and recovery in this population. This study retrospectively investigated the neurobehavioral progress and the signs of transition between states of consciousness in a group of children admitted to a rehabilitation program either with an unresponsive wakefulness syndrome (UWS) or in a minimally conscious state (MCS). METHODS Systematic weekly assessments were conducted with the Coma Recovery Scale-Revised (CRS-R) until emergence from MCS, discharge, or death. RESULTS Twenty-one children, nine admitted with a UWS and 12 admitted in an MCS, were included in the study. Four children with a UWS transitioned to an MCS with a CRS-R of 10 (9.2 to 12.2) by showing visual pursuit, visual fixation, or localization to noxious stimulation. Twelve children emerged from the MCS with a CRS-R of 20.5 (19 to 21.7). Children who emerged from the MCS had had a shorter time postinjury and higher CRS-R at admission, compared with those who did not emerge. CONCLUSIONS Almost half of the children who were admitted with a UWS transitioned to an MCS, and almost all who were admitted in an MCS emerged from this state. Children who emerged had shorter times since injury and higher scores on the CRS-R at admission, compared with those who did not emerge.
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Affiliation(s)
- Carolina Colomer
- IRENEA, Instituto de Rehabilitación Neurológica, Fundación Hospitales Vithas, València, Spain.
| | - Roberto Llorens
- IRENEA, Instituto de Rehabilitación Neurológica, Fundación Hospitales Vithas, València, Spain; Neurorehabilitation and Brain Research Group, Institute for Human-Centered Technology Research, Universitat Politècnica de València, València, Spain
| | - María Dolores Navarro
- IRENEA, Instituto de Rehabilitación Neurológica, Fundación Hospitales Vithas, València, Spain
| | - Enrique Noé
- IRENEA, Instituto de Rehabilitación Neurológica, Fundación Hospitales Vithas, València, Spain
| | - Joan Ferri
- IRENEA, Instituto de Rehabilitación Neurológica, Fundación Hospitales Vithas, València, Spain
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Zhong L, Wu M, Liu ZY, Liu Y, Liu ZF. Risk factors for brain injury in patients with exertional heatstroke: A 5-year experience. Chin J Traumatol 2024; 27:91-96. [PMID: 37973473 DOI: 10.1016/j.cjtee.2023.10.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2022] [Revised: 09/21/2023] [Accepted: 10/31/2023] [Indexed: 11/19/2023] Open
Abstract
PURPOSE Minimal data exist on brain injury in patients with exertional heatstroke (EHS) in developing country. In this study, we explored the risk factors for brain injury induced by EHS 90-day after onset. METHODS A retrospective cohort study of patients with EHS was conducted in the intensive care unit of the General Hospital of Southern Theater Command of PLA in China from April 2014 to June 2019. Patients were divided into non-brain injury (fully recovered) and brain injury groups (comprising deceased patients or those with neurological sequelae). The brain injury group was further subdivided into a death group and a sequela group for detailed analysis. General information, neurological performance and information on important organ injuries in the acute stage were recorded and analysed. Multivariable logistic regression was used to identify risk factors for brain injury after EHS and mortality risk factors for brain injury, and Kaplan-Meier survival curve was used to evaluate the effect of the neurological dysfunction on survival. RESULTS Out of the 147 EHS patients, 117 were enrolled, of which 96 (82.1%) recovered, 13 (11.1%) died, and 8 (6.8%) experienced neurological sequelae. Statistically significant differences were found between non-brain injury and brain injury groups in age, hypotension, duration of consciousness disorders, time to drop core body temperature below 38.5°C, lymphocyte counts, platelet counts, procalcitonin, alanine aminotransferase, aspartate aminotransferase, creatinine, cystatin C, coagulation parameters, international normalized ratio, acute physiology and chronic health evaluation II scores, sequential organ failure assessment (SOFA) scores, and Glasgow coma scale scores (all p < 0.05). Multivariate logistic regression showed that age (OR = 1.090, 95% CI: 1.02 - 1.17, p = 0.008), time to drop core temperature (OR = 8.223, 95% CI: 2.30 - 29.40, p = 0.001), and SOFA scores (OR = 1.676, 95% CI: 1.29 - 2.18, p < 0.001) are independent risk factors for brain injury induced by EHS. The Kaplan-Meier curves suggest significantly prolonged survival (p < 0.001) in patients with early Glasgow coma scale score > 8 and duration of consciousness disorders ≤ 24 h. CONCLUSIONS Advanced age, delayed cooling, and higher SOFA scores significantly increase the risk of brain injury post-EHS. These findings underscore the importance of rapid cooling and early assessment of organ failure to improve outcomes in EHS patients.
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Affiliation(s)
- Li Zhong
- Department of Traditional Chinese Medicine, The First Affiliated Hospital, Guizhou University of Chinese Medicine, Guiyang, 550001, China
| | - Ming Wu
- Department of Infection and Critical Care Medicine, The Second People's Hospital of Shenzhen & First Affiliated Hospital of Shenzhen University, Health Science Center, Shenzhen, Guangdong province, 518035, China
| | - Zhe-Ying Liu
- Department of Medical Critical Care Medicine, General Hospital of Southern Theatre Command of PLA, Guangzhou, 510010, China
| | - Yan Liu
- Department of Infection and Critical Care Medicine, The Second People's Hospital of Shenzhen & First Affiliated Hospital of Shenzhen University, Health Science Center, Shenzhen, Guangdong province, 518035, China
| | - Zhi-Feng Liu
- Department of Medical Critical Care Medicine, General Hospital of Southern Theatre Command of PLA, Guangzhou, 510010, China; Guangdong Branch Center, National Clinical Research Center for Geriatric Diseases (Chinese PLA General Hospital), Guangzhou, 510010, China.
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Boerwinkle VL, Manjón I, Sussman BL, McGary A, Mirea L, Gillette K, Broman-Fulks J, Cediel EG, Arhin M, Hunter SE, Wyckoff SN, Allred K, Tom D. Resting-State Functional Magnetic Resonance Imaging Network Association With Mortality, Epilepsy, Cognition, and Motor Two-Year Outcomes in Suspected Severe Neonatal Acute Brain Injury. Pediatr Neurol 2024; 152:41-55. [PMID: 38198979 DOI: 10.1016/j.pediatrneurol.2023.12.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Revised: 11/14/2023] [Accepted: 12/06/2023] [Indexed: 01/12/2024]
Abstract
BACKGROUND AND OBJECTIVES In acute brain injury of neonates, resting-state functional magnetic resonance imaging (MRI) (RS) showed incremental association with consciousness, mortality, cognitive and motor development, and epilepsy, with correction for multiple comparisons, at six months postgestation in neonates with suspected acute brain injury (ABI). However, there are relatively few developmental milestones at six months to benchmark against, thus, we extended this cohort study to evaluate two-year outcomes. METHODS In 40 consecutive neonates with ABI and RS, ordinal scores of resting-state networks; MRI, magnetic resonance spectroscopy, and electroencephalography; and up to 42-month outcomes of mortality, general and motor development, Pediatric Cerebral Performance Category Scale (PCPC), and epilepsy informed associations between tests and outcomes. RESULTS Mean gestational age was 37.8 weeks, 68% were male, and 60% had hypoxic-ischemic encephalopathy. Three died in-hospital, four at six to 42 months, and five were lost to follow-up. Associations included basal ganglia network with PCPC (P = 0.0003), all-mortality (P = 0.005), and motor (P = 0.0004); language/frontoparietal network with developmental delay (P = 0.009), PCPC (P = 0.006), and all-mortality (P = 0.01); default mode network with developmental delay (P = 0.003), PCPC (P = 0.004), neonatal intensive care unit mortality (P = 0.01), and motor (P = 0.009); RS seizure onset zone with epilepsy (P = 0.01); and anatomic MRI with epilepsy (P = 0.01). CONCLUSION For the first time, at any age, resting state functional MRI in ABI is associated with long-term epilepsy and RSNs predicted mortality in neonates. Severity of RSN abnormality was associated with incrementally worsened neurodevelopment including cognition, language, and motor function over two years.
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Affiliation(s)
- Varina L Boerwinkle
- Division of Child Neurology, University of North Carolina Medical School, Chapel Hill, North Carolina.
| | - Iliana Manjón
- University of Arizona College of Medicine - Tucson, Tucson, Arizona
| | - Bethany L Sussman
- Division of Neuroscience Research, Barrow Neurological Institute at Phoenix Children's Hospital, Phoenix, Arizona
| | - Alyssa McGary
- Department of Clinical Research, Phoenix Children's Hospital, Phoenix, Arizona
| | - Lucia Mirea
- Department of Clinical Research, Phoenix Children's Hospital, Phoenix, Arizona
| | - Kirsten Gillette
- Division of Child Neurology, University of North Carolina Medical School, Chapel Hill, North Carolina
| | - Jordan Broman-Fulks
- Division of Child Neurology, University of North Carolina Medical School, Chapel Hill, North Carolina
| | - Emilio G Cediel
- Division of Child Neurology, University of North Carolina Medical School, Chapel Hill, North Carolina
| | - Martin Arhin
- Division of Child Neurology, University of North Carolina Medical School, Chapel Hill, North Carolina
| | - Senyene E Hunter
- Division of Child Neurology, University of North Carolina Medical School, Chapel Hill, North Carolina
| | - Sarah N Wyckoff
- Division of Neuroscience Research, Barrow Neurological Institute at Phoenix Children's Hospital, Phoenix, Arizona
| | - Kimberlee Allred
- Division of Neonatology, Phoenix Children's Hospital, Phoenix, Arizona
| | - Deborah Tom
- Division of Neonatology, Phoenix Children's Hospital, Phoenix, Arizona
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Appel A, Spier E. Strategy and Philosophy for Treating Pain and Sleep in Disorders of Consciousness. Phys Med Rehabil Clin N Am 2024; 35:145-154. [PMID: 37993184 DOI: 10.1016/j.pmr.2023.06.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2023]
Abstract
Despite the evolving practice of brain injury medicine, consciousness remains enigmatic. Most patients with disorders of consciousness have disordered sleep and return of normal sleep architecture is essential to the emergence of consciousness and the healing brain. In this article we lay a framework for understanding the emergence of consciousness in brain-injured patients. We then explore ways to use that framework to evaluate and tailor treatment of sleep and pain in patients with disorders of consciousness. Although more research is needed to empower better treatment in the future, validated tools now exist for evaluation of emergent consciousness, pain, and sleep.
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Affiliation(s)
- Amanda Appel
- Department of Pediatric Rehabilitation Medicine, Children's Hospital Colorado, Aurora, CO, USA; Department of Pediatrics, Children's Hospital Colorado, Aurora, CO, USA; Department of Physical Medicine and Rehabilitation, University of Colorado Anschutz School of Medicine, Aurora, CO, USA
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10
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Monti MM, Beekman R, Spivak NM, Thibaut A, Schnakers C, Whyte J, Molteni E. Common Data Element for Disorders of Consciousness: Recommendations from the Working Group on Therapeutic Interventions. Neurocrit Care 2024; 40:51-57. [PMID: 38030874 DOI: 10.1007/s12028-023-01873-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2023] [Accepted: 09/29/2023] [Indexed: 12/01/2023]
Abstract
BACKGROUND Over the past 30 years, there have been significant advances in the understanding of the mechanisms associated with loss and recovery of consciousness following severe brain injury. This work has provided a strong grounding for the development of novel restorative therapeutic interventions. Although all interventions are aimed at modulating and thereby restoring brain function, the landscape of existing interventions encompasses a very wide scope of techniques and protocols. Despite vigorous research efforts, few approaches have been assessed with rigorous, high-quality randomized controlled trials. As a growing number of exploratory interventions emerge, it is paramount to develop standardized approaches to reporting results. The successful evaluation of novel interventions depends on implementation of shared nomenclature and infrastructure. To address this gap, the Neurocritical Care Society's Curing Coma Campaign convened nine working groups and charged them with developing common data elements (CDEs). Here, we report the work of the Therapeutic Interventions Working Group. METHODS The working group reviewed existing CDEs relevant to therapeutic interventions within the National Institutes of Health National Institute of Neurological Disorders and Stroke database and reviewed the literature for assessing key areas of research in the intervention space. CDEs were then proposed, iteratively discussed and reviewed, classified, and organized in a case report form (CRF). RESULTS We developed a unified CRF, including CDEs and key design elements (i.e., methodological or protocol parameters), divided into five sections: (1) patient information, (2) general study information, (3) behavioral interventions, (4) pharmacological interventions, and (5) device interventions. CONCLUSIONS The newly created CRF enhances systematization of future work by proposing a portfolio of measures that should be collected in the development and implementation of studies assessing novel interventions intended to increase the level of consciousness or rate of recovery of consciousness in patients with disorders of consciousness.
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Affiliation(s)
- Martin M Monti
- Department of Psychology, University of California Los Angeles, 6522 Pritzker Hall, Los Angeles, CA, USA.
| | - Rachel Beekman
- Department of Neurology, Yale University School of Medicine, New Haven, CT, USA
| | - Norman M Spivak
- David Geffen School of Medicine, University of California, Los Angeles, CA, USA
| | - Aurore Thibaut
- Coma Science Group, GIGA-Consciousness, University of Liège, Liège, Belgium
| | | | - John Whyte
- Moss Rehabilitation Research Institute, Elkins Park, PA, USA
| | - Erika Molteni
- School of Biomedical Engineering and Imaging Sciences, Faculty of Life Sciences and Medicine, School of Life Course Sciences, King's College London, London, UK
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11
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Harris KA, Zhou Y, Jou S, Greenwald BD. Disorders of Consciousness Programs: Components, Organization, and Implementation. Phys Med Rehabil Clin N Am 2024; 35:65-77. [PMID: 37993194 DOI: 10.1016/j.pmr.2023.06.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2023]
Abstract
Rehabilitation of patients with disorders of consciousness (DoC) presents unique challenges requiring comprehensive and specialized care. This article reviews the components, organization, and implementation of an inpatient DoC program under the framework of recent evidence-based practice guidelines and minimum competency recommendations. The evidence and clinical applications of these recommendations are elaborated upon with the goal of offering providers a reference to translate guidelines into clinical practice.
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Affiliation(s)
- Kristen A Harris
- JFK Johnson Rehabilitation Institute/Hackensack Meridian School of Medicine, Rutgers Robert Wood Johnson Medical School, 65 James Street, Edison, NJ 08820, USA.
| | - Yi Zhou
- JFK Johnson Rehabilitation Institute/Hackensack Meridian School of Medicine, Rutgers Robert Wood Johnson Medical School, 65 James Street, Edison, NJ 08820, USA
| | - Stacey Jou
- JFK Johnson Rehabilitation Institute/Hackensack Meridian School of Medicine, Rutgers Robert Wood Johnson Medical School, 65 James Street, Edison, NJ 08820, USA
| | - Brian D Greenwald
- JFK Johnson Rehabilitation Institute/Hackensack Meridian School of Medicine, Rutgers Robert Wood Johnson Medical School, 65 James Street, Edison, NJ 08820, USA
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12
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Marino MH. Pharmacology in Treatment of Patients with Disorders of Consciousness. Phys Med Rehabil Clin N Am 2024; 35:155-165. [PMID: 37993186 DOI: 10.1016/j.pmr.2023.06.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2023]
Abstract
Pharmacologic treatment of disorders of consciousness remains a critical but challenging task for clinicians. Amantadine has been shown to promote the rate of neurologic recovery for patients with traumatic disorders of consciousness when administered between 4 and 16 weeks, as demonstrated by a well-designed randomized control trial. While there are no large, randomized controlled trials to support the use of other dopaminergic medicines (bromocriptine, levodopa, apomorphine), there is a large body of literature implicating their role in improving alertness and responsiveness in disorders of consciousness. Zolpidem can increase the level of consciousness in a small subset of patients. Zolpidem and intrathecal baclofen likely increase the level of consciousness via the mesocircuit pathway. Psychostimulant medications can be initiated in patients, even without strong evidence to support their use, as long as basic principles of brain injury medicine are followed, and there are systems in place to evaluate therapeutic response.
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Affiliation(s)
- Michael H Marino
- Moss Rehab, 60 Township Line Road, Elkins Park, PA 19027, USA; Remed Residential Brain Injury Center.
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13
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Golden K, Bodien YG, Giacino JT. Disorders of Consciousness: Classification and Taxonomy. Phys Med Rehabil Clin N Am 2024; 35:15-33. [PMID: 37993185 DOI: 10.1016/j.pmr.2023.06.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2023]
Abstract
In this article, we discuss the taxonomy associated with the four major disorders of consciousness (DoC): coma, vegetative state or unresponsive wakefulness syndrome, minimally conscious state, and post-traumatic confusional state. We briefly review the history of each disorder and then provide operational definitions and diagnostic criteria for each one. We rely heavily on recently released practice guidelines and, where appropriate, identify knowledge gaps and discuss future directions to advance DoC research and practice.
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Affiliation(s)
- Katherine Golden
- School of Health & Rehabilitation Sciences, MGH Institute of Health Professions, 36 1st Avenue, Boston, MA 02129, USA
| | - Yelena G Bodien
- Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, 300 1st Avenue, Charlestown, MA, 02129, USA; Center for Neurotechnology and Neurorecovery, Department of Neurology, Massachusetts General Hospital and Harvard Medical School, 55 Fruit Street, Boston, MA 02114, USA; Department of Physical Medicine and Rehabilitation, Harvard Medical School, 25 Shattuck Street, Boston, MA, USA
| | - Joseph T Giacino
- Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, 300 1st Avenue, Charlestown, MA, 02129, USA; Center for Neurotechnology and Neurorecovery, Department of Neurology, Massachusetts General Hospital and Harvard Medical School, 55 Fruit Street, Boston, MA 02114, USA.
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14
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Woo JE, Azariah A, Reed EA, Gut N. Medical, Neurologic, and Neuromusculoskeletal Complications. Phys Med Rehabil Clin N Am 2024; 35:127-144. [PMID: 37993183 DOI: 10.1016/j.pmr.2023.06.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2023]
Abstract
For patients with disorders of consciousness (DoC), treating the medical, neurologic, and neuromuscular complications not only stabilizes their medical disturbances, but minimizes confounding factors that may obscure the ability to accurately identify the level of consciousness and increase the chance of patients' neurologic and functional recovery. Lack of reliable communication and low-level function of patients with DoC make it challenging to diagnose some of the complications. Skilled clinical observation will be imperative to appropriately care for the patients.
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Affiliation(s)
- Jean E Woo
- TIRR Memorial Hermann, 1333 Moursund Street, Houston, TX 77030, USA; H. Ben Taub Department of Physical Medicine and Rehabilitation, Baylor College of Medicine, 7200 Cambridge Street, Houston, TX 77030, USA.
| | - Abana Azariah
- TIRR Memorial Hermann, 1333 Moursund Street, Houston, TX 77030, USA; Department of Physical Medicine and Rehabilitation, McGovern Medical School, The University of Texas Health Science Center at Houston, 1333 Moursund Street, Houston, TX 77030, USA
| | - Eboni A Reed
- H. Ben Taub Department of Physical Medicine and Rehabilitation, Baylor College of Medicine, 7200 Cambridge Street, Houston, TX 77030, USA
| | - Nicholas Gut
- Department of Physical Medicine and Rehabilitation, McGovern Medical School, The University of Texas Health Science Center at Houston, 1333 Moursund Street, Houston, TX 77030, USA
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15
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Sangare A, Rohaut B, Borden A, Zyss J, Velazquez A, Doyle K, Naccache L, Claassen J. A Novel Approach to Screen for Somatosensory Evoked Potentials in Critical Care. Neurocrit Care 2024; 40:237-250. [PMID: 36991177 DOI: 10.1007/s12028-023-01710-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2022] [Accepted: 02/27/2023] [Indexed: 03/31/2023]
Abstract
BACKGROUND Somatosensory evoked potentials (SSEPs) help prognostication, particularly in patients with diffuse brain injury. However, use of SSEP is limited in critical care. We propose a novel, low-cost approach allowing acquisition of screening SSEP using widely available intensive care unit (ICU) equipment, specifically a peripheral "train-of-four" stimulator and standard electroencephalograph. METHODS The median nerve was stimulated using a train-of-four stimulator, and a standard 21-channel electroencephalograph was recorded to generate the screening SSEP. Generation of the SSEP was supported by visual inspection, univariate event-related potentials statistics, and a multivariate support vector machine (SVM) decoding algorithm. This approach was validated in 15 healthy volunteers and validated against standard SSEPs in 10 ICU patients. The ability of this approach to predict poor neurological outcome, defined as death, vegetative state, or severe disability at 6 months, was tested in an additional set of 39 ICU patients. RESULTS In each of the healthy volunteers, both the univariate and the SVM methods reliably detected SSEP responses. In patients, when compared against the standard SSEP method, the univariate event-related potentials method matched in nine of ten patients (sensitivity = 94%, specificity = 100%), and the SVM had 100% sensitivity and specificity when compared with the standard method. For the 49 ICU patients, we performed both the univariate and the SVM methods: a bilateral absence of short latency responses (n = 8) predicted poor neurological outcome with 0% FPR (sensitivity = 21%, specificity = 100%). CONCLUSIONS Somatosensory evoked potentials can reliably be recorded using the proposed approach. Given the very good but slightly lower sensitivity of absent SSEPs in the proposed screening approach, confirmation of absent SSEP responses using standard SSEP recordings is advised.
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Affiliation(s)
- Aude Sangare
- Brain Institute, ICM, CNRS, Sorbonne Université, Inserm U1127, UMR 7225, Paris, France.
- Department of Neurophysiology, Pitié-Salpêtrière, Groupe Hospitalier Universitaire Assistance Publique-Hôpitaux de Paris Sorbonne Université, Paris, France.
- Sorbonne University, Paris, France.
| | - Benjamin Rohaut
- Brain Institute, ICM, CNRS, Sorbonne Université, Inserm U1127, UMR 7225, Paris, France
- Department of Neurophysiology, Pitié-Salpêtrière, Groupe Hospitalier Universitaire Assistance Publique-Hôpitaux de Paris Sorbonne Université, Paris, France
- Neurological Intensive Care Unit, Department of Neurology, Pitié-Salpêtrière, Groupe Hospitalier Universitaire Assistance Publique-Hôpitaux de Paris Sorbonne Université, Paris, France
- Department of Neurology, Columbia University, New York, NY, USA
- New York Presbyterian Hospital, New York, NY, USA
| | - Alaina Borden
- Department of Neurophysiology, Pitié-Salpêtrière, Groupe Hospitalier Universitaire Assistance Publique-Hôpitaux de Paris Sorbonne Université, Paris, France
| | - Julie Zyss
- Department of Neurophysiology, Pitié-Salpêtrière, Groupe Hospitalier Universitaire Assistance Publique-Hôpitaux de Paris Sorbonne Université, Paris, France
| | | | - Kevin Doyle
- Department of Neurology, Columbia University, New York, NY, USA
| | - Lionel Naccache
- Brain Institute, ICM, CNRS, Sorbonne Université, Inserm U1127, UMR 7225, Paris, France
- Department of Neurophysiology, Pitié-Salpêtrière, Groupe Hospitalier Universitaire Assistance Publique-Hôpitaux de Paris Sorbonne Université, Paris, France
- Sorbonne University, Paris, France
| | - Jan Claassen
- Department of Neurology, Columbia University, New York, NY, USA
- New York Presbyterian Hospital, New York, NY, USA
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16
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Cho SM, Robba C, Diringer MN, Hanley DF, Hemphill JC, Horn J, Lewis A, Livesay SL, Menon D, Sharshar T, Stevens RD, Torner J, Vespa PM, Ziai WC, Spann M, Helbok R, Suarez JI. Optimal Design of Clinical Trials Involving Persons with Disorders of Consciousness. Neurocrit Care 2024; 40:74-80. [PMID: 37535178 DOI: 10.1007/s12028-023-01813-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2023] [Accepted: 07/11/2023] [Indexed: 08/04/2023]
Abstract
BACKGROUND Limited data exist regarding the optimal clinical trial design for studies involving persons with disorders of consciousness (DoC), and only a few therapies have been tested in high-quality clinical trials. To address this, the Curing Coma Campaign Clinical Trial Working Group performed a gap analysis on the current state of clinical trials in DoC to identify the optimal clinical design for studies involving persons with DoC. METHODS The Curing Coma Campaign Clinical Trial Working Group was divided into three subgroups to (1) review clinical trials involving persons with DoC, (2) identify unique challenges in the design of clinical trials involving persons with DoC, and (3) recommend optimal clinical trial designs for DoC. RESULTS There were 3055 studies screened, and 66 were included in this review. Several knowledge gaps and unique challenges were identified. There is a lack of high-quality clinical trials, and most data regarding patients with DoC are based on observational studies focusing on patients with traumatic brain injury and cardiac arrest. There is a lack of a structured long-term outcome assessment with significant heterogeneity in the methodology, definitions of outcomes, and conduct of studies, especially for long-term follow-up. Another major barrier to conducting clinical trials is the lack of resources, especially in low-income countries. Based on the available data, we recommend incorporating trial designs that use master protocols, sequential multiple assessment randomized trials, and comparative effectiveness research. Adaptive platform trials using a multiarm, multistage approach offer substantial advantages and should make use of biomarkers to assess treatment responses to increase trial efficiency. Finally, sound infrastructure and international collaboration are essential to facilitate the conduct of trials in patients with DoC. CONCLUSIONS Conduct of trials in patients with DoC should make use of master protocols and adaptive design and establish international registries incorporating standardized assessment tools. This will allow the establishment of evidence-based practice recommendations and decrease variations in care.
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Affiliation(s)
- Sung-Min Cho
- Neuroscience Critical Care Division, Departments of Neurology, and Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, 600 N. Wolfe Street , Baltimore, MD, 21287, USA
| | - Chiara Robba
- IRCCS for Oncology and Neuroscience and Department of Surgical Science and Integrated Diagnostic, San Martino Policlinico Hospital, University of Genoa, Genoa, Italy
| | - Michael N Diringer
- Departments of Neurology, Washington University in St. Louis, St. Louis, MO, USA
| | - Daniel F Hanley
- Neuroscience Critical Care Division, Departments of Neurology, and Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, 600 N. Wolfe Street , Baltimore, MD, 21287, USA
| | - J Claude Hemphill
- Weill Institute for Neurosciences, University of California, San Francisco, San Francisco, CA, USA
| | | | - Ariane Lewis
- Division of Neurocritical Care, Department of Neurology and Neurosurgery, New York University, New York, NY, USA
| | - Sarah L Livesay
- Department of Adult Health and Gerontological Nursing, College of Nursing, Rush University, Chicago, IL, USA
| | - David Menon
- Department of Medicine, University of Cambridge, Cambridge, UK
| | - Tarek Sharshar
- Departments of Neurology and Intensive Care Medicine, Paris-Descartes University, Paris, France
| | - Robert D Stevens
- Neuroscience Critical Care Division, Departments of Neurology, and Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, 600 N. Wolfe Street , Baltimore, MD, 21287, USA
| | - James Torner
- Department of Epidemiology, University of Iowa, Iowa City, IA, USA
| | - Paul M Vespa
- Departments of Neurology and Neurosurgery, University of California, Los Angeles, Los Angeles, CA, USA
| | - Wendy C Ziai
- Neuroscience Critical Care Division, Departments of Neurology, and Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, 600 N. Wolfe Street , Baltimore, MD, 21287, USA
| | - Marcus Spann
- Neuroscience Critical Care Division, Departments of Neurology, and Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, 600 N. Wolfe Street , Baltimore, MD, 21287, USA
| | - Raimund Helbok
- Departments of Neurology and Medicine, Innsbruck Medical University, Innsbruck, Austria
| | - Jose I Suarez
- Neuroscience Critical Care Division, Departments of Neurology, and Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, 600 N. Wolfe Street , Baltimore, MD, 21287, USA.
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17
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Abstract
Patients with disorders of consciousness who survive to discharge following severe acute brain injury may face profoundly complex medical, ethical, and psychosocial challenges during their courses of recovery and rehabilitation. Although issues encountered in caring for such patients during acute hospitalization have received substantial attention, ethical challenges that may arise in subacute and chronic phases have been underexplored. Shedding light on these issues, this article explores the landscape of normative issues in the course of treating and facilitating access to care for persons with disorders of consciousness during rehabilitation and examines potential implications for patients, clinicians, family members, and society.
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Affiliation(s)
- Michael J Young
- Department of Neurology, Massachusetts General Hospital, Center for Neurotechnology and Neurorecovery, 101 Merrimac Street, Suite 310, Boston, MA 02114, USA.
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18
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Xu LB, Hampton S, Fischer D. Neuroimaging in Disorders of Consciousness and Recovery. Phys Med Rehabil Clin N Am 2024; 35:51-64. [PMID: 37993193 DOI: 10.1016/j.pmr.2023.06.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2023]
Abstract
There is a clinical need for more accurate diagnosis and prognostication in patients with disorders of consciousness (DoC). There are several neuroimaging modalities that enable detailed, quantitative assessment of structural and functional brain injury, with demonstrated diagnostic and prognostic value. Additionally, longitudinal neuroimaging studies have hinted at quantifiable structural and functional neuroimaging biomarkers of recovery, with potential implications for the management of DoC.
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Affiliation(s)
- Linda B Xu
- Department of Neurology, University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA 19104, USA.
| | - Stephen Hampton
- Department of Physical Medicine and Rehabilitation, University of Pennsylvania, 1800 Lombard Street, Philadelphia, PA 19146, USA
| | - David Fischer
- Department of Neurology, University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA 19104, USA.
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19
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Young MJ, Kazazian K, Fischer D, Lissak IA, Bodien YG, Edlow BL. Disclosing Results of Tests for Covert Consciousness: A Framework for Ethical Translation. Neurocrit Care 2024:10.1007/s12028-023-01899-8. [PMID: 38243150 DOI: 10.1007/s12028-023-01899-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Accepted: 11/22/2023] [Indexed: 01/21/2024]
Abstract
The advent of neurotechnologies including advanced functional magnetic resonance imaging and electroencephalography to detect states of awareness not detectable by traditional bedside neurobehavioral techniques (i.e., covert consciousness) promises to transform neuroscience research and clinical practice for patients with brain injury. As these interventions progress from research tools into actionable, guideline-endorsed clinical tests, ethical guidance for clinicians on how to responsibly communicate the sensitive results they yield is crucial yet remains underdeveloped. Drawing on insights from empirical and theoretical neuroethics research and our clinical experience with advanced neurotechnologies to detect consciousness in behaviorally unresponsive patients, we critically evaluate ethical promises and perils associated with disclosing the results of clinical covert consciousness assessments and describe a semistructured approach to responsible data sharing to mitigate potential risks.
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Affiliation(s)
- Michael J Young
- Center for Neurotechnology and Neurorecovery, Department of Neurology, Massachusetts General Hospital and Harvard Medical School, 101 Merrimac Street, Suite 310, Boston, MA, 02114, USA.
| | - Karnig Kazazian
- Center for Neurotechnology and Neurorecovery, Department of Neurology, Massachusetts General Hospital and Harvard Medical School, 101 Merrimac Street, Suite 310, Boston, MA, 02114, USA
- Western Institute of Neuroscience, Western University, London, ON, Canada
| | - David Fischer
- University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - India A Lissak
- Center for Neurotechnology and Neurorecovery, Department of Neurology, Massachusetts General Hospital and Harvard Medical School, 101 Merrimac Street, Suite 310, Boston, MA, 02114, USA
| | - Yelena G Bodien
- Center for Neurotechnology and Neurorecovery, Department of Neurology, Massachusetts General Hospital and Harvard Medical School, 101 Merrimac Street, Suite 310, Boston, MA, 02114, USA
| | - Brian L Edlow
- Center for Neurotechnology and Neurorecovery, Department of Neurology, Massachusetts General Hospital and Harvard Medical School, 101 Merrimac Street, Suite 310, Boston, MA, 02114, USA
- Athinoula A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital and Harvard Medical School, Charlestown, MA, USA
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20
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Cruse D, Ragazinskaite K, Chinner A, Bareham C, Roberts N, Banner R, Chennu S, Villa D. Family caregivers' sense-making of the results of functional neurodiagnostics for patients with Prolonged Disorders of Consciousness. Neuropsychol Rehabil 2024:1-22. [PMID: 38230516 DOI: 10.1080/09602011.2023.2299448] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2023] [Accepted: 12/06/2023] [Indexed: 01/18/2024]
Abstract
Functional neuroimaging and electrophysiological assessments can identify evidence of residual consciousness and cognition in patients with prolonged disorders of consciousness (PDOC) who are otherwise behaviourally unresponsive. These functional neurodiagnostics are increasingly available in clinical settings and are recommended by international clinical guidelines to reduce diagnostic and prognostic uncertainty, and thereby assist family caregivers in their best-interests decision-making. Nevertheless, little is known about how family caregivers make sense of the results of these state-of-the-art functional neurodiagnostics. By applying Interpretative Phenomenological Analysis (IPA) to interviews with family caregivers of patients with diagnoses of PDOC who had received a functional neurodiagnostic assessment, we identify three primary themes of sense-making: The special significance of "brain scans"; A dynamic sense-making process; Holding on to hope and holding on to the person. These themes highlight the challenges of helping family caregivers to balance the relative importance of functional neurodiagnostic results with other clinical assessments and identify an ability of family caregivers to hold a contradiction in which they hope for recovery but simultaneously express a rational understanding of evidence to the contrary. We offer several recommendations for the ways in which family caregivers can be better supported to make sense of the results of functional neurodiagnostics.
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Affiliation(s)
- Damian Cruse
- Centre for Human Brain Health, University of Birmingham, Edgbaston, UK
- School of Psychology, University of Birmingham, Edgbaston, UK
| | | | - Amy Chinner
- School of Psychology, University of Birmingham, Edgbaston, UK
| | | | - Neil Roberts
- Sawbridgeworth Medical Services, Jacobs & Gardens Neuro Centres, Sawbridgeworth, UK
| | - Ruth Banner
- Birmingham Community Healthcare NHS Foundation Trust, Birmingham, UK
| | - Srivas Chennu
- School of Computing, University of Kent, Canterbury, UK
| | - Darrelle Villa
- School of Psychology, University of Birmingham, Edgbaston, UK
- Centre for Applied Psychology, University of Birmingham, Edgbaston, UK
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21
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Drążyk D, Przewrocki K, Górska-Klimowska U, Binder M. Distinct Spectral Profiles of Awake Resting EEG in Disorders of Consciousness: The Role of Frequency and Topography of Oscillations. Brain Topogr 2024; 37:138-151. [PMID: 38158511 PMCID: PMC10771586 DOI: 10.1007/s10548-023-01024-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2022] [Accepted: 11/18/2023] [Indexed: 01/03/2024]
Abstract
The prolonged disorders of consciousness (PDOC) pose a challenge for an accurate clinical diagnosis, mainly due to patients' scarce or ambiguous behavioral responsiveness. Measurement of brain activity can support better diagnosis, independent of motor restrictions. Methods based on spectral analysis of resting-state EEG appear as a promising path, revealing specific changes within the internal brain dynamics in PDOC patients. In this study we used a robust method of resting-state EEG power spectrum parameter extraction to identify distinct spectral properties for different types of PDOC. Sixty patients and 37 healthy volunteers participated in this study. Patient group consisted of 22 unresponsive wakefulness patients, 25 minimally conscious patients and 13 patients emerging from the minimally conscious state. Ten minutes of resting EEG was acquired during wakefulness and transformed into individual power spectra. For each patient, using the spectral decomposition algorithm, we extracted maximum peak frequency within 1-14 Hz range in the centro-parietal region, and the antero-posterior (AP) gradient of the maximal frequency peak. All patients were behaviorally diagnosed using coma recovery scale-revised (CRS-R). The maximal peak frequency in the 1-14 Hz range successfully predicted both neurobehavioral capacity of patients as indicated by CRS-R total score and PDOC diagnosis. Additionally, in patients in whom only one peak within the 1-14 Hz range was observed, the AP gradient significantly contributed to the accuracy of prediction. We have identified three distinct spectral profiles of patients, likely representing separate neurophysiological modes of thalamocortical functioning. Etiology did not have significant influence on the obtained results.
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Affiliation(s)
- Dominika Drążyk
- Institute of Neurosciences, Université Catholique de Louvain, Brussels, Belgium
| | - Karol Przewrocki
- Donders Institute for Brain, Cognition and Behavior, Radboud University Nijmegen, Nijmegen, Netherlands
| | | | - Marek Binder
- Institute of Psychology, Jagiellonian University, Ul. Ingardena 6, 30-060, Krakow, Poland.
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22
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Estraneo A, Briand MM, Noé E. Medical comorbidities in patients with prolonged disorder of consciousness: A narrative review. NeuroRehabilitation 2024; 54:61-73. [PMID: 38217620 DOI: 10.3233/nre-230130] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2024]
Abstract
BACKGROUND A few studies specifically addressed medical comorbidities (MCs) in patients with severe acquired traumatic or non-traumatic brain injury and prolonged disorders of consciousness (pDoC; i.e., patients in vegetative state/unresponsive wakefulness syndrome, VS/UWS, or in minimally conscious state, MCS). OBJECTIVE To provide an overview on incidence of MCs in patients with pDoC. METHODS Narrative review on most impacting MCs in patients with pDoC, both those directly related to brain damage (epilepsy, neurosurgical complications, spasticity, paroxysmal sympathetic hyperactivity, PSH), and those related to severe disability and prolonged immobility (respiratory comorbidities, endocrine disorders, metabolic abnormalities, heterotopic ossifications). RESULTS Patients with pDoC are at high risk to develop at least one MC. Moderate or severe respiratory and musculoskeletal comorbidities are the most common MCs. Epilepsy and PSH seem to be more frequent in patients in VS/UWS compared to patients in MCS, likely because of higher severity in the brain damage in VS. Endocrine metabolic, PSH and respiratory complications are less frequent in traumatic etiology, whereas neurogenic heterotopic ossifications are more frequent in traumatic etiology. Spasticity did not significantly differ between VS/UWS and MCS and in the three etiologies. MCs are associated with higher mortality rates, worse clinical improvement and can impact accuracy in the clinical diagnosis. CONCLUSIONS The frequent occurrence of several MCs requires a specialized rehabilitative setting with high level of multidisciplinary medical expertise to prevent, appropriately recognize and treat them. Comprehensive rehabilitation could avoid possible progression to more serious complications that can negatively impact clinical outcomes.
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Affiliation(s)
- Anna Estraneo
- IRCCS Fondazione Don Carlo Gnocchi ONLUS, Florence, Italy
| | - Marie-Michele Briand
- Research Center of Hôpital du Sacré-Coeur de Montréal, CIUSSS-NÎM, Montreal, QC, Canada
- Institutde Réadaptation en Déficience Physique de Québec, Quebec, QC, Canada
- Faculty of Medicine, Université de Montréal, Montreal, QC, Canada
| | - Enrique Noé
- IRENEA-Instituto de Rehabilitación Neurológica, Fundación Hospitales Vithas, Valencia, Spain
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Hu Y, Hu L, Wang Y, Luo X, Zhao X, He L. The effects of non-invasive brain stimulation on disorder of consciousness in patients with brain injury: A systematic review and meta-analysis of randomized controlled trial. Brain Res 2024; 1822:148633. [PMID: 37839670 DOI: 10.1016/j.brainres.2023.148633] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Revised: 09/30/2023] [Accepted: 10/11/2023] [Indexed: 10/17/2023]
Abstract
INTRODUCTION Disorders of consciousness (DOC) result from neural system injury and manifest as changes in arousal or awareness. This systematic review and meta-analysis aimed to investigate the therapeutic effects of non-invasive brain stimulation (NIBS) techniques, such as transcranial magnetic stimulation (TMS) and transcranial direct current stimulation (tDCS), on consciousness dysfunction in patients with brain disorders. METHODS Literature was systematically searched in Medline, Embase, Cochrane database, Web of Science, EBSCO from inception to May 2023. Only randomized controlled trial with NIBS as an intervention and participants with DOC were included. RESULTS A total of 7 studies with 313 participants were included for meta-analysis. Compared with sham- or placebo-stimulation, NIBS can improve the Coma Recovery Scale-Revised scores significantly (mean difference [MD] = 1.96, 95 % confidence interval [CI] = [1.49; 2.43], P <.0001). CONCLUSION NIBS has a significant positive effect in enhancing the symptoms of DOC. Nevertheless, it is imperative for further investigations comprising high-quality research designs and larger sample sizes in order to comprehensively elucidate the effects of NIBS techniques on diverse targets of stimulation within the population of individuals suffering from DOC.
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Affiliation(s)
- Yu Hu
- Department of Rehabilitation Medicine, The Third People's Hospital of Chengdu, Affiliated Hospital of Southwest Jiaotong University, 82 Qinglong Street, Chengdu 610014, China.
| | - Linzhe Hu
- Department of Rehabilitation Medicine, The Third People's Hospital of Chengdu, Affiliated Hospital of Southwest Jiaotong University, 82 Qinglong Street, Chengdu 610014, China.
| | - Yuchan Wang
- Department of Rehabilitation Medicine, The Third People's Hospital of Chengdu, Affiliated Hospital of Southwest Jiaotong University, 82 Qinglong Street, Chengdu 610014, China.
| | - Xiaozhou Luo
- Department of Rehabilitation Medicine, The Third People's Hospital of Chengdu, Affiliated Hospital of Southwest Jiaotong University, 82 Qinglong Street, Chengdu 610014, China.
| | - Xin Zhao
- Department of Rehabilitation Medicine, The Third People's Hospital of Chengdu, Affiliated Hospital of Southwest Jiaotong University, 82 Qinglong Street, Chengdu 610014, China.
| | - Lin He
- Department of Rehabilitation Medicine, West China Hospital, Sichuan University, GuoXueXiang 37, Chengdu 610041, China.
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Farisco M, Formisano R, Gosseries O, Kato Y, Koboyashi S, Laureys S, Lejeune N, Martial C, Matar A, Morrisey AM, Schnakers C, Yakufujiang M, Yamaki T, Veeramuthu V, Zandalasini M, Zasler N, Magliacano A, Estraneo A. International survey on the implementation of the European and American guidelines on disorders of consciousness. J Neurol 2024; 271:395-407. [PMID: 37740739 PMCID: PMC10770208 DOI: 10.1007/s00415-023-11956-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2023] [Revised: 08/17/2023] [Accepted: 08/18/2023] [Indexed: 09/25/2023]
Abstract
Diagnostic, prognostic, and therapeutic procedures for patients with prolonged disorders of consciousness (pDoCs) vary significantly across countries and clinical settings, likely due to organizational factors (e.g., research vs. non-academic hospitals), expertise and availability of resources (e.g., financial and human). Two international guidelines, one from the European Academy of Neurology (EAN) and one from the American Academy of Neurology (AAN) in collaboration with the American Congress of Rehabilitation Medicine (ACRM) and the National Institute on Disability, Independent Living, and Rehabilitation Research (NIDILRR), were developed to facilitate consistent practice among professionals working with this challenging patient population. While the recommendations of both guidelines agree in principle, it remains an open issue how to implement them into clinical practice in the care pathway for patients with pDoCs. We conducted an online survey to explore health professional clinical practices related to the management of patients with pDoCs, and compare said practices with selected recommendations from both the guidelines. The survey revealed that while some recommendations are being followed, others are not and/or may require more honing/specificity to enhance their clinical utility. Particular attention should be given to the implementation of a multimodal assessment of residual consciousness, to the detection and treatment of pain, and to the impact of restrictions imposed by COVID-19 pandemics on the involvement of patients' families/representatives.
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Affiliation(s)
- Michele Farisco
- Centre for Research Ethics and Bioethics, Uppsala University, Uppsala, Sweden.
- Biogem, Biology and Molecular Genetics Research Institute, Ariano Irpino, AV, Italy.
| | | | - Olivia Gosseries
- Coma Science Group, GIGA-Consciousness, University of Liège, Liège, Belgium
- Centre du Cerveau, University Hospital of Liège, Liège, Belgium
| | - Yoko Kato
- Department of Neurosurgery, Fujita Health University Bantane Hospital, Nagoya, Aichi, Japan
| | - Shigeki Koboyashi
- Division of Neurosurgery, Rehabilitation Center for Traumatic Apallics Chiba, National Agency for Automotive Safety and Victims' Aid, 3-30-1 Isobe, Mihamaku, Chibashi, Chiba, 261-0012, Japan
| | - Steven Laureys
- Coma Science Group, GIGA-Consciousness, University of Liège, Liège, Belgium
- Centre du Cerveau, University Hospital of Liège, Liège, Belgium
- CERVO Brain Research Center, University of Laval, Québec, QC, Canada
| | - Nicolas Lejeune
- Coma Science Group, GIGA-Consciousness, University of Liège, Liège, Belgium
- CHN William Lennox, Ottignies-Louvain-La Neuve, Belgium
- Institute of NeuroScienceUCLouvain, Ottignies-Louvain-La Neuve, Belgium
| | - Charlotte Martial
- Coma Science Group, GIGA-Consciousness, University of Liège, Liège, Belgium
- Centre du Cerveau, University Hospital of Liège, Liège, Belgium
| | - Amal Matar
- Centre for Research Ethics and Bioethics, Uppsala University, Uppsala, Sweden
| | - Ann-Marie Morrisey
- School of Allied Health, Faculty of Education and Health Sciences, Ageing Research Centre, Health Research Institute, University of Limerick, Limerick, Ireland
| | - Caroline Schnakers
- Research Institute, Casa Colina Hospital and Centers for Healthcare, Pomona, CA, USA
| | - Maidinamu Yakufujiang
- Division of Neurosurgery, Rehabilitation Center for Traumatic Apallics Chiba, National Agency for Automotive Safety and Victims' Aid, 3-30-1 Isobe, Mihamaku, Chibashi, Chiba, 261-0012, Japan
| | - Tomohiro Yamaki
- Division of Neurosurgery, Rehabilitation Center for Traumatic Apallics Chiba, National Agency for Automotive Safety and Victims' Aid, 3-30-1 Isobe, Mihamaku, Chibashi, Chiba, 261-0012, Japan
| | | | - Matteo Zandalasini
- Unità Spinale, Neuroriabilitazione E Medicina Riabilitativa Intensiva, Dipartimento Di Medicina Riabilitativa, Azienda USL Di Piacenza, Piacenza, Italy
| | - Nathan Zasler
- Concussion Care Centre of Virginia, LTD, Henrico, VA, 23233, USA
- Department of Physical Medicine and Rehabilitation, Virginia Commonwealth University, Richmond, VA, 23298, USA
| | - Alfonso Magliacano
- IRCCS Fondazione Don Carlo Gnocchi ONLUS, Florence and Sant'Angelo dei Lombardi, AV, Italy
| | - Anna Estraneo
- IRCCS Fondazione Don Carlo Gnocchi ONLUS, Florence and Sant'Angelo dei Lombardi, AV, Italy
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25
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Russell ME, Hammond FM, Murtaugh B. Prognosis and enhancement of recovery in disorders of consciousness. NeuroRehabilitation 2024; 54:43-59. [PMID: 38277313 DOI: 10.3233/nre-230148] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2024]
Abstract
Disorders of consciousness after severe brain injury encompass conditions of coma, vegetative state/unresponsive wakefulness syndrome, and minimally conscious state. DoC clinical presentation pose perplexing challenges to medical professionals, researchers, and families alike. The outcome is uncertain in the first weeks to months after a brain injury, with families and medical providers often making important decisions that require certainty. Prognostication for individuals with these conditions has been the subject of intense scientific investigation that continues to strive for valid prognostic indicators and algorithms for predicting recovery of consciousness. This manuscript aims to provide an overview of the current clinical landscape surrounding prognosis and optimizing recovery in DoC and the current and future research that could improve prognostic accuracy after severe brain injury. Improved understanding of these factors will aid healthcare professionals in providing optimal care, fostering hope, and advocating for ethical practices in the management of individuals with DoC.
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Affiliation(s)
- Mary E Russell
- Department of Physical Medicine and Rehabilitation, University of Texas McGovern Medical School, Houston, TX, USA
- TIRR Memorial Hermann - The Woodlands, Shenandoah, TX, USA
| | - Flora M Hammond
- Department of Physical Medicine and Rehabilitation, Indiana University School of Medicine, Indianapolis, IN, USA
- Rehabilitation Hospital of Indiana, Indianapolis, IN, USA
| | - Brooke Murtaugh
- Department of Rehabilitation Programs, Madonna Rehabilitation Hospitals, Lincoln, NE, USA
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26
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Ren S, Zhu J, Xie X, Liu X, Jiang H, Ying C, Hu J, Di H, Hu N. The visual stimulation in disorders of consciousness. Appl Neuropsychol Adult 2023:1-8. [PMID: 38104423 DOI: 10.1080/23279095.2023.2292244] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/19/2023]
Abstract
Severe brain damage usually leads to disorders of consciousness (DOC), which include coma, unresponsive wakefulness syndrome (UWS) and a minimally conscious state (MCS). Visual stimulation is widely used, especially in the diagnosis and treatment and treatment of DOC. Researchers have indicated that tests based on visual stimulation including visual pursuit, when used in conjunction with the Coma Recovery Scale-Revised, are able to differentiate between UWS from an MCS. Recently, targeting patients' circadian rhythms has been proposed to be a possible treatment target for DOC. Indeed, light therapy has been applied in some other fields, including treating seasonal affective disorder, sleep problems, and Parkinson's disease. However, at present, although visual stimulation and light therapy are frequently used in DOC, there is still no international unified standard. Therefore, we recommend the development of an international consensus in regard to the definitions, operational criteria and assessment procedures of visual stimulation and light therapy. This review combines visual stimulation, circadian rhythm recovery, and light therapy in DOC patients and presents the mechanisms and current advances in applications related to light therapy and visual stimulation in an attempt to provide additional ideas for future research and treatment of DOC.
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Affiliation(s)
- Siyan Ren
- International Unresponsive Wakefulness Syndrome and Consciousness Science Institute, Hangzhou Normal University, Hangzhou, China
| | - Jiajie Zhu
- Department of Pediatric Surgery, Children's Hospital of Fudan University, Shanghai Key Laboratory of Birth Defect, Shanghai, China
| | - Xiangyu Xie
- International Unresponsive Wakefulness Syndrome and Consciousness Science Institute, Hangzhou Normal University, Hangzhou, China
| | - Ximeng Liu
- International Unresponsive Wakefulness Syndrome and Consciousness Science Institute, Hangzhou Normal University, Hangzhou, China
| | - Hui Jiang
- International Unresponsive Wakefulness Syndrome and Consciousness Science Institute, Hangzhou Normal University, Hangzhou, China
| | - Chenxi Ying
- International Unresponsive Wakefulness Syndrome and Consciousness Science Institute, Hangzhou Normal University, Hangzhou, China
| | - Jia Hu
- International Unresponsive Wakefulness Syndrome and Consciousness Science Institute, Hangzhou Normal University, Hangzhou, China
| | - Haibo Di
- International Unresponsive Wakefulness Syndrome and Consciousness Science Institute, Hangzhou Normal University, Hangzhou, China
| | - Nantu Hu
- International Unresponsive Wakefulness Syndrome and Consciousness Science Institute, Hangzhou Normal University, Hangzhou, China
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Soulier T, Colliot O, Ayache N, Rohaut B. How will tomorrow's algorithms fuse multimodal data? The example of the neuroprognosis in Intensive Care. Anaesth Crit Care Pain Med 2023; 42:101301. [PMID: 37709200 DOI: 10.1016/j.accpm.2023.101301] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2023] [Accepted: 09/03/2023] [Indexed: 09/16/2023]
Affiliation(s)
- Théodore Soulier
- Sorbonne Université, Institut du Cerveau - Paris Brain Institute - ICM, CNRS, Inserm, AP-HP, Hôpital de la Pitié Salpêtrière, F-75013, Paris, France.
| | - Olivier Colliot
- Sorbonne Université, Institut du Cerveau - Paris Brain Institute - ICM, CNRS, Inria, Inserm, AP-HP, Hôpital de la Pitié Salpêtrière, F-75013, Paris, France
| | | | - Benjamin Rohaut
- Sorbonne Université, Institut du Cerveau - Paris Brain Institute - ICM, CNRS, Inserm, AP-HP, Hôpital de la Pitié Salpêtrière, F-75013, Paris, France; Department of Neurology, Groupe Hospitalier Pitié-Salpêtrière, AP-HP, Paris, France
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28
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Lewis A, Young MJ, Rohaut B, Jox RJ, Claassen J, Creutzfeldt CJ, Illes J, Kirschen M, Trevick S, Fins JJ. Ethics Along the Continuum of Research Involving Persons with Disorders of Consciousness. Neurocrit Care 2023; 39:565-577. [PMID: 36977963 PMCID: PMC11023737 DOI: 10.1007/s12028-023-01708-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2022] [Accepted: 02/23/2023] [Indexed: 03/30/2023]
Abstract
Interest in disorders of consciousness (DoC) has grown substantially over the past decade and has illuminated the importance of improving understanding of DoC biology; care needs (use of monitoring, performance of interventions, and provision of emotional support); treatment options to promote recovery; and outcome prediction. Exploration of these topics requires awareness of numerous ethics considerations related to rights and resources. The Curing Coma Campaign Ethics Working Group used its expertise in neurocritical care, neuropalliative care, neuroethics, neuroscience, philosophy, and research to formulate an informal review of ethics considerations along the continuum of research involving persons with DoC related to the following: (1) study design; (2) comparison of risks versus benefits; (3) selection of inclusion and exclusion criteria; (4) screening, recruitment, and enrollment; (5) consent; (6) data protection; (7) disclosure of results to surrogates and/or legally authorized representatives; (8) translation of research into practice; (9) identification and management of conflicts of interest; (10) equity and resource availability; and (11) inclusion of minors with DoC in research. Awareness of these ethics considerations when planning and performing research involving persons with DoC will ensure that the participant rights are respected while maximizing the impact and meaningfulness of the research, interpretation of outcomes, and communication of results.
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Affiliation(s)
- Ariane Lewis
- NYU Langone Medical Center, 530 First Avenue, Skirball-7R, New York, NY, 10016, USA.
| | - Michael J Young
- Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Benjamin Rohaut
- Inserm, CNRS, APHP - Hôpital de la Pitié Salpêtrière, Paris Brain Institute - ICM, DMU Neuroscience, Sorbonne University, Paris, France
| | - Ralf J Jox
- Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Jan Claassen
- New York Presbyterian Hospital, Columbia University, New York, NY, USA
| | - Claire J Creutzfeldt
- Harborview Medical Center, Seattle, WA, USA
- University of Washington, Seattle, WA, USA
- Cambia Palliative Care Center of Excellence, Seattle, WA, USA
| | - Judy Illes
- University of British Columbia, Vancouver, BC, Canada
| | | | | | - Joseph J Fins
- Weill Cornell Medical College, New York, NY, USA
- Yale Law School, New Haven, CT, USA
- Rockefeller University, New York, NY, USA
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29
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Papadimitriou C, Lindemann L, Meehan AJ. Making the visible seen: The interactional competence of a person in a disordered state of consciousness. Soc Sci Med 2023; 336:116261. [PMID: 37806147 DOI: 10.1016/j.socscimed.2023.116261] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Revised: 08/18/2023] [Accepted: 09/21/2023] [Indexed: 10/10/2023]
Abstract
We examine a 12-min video-recorded interaction among a patient (KN) in a disordered state of consciousness (DOC) and a speech language pathologist clinician (CL) that takes place in a medical rehabilitation setting. The video is a demonstration of how caregivers could use a clinical assessment to observe their loved one's behavior to communicate potential behavioral changes to healthcare professionals. The purpose of this paper is to make visible the communication practices used by participants that may not be obvious to researchers, medical rehabilitation practitioners, and clinical assessment developers. We use phenomenological, linguistic and conversation analytic approaches to analyze the interaction. We found that KN demonstrates multiple conversational competencies, some (but not all) of which are acknowledged by CL, and most of which are not directly addressed by the assessment scoring criteria. For example, KN demonstrates conversational competency by responding non-verbally to CL's prompts from the assessment protocol and following along with the unspoken rules of discourse. He does this primarily through gaze, which broadcasts the focus of his attention and actively signals his participation in the conversation. Though KN does not always respond correctly to CL's questions, he nevertheless demonstrates implicit conversational competencies during turns of talk such as returning to 'neutral' position which signals the completion of a turn of talk. KN's conversational competencies may be missed by CL and the assessment protocol but we argue that they are important in understanding KN's capacity. Our analyses show that competency is not simply a performance by one person who appropriately and correctly responds to a series of questions in a prescribed time frame. Competence is a collaborative achievement among participants, co-produced in situ, and influenced by linguistic and cultural habits of talk and epistemic norms that privilege clinical knowledge and expertise.
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Affiliation(s)
| | - Luke Lindemann
- George Washington University, 2121 I St NW, Washington, DC, 20052, USA.
| | - Albert J Meehan
- Oakland University, 318 Meadow Brook Rd, Rochester, MI, 48309, USA.
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30
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Neveu A, Degos V, Barberousse A. Epistemological challenges for neural correlates of consciousness: A defense of medical research on consciousness. Presse Med 2023; 52:104183. [PMID: 37839773 DOI: 10.1016/j.lpm.2023.104183] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Revised: 10/06/2023] [Accepted: 10/09/2023] [Indexed: 10/17/2023] Open
Abstract
Recent work in the field of consciousness science has predominantly focused on the search for neural correlates of consciousness (NCC). However, despite significant technological advances in recent decades, defining NCC remains an ambitious goal in consciousness research. The main difficulty stems from an epistemological challenge known as the "Problem of coordination", which hinders or at least slows down the experimental process inherent to the study of consciousness. Fundamental research has mainly focused on a content-based conception of consciousness, often referred to as a "local" conception of consciousness. This approach suffers from the Problem of coordination and its consequences. However, an alternative, more reliable approach could be considered, namely, the global or "state-based" approach, which is grounded in clinical research on consciousness disorders.
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Affiliation(s)
- Armance Neveu
- Sciences, Normes, Démocratie, Sorbonne-Université, Paris, France.
| | - Vincent Degos
- Hôpital Pitié-Salpêtrière, APHP Sorbonne Université, Département d'Anesthésie Réanimation, Paris, France
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Mahajan C, Prabhakar H, Rass V, McNett M, Kapoor I, Helbok R, Zirpe K. A National Survey on Coma Epidemiology, Evaluation, and Therapy in India: Revisiting the Curing Coma Campaign Come Together Survey. Neurocrit Care 2023:10.1007/s12028-023-01852-9. [PMID: 37821721 DOI: 10.1007/s12028-023-01852-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Accepted: 08/31/2023] [Indexed: 10/13/2023]
Abstract
BACKGROUND The limited representation from developing countries in the original COME TOGETHER survey gave us an impetus to conduct this survey in the Indian subcontinent. METHODS This cross-sectional online survey was conducted from August through September 2022. Participants were health care physicians caring for patients with coma and disorders of consciousness. Fischer's exact test or the Mann-Whitney U-test was used to compare respondents who agreed or disagreed with the preestablished coma definition. Fleiss κ values were calculated to assess agreement among respondents. A p value less than 0.05 was considered statistically significant. RESULTS The survey was completed by 130 physicians. We found substantial interrater agreement on absence of wakefulness (71.54%; κ = 0.71), Glasgow Coma Score ≤ 8 (78.46%; κ = 0.78), and failure to respond purposefully to visual, verbal, or tactile stimuli (66.15%; κ = 0.66). Reported common etiologies of coma included traumatic brain injury (50.76%), ischemic stroke (30%), and intracerebral hemorrhage (29.23%). The most common clinical assessment tools used for coma included the Glasgow Coma Score (92.3%) and neurological examination (60.8%). Neurological examination was the most common diagnostic tool used (100%), followed by magnetic resonance imaging (89.2%), basic laboratory studies (88.5%), and head computed tomography/angiography (86.9%). Pharmacological interventions used to stimulate arousal in patients with coma were sedation vacation (91.5%), electrolyte/endocrine correction (65.4%), osmotic therapy with mannitol (60%), hypertonic saline (54.6%), modafinil (46.9%), and antidote for drugs (45.4%). Among the nonpharmacological interventions, sensory stimulation (57.7%) was the most commonly used modality. The most common discharge disposition for comatose patients who survived hospitalization were home with or without services (70.0%). CONCLUSIONS Differences from the global survey were noted regarding the following: traumatic brain injury being the most common etiology of coma in India, more frequent practice of sedation interruption, less frequent use of electroencephalography in India, rare use of pharmacological neurostimulants, and home being the most common discharge disposition in India.
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Affiliation(s)
- Charu Mahajan
- Department of Neuroanaesthesiology and Critical Care, All India Institute of Medical Sciences, New Delhi, 110029, India
| | - Hemanshu Prabhakar
- Department of Neuroanaesthesiology and Critical Care, All India Institute of Medical Sciences, New Delhi, 110029, India.
| | - Verena Rass
- Neuro-Intensive Care Unit, Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - Molly McNett
- College of Nursing, The Ohio State University, Columbus, OH, USA
| | - Indu Kapoor
- Department of Neuroanaesthesiology and Critical Care, All India Institute of Medical Sciences, New Delhi, 110029, India
| | - Raimund Helbok
- Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
- Department of Neurology, Johannes Kepler University Linz, Linz, Austria
| | - Kapil Zirpe
- Neurotrauma Unit, Ruby Hall Clinic, Pune, Maharashtra, India
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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] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [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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Ling Y, Xu C, Wen X, Li J, Gao J, Luo B. Cortical responses to auditory stimulation predict the prognosis of patients with disorders of consciousness. Clin Neurophysiol 2023; 153:11-20. [PMID: 37385110 DOI: 10.1016/j.clinph.2023.06.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2022] [Revised: 05/15/2023] [Accepted: 06/03/2023] [Indexed: 07/01/2023]
Abstract
OBJECTIVE This study aimed to assess the prognosis of patients with disorders of consciousness (DoC) using auditory stimulation with electroencephalogram (EEG) recordings. METHODS We enrolled 72 patients with DoC in the study, which involved subjecting patients to auditory stimulation while EEG responses were recorded. Coma Recovery Scale-Revised (CRS-R) scores and Glasgow Outcome Scale (GOS) were determined for each patient and followed up for three months. A frequency spectrum analysis was performed on the EEG recordings. Finally, the power spectral density (PSD) index was used to predict the prognosis of patients with DoC based on a support vector machine (SVM) model. RESULTS Power spectral analyses revealed that the cortical response to auditory stimulation showed a decreasing trend with decreasing consciousness levels. Auditory stimulation-induced changes in absolute PSD at the delta and theta bands were positively correlated with the CRS-R and GOS scores. Furthermore, these cortical responses to auditory stimulation had a good ability to discriminate between good and poor prognoses of patients with DoC. CONCLUSIONS Auditory stimulation-induced changes in the PSD were highly predictive of DoC outcomes. SIGNIFICANCE Our findings showed that cortical responses to auditory stimulation may be an important electrophysiological indicator of prognosis in patients with DoC.
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Affiliation(s)
- Yi Ling
- Department of Neurology, First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou 310000, China
| | - Chuan Xu
- Department of Neurology, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou 310016, China
| | - Xinrui Wen
- Department of Neurology, First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou 310000, China
| | - Jingqi Li
- Department of Rehabilitation, Hangzhou Mingzhou Brain Rehabilitation Hospital, Hangzhou 311215, China
| | - Jian Gao
- Department of Rehabilitation, Hangzhou Mingzhou Brain Rehabilitation Hospital, Hangzhou 311215, China
| | - Benyan Luo
- Department of Neurology, First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou 310000, China.
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Kondziella D. Neuroprognostication after cardiac arrest: what the cardiologist should know. Eur Heart J Acute Cardiovasc Care 2023; 12:550-558. [PMID: 36866627 DOI: 10.1093/ehjacc/zuad019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Revised: 02/24/2023] [Accepted: 02/28/2023] [Indexed: 03/04/2023]
Abstract
Two aspects are a key to mastering prognostication of comatose cardiac arrest survivors: a detailed knowledge about the clinical trajectories of consciousness recovery (or lack thereof) and the ability to correctly interpret the results of multimodal investigations, which include clinical examination, electroencephalography, neuroimaging, evoked potentials, and blood biomarkers. While the very good and the very poor ends of the clinical spectrum typically do not pose diagnostic challenges, the intermediate 'grey zone' of post-cardiac arrest encephalopathy requires cautious interpretation of the available information and sufficiently long clinical observation. Late recovery of coma patients with initially ambiguous diagnostic results is increasingly reported, as are unresponsive patients with various forms of residual consciousness, including so-called cognitive motor dissociation, rendering prognostication of post-anoxic coma highly complex. The aim of this paper is to provide busy clinicians with a high-yield, concise overview of neuroprognostication after cardiac arrest, emphasizing notable developments in the field since 2020.
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Affiliation(s)
- Daniel Kondziella
- Department of Neurology, Rigshospitalet, Copenhagen University Hospital, Blegdamsvej 9, DK-2100 Copenhagen, Denmark
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Wu Y, Xu YY, Deng H, Zhang W, Zhang SX, Li JM, Xiong BT, Xiao LL, Li DH, Ren ZY, Qin YF, Yang RQ, Wang W. Spinal cord stimulation and deep brain stimulation for disorders of consciousness: a systematic review and individual patient data analysis of 608 cases. Neurosurg Rev 2023; 46:200. [PMID: 37578633 DOI: 10.1007/s10143-023-02105-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2023] [Revised: 07/10/2023] [Accepted: 08/01/2023] [Indexed: 08/15/2023]
Abstract
The application of spinal cord stimulation (SCS) and deep brain stimulation (DBS) for disorders of consciousness (DoC) has been increasingly reported. However, there is no sufficient evidence to determine how effective and safe SCS and DBS are for DoC owing to various methodological limitations. We conducted a systematic review to elucidate the safety and efficacy of SCS and DBS for DoC by systematically reviewing related literature by searching PubMed, EMBASE, Medline, and Cochrane Library. Twenty eligible studies with 608 patients were included in this study. Ten studies with 508 patients reported the efficacy of SCS for DoC, and the estimated overall effectiveness rate was 37%. Five studies with 343 patients reported the efficacy of SCS for VS, and the estimated effectiveness rate was 30%. Three studies with 53 patients reported the efficacy of SCS for MCS, and the estimated effectiveness rate was 63%. Five studies with 92 patients reported the efficacy of DBS for DoC, and the estimated overall effectiveness rate was 40%. Four studies with 63 patients reported the efficacy of DBS for VS, and the estimated effectiveness rate was 26%. Three studies with 19 patients reported the efficacy of DBS for MCS, and the estimated effectiveness rate was 74%. The adverse event rate of DoC was 8.1% and 18.2% after SCS and DBS, respectively. These results suggest that SCS and DBS can be considered reasonable treatments for DoC with considerable efficacy and safety.
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Affiliation(s)
- Yang Wu
- Department of Neurosurgery, West China Hospital, Sichuan University, 37 Guoxue Alley, Chengdu, Sichuan Province, China
| | - Yang-Yang Xu
- Department of Neurosurgery, West China Hospital, Sichuan University, 37 Guoxue Alley, Chengdu, Sichuan Province, China
| | - Hao Deng
- Department of Neurosurgery, West China Hospital, Sichuan University, 37 Guoxue Alley, Chengdu, Sichuan Province, China
| | - Wei Zhang
- Department of Neurosurgery, West China Hospital, Sichuan University, 37 Guoxue Alley, Chengdu, Sichuan Province, China
| | - Shu-Xin Zhang
- Department of Histoembryology and Neurobiology, West China College of Basic Medicine and Forensic Medicine, Sichuan University, Chengdu, Sichuan Province, China
| | - Jia-Ming Li
- Department of Neurosurgery, West China Hospital, Sichuan University, 37 Guoxue Alley, Chengdu, Sichuan Province, China
| | - Bo-Tao Xiong
- Department of Neurosurgery, West China Hospital, Sichuan University, 37 Guoxue Alley, Chengdu, Sichuan Province, China
| | - Ling-Long Xiao
- Department of Neurosurgery, West China Hospital, Sichuan University, 37 Guoxue Alley, Chengdu, Sichuan Province, China
| | - Deng-Hui Li
- Department of Neurosurgery, West China Hospital, Sichuan University, 37 Guoxue Alley, Chengdu, Sichuan Province, China
| | - Zhi-Yi Ren
- Department of Histoembryology and Neurobiology, West China College of Basic Medicine and Forensic Medicine, Sichuan University, Chengdu, Sichuan Province, China
| | - Yi-Fan Qin
- Department of Histoembryology and Neurobiology, West China College of Basic Medicine and Forensic Medicine, Sichuan University, Chengdu, Sichuan Province, China
| | - Rui-Qing Yang
- Department of Neurosurgery, West China Hospital, Sichuan University, 37 Guoxue Alley, Chengdu, Sichuan Province, China
| | - Wei Wang
- Department of Neurosurgery, West China Hospital, Sichuan University, 37 Guoxue Alley, Chengdu, Sichuan Province, China.
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Liuzzi P, Hakiki B, Scarpino M, Burali R, Maiorelli A, Draghi F, Romoli AM, Grippo A, Cecchi F, Mannini A. Neural coding of autonomic functions in different states of consciousness. J Neuroeng Rehabil 2023; 20:96. [PMID: 37491259 PMCID: PMC10369699 DOI: 10.1186/s12984-023-01216-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2023] [Accepted: 07/10/2023] [Indexed: 07/27/2023] Open
Abstract
Detecting signs of residual neural activity in patients with altered states of consciousness is a crucial issue for the customization of neurorehabilitation treatments and clinical decision-making. With this large observational prospective study, we propose an innovative approach to detect residual signs of consciousness via the assessment of the amount of autonomic information coded within the brain. The latter was estimated by computing the mutual information (MI) between preprocessed EEG and ECG signals, to be then compared across consciousness groups, together with the absolute power and an international qualitative labeling. One-hundred seventy-four patients (73 females, 42%) were included in the study (median age of 65 years [IQR = 20], MCS +: 29, MCS -: 23, UWS: 29). Electroencephalography (EEG) information content was found to be mostly related to the coding of electrocardiography (ECG) activity, i.e., with higher MI (p < 0.05), in Unresponsive Wakefulness Syndrome and Minimally Consciousness State minus (MCS -). EEG-ECG MI, besides clearly discriminating patients in an MCS - and +, significantly differed between lesioned areas (sides) in a subgroup of unilateral hemorrhagic patients. Crucially, such an accessible and non-invasive measure of residual consciousness signs was robust across electrodes and patient groups. Consequently, exiting from a strictly neuro-centric consciousness detection approach may be the key to provide complementary insights for the objective assessment of patients' consciousness levels and for the patient-specific planning of rehabilitative interventions.
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Affiliation(s)
- Piergiuseppe Liuzzi
- Sant’Anna School of Advanced Studies, The BioRobotics Institute, Viale Rinaldo Piaggio 69, 56025 Pontedera, PI Italy
- IRCSS Fondazione Don Carlo Gnocchi ONLUS, Via di Scandicci 269, FI 50143 Florence, Italy
| | - Bahia Hakiki
- IRCSS Fondazione Don Carlo Gnocchi ONLUS, Via di Scandicci 269, FI 50143 Florence, Italy
| | - Maenia Scarpino
- IRCSS Fondazione Don Carlo Gnocchi ONLUS, Via di Scandicci 269, FI 50143 Florence, Italy
| | - Rachele Burali
- IRCSS Fondazione Don Carlo Gnocchi ONLUS, Via di Scandicci 269, FI 50143 Florence, Italy
| | - Antonio Maiorelli
- IRCSS Fondazione Don Carlo Gnocchi ONLUS, Via di Scandicci 269, FI 50143 Florence, Italy
| | - Francesca Draghi
- IRCSS Fondazione Don Carlo Gnocchi ONLUS, Via di Scandicci 269, FI 50143 Florence, Italy
| | - Anna Maria Romoli
- IRCSS Fondazione Don Carlo Gnocchi ONLUS, Via di Scandicci 269, FI 50143 Florence, Italy
| | - Antonello Grippo
- IRCSS Fondazione Don Carlo Gnocchi ONLUS, Via di Scandicci 269, FI 50143 Florence, Italy
| | - Francesca Cecchi
- IRCSS Fondazione Don Carlo Gnocchi ONLUS, Via di Scandicci 269, FI 50143 Florence, Italy
- Department of Experimental and Clinical Medicine, University of Florence, Largo Brambilla 3, 50143 Florence, FI Italy
| | - Andrea Mannini
- IRCSS Fondazione Don Carlo Gnocchi ONLUS, Via di Scandicci 269, FI 50143 Florence, Italy
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Luppi AI, Cabral J, Cofre R, Mediano PAM, Rosas FE, Qureshi AY, Kuceyeski A, Tagliazucchi E, Raimondo F, Deco G, Shine JM, Kringelbach ML, Orio P, Ching S, Sanz Perl Y, Diringer MN, Stevens RD, Sitt JD. Computational modelling in disorders of consciousness: Closing the gap towards personalised models for restoring consciousness. Neuroimage 2023; 275:120162. [PMID: 37196986 PMCID: PMC10262065 DOI: 10.1016/j.neuroimage.2023.120162] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2023] [Revised: 04/16/2023] [Accepted: 05/09/2023] [Indexed: 05/19/2023] Open
Abstract
Disorders of consciousness are complex conditions characterised by persistent loss of responsiveness due to brain injury. They present diagnostic challenges and limited options for treatment, and highlight the urgent need for a more thorough understanding of how human consciousness arises from coordinated neural activity. The increasing availability of multimodal neuroimaging data has given rise to a wide range of clinically- and scientifically-motivated modelling efforts, seeking to improve data-driven stratification of patients, to identify causal mechanisms for patient pathophysiology and loss of consciousness more broadly, and to develop simulations as a means of testing in silico potential treatment avenues to restore consciousness. As a dedicated Working Group of clinicians and neuroscientists of the international Curing Coma Campaign, here we provide our framework and vision to understand the diverse statistical and generative computational modelling approaches that are being employed in this fast-growing field. We identify the gaps that exist between the current state-of-the-art in statistical and biophysical computational modelling in human neuroscience, and the aspirational goal of a mature field of modelling disorders of consciousness; which might drive improved treatments and outcomes in the clinic. Finally, we make several recommendations for how the field as a whole can work together to address these challenges.
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Affiliation(s)
- Andrea I Luppi
- Division of Anaesthesia and Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK; Montreal Neurological Institute, McGill University, Montreal, Quebec, Canada.
| | - Joana Cabral
- Life and Health Sciences Research Institute, University of Minho, Portugal
| | - Rodrigo Cofre
- CIMFAV-Ingemat, Facultad de Ingeniería, Universidad de Valparaíso, Valparaíso, Chile; Centre National de la Recherche Scientifique (CNRS), Institute of Neuroscience (NeuroPSI), Paris-Saclay University, Gif-sur-Yvette, France
| | - Pedro A M Mediano
- Department of Computing, Imperial College London, London, UK; Department of Psychology, University of Cambridge, Cambridge, UK
| | - Fernando E Rosas
- Department of Informatics, University of Sussex, Brighton, UK; Centre for Psychedelic Research, Department of Brain Sciences, Imperial College London, London, UK; Centre for Complexity Science, Imperial College London, London, UK; Centre for Eudaimonia and Human Flourishing, Linacre College, University of Oxford, Oxford, UK
| | - Abid Y Qureshi
- University of Kansas Medical Center, Kansas City, MO, USA
| | - Amy Kuceyeski
- Department of Radiology, Weill Cornell Medicine, New York, USA
| | - Enzo Tagliazucchi
- Departamento de Física (UBA) e Instituto de Fisica de Buenos Aires (CONICET), Buenos Aires, Argentina; Latin American Brain Health Institute (BrainLat), Universidad Adolfo Ibáñez, Santiago, Chile
| | - Federico Raimondo
- Institute of Neuroscience and Medicine (INM-7: Brain and Behaviour), Research Centre Jülich, Germany; Institute of Systems Neuroscience, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Gustavo Deco
- Center for Brain and Cognition, Department of Information and Communication Technologies, Universitat Pompeu Fabra, Barcelona, Spain; Department of Neuropsychology, Max Planck Institute for Human Cognitive and Brain Sciences, Leipzig, Germany; Institució Catalana de Recerca i Estudis Avançats (ICREA), Barcelona, Spain; Turner Institute for Brain and Mental Health, Monash University, Melbourne, VIC, Australia
| | - James M Shine
- Brain and Mind Center, The University of Sydney, Sydney, Australia
| | - Morten L Kringelbach
- Centre for Eudaimonia and Human Flourishing, Linacre College, University of Oxford, Oxford, UK; Department of Psychiatry, University of Oxford, Oxford, UK; Center for Music in the Brain, Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Patricio Orio
- Centro Interdisciplinario de Neurociencia de Valparaíso and Instituto de Neurociencia, Universidad de Valparaíso, Valparaíso, Chile
| | - ShiNung Ching
- Electrical and Systems Engineering, Washington University in St. Louis, St. Louis, MO, USA
| | - Yonatan Sanz Perl
- Center for Brain and Cognition, Department of Information and Communication Technologies, Universitat Pompeu Fabra, Barcelona, Spain; Institut du Cerveau et de la Moelle épinière - Paris Brain Institute, ICM, Paris, France; National Scientific and Technical Research Council (CONICET), Godoy Cruz, CABA 2290, Argentina
| | - Michael N Diringer
- Department of Neurology and Neurosurgery, Washington University in St. Louis, St. Louis, MO, USA
| | - Robert D Stevens
- Departments of Anesthesiology and Critical Care Medicine, Neurology, and Biomedical Engineering, Johns Hopkins University, Baltimore, MD, USA
| | - Jacobo Diego Sitt
- Institut du Cerveau et de la Moelle épinière - Paris Brain Institute, ICM, Paris, France; Sorbonne Université, Inserm, CNRS, APHP, Hôpital de la Pitié Salpêtrière, Paris, France.
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Adama S, Bogdan M. Assessing consciousness in patients with disorders of consciousness using soft-clustering. Brain Inform 2023; 10:16. [PMID: 37450213 PMCID: PMC10348975 DOI: 10.1186/s40708-023-00197-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Accepted: 06/25/2023] [Indexed: 07/18/2023] Open
Abstract
Consciousness is something we experience in our everyday life, more especially between the time we wake up in the morning and go to sleep at night, but also during the rapid eye movement (REM) sleep stage. Disorders of consciousness (DoC) are states in which a person's consciousness is damaged, possibly after a traumatic brain injury. Completely locked-in syndrome (CLIS) patients, on the other hand, display covert states of consciousness. Although they appear unconscious, their cognitive functions are mostly intact. Only, they cannot externally display it due to their quadriplegia and inability to speak. Determining these patients' states constitutes a challenging task. The ultimate goal of the approach presented in this paper is to assess these CLIS patients consciousness states. EEG data from DoC patients are used here first, under the assumption that if the proposed approach is able to accurately assess their consciousness states, it will assuredly do so on CLIS patients too. This method combines different sets of features consisting of spectral, complexity and connectivity measures in order to increase the probability of correctly estimating their consciousness levels. The obtained results showed that the proposed approach was able to correctly estimate several DoC patients' consciousness levels. This estimation is intended as a step prior attempting to communicate with them, in order to maximise the efficiency of brain-computer interfaces (BCI)-based communication systems.
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Affiliation(s)
- Sophie Adama
- Department of Neuromorphe Information Processing, Leipzig University, Augustusplatz 10, Leipzig, 04109 Germany
| | - Martin Bogdan
- Department of Neuromorphe Information Processing, Leipzig University, Augustusplatz 10, Leipzig, 04109 Germany
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McLaughlin MJ, Vadivelu S, Hartman KC. Rehabilitation Care of the Child with an Acute Severe Traumatic Brain Injury. Pediatr Clin North Am 2023; 70:415-428. [PMID: 37121634 DOI: 10.1016/j.pcl.2023.01.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/02/2023]
Abstract
Children with traumatic brain injury (TBI) represent a unique and evolving population. Recovery and long-term prognosis are variable given the heterogeneity of ages, developmental stages, and types of injuries. This article summarizes important information regarding severe TBI epidemiology, pathophysiology, classification, and acute management. Early and longitudinal involvement of rehabilitation experts, such as pediatric physiatrists, is critical in managing complications and optimizing outcomes.
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Affiliation(s)
- Matthew J McLaughlin
- Children's Mercy - Kansas City/University of Missouri, Kansas City School of Medicine, 2401 Gillham Road, Kansas City, MO 64108, USA; Department of Physical Medicine and Rehabilitation, University of Kansas School of Medicine, 3901 Rainbow Blvd, Kansas City, KS 66160, USA.
| | - Sathya Vadivelu
- Children's Mercy - Kansas City/University of Missouri, Kansas City School of Medicine, 2401 Gillham Road, Kansas City, MO 64108, USA; Department of Physical Medicine and Rehabilitation, University of Kansas School of Medicine, 3901 Rainbow Blvd, Kansas City, KS 66160, USA
| | - Kimberly C Hartman
- Children's Mercy - Kansas City/University of Missouri, Kansas City School of Medicine, 2401 Gillham Road, Kansas City, MO 64108, USA; Department of Physical Medicine and Rehabilitation, University of Kansas School of Medicine, 3901 Rainbow Blvd, Kansas City, KS 66160, USA
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Blond N, Andersen LM, Wæhrens EE, Høybye MT. Perspectives on consciousness in patients with disorders of consciousness from brain injury: group concept mapping study across clinic, research, and families. BMC Health Serv Res 2023; 23:471. [PMID: 37165429 PMCID: PMC10173477 DOI: 10.1186/s12913-023-09438-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2023] [Accepted: 04/24/2023] [Indexed: 05/12/2023] Open
Abstract
BACKGROUND An effective healthcare system depends on clinic, research, and patient/relatives interactions. Such interactions may at their core be challenged by misalignments of concepts and the practices that constitute them. The concept of consciousness and what is experienced and understood as signs of consciousness in patients with severe acquired brain injury is one of these potential areas of misalignment. Different perspectives and experiences of consciousness are challenging the delivery of care and the high-stake decision-making process on the potential withdrawal of treatment. The enhanced uncertainties call for reflections on how key stakeholders perceive and identify consciousness in current clinical encounters and practice. METHODS The study empirically explores the actual experiences and conceptions of consciousness concerning patients with disorders of consciousness (DoC) from the perspectives of researchers, health professionals, and relatives of patients, to understand the challenges of the diversity of understandings of consciousness. Engaging the stakeholders by employing Group Concept Mapping methodology, the study developed a situated conceptual map, which reflects nuances and the importance of perspectives on and signs of consciousness. RESULTS Twenty-seven participants contributed to the generation of ideas, 14 took part in the structuring of statements and 10 took part in the validation meeting to interpret the cluster rating map. A total of 85 unique statements were identified and organized into six clusters: (1) Presence, (2) Intentional Activity, (3) Experience of self, (4) Participation in Social Interaction, (5) (Repeated) Response, and (6) Unspecific Reaction. The conceptual mapping demonstrates an extensive overlap in perspectives on consciousness among participants, prioritizing signs that are observable at the bedside. CONCLUSIONS The study provides a first step toward a future framework for the difficult process of decision-making concerning a segment of patients with DoC. The study highlights the importance of repeatable signs of consciousness observed at the bedside and the patient's ability to participate in social interactions, while also considering the importance of non-clinically observable signs of consciousness.
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Affiliation(s)
- Niklas Blond
- Interacting Minds Centre, Department of Clinical Medicine, Aarhus University, Jens Chr. Skous Vej 4, Aarhus C, DK- 8000, Denmark
| | - Lise Marie Andersen
- Center for Elective Surgery, Silkeborg Regional Hospital, Silkeborg, Denmark
| | - Eva Elisabeth Wæhrens
- The Parker Institute, Copenhagen University Hospital Bispebjerg and Frederiksberg, Copenhagen, Denmark
- Occupational Science, Department of Public Health, User Perspectives and Community-based Interventions, University of Southern Denmark, Odense, Denmark
| | - Mette Terp Høybye
- Interacting Minds Centre, Department of Clinical Medicine, Aarhus University, Jens Chr. Skous Vej 4, Aarhus C, DK- 8000, Denmark.
- Center for Elective Surgery, Silkeborg Regional Hospital, Silkeborg, Denmark.
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Ma H, Fan S, Xu Z, Wan X, Yang Q, Yin Y, Wu X, Wu S, Zhang H, Ma C. Trigeminal nerve stimulation for prolonged disorders of consciousness: A randomized double-blind sham-controlled study. Brain Stimul 2023; 16:819-827. [PMID: 37182683 DOI: 10.1016/j.brs.2023.05.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Revised: 04/19/2023] [Accepted: 05/03/2023] [Indexed: 05/16/2023] Open
Abstract
BACKGROUND Trigeminal nerve stimulation (TNS) has been proposed as a promising intervention for coma awakening. However, the effect of TNS on patients with prolonged disorders of consciousness (pDoC) is still unclear. OBJECTIVE This study aimed to investigate the therapeutic effects of TNS in pDoC caused by stroke, trauma, and anoxia. METHODS A total of 60 patients (male =25, female =35) aged over 18 who were in a vegetative state or minimally conscious state were randomly assigned to the TNS (N = 30) or sham TNS (N = 30) groups. 4 weeks of intervention and a followed up for 8 weeks were performed. The Glasgow Coma Scale (GCS) and Coma Recovery Scale-Revised (CRS-R) scores as primary outcomes were assessed at baseline and at 2, 4, 8, and 12 weeks. RESULTS The score changes in the TNS group over time for CRS-R (2-week: mean difference = 0.9, 95% CI = [0.3, 1.5], P = 0.006; 4-week: 1.6, 95% CI = [0.8, 2.5], P < 0.001; 8-week: mean difference = 2.4, 95% CI = [1.3, 3.5], P < 0.001; 12-week: mean difference = 2.3, 95% CI = [1.1, 3.4], P < 0.001) and GCS (4-week: mean difference = 0.7, 95% CI = [0.3, 1.2], P = 0.002; 8-week: mean difference = 1.1, 95% CI = [0.6, 1.7], P < 0.001; 12-week: 1.1, 95% CI = [0.5, 1.7], P = 0.003) were higher than those in the sham group. 18-Fluorodeoxyglucose Positron Emission Tomography (FDG-PET) revealed that the metabolism of the right parahippocampal cortex, right precuneus, and bilateral middle cingulate cortex was significantly increased in TNS group. CONCLUSION The results of this study indicate that TNS could increase local brain metabolism and may promote functional recovery in patients with prolonged disorders of consciousness. REGISTRATION INFORMATION Name of the registry: Chinese Clinical Trial Registry. REGISTRATION NUMBER ChiCTR1900025573. The date that the study was submitted to a registry: 2019-09-01. The date when the first patient was enrolled was 2021-01-20.
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Affiliation(s)
- Haiyun Ma
- Department of Rehabilitation Medicine, Sun Yat-sen Memorial Hospital, Guangzhou, Guangdong, People's Republic of China
| | - Shengnuo Fan
- Department of Rehabilitation Medicine, Sun Yat-sen Memorial Hospital, Guangzhou, Guangdong, People's Republic of China
| | - Zhen Xu
- Department of Rehabilitation Medicine, Sun Yat-sen Memorial Hospital, Guangzhou, Guangdong, People's Republic of China
| | - Xiaoting Wan
- Department of Nuclear Medicine, Sun Yat-sen Memorial Hospital, Guangzhou, Guangdong, People's Republic of China
| | - Qian Yang
- Department of Rehabilitation Medicine, Sun Yat-sen Memorial Hospital, Guangzhou, Guangdong, People's Republic of China
| | - Yuping Yin
- Department of Nuclear Medicine, Sun Yat-sen Memorial Hospital, Guangzhou, Guangdong, People's Republic of China
| | - Xuemeng Wu
- Department of Rehabilitation Medicine, Sun Yat-sen Memorial Hospital, Guangzhou, Guangdong, People's Republic of China
| | - Shaoling Wu
- Department of Rehabilitation Medicine, Sun Yat-sen Memorial Hospital, Guangzhou, Guangdong, People's Republic of China.
| | - Hong Zhang
- Department of Nuclear Medicine, Sun Yat-sen Memorial Hospital, Guangzhou, Guangdong, People's Republic of China.
| | - Chao Ma
- Department of Rehabilitation Medicine, Sun Yat-sen Memorial Hospital, Guangzhou, Guangdong, People's Republic of China.
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Magee WL, Narayanan A, O'Connor R, Haughey F, Wegener E, Chu BHL, Delargy M, Gray D, Seu AD, Siegert RJ, Tyas RJ, Yelden KC, Schnakers C. VALIDATION OF THE MUSIC THERAPY ASSESSMENT TOOL FOR AWARENESS IN DISORDERS OF CONSCIOUSNESS WITH THE COMA RECOVERY SCALE-REVISED. Arch Phys Med Rehabil 2023:S0003-9993(23)00175-2. [PMID: 37086939 DOI: 10.1016/j.apmr.2023.03.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2022] [Revised: 03/09/2023] [Accepted: 03/14/2023] [Indexed: 04/24/2023]
Abstract
OBJECTIVE To examine (1) the concurrent validity of the Music Therapy Assessment Tool for Awareness in Disorders of Consciousness (MATADOC) with the criterion standard Coma Recovery Scale Revised (CRS-R) for outcomes of awareness in patients with prolonged disorders of consciousness (PDoC); (2) the relationship between MATADOC items and CRS-R function subscales (FS) in similar domains; and (3) determine if items/FS measure different constructs. DESIGN A prospective multicentric blinded study with repeated concurrent measures. SETTING 3 inpatient rehabilitation units. PARTICIPANTS Convenience sample of 74 adults with PDoC. MAIN OUTCOME MEASURE(S) The MATADOC protocol elicits behavioral responsiveness using live music in five tasks. A total score ranges 0-10 scoring behaviors across 14-items. The CRS-R uses a language-based protocol and scores observed responses ranging 0-23 in six FS. Both measures were delivered at 4 concurrent timepoints over two weeks. RESULTS Fair (k=0.238, p=.006) ranging to moderate (k=0.419, p<.001) significant agreement was found between CRS-R and MATADOC diagnostic outcomes. Fair-borderline moderate significant agreement was found for overall diagnostic outcomes across all diagnostic categories (k=0.397, p=.001). There was moderate significant agreement between measures for motor scores (.551≤k.571, p<.001) and visual outcomes (.192≤k.415, .001≤p<.005) but no agreement for item/FS outcomes assessing auditory responsiveness. Exploratory factor analysis of all items showed two factors, suggesting that MATADOC and CRS-R measure the same underlying latent variable (awareness) in different ways and could complement each other for diagnosis and intervention purposes. This was supported by scale analysis which showed increased reliability when the two scales are used together rather than separately. CONCLUSIONS Unlike the CRS-R, the music-based MATADOC scores auditory localization for complexity of response and categorizes these behaviors as conscious rather than reflexive. The MATADOC may supplement the CRS-R, having a particular role in interdisciplinary programming for providing a more robust assessment of auditory responsiveness due to using non-verbal musical stimuli.
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Affiliation(s)
- Wendy L Magee
- Temple University, Boyer College of Music and Dance, Music Education and Therapy.
| | - Ajit Narayanan
- Auckland University of Technology, School of Engineering, Computer and Mathematical Sciences, Department of Computer Science
| | - Rebecca O'Connor
- National Rehabilitation Hospital, Dublin, Ireland; Creative Arts Therapy Department, Music Therapy Department, University of Limerick, Ireland
| | - Fiona Haughey
- National Rehabilitation Hospital, Occupational Therapy Department, Dublin
| | - Erin Wegener
- Spectrum Health, Neuro Rehabilitation Services, Rehab and Nursing Center- Kalamazoo Ave, Music Therapy
| | - Bernice H L Chu
- Royal Hospital for Neuro-disability, Music Therapy Department
| | - Mark Delargy
- National Rehabilitation Hospital, Dublin, RCSI Dublin 2021
| | - Dee Gray
- National Rehabilitation Hospital, Creative Arts Therapy Department, Dublin
| | - Alika D Seu
- Spectrum Health, Neuro Rehabilitation Services, Rehab and Nursing Center- Kalamazoo Ave, Music Therapy
| | - Richard J Siegert
- Auckland University of Technology, School of Clinical Sciences, Department of Psychology and Neuroscience
| | - Rosanne J Tyas
- Royal Hospital for Neuro-disability, Music Therapy Department
| | - Kudret C Yelden
- Research Department, Royal Hospital for Neuro-disability, Neurological Rehabilitation, King's College Hospital NHS Trust
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Jakobsen EW, Nersesjan V, Albrechtsen SS, Othman MH, Amiri M, Knudsen NV, Larson MD, Hassager C, Møller K, Kjaergaard J, Kondziella D. Brimonidine eye drops reveal diminished sympathetic pupillary tone in comatose patients with brain injury. Acta Neurochir (Wien) 2023; 165:1483-1494. [PMID: 37014450 DOI: 10.1007/s00701-023-05569-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2022] [Accepted: 02/20/2023] [Indexed: 04/05/2023]
Abstract
BACKGROUND There is an urgent need for easy-to-perform bedside measures to detect residual consciousness in clinically unresponsive patients with acute brain injury. Interestingly, the sympathetic control of pupil size is thought to be lost in states of unconsciousness. We therefore hypothesized that administration of brimonidine (an alpha-2-adrenergic agonist) eye drops into one eye should produce a pharmacologic Horner's syndrome if the clinically unresponsive patient is conscious, but not if the patient is unconscious. Here, in a first step to explore this hypothesis, we investigated the potential of brimonidine eye drops to distinguish preserved sympathetic pupillary function in awake volunteers from impairment of sympathetic tone in patients in a coma. METHODS We enrolled comatose patients admitted for acute brain injury to one of the intensive care units (ICU) of a tertiary referral center, in whom EEG and/or neuroimaging for all practical purposes had ruled out residual consciousness. Exclusion criteria were deep sedation, medications with known drug interactions with brimonidine, and a history of eye disease. Age- and sex-matched healthy and awake volunteers served as controls. We measured pupils of both eyes, under scotopic conditions, at baseline and five times 5-120 min after administering brimonidine into the right eye, using automated pupillometry. Primary outcomes were miosis and anisocoria at the individual and group levels. RESULTS We included 15 comatose ICU patients (seven women, mean age 59 ± 13.8 years) and 15 controls (seven women, mean age 55 ± 16.3 years). At 30 min, miosis and anisocoria were seen in all 15 controls (mean difference between the brimonidine-treated pupil and the control pupil: - 1.31 mm, 95% CI [- 1.51; - 1.11], p < 0.001), but in none (p < 0.001) of the 15 ICU patients (mean difference: 0.09 mm, 95% CI [- 0.12;0.30], p > 0.99). This effect was unchanged after 120 min and remained robust in sensitivity analyses correcting for baseline pupil size, age, and room illuminance. CONCLUSION In this proof-of-principle study, brimonidine eye drops produced anisocoria in awake volunteers but not in comatose patients with brain injury. This suggests that automated pupillometry after administration of brimonidine can distinguish between the extremes of the spectrum of consciousness (i.e., fully conscious vs. deeply comatose). A larger study testing the "intermediate zone" of disorders of consciousness in the ICU seems warranted.
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Affiliation(s)
- Elisabeth Waldemar Jakobsen
- Department of Neurology, Rigshospitalet, Copenhagen University Hospital, Blegdamsvej 9, DK-2100, Copenhagen, Denmark
| | - Vardan Nersesjan
- Department of Neurology, Rigshospitalet, Copenhagen University Hospital, Blegdamsvej 9, DK-2100, Copenhagen, Denmark
| | - Simon Sander Albrechtsen
- Department of Neurology, Rigshospitalet, Copenhagen University Hospital, Blegdamsvej 9, DK-2100, Copenhagen, Denmark
| | - Marwan H Othman
- Department of Neurology, Rigshospitalet, Copenhagen University Hospital, Blegdamsvej 9, DK-2100, Copenhagen, Denmark
| | - Moshgan Amiri
- Department of Neurology, Rigshospitalet, Copenhagen University Hospital, Blegdamsvej 9, DK-2100, Copenhagen, Denmark
| | - Niels Vendelbo Knudsen
- Department of Neuroanesthesiology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Merlin D Larson
- Department of Anesthesiology, University of California San Francisco, San Francisco, CA, USA
| | - Christian Hassager
- Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, 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, Blegdamsvej 9, DK-2100, Copenhagen, Denmark.
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark.
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Liu Y, Zeng W, Pan N, Xia X, Huang Y, He J. EEG complexity correlates with residual consciousness level of disorders of consciousness. BMC Neurol 2023; 23:140. [PMID: 37013466 PMCID: PMC10069047 DOI: 10.1186/s12883-023-03167-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Accepted: 03/15/2023] [Indexed: 04/05/2023] Open
Abstract
BACKGROUND AND OBJECTIVE Electroencephalography (EEG) and neuroimaging measurements have been highly encouraged to be applied in clinics of disorders of consciousness (DOC) to improve consciousness detection. We tested the relationships between neural complexity measured on EEG and residual consciousness levels in DOC patients. METHODS Resting-state EEG was recorded from twenty-five patients with DOC. Lempel-Ziv complexity (LZC) and permutation Lempel-Ziv complexity (PLZC) were measured on the EEG, and their relationships were analyzed with the consciousness levels of the patients. RESULTS PLZC and LZC values significantly distinguished patients with a minimally conscious state (MCS), vegetative state/unresponsive wakefulness syndrome (VS/UWS), and healthy controls. PLZC was significantly correlated with the Coma Recovery Scale-Revised (CRS-R) scores of DOC patients in the global brain, particularly in electrodes locating in the anterior and posterior brain regions. Patients with higher CRS-R scores showed higher PLZC values. The significant difference in PLZC values between MCS and VS/UWS was mainly located in the bilateral frontal and right hemisphere regions. CONCLUSION Neural complexity measured on EEG correlates with residual consciousness levels of DOC patients. PLZC showed higher sensitivity than LZC in the classification of consciousness levels.
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Affiliation(s)
- Yangfeng Liu
- Xijing 986 Hospital Department, Fourth Military Medical University, Xi'an, China
- The Seventh Medical Center of PLA General Hospital, Beijing, China
| | - Wentao Zeng
- Department of Medical Imaging, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Na Pan
- Xijing 986 Hospital Department, Fourth Military Medical University, Xi'an, China
| | - Xiaoyu Xia
- The Seventh Medical Center of PLA General Hospital, Beijing, China
| | - Yonghua Huang
- The Seventh Medical Center of PLA General Hospital, Beijing, China
| | - Jianghong He
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.
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Luppi AI, Mediano PAM, Rosas FE, Allanson J, Pickard JD, Williams GB, Craig MM, Finoia P, Peattie ARD, Coppola P, Menon DK, Bor D, Stamatakis EA. Reduced emergent character of neural dynamics in patients with a disrupted connectome. Neuroimage 2023; 269:119926. [PMID: 36740030 PMCID: PMC9989666 DOI: 10.1016/j.neuroimage.2023.119926] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Revised: 01/23/2023] [Accepted: 02/02/2023] [Indexed: 02/05/2023] Open
Abstract
High-level brain functions are widely believed to emerge from the orchestrated activity of multiple neural systems. However, lacking a formal definition and practical quantification of emergence for experimental data, neuroscientists have been unable to empirically test this long-standing conjecture. Here we investigate this fundamental question by leveraging a recently proposed framework known as "Integrated Information Decomposition," which establishes a principled information-theoretic approach to operationalise and quantify emergence in dynamical systems - including the human brain. By analysing functional MRI data, our results show that the emergent and hierarchical character of neural dynamics is significantly diminished in chronically unresponsive patients suffering from severe brain injury. At a functional level, we demonstrate that emergence capacity is positively correlated with the extent of hierarchical organisation in brain activity. Furthermore, by combining computational approaches from network control theory and whole-brain biophysical modelling, we show that the reduced capacity for emergent and hierarchical dynamics in severely brain-injured patients can be mechanistically explained by disruptions in the patients' structural connectome. Overall, our results suggest that chronic unresponsiveness resulting from severe brain injury may be related to structural impairment of the fundamental neural infrastructures required for brain dynamics to support emergence.
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Affiliation(s)
- Andrea I Luppi
- Division of Anaesthesia, School of Clinical Medicine, University of Cambridge, UK; Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK; Leverhulme Centre for the Future of Intelligence, Cambridge, UK; The Alan Turing Institute, London, UK.
| | - Pedro A M Mediano
- Department of Computing, Imperial College London, London, UK; Department of Psychology, University of Cambridge, Cambridge, UK
| | - Fernando E Rosas
- Department of Brain Science, Center for Psychedelic Research, Imperial College London, London, UK; Data Science Institute, Imperial College London, London, UK; Centre for Complexity Science, Imperial College London, London, UK; Center for Eudaimonia and Human Flourishing, University of Oxford, Oxford, UK; Department of Informatics, University of Sussex, Brighton, UK
| | - Judith Allanson
- Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK; Department of Neurosciences, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation, Cambridge, UK
| | - John D Pickard
- Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| | - Guy B Williams
- Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK; Wolfson Brain Imaging Centre, University of Cambridge, Cambridge, UK
| | - Michael M Craig
- Division of Anaesthesia, School of Clinical Medicine, University of Cambridge, UK; Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| | - Paola Finoia
- Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| | - Alexander R D Peattie
- Division of Anaesthesia, School of Clinical Medicine, University of Cambridge, UK; Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| | - Peter Coppola
- Division of Anaesthesia, School of Clinical Medicine, University of Cambridge, UK; Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| | - David K Menon
- Division of Anaesthesia, School of Clinical Medicine, University of Cambridge, UK; Wolfson Brain Imaging Centre, University of Cambridge, Cambridge, UK
| | - Daniel Bor
- Department of Psychology, University of Cambridge, Cambridge, UK; Department of Psychology, Queen Mary University of London, UK
| | - Emmanuel A Stamatakis
- Division of Anaesthesia, School of Clinical Medicine, University of Cambridge, UK; Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
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Xu C, Zhu Z, Wu W, Zheng X, Zhong H, Huang X, Xie Q, Qian X. Effects of 10 Hz individualized repetitive transcranial magnetic stimulation on patients with disorders of consciousness: a study protocol for an exploratory double-blind crossover randomized sham-controlled trial. Trials 2023; 24:249. [PMID: 37005647 PMCID: PMC10067296 DOI: 10.1186/s13063-023-07122-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2022] [Accepted: 01/28/2023] [Indexed: 04/04/2023] Open
Abstract
BACKGROUND Repetitive transcranial magnetic stimulation (rTMS), as a non-invasive brain stimulation technique, has shown potentials for consciousness recovery of patients with disorders of consciousness (DoC), as, to a certain extent, it is effective in regulating the excitability of central nervous system. However, it is difficult to achieve satisfactory effect with "one size fits all" rTMS treatment due to different clinical conditions of patients. There is an urgent need to develop individualized strategy to improve the effectiveness of rTMS on patients with DoC. METHODS Our protocol is a randomized double-blind sham-controlled crossover trial that includes 30 DoC patients. Each patient will received 20 sessions, in which 10 sessions will be rTMS-active stimulus, and the other 10 sessions will be sham stimulus, separated by no less than 10 days' washout period. The rTMS-active will include 10 Hz rTMS over the individualized-targeted selection area for each patient according to the different insult regions of the brain. Coma Recovery Scale-Revised (CRS-R) will be used as primary outcome at baseline, after the first stage of stimulation, at the end of the washout period, and after the second stage of stimulation. Secondary outcomes will be measured at the same time, including efficiency, relative spectral power, and functional connectivity of high-density electroencephalograph (EEG). Adverse events will be recorded during the study. DISCUSSION rTMS has obtained grade A evidence in treating patients with several central nervous system diseases, and there has been some evidence showing partial improvement on level of consciousness in DoC patients. However, the effectiveness of rTMS in DoC is only 30~36%, mostly due to the non-specific target selection. In this protocol, we present a double-blind crossover randomized sham-controlled trial based on the individualized-targeted selection strategy that aims to study the effectiveness of rTMS therapy for DoC, and the result may provide new insights to non-invasive brain stimulation. TRIAL REGISTRATION ClinicalTrials.gov : NCT05187000. Registered on January 10, 2022.
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Affiliation(s)
- Chengwei Xu
- Department of Rehabilitation Medicine, Zhujiang Hospital of Southern Medical University, Guangzhou, Guangdong Province, 510280, People's Republic of China
| | - Zhaohua Zhu
- Clinical Research Center, Zhujiang Hospital of Southern Medical University, Guangzhou, Guangdong Province, 510280, People's Republic of China
| | - Wanchun Wu
- Department of Rehabilitation Medicine, Zhujiang Hospital of Southern Medical University, Guangzhou, Guangdong Province, 510280, People's Republic of China
| | - Xiaochun Zheng
- Department of Rehabilitation Medicine, Zhujiang Hospital of Southern Medical University, Guangzhou, Guangdong Province, 510280, People's Republic of China
| | - Haili Zhong
- Department of Rehabilitation Medicine, Zhujiang Hospital of Southern Medical University, Guangzhou, Guangdong Province, 510280, People's Republic of China
| | - Xiyan Huang
- Department of Rehabilitation Medicine, Zhujiang Hospital of Southern Medical University, Guangzhou, Guangdong Province, 510280, People's Republic of China.
| | - Qiuyou Xie
- Department of Rehabilitation Medicine, Zhujiang Hospital of Southern Medical University, Guangzhou, Guangdong Province, 510280, People's Republic of China.
| | - Xinyi Qian
- School of Rehabilitation Medicine, Gannan Medical University, Ganzhou, Jiangxi province, 341000, People's Republic of China
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Luauté J, Beaudoin-Gobert M. Optimising recovery of consciousness after coma. From bench to bedside and vice versa. Presse Med 2023; 52:104165. [PMID: 36948412 DOI: 10.1016/j.lpm.2023.104165] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2023] [Accepted: 03/13/2023] [Indexed: 03/24/2023] Open
Abstract
BACKGROUND Several methods have been proposed to foster recovery of consciousness in patients with disorders of consciousness (DoC). OBJECTIVE Critically assess pharmacological and non-pharmacological treatments for patients with chronic DoC. METHODS A narrative mini-review, and critical analysis of the scientific literature on the various proposed therapeutic approaches, with particular attention to level of evidence, risk-benefit ratio, and feasibility. RESULTS AND DISCUSSION Personalised sensory stimulation, median nerve stimulation, transcranial direct current stimulation (tDCS), amantadine and zolpidem all have favourable risk-benefit ratios and are easy to implement in clinical practice. These treatments should be proposed to every patient with chronic DoC. Comprehensive patient management should also include regular lifting, pain assessment and treatment, attempts to restore sleep and circadian rhythms, implementation of rest periods, comfort and nursing care, and a rehabilitation program with a multi-disciplinary team with expertise in this field. More invasive treatments may cause adverse effects and require further investigation to confirm preliminary, encouraging results and to better define responders' intervention parameters. Scientific studies are essential and given the severity of the disability and handicap that results from DoC, research in this area should aim to develop new therapeutic approaches.
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Affiliation(s)
- Jacques Luauté
- Université Claude Bernard Lyon 1, CNRS, INSERM, Centre de Recherche en Neurosciences de Lyon CRNL U1028 UMR5292, Trajectoires, F-69500, Bron, France; Hospices Civils de Lyon, Hôpital Henry Gabrielle, Saint-Genis Laval, 69230, France.
| | - Maude Beaudoin-Gobert
- Université Claude Bernard Lyon 1, CNRS, INSERM, Centre de Recherche en Neurosciences de Lyon CRNL U1028 UMR5292, Trajectoires, F-69500, Bron, France
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Shu Z, Wu J, Li H, Liu J, Lu J, Lin J, Liang S, Wu J, Han J, Yu N. fNIRS-based functional connectivity signifies recovery in patients with disorders of consciousness after DBS treatment. Clin Neurophysiol 2023; 147:60-68. [PMID: 36702043 DOI: 10.1016/j.clinph.2022.12.011] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Revised: 11/20/2022] [Accepted: 12/12/2022] [Indexed: 01/17/2023]
Abstract
OBJECTIVE While deep brain stimulation (DBS) has proved effective for certain patients with disorders of consciousness (DOC), the working neural mechanism is not clear, the response varies for patients, and the assessment is inadequate. This paper aims to quantify the DBS-induced changes of consciousness in DOC patients at the neural functional level. METHODS Ten DOC patients were included for DBS surgery. The DBS target was the right centromedian-parafascicular (CM-pf) nuclei for four patients and the bilateral CM-pf nuclei for six patients. Functional near-infrared spectroscopy (fNIRS) was taken to measure the neural activation of patients, in parallel with Coma Recovery Scale-Revised (CRS-R), before the DBS surgery and one month after. The fNIRS signals were recorded from the frontal, parietal, and occipital lobes. Functional connectivity analysis quantified the communication between brain regions, area communication strength, and global communication efficiency. Linear regression analysis was conducted between the changes of indices based on functional connectivity analysis and the changes of the CRS-R index. RESULTS Patients with trauma (n = 4) exhibited a greater increase of CRS-R scores after DBS treatment compared with patients with hemorrhage (n = 4) and brainstem infarction (n = 2). Global communication efficiency changed consistently with the CRS-R index (slope = 57.384, p < 0.05, R2=0.483). No significant relationship was found between the changes of area communication strength of six brain lobes and the changes of the CRS-R index. CONCLUSIONS The cause of DOC is essential for the outcome of DBS treatment, and brain communication efficiency is a promising functional marker for DOC recovery. SIGNIFICANCE fNIRS-based functional connectivity analysis on brain network signifies changes of consciousness in DOC patients after DBS treatment.
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Affiliation(s)
- Zhilin Shu
- College of Artificial Intelligence, Nankai University, Tianjin 300350, China; Tianjin Key Laboratory of Intelligent Robotics, Nankai University, Tianjin 300350, China
| | - Jingchao Wu
- Department of Neurosurgery, Tianjin Huanhu Hospital, Tianjin 300350, China
| | - Haitao Li
- Department of Neurosurgery, Tianjin Huanhu Hospital, Tianjin 300350, China
| | - Jinrui Liu
- College of Artificial Intelligence, Nankai University, Tianjin 300350, China; Tianjin Key Laboratory of Intelligent Robotics, Nankai University, Tianjin 300350, China
| | - Jiewei Lu
- College of Artificial Intelligence, Nankai University, Tianjin 300350, China; Tianjin Key Laboratory of Intelligent Robotics, Nankai University, Tianjin 300350, China
| | - Jianeng Lin
- College of Artificial Intelligence, Nankai University, Tianjin 300350, China; Tianjin Key Laboratory of Intelligent Robotics, Nankai University, Tianjin 300350, China
| | - Siquan Liang
- Department of Neurosurgery, Tianjin Huanhu Hospital, Tianjin 300350, China.
| | - Jialing Wu
- Department of Neurology, Tianjin Huanhu Hospital, Tianjin 300350, China; Laboratory of Cerebral Vascular and Neurodegenerative Diseases, Tianjin Neurosurgical Institute, Tianjin Huanhu Hospital, Tianjin 300350, China.
| | - Jianda Han
- College of Artificial Intelligence, Nankai University, Tianjin 300350, China; Tianjin Key Laboratory of Intelligent Robotics, Nankai University, Tianjin 300350, China.
| | - Ningbo Yu
- College of Artificial Intelligence, Nankai University, Tianjin 300350, China; Tianjin Key Laboratory of Intelligent Robotics, Nankai University, Tianjin 300350, China.
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Narayanan A, Magee WL, Siegert RJ. Machine learning and network analysis for diagnosis and prediction in disorders of consciousness. BMC Med Inform Decis Mak 2023; 23:41. [PMID: 36855149 PMCID: PMC9972731 DOI: 10.1186/s12911-023-02128-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2022] [Accepted: 02/01/2023] [Indexed: 03/02/2023] Open
Abstract
BACKGROUND Prolonged Disorders of Consciousness (PDOC) resulting from severe acquired brain injury can lead to complex disabilities that make diagnosis challenging. The role of machine learning (ML) in diagnosing PDOC states and identifying intervention strategies is relatively under-explored, having focused on predicting mortality and poor outcome. This study aims to: (a) apply ML techniques to predict PDOC diagnostic states from variables obtained from two non-invasive neurobehavior assessment tools; and (b) apply network analysis for guiding possible intervention strategies. METHODS The Coma Recovery Scale-Revised (CRS-R) is a well-established tool for assessing patients with PDOC. More recently, music has been found to be a useful medium for assessment of coma patients, leading to the standardization of a music-based assessment of awareness: Music Therapy Assessment Tool for Awareness in Disorders of Consciousness (MATADOC). CRS-R and MATADOC data were collected from 74 PDOC patients aged 16-70 years at three specialist centers in the USA, UK and Ireland. The data were analyzed by three ML techniques (neural networks, decision trees and cluster analysis) as well as modelled through system-level network analysis. RESULTS PDOC diagnostic state can be predicted to a relatively high level of accuracy that sets a benchmark for future ML analysis using neurobehavioral data only. The outcomes of this study may also have implications for understanding the role of music therapy in interdisciplinary rehabilitation to help patients move from one coma state to another. CONCLUSIONS This study has shown how ML can derive rules for diagnosis of PDOC with data from two neurobehavioral tools without the need to harvest large clinical and imaging datasets. Network analysis using the measures obtained from these two non-invasive tools provides novel, system-level ways of interpreting possible transitions between PDOC states, leading to possible use in novel, next-generation decision-support systems for PDOC.
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Affiliation(s)
- Ajit Narayanan
- grid.252547.30000 0001 0705 7067Department of Computer Science, School of Engineering, Computer and Mathematical Sciences, Auckland University of Technology, Auckland, New Zealand
| | - Wendy L. Magee
- grid.264727.20000 0001 2248 3398Boyer College of Music and Dance, Music Education and Therapy, Temple University, Philadelphia, USA
| | - Richard J. Siegert
- grid.252547.30000 0001 0705 7067Department of Psychology and Neuroscience, School of Clinical Sciences, Auckland University of Technology, Auckland, New Zealand
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Alnagger N, Cardone P, Martial C, Laureys S, Annen J, Gosseries O. The current and future contribution of neuroimaging to the understanding of disorders of consciousness. Presse Med 2023; 52:104163. [PMID: 36796250 DOI: 10.1016/j.lpm.2022.104163] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Revised: 11/21/2022] [Accepted: 12/13/2022] [Indexed: 02/16/2023] Open
Abstract
Patients with disorders of consciousness (DoC) represent a group of severely brain-injured patients with varying capacities for consciousness in terms of both wakefulness and awareness. The current state-of-the-art for assessing these patients is through standardised behavioural examinations, but inaccuracies are commonplace. Neuroimaging and electrophysiological techniques have revealed vast insights into the relationships between neural alterations, andcognitive and behavioural features of consciousness in patients with DoC. This has led to the establishment of neuroimaging paradigms for the clinical assessment of DoC patients. Here, we review selected neuroimaging findings on the DoC population, outlining key findings of the dysfunction underlying DoC and presenting the current clinical utility of neuroimaging tools. We discuss that whilst individual brain areas play instrumental roles in generating and supporting consciousness, activation of these areas alone is not sufficient for conscious experience. Instead, for consciousness to arise, we need preserved thalamo-cortical circuits, in addition to sufficient connectivity between distinctly differentiated brain networks, underlined by connectivity both within, and between such brain networks. Finally, we present recent advances and future perspectives in computational methodologies applied to DoC, supporting the notion that progress in the science of DoC will be driven by a symbiosis of these data-driven analyses, and theory-driven research. Both perspectives will work in tandem to provide mechanistic insights contextualised within theoretical frameworks which ultimately inform the practice of clinical neurology.
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Affiliation(s)
- Naji Alnagger
- Coma Science Group, GIGA-Consciousness, University of Liège, Liège, Belgium; Centre du Cerveau(2), University Hospital of Liège, Liège, Belgium
| | - Paolo Cardone
- Coma Science Group, GIGA-Consciousness, University of Liège, Liège, Belgium; Centre du Cerveau(2), University Hospital of Liège, Liège, Belgium
| | - Charlotte Martial
- Coma Science Group, GIGA-Consciousness, University of Liège, Liège, Belgium; Centre du Cerveau(2), University Hospital of Liège, Liège, Belgium
| | - Steven Laureys
- Coma Science Group, GIGA-Consciousness, University of Liège, Liège, Belgium; Centre du Cerveau(2), University Hospital of Liège, Liège, Belgium; CERVO Research Center, Laval University, Quebec, Canada
| | - Jitka Annen
- Coma Science Group, GIGA-Consciousness, University of Liège, Liège, Belgium; Centre du Cerveau(2), University Hospital of Liège, Liège, Belgium
| | - Olivia Gosseries
- Coma Science Group, GIGA-Consciousness, University of Liège, Liège, Belgium; Centre du Cerveau(2), University Hospital of Liège, Liège, Belgium.
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