Peculiarities of cerebral haemodynamics in patients with prolonged disorder of consciousness

Abstract Background Disorder of consciousness diagnosis, especially when is classified as persistent vegetative state (without misestimating the other diagnosis classifications), in the intensive care is an important diagnosis to evaluate and treat. Persistent vegetative state diagnosis is a challenge in the daily clinical practice because the diagnosis is made mainly based upon the clinical history and the patient behavior observation. There are some specific criteria for this diagnosis, and this could be very tricky when the physician is not well trained. Main body We made a literature review regarding the persistent vegetative state diagnosis, clinical features, management, prognosis, and daily medical practice challenges while considering the bioethical issues and the family perspective about the patient status. The objective of this overview is to provide updated information regarding this clinical state’s features while considering the current medical literature available. Conclusions Regardless of the currently available guidelines and literature, there is still a lot of what we do not know about the persistent vegetative state. There is a lack of evidence regarding the optimal diagnosis and even more, about how to expect a natural history of this disorder of consciousness. It is important to recall that the patients (despite of their altered mental state diagnosis) should always be treated to avoid some of the intensive care unit long-stance complications.

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Delta band activity contributes to the identification of command following in disorder of consciousness

Scientific Reports ◽

10.1038/s41598-021-95818-6 ◽

2021 ◽

Vol 11 (1) ◽

Author(s):

Gonzalo Rivera-Lillo ◽

Emmanuel A. Stamatakis ◽

Tristan A. Bekinschtein ◽

David K. Menon ◽

Srivas Chennu

Keyword(s):

Functional Neuroimaging ◽

Brain Activity ◽

Disorder Of Consciousness ◽

Fine Grained ◽

Electrical Brain Activity ◽

Delta Band ◽

Delta Modulation ◽

Command Following ◽

Band Activity

AbstractThe overt or covert ability to follow commands in patients with disorders of consciousness is considered a sign of awareness and has recently been defined as cortically mediated behaviour. Despite its clinical relevance, the brain signatures of the perceptual processing supporting command following have been elusive. This multimodal study investigates the temporal spectral pattern of electrical brain activity to identify features that differentiated healthy controls from patients both able and unable to follow commands. We combined evidence from behavioural assessment, functional neuroimaging during mental imagery and high-density electroencephalography collected during auditory prediction, from 21 patients and 10 controls. We used a penalised regression model to identify command following using features from electroencephalography. We identified seven well-defined spatiotemporal signatures in the delta, theta and alpha bands that together contribute to identify DoC subjects with and without the ability to follow command, and further distinguished these groups of patients from controls. A fine-grained analysis of these seven signatures enabled us to determine that increased delta modulation at the frontal sensors was the main feature in command following patients. In contrast, higher frequency theta and alpha modulations differentiated controls from both groups of patients. Our findings highlight a key role of spatiotemporally specific delta modulation in supporting cortically mediated behaviour including the ability to follow command. However, patients able to follow commands nevertheless have marked differences in brain activity in comparison with healthy volunteers.

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Pain Perception in Disorder of Consciousness: A Scoping Review on Current Knowledge, Clinical Applications, and Future Perspective

Brain Sciences ◽

10.3390/brainsci11050665 ◽

2021 ◽

Vol 11 (5) ◽

pp. 665

Author(s):

Rocco Salvatore Calabrò ◽

Loris Pignolo ◽

Claudia Müller-Eising ◽

Antonino Naro

Keyword(s):

Functional Connectivity ◽

Scoping Review ◽

Pain Perception ◽

Current Knowledge ◽

Conscious Experience ◽

Minimally Conscious State ◽

Conscious State ◽

Future Perspective ◽

Disorder Of Consciousness ◽

Minimally Conscious

Pain perception in individuals with prolonged disorders of consciousness (PDOC) is still a matter of debate. Advanced neuroimaging studies suggest some cortical activations even in patients with unresponsive wakefulness syndrome (UWS) compared to those with a minimally conscious state (MCS). Therefore, pain perception has to be considered even in individuals with UWS. However, advanced neuroimaging assessment can be challenging to conduct, and its findings are sometimes difficult to be interpreted. Conversely, multichannel electroencephalography (EEG) and laser-evoked potentials (LEPs) can be carried out quickly and are more adaptable to the clinical needs. In this scoping review, we dealt with the neurophysiological basis underpinning pain in PDOC, pointing out how pain perception assessment in these individuals might help in reducing the misdiagnosis rate. The available literature data suggest that patients with UWS show a more severe functional connectivity breakdown among the pain-related brain areas compared to individuals in MCS, pointing out that pain perception increases with the level of consciousness. However, there are noteworthy exceptions, because some UWS patients show pain-related cortical activations that partially overlap those observed in MCS individuals. This suggests that some patients with UWS may have residual brain functional connectivity supporting the somatosensory, affective, and cognitive aspects of pain processing (i.e., a conscious experience of the unpleasantness of pain), rather than only being able to show autonomic responses to potentially harmful stimuli. Therefore, the significance of the neurophysiological approach to pain perception in PDOC seems to be clear, and despite some methodological caveats (including intensity of stimulation, multimodal paradigms, and active vs. passive stimulation protocols), remain to be solved. To summarize, an accurate clinical and neurophysiological assessment should always be performed for a better understanding of pain perception neurophysiological underpinnings, a more precise differential diagnosis at the level of individual cases as well as group comparisons, and patient-tailored management.

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Feasibility and Safety of Fiberoptic Endoscopic Evaluation of Swallowing in People with Disorder of Consciousness: A Systematic Review

Dysphagia ◽

10.1007/s00455-021-10327-y ◽

2021 ◽

Author(s):

Martin Checklin ◽

Tanya Dahl ◽

Gracie Tomolo

Keyword(s):

Systematic Review ◽

Endoscopic Evaluation ◽

Disorder Of Consciousness

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Clinical course of SARS-CoV-2 infection in patients with severe acquired brain injury and a disorder of consciousness: an observational study

Brain Injury ◽

10.1080/02699052.2021.1887937 ◽

2021 ◽

Vol 35 (5) ◽

pp. 520-529

Author(s):

Antonio Caronni ◽

Emanuele Liaci ◽

Anna Bianchi ◽

Alessandro Viganò ◽

Francesco Marenco ◽

...

Keyword(s):

Brain Injury ◽

Observational Study ◽

Clinical Course ◽

Acquired Brain Injury ◽

Disorder Of Consciousness ◽

Severe Acquired Brain Injury

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Measuring resting cerebral haemodynamics using MRI arterial spin labelling and transcranial Doppler ultrasound: Comparison in younger and older adults

Brain and Behavior ◽

10.1002/brb3.2126 ◽

2021 ◽

Author(s):

Claire V. Burley ◽

Susan T. Francis ◽

Anna C. Whittaker ◽

Karen J. Mullinger ◽

Samuel J.E. Lucas

Keyword(s):

Older Adults ◽

Doppler Ultrasound ◽

Transcranial Doppler ◽

Transcranial Doppler Ultrasound ◽

Arterial Spin Labelling ◽

Cerebral Haemodynamics ◽

Spin Labelling

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Noninvasive brain stimulation for patients with a disorder of consciousness: a systematic review and meta-analysis

Reviews in the Neurosciences ◽

10.1515/revneuro-2020-0033 ◽

2020 ◽

Vol 31 (8) ◽

pp. 905-914 ◽

Cited By ~ 1

Author(s):

Yali Feng ◽

Jiaqi Zhang ◽

Yi Zhou ◽

Zhongfei Bai ◽

Ying Yin

Keyword(s):

Brain Stimulation ◽

Meta Analysis ◽

Minimally Conscious State ◽

Conscious State ◽

Primary Outcome Measure ◽

Noninvasive Brain Stimulation ◽

Disorder Of Consciousness ◽

Left Dlpfc ◽

Dorsolateral Prefrontal ◽

Minimally Conscious

AbstractNoninvasive brain stimulation (NIBS) techniques have been used to facilitate the recovery from prolonged unconsciousness as a result of brain injury. The aim of this study is to systematically assess the effects of NIBS in patients with a disorder of consciousness (DOC). We searched four databases for any randomized controlled trials on the effect of NIBS in patients with a DOC, which used the JFK Coma Recovery Scale-Revised (CRS-R) as the primary outcome measure. A random-effects meta-analysis was conducted to pool effect sizes. Fourteen studies with 273 participants were included in this review, of which 12 studies with sufficient data were included in the meta-analysis. Our meta-analysis showed a significant effect on increasing CRS-R scores in favor of real stimulation as compared to sham (Hedges’ g = 0.522; 95% confidence interval [CI], 0.318–0.726; P < 0.0001, I2 = 0.00%). Subgroup analysis demonstrated that only anodal transcranial direct current stimulation (tDCS) of the left dorsolateral prefrontal cortex (DLPFC) significantly enhances the CRS-R scores in patients with a DOC, as compared to sham (Hedges’ g = 0.703; 95% CI, 0.419–0.986; P < 0.001), and this effect was predominant in patients in a minimally conscious state (MCS) (Hedges’ g = 0.815; 95% CI, 0.429–1.200; P < 0.001). Anodal tDCS of the left DLPFC appears to be an effective approach for patients with MCS.

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The accuracy of initial diagnoses in coma: an observational study in 835 patients with non-traumatic disorder of consciousness

Scandinavian Journal of Trauma Resuscitation and Emergency Medicine ◽

10.1186/s13049-020-00822-w ◽

2021 ◽

Vol 29 (1) ◽

Author(s):

Maximilian Lutz ◽

Martin Möckel ◽

Tobias Lindner ◽

Christoph J. Ploner ◽

Mischa Braun ◽

...

Keyword(s):

Emergency Care ◽

Final Diagnosis ◽

Class I ◽

Prehospital Emergency Care ◽

Unknown Etiology ◽

Care Providers ◽

Cohen’S Kappa ◽

Disorder Of Consciousness ◽

Cohen's Kappa ◽

Suspected Diagnosis

Abstract Background Management of patients with coma of unknown etiology (CUE) is a major challenge in most emergency departments (EDs). CUE is associated with a high mortality and a wide variety of pathologies that require differential therapies. A suspected diagnosis issued by pre-hospital emergency care providers often drives the first approach to these patients. We aim to determine the accuracy and value of the initial diagnostic hypothesis in patients with CUE. Methods Consecutive ED patients presenting with CUE were prospectively enrolled. We obtained the suspected diagnoses or working hypotheses from standardized reports given by prehospital emergency care providers, both paramedics and emergency physicians. Suspected and final diagnoses were classified into I) acute primary brain lesions, II) primary brain pathologies without acute lesions and III) pathologies that affected the brain secondarily. We compared suspected and final diagnosis with percent agreement and Cohen’s Kappa including sub-group analyses for paramedics and physicians. Furthermore, we tested the value of suspected and final diagnoses as predictors for mortality with binary logistic regression models. Results Overall, suspected and final diagnoses matched in 62% of 835 enrolled patients. Cohen’s Kappa showed a value of κ = .415 (95% CI .361–.469, p < .005). There was no relevant difference in diagnostic accuracy between paramedics and physicians. Suspected diagnoses did not significantly interact with in-hospital mortality (e.g., suspected class I: OR .982, 95% CI .518–1.836) while final diagnoses interacted strongly (e.g., final class I: OR 5.425, 95% CI 3.409–8.633). Conclusion In cases of CUE, the suspected diagnosis is unreliable, regardless of different pre-hospital care providers’ qualifications. It is not an appropriate decision-making tool as it neither sufficiently predicts the final diagnosis nor detects the especially critical comatose patient. To avoid the risk of mistriage and unnecessarily delayed therapy, we advocate for a standardized diagnostic work-up for all CUE patients that should be triggered by the emergency symptom alone and not by any suspected diagnosis.

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