scholarly journals Selegiline in Patients With Disorder of Consciousness: An Open Pilot Study

2018 ◽  
Vol 45 (6) ◽  
pp. 688-691
Author(s):  
Orsola Masotta ◽  
Luigi Trojano ◽  
Vincenzo Loreto ◽  
Pasquale Moretta ◽  
Anna Estraneo
Keyword(s):  
Vegetative State ◽  
Minimally Conscious State ◽  
Conscious State ◽  
Clinical Effects ◽  
Disorder Of Consciousness ◽  
Brain Injured ◽  
Minimally Conscious ◽  
Injured Patients ◽  
Open Pilot

AbstractThis open study investigated the clinical effects of 10-week selegiline administration in six patients in vegetative state and in four patients in a minimally conscious state, at least 6 months after onset. Clinical outcome was assessed by Coma Recovery Scale-Revised once a week during selegiline administration and 1 month later. Three patients stopped treatment because of possible side effects. After treatment and at 1 month of follow-up, four patients showed improvements in clinical diagnosis, and three patients showed an increase in arousal level only. Selegiline might represent a relatively safe option to enhance arousal and promote recovery in brain-injured patients with disorders of consciousness.

scholarly journals Outcome prediction in disorders of consciousness: the role of coma recovery scale revised

2018 ◽  
Author(s):  
Lucia Francesca Lucca ◽  
Danilo Lofaro ◽  
Loris Pignolo ◽  
Elio Leto ◽  
Maria Ursino ◽  
...  
Keyword(s):  
Cox Regression ◽  
Vegetative State ◽  
Minimally Conscious State ◽  
Conscious State ◽  
Functional Improvement ◽  
Disorder Of Consciousness ◽  
Rehabilitation Care ◽  
Minimally Conscious ◽  
Injured Patients

Abstract Background: To evaluate the utility of the revised coma remission scale (CRS-r), together with other clinical variables, in predicting emergence from a disorder of consciousness (DoC) after intensive rehabilitation care. Method: This is a prospective observational cohort study of consecutive 180 brain-injured patients with prolonged DoC upon admission to neurorehabilitation unit. 123 patients in a vegetative state (VS) and 57 in a minimally conscious state (MCS) were included and followed for a period of 8 weeks in the intensive care unit (ICU). Demographical and clinical factors were used as outcome measures. Univariate and multivariate Cox regression models were employed for examining potential predictors for clinical outcome along the time. Results: VS and MCS groups were matched for demographical and clinical (i.e., aetiology, tracheostomy and feed administration) variables. Within 2 months after admission in intensive neurorehabilitation unit, 3.9% were dead, 35.5% had a full recovery of consciousness and 111 66.7% remained in VS or MCS. Multivariate analysis demonstrated that the best predictor of functional improvement were the CRS-r scores. In particular, patients with values greater than 12 at admission were those with favorable likelihood of emergence from DoC. Conclusions: Our study highlights the role of the CRS-r scores for predicting short-term favorable outcome.

scholarly journals Detecting the Potential for Consciousness in Unresponsive Patients Using the Perturbational Complexity Index

2020 ◽  
Vol 10 (12) ◽  
pp. 917
Author(s):  
Dmitry O. Sinitsyn ◽  
Alexandra G. Poydasheva ◽  
Ilya S. Bakulin ◽  
Liudmila A. Legostaeva ◽  
Elizaveta G. Iazeva ◽  
...  
Keyword(s):  
Minimally Conscious State ◽  
Qualitative Evaluation ◽  
Low Complexity ◽  
Conscious State ◽  
Complexity Index ◽  
Brain Injured ◽  
Diagnostic Approaches ◽  
The Individual ◽  
Minimally Conscious ◽  
Injured Patients

The difficulties of behavioral evaluation of prolonged disorders of consciousness (DOC) motivate the development of brain-based diagnostic approaches. The perturbational complexity index (PCI), which measures the complexity of electroencephalographic (EEG) responses to transcranial magnetic stimulation (TMS), showed a remarkable sensitivity in detecting minimal signs of consciousness in previous studies. Here, we tested the reliability of PCI in an independently collected sample of 24 severely brain-injured patients, including 11 unresponsive wakefulness syndrome (UWS), 12 minimally conscious state (MCS) patients, and 1 emergence from MCS patient. We found that the individual maximum PCI value across stimulation sites fell within the consciousness range (i.e., was higher than PCI*, which is an empirical cutoff previously validated on a benchmark population) in 11 MCS patients, yielding a sensitivity of 92% that surpassed qualitative evaluation of resting EEG. Most UWS patients (n = 7, 64%) showed a slow and stereotypical TMS-EEG response, associated with low-complexity PCI values (i.e., ≤PCI*). Four UWS patients (36%) provided high-complexity PCI values, which might suggest a covert capacity for consciousness. In conclusion, this study successfully replicated the performance of PCI in discriminating between UWS and MCS patients, further motivating the application of TMS-EEG in the workflow of DOC evaluation.

Ethical Considerations of the Neurosurgical Patient

2019 ◽  
Author(s):  
Benjamin Tolchin
Keyword(s):  
Ethical Issues ◽  
Vegetative State ◽  
Minimally Conscious State ◽  
Conscious State ◽  
Neurologically Impaired ◽  
Ethical Frameworks ◽  
Neurosurgical Patient ◽  
Surrogate Decision ◽  
Minimally Conscious ◽  
Injured Patients

Neurosurgeons, anesthesiologists, and other clinicians treating patients with neurological disorders can encounter a set of unusually difficult ethical issues, including especially questions about whether to initiate or continue neurosurgical or life-sustaining interventions for neurologically impaired patients. These questions are especially challenging because neurologically injured patients are often unable to make treatment decisions for themselves and because the prognosis for recovery is often uncertain. This article includes ethical frameworks for addressing these difficult questions. This review contains 5 tables, and 31 references.  Keywords: Bioethics, Autonomy, Beneficence, Justice, Informed consent, Surrogate decision making, Vegetative state, Minimally conscious state, Brain death, Organ donation

scholarly journals Dissecting the coma spectrum using Bayesian classification

2019 ◽  
Author(s):  
Martin J. Dietz ◽  
Bochra Zareini ◽  
Risto Näätänen ◽  
Morten Overgaard
Keyword(s):  
Vegetative State ◽  
Minimally Conscious State ◽  
Conscious State ◽  
Small Sample ◽  
Control Group ◽  
Disorder Of Consciousness ◽  
Clinical Disorder ◽  
Electrophysiological Responses ◽  
Alternative Hypotheses ◽  
Minimally Conscious

AbstractA patient who does not regain full consciousness after coma is typically classified as being in a vegetative state or a minimally conscious state. While the key determinants in this differential diagnosis are inferred uniquely from the observed behaviour of the patient, nothing can, in principle, be known about the patient’s awareness of the external world. Given the subjective nature of current diagnostic practice, the quest for neurophysiological markers that could complement the nosology of the coma spectrum is becoming more and more acute. We here present a method for the classification of patients based on electrophysiological responses using Bayesian model selection. We validate the method in a sample of fourteen patients with a clinical disorder of consciousness (DoC) and a control group of fifteen healthy adults. By formally comparing a set of alternative hypotheses about the nosology of DoC patients, the results of our validation study show that we can disambiguate between alternative models of how patients are classified. Although limited to this small sample of patients, this allowed us to assert that there is no evidence of subgroups when looking at the MMN response in this sample of patients. We believe that the methods presented in this article are an important contribution to testing alternative hypotheses about how patients are grouped at both the group and single-patient level and propose that electrophysiological responses, recorded invasively or non-invasively, may be informative for the nosology of the coma spectrum on a par with behavioural diagnosis.

scholarly journals Results of a prospective study (CATS) on the effects of thalamic stimulation in minimally conscious and vegetative state patients

2016 ◽  
Vol 125 (4) ◽  
pp. 972-981 ◽  
Author(s):  
Lorenzo Magrassi ◽  
Giorgio Maggioni ◽  
Caterina Pistarini ◽  
Carol Di Perri ◽  
Stefano Bastianello ◽  
...  
Keyword(s):  
Vegetative State ◽  
Minimally Conscious State ◽  
Conscious State ◽  
Cortical Activation ◽  
Disorder Of Consciousness ◽  
Chronic Stimulation ◽  
Thalamic Stimulation ◽  
Minimally Conscious ◽  
Deep Brain ◽  
Stimulation Of

OBJECTIVE Deep brain stimulation of the thalamus was introduced more than 40 years ago with the objective of improving the performance and attention of patients in a vegetative or minimally conscious state. Here, the authors report the results of the Cortical Activation by Thalamic Stimulation (CATS) study, a prospective multiinstitutional study on the effects of bilateral chronic stimulation of the anterior intralaminar thalamic nuclei and adjacent paralaminar regions in patients affected by a disorder of consciousness. METHODS The authors evaluated the clinical and radiological data of 29 patients in a vegetative state (unresponsive wakefulness syndrome) and 11 in a minimally conscious state that lasted for more than 6 months. Of these patients, 5 were selected for bilateral stereotactic implantation of deep brain stimulating electrodes into their thalamus. A definitive consensus for surgery was obtained for 3 of the selected patients. All 3 patients (2 in a vegetative state and 1 in a minimally conscious state) underwent implantation of bilateral thalamic electrodes and submitted to chronic stimulation for a minimum of 18 months and a maximum of 48 months. RESULTS In each case, there was an increase in desynchronization and the power spectrum of electroencephalograms, and improvement in the Coma Recovery Scale–Revised scores was found. Furthermore, the severity of limb spasticity and the number and severity of pathological movements were reduced. However, none of these patients returned to a fully conscious state. CONCLUSIONS Despite the limited number of patients studied, the authors confirmed that bilateral thalamic stimulation can improve the clinical status of patients affected by a disorder of consciousness, even though this stimulation did not induce persistent, clinically evident conscious behavior in the patients. Clinical trial registration no.: NCT01027572 (ClinicalTrials.gov)

scholarly journals Disorders of Consciousness: Is a Dichotomous Legal Approach Justified?

2018 ◽  
Vol 25 (3) ◽  
pp. 239-260
Author(s):  
Richard W.M. Law ◽  
Kartina A. Choong
Keyword(s):  
Vegetative State ◽  
Medical Knowledge ◽  
Minimally Conscious State ◽  
Acquired Brain Injury ◽  
Conscious State ◽  
Disorders Of Consciousness ◽  
Decision Making Process ◽  
Disorder Of Consciousness ◽  
Minimally Conscious ◽  
Made In

Abstract Advances made in medical care mean that many critically ill patients with an acquired brain injury may survive with a disorder of consciousness. This may be in the form of a vegetative state (VS) or a minimally conscious state (MCS). Medically, there is a growing tendency to view these conditions as occupying the same clinical spectrum rather than be considered as discrete entities. In other words, their difference is now understood as one of degree rather than kind. However, is English law keeping pace with this development in medical knowledge? This article seeks to highlight the duality that exists in the legal decision-making process in England and Wales, and question the justifiability and sustainability of this dichotomous approach in the light of medicine’s current understanding on disorders of consciousness.

Poster 31 Assessing Neglect in Severely Brain-injured Patients Diagnosed with Minimally Conscious State

2011 ◽  
Vol 92 (10) ◽  
pp. 1702 ◽  
Author(s):  
Caroline Schnakers ◽  
Karin Sparmant ◽  
John Whyte ◽  
Steven Laureys ◽  
Steve Majerus
Keyword(s):  
Minimally Conscious State ◽  
Conscious State ◽  
Brain Injured ◽  
Minimally Conscious ◽  
Injured Patients

scholarly journals Quantitative Rates of Brain Glucose Metabolism Distinguish Minimally Conscious from Vegetative State Patients

2014 ◽  
Vol 35 (1) ◽  
pp. 58-65 ◽  
Author(s):  
Johan Stender ◽  
Ron Kupers ◽  
Anders Rodell ◽  
Aurore Thibaut ◽  
Camille Chatelle ◽  
...  
Keyword(s):  
Glucose Metabolism ◽  
Vegetative State ◽  
Minimally Conscious State ◽  
Conscious State ◽  
Operating Characteristics ◽  
Whole Brain ◽  
Clinical Issue ◽  
Level Of Consciousness ◽  
Minimally Conscious ◽  
Injured Patients

The differentiation of the vegetative or unresponsive wakefulness syndrome (VS/UWS) from the minimally conscious state (MCS) is an important clinical issue. The cerebral metabolic rate of glucose (CMRglc) declines when consciousness is lost, and may reveal the residual cognitive function of these patients. However, no quantitative comparisons of cerebral glucose metabolism in VS/UWS and MCS have yet been reported. We calculated the regional and whole-brain CMRglc of 41 patients in the states of VS/UWS ( n=14), MCS ( n=21) or emergence from MCS (EMCS, n=6), and healthy volunteers ( n=29). Global cortical CMRglc in VS/UWS and MCS averaged 42% and 55% of normal, respectively. Differences between VS/UWS and MCS were most pronounced in the frontoparietal cortex, at 42% and 60% of normal. In brainstem and thalamus, metabolism declined equally in the two conditions. In EMCS, metabolic rates were indistinguishable from those of MCS. Ordinal logistic regression predicted that patients are likely to emerge into MCS at CMRglc above 45% of normal. Receiver-operating characteristics showed that patients in MCS and VS/UWS can be differentiated with 82% accuracy, based on cortical metabolism. Together these results reveal a significant correlation between whole-brain energy metabolism and level of consciousness, suggesting that quantitative values of CMRglc reveal consciousness in severely brain-injured patients.

scholarly journals Slow cortico-cortical connectivity (2-5Hz) is a new robust signature of conscious states

2019 ◽  
Author(s):  
Pierre Bourdillon ◽  
Bertrand Hermann ◽  
Marc Guénot ◽  
Hélène Bastuji ◽  
Jean Isnard ◽  
...  
Keyword(s):  
Long Range ◽  
Slow Wave Sleep ◽  
Vegetative State ◽  
Minimally Conscious State ◽  
Conscious State ◽  
Conclusive Evidence ◽  
Necessary Condition ◽  
Specific Marker ◽  
Minimally Conscious ◽  
Injured Patients

AbstractWhile long-range cortico-cortical functional connectivity has been reported by several studies as a necessary condition of conscious state, precise empirical evidence is still scarce. In the present work we provide such a direct and conclusive evidence in a set of three experiments. In the two first experiments intracranial-EEG was recorded during four distinct states in the same individuals: conscious wakefulness (CW), rapid-eye-movement sleep (REM), stable periods of slow-wave sleep (SWS) and deep propofol anaesthesia (PA). We discovered that long-range FC, computed by the weighted Symbolic-Mutual-Information (wSMI) in the 2-5Hz frequency band was a specific marker of conscious states that could discriminate CW and REM from SWS and PA. In the third experiment, we generalized this original finding on a large cohort of brain-injured patients by revealing that wSMI in the 2-5 Hz range was also able to accurately discriminate patients in the vegetative state (or unresponsive wakefulness syndrome) from patients in the minimally conscious state. Taken together the present results suggest that 2-5Hz FC is a new and robust signature of conscious states.

Plum and Posner's Diagnosis and Treatment of Stupor and Coma

2019 ◽  
Author(s):  
Jerome B. Posner ◽  
Clifford B. Saper ◽  
Nicholas D. Schiff ◽  
Jan Claassen
Keyword(s):  
Brain Death ◽  
Vegetative State ◽  
Persistent Vegetative State ◽  
Minimally Conscious State ◽  
Conscious State ◽  
Diagnosis And Treatment ◽  
Comprehensive Treatment ◽  
Disorder Of Consciousness ◽  
Disease States ◽  
Minimally Conscious

This text is an update of a classic work on diagnosing the cause of coma, with the addition of new sections on the treatment of comatose patients. The first chapter provides an up-to-date review on the brain mechanisms that maintain a conscious state in humans and how lesions that damage these mechanisms cause loss of consciousness or coma. The second chapter reviews the neurological examination of the comatose patient, which provides the basis for determining whether the patient is suffering from a structural brain injury causing the coma or from a metabolic disorder of consciousness. The third and fourth chapters review the pathophysiology of structural lesions causing coma and the specific disease states that result in coma. Chapter 5 is a comprehensive treatment of the many causes of metabolic coma. Chapter 6 review psychiatric causes of unresponsiveness and how to identify and treat them. Chapters 7 and 8 review the overall emergency treatment of comatose patients, followed by the treatment of specific causes of coma. Chapter 9 examines the long-term outcomes of coma, including the minimally conscious state and the persistent vegetative state, how they can be distinguished, and their implications for eventual useful recovery. Chapter 10 reviews the topic of brain death, the standards for examination of a patient that are required to make the determination of brain death, and the ethics of diagnosis and treatment of patients who, by definition, have no way to approve of or communicate about their wishes.

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