Behavioral signs of recovery from unresponsive wakefulness syndrome to emergence of minimally conscious state after severe brain injury

As improvements in neuroscience have enabled a better understanding of disorders of consciousness as well as methods to treat them, a hurdle that has become all too prevalent is the denial of coverage for treatment and rehabilitation services. In 2011, a settlement emerged from a Vermont District Court case, Jimmo v. Sebelius, which was brought to stop the use of an “improvement standard” that required tangible progress over an identifiable period of time for Medicare coverage of services. While the use of this standard can have deleterious effects on those with many chronic conditions, it is especially burdensome for those in the minimally conscious state (MCS), where improvements are unpredictable and often not manifested through repeatable overt behaviors. Though the focus of this paper is on the challenges of brain injury and the minimally conscious state, which an estimated 100,000 to 200,000 individuals suffer from in the United States, the post-Jimmo arguments presented can and should have a broad impact as envisioned by the plaintiffs who brought the case on behalf of multiple advocacy groups representing patients with a range of chronic care conditions.

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Disorders of Consciousness and Neuro-Palliative Care

10.1093/oxfordhb/9780199974412.013.15 ◽

2015 ◽

Author(s):

Joseph J. Fins ◽

Maria Masters

Keyword(s):

Palliative Care ◽

Brain Injury ◽

Minimally Conscious State ◽

Conscious State ◽

Disorders Of Consciousness ◽

Right To Die ◽

Severe Brain Injury ◽

Brain States ◽

The Right ◽

Minimally Conscious

This chapter explains how neuro-palliative care can be provided to patients with severe brain injury. Before arguing that the right to die must be preserved and that the right to care for patients who are minimally conscious must be supported, it defines and reviews brain states that constitute disorders of consciousness along with their differential biology. It then gives an overview of palliative care for patients with severe brain injury and the challenges involved in diagnosing the minimally conscious state. It proceeds by discussing advances in technology, particularly neuroimaging, that may help meet the needs of such patients. It also considers the neuroethics of diagnosis and concludes by suggesting ways to integrate the needs of individuals suffering from disorders of consciousness in both the local and national palliative care infrastructure.

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Course of recovery and prediction of outcome in young patients in a prolonged vegetative or minimally conscious state after severe brain injury: An exploratory study

Journal of Pediatric Rehabilitation Medicine ◽

10.3233/prm-130241 ◽

2013 ◽

Vol 6 (2) ◽

pp. 73-83 ◽

Cited By ~ 13

Author(s):

Henk J. Eilander ◽

Caroline M. van Heugten ◽

Viona J.M. Wijnen ◽

Marcel A. Croon ◽

Paul L.M. de Kort ◽

...

Keyword(s):

Brain Injury ◽

Exploratory Study ◽

Young Patients ◽

Minimally Conscious State ◽

Conscious State ◽

Severe Brain Injury ◽

Prediction Of Outcome ◽

Minimally Conscious

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Neuro-palliative care and disorders of consciousness

10.1093/med/9780199656097.003.0103 ◽

2015 ◽

Cited By ~ 6

Author(s):

Joseph J. Fins ◽

Barbara Pohl

Keyword(s):

Palliative Care ◽

Brain Injury ◽

Minimally Conscious State ◽

Conscious State ◽

Disorders Of Consciousness ◽

Therapeutic Interventions ◽

Severe Brain Injury ◽

Minimally Conscious ◽

Neuroprosthetic Devices ◽

Deep Brain

Neuro-palliative care is an important resource for patients and families confronting severe brain injury. Although many clinicians equate brain injury with certain death or futility, survivors have substantial needs that might be met by palliative care expertise. This chapter suggests that the boundaries of palliative medicine include those with severe brain injury, most notably those in the minimally conscious state, and that with this nosological expansion practitioners of palliative care reflect carefully on often nihilistic attitudes directed towards patients with disorders of consciousness. This chapter establishes how to better meet the needs of these patients and their surrogates, reviewing definitional criteria for the vegetative and minimally conscious states, highlighting advances in diagnostic and therapeutic interventions (such as neuroimaging, drugs, and deep brain stimulation) and considering what neuroprosthetic devices tell us of the capacity of patients to experience-and functionally communicate-pain, distress, and suffering.

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When, How, and to What Extent Are Individuals with Unresponsive Wakefulness Syndrome Able to Progress? Neurobehavioral Progress

Brain Sciences ◽

10.3390/brainsci11010126 ◽

2021 ◽

Vol 11 (1) ◽

pp. 126

Author(s):

Enrique Noé ◽

Joan Ferri ◽

José Olaya ◽

María Dolores Navarro ◽

Myrtha O’Valle ◽

...

Keyword(s):

Clinical Decision Making ◽

Minimally Conscious State ◽

Clinical Decision ◽

Total Sample ◽

Conscious State ◽

Accurate Estimation ◽

Functional Communication ◽

Unresponsive Wakefulness Syndrome ◽

Object Use ◽

Minimally Conscious

Accurate estimation of the neurobehavioral progress of patients with unresponsive wakefulness syndrome (UWS) is essential to anticipate their most likely clinical course and guide clinical decision making. Although different studies have described this progress and possible predictors of neurobehavioral improvement in these patients, they have methodological limitations that could restrict the validity and generalization of the results. This study investigates the neurobehavioral progress of 100 patients with UWS consecutively admitted to a neurorehabilitation center using systematic weekly assessments based on standardized measures, and the prognostic factors of changes in their neurobehavioral condition. Our results showed that, during the analyzed period, 34% of the patients were able to progress from UWS to minimally conscious state (MCS), 12% of the total sample (near one third from those who progressed to MCS) were able to emerge from MCS, and 10% of the patients died. Transition to MCS was mostly denoted by visual signs, which appeared either alone or in combination with motor signs, and was predicted by etiology and the score on the Coma Recovery Scale-Revised at admission with an accuracy of 75%. Emergence from MCS was denoted in the same proportion by functional communication and object use. Predictive models of emergence from MCS and mortality were not valid and the identified predictors could not be accounted for.

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Functional Brain Network Topology Discriminates between Patients with Minimally Conscious State and Unresponsive Wakefulness Syndrome

Journal of Clinical Medicine ◽

10.3390/jcm8030306 ◽

2019 ◽

Vol 8 (3) ◽

pp. 306 ◽

Cited By ~ 12

Author(s):

Alberto Cacciola ◽

Antonino Naro ◽

Demetrio Milardi ◽

Alessia Bramanti ◽

Leonardo Malatacca ◽

...

Keyword(s):

Functional Connectivity ◽

Network Topology ◽

Minimally Conscious State ◽

Conscious State ◽

Clustering Coefficient ◽

Unresponsive Wakefulness Syndrome ◽

Topological Network ◽

Functional Brain Network ◽

Minimally Conscious ◽

Nodal Level

Consciousness arises from the functional interaction of multiple brain structures and their ability to integrate different complex patterns of internal communication. Although several studies demonstrated that the fronto-parietal and functional default mode networks play a key role in conscious processes, it is still not clear which topological network measures (that quantifies different features of whole-brain functional network organization) are altered in patients with disorders of consciousness. Herein, we investigate the functional connectivity of unresponsive wakefulness syndrome (UWS) and minimally conscious state (MCS) patients from a topological network perspective, by using resting-state EEG recording. Network-based statistical analysis reveals a subnetwork of decreased functional connectivity in UWS compared to in the MCS patients, mainly involving the interhemispheric fronto-parietal connectivity patterns. Network topological analysis reveals increased values of local-community-paradigm correlation, as well as higher clustering coefficient and local efficiency in UWS patients compared to in MCS patients. At the nodal level, the UWS patients showed altered functional topology in several limbic and temporo-parieto-occipital regions. Taken together, our results highlight (i) the involvement of the interhemispheric fronto-parietal functional connectivity in the pathophysiology of consciousness disorders and (ii) an aberrant connectome organization both at the network topology level and at the nodal level in UWS patients compared to in the MCS patients.

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Treating Vegetative State or Minimally Conscious State with Bromocriptine in Traumatic Brain Injury: Review of Clinical Cases

Archives of Physical Medicine and Rehabilitation ◽

10.1016/j.apmr.2016.08.283 ◽

2016 ◽

Vol 97 (10) ◽

pp. e92

Author(s):

Rosa Martin-Mourelle ◽

Sergio Otero-Villaverde ◽

Carmen Crespo Lopez ◽

Jorge Cabrera Sarmiento ◽

Nelson Gaitan Perez ◽

...

Keyword(s):

Traumatic Brain Injury ◽

Brain Injury ◽

Vegetative State ◽

Minimally Conscious State ◽

Conscious State ◽

Minimally Conscious ◽

Clinical Cases

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Evaluation of structural variations in the pituitary gland, hormonal status and laboratory markers of the central nervous system functioning in patients with chronic disorders of consciousness

Journal of obstetrics and women s diseases ◽

10.17816/jowd77930 ◽

2021 ◽

Vol 70 (5) ◽

pp. 23-36

Author(s):

Ekaterina A. Kondratyeva ◽

Alina O. Ivanova ◽

Maria I. Yarmolinskaya ◽

Elena G. Potyomkina ◽

Natalya V. Dryagina ◽

...

Keyword(s):

Cerebrospinal Fluid ◽

Blood Serum ◽

Minimally Conscious State ◽

Conscious State ◽

Disorders Of Consciousness ◽

Unresponsive Wakefulness Syndrome ◽

Level Of Consciousness ◽

Chronic Disorders ◽

Minimally Conscious ◽

Chronic Disorders Of Consciousness

BACKGROUND: Consciousness is the state of being awake and aware of oneself and the environment. The disorders of consciousness result from pathologies that impair awareness. The development of effective comprehensive personalized interventions contributing to the recovery of consciousness in patients with chronic disorders of consciousness is one of the most pressing and challenging tasks in modern rehabilitation. AIM: The aim of this study was to understand structural problems of the pituitary gland, blood levels of gonadotropins and melatonin as well as brain damage markers in the blood and cerebrospinal fluid in patients with chronic disorders of consciousness and to analyze the levels of the above markers among different groups of patients depending on the level of impaired consciousness. MATERIALS AND METHODS: We examined 61 chronic disorders of consciousness patients and identified three groups depending on the level of consciousness including 24 patients with unresponsive wakefulness syndrome, 24 patients with a minus minimally conscious state, and 13 patients with minimally conscious state plus. We performed magnetic resonance imaging of chiasmatic-sellar region and determined blood serum levels of follicle-stimulating and luteinizing hormones and melatonin, as well as urinary level of 6-sulfatoxymelatonin and the content of brain derived neurotrophic factor (BDNF), apoptosis antigen (APO-1), FasL, glutamate, and S100 protein in the blood serum and cerebrospinal fluid. RESULTS: The patients were examined in the age ranging from 15 to 61 years old. Patient groups were homogeneous by the level of consciousness in terms of age and duration of chronic disorders of consciousness by the time of examination. The patients did not differ in the pituitary volume regardless of the level of consciousness. No significant differences were found between the groups with different levels of consciousness when studying the levels of melatonin in the blood serum and its metabolite in the urine. A peak in melatonin secretion was detected at 3 a.m. in 54.5 % of the patients, which can be considered as a favorable prognostic marker for further recovery of consciousness. Hypogonadotropic ovarian failure was found in 34 % of the patients, with normogonadotropic ovarian failure in the remaining patients. Serum APO-1 and BDNF levels were significantly higher in patients with minimally conscious state relative to those with unresponsive wakefulness syndrome. Significantly lower levels of glutamate in the cerebrospinal fluid were detected in women with unresponsive wakefulness syndrome compared to patients with minimally conscious state. CONCLUSIONS: Further in-depth examination and accumulation of data on patients with chronic disorders of consciousness may provide an opportunity to identify highly informative markers for predicting outcomes and to develop new effective approaches to rehabilitation of consciousness in this category of patients.

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When, How, and to What Extent Are Individuals with Unresponsive Wakefulness Syndrome Able to Progress? Functional Independence

Brain Sciences ◽

10.3390/brainsci10120990 ◽

2020 ◽

Vol 10 (12) ◽

pp. 990

Author(s):

José Olaya ◽

Enrique Noé ◽

María Dolores Navarro ◽

Myrtha O’Valle ◽

Carolina Colomer ◽

...

Keyword(s):

Minimally Conscious State ◽

Functional Independence ◽

Conscious State ◽

Functional Improvement ◽

Accurate Estimation ◽

Unresponsive Wakefulness Syndrome ◽

Functional Changes ◽

Domain Specific ◽

One Year ◽

Minimally Conscious

Accurate estimation of the functional independence of patients with unresponsive wakefulness syndrome (UWS) is essential to adjust family and clinical expectations and plan long-term necessary resources. Although different studies have described the clinical course of these patients, they have methodological limitations that could restrict generalization of the results. This study investigates the neurobehavioral progress of 100 patients with UWS consecutively admitted to a neurorehabilitation center using systematic weekly assessments based on standardized measures, and the functional independence staging of those patients who emerged from a minimally conscious state (MCS) during the first year post-emergence. Our results showed that one year after emergence, most patients were severely dependent, although some of them showed extreme or moderate severity. Clinically meaningful functional improvement was less likely to occur in cognitively-demanding activities, such as activities of daily living and executive function. Consequently, the use of specific and staging functional independence measures, with domain-specific evaluations, are recommended to detect the functional changes that might be expected in these patients. The information provided by these instruments, together with that obtained from repeated assessments of the preserved consciousness with standardized instruments, could help clinicians to adjust expectations and plan necessary resources for this population.

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