Zolpidem Action During Prolonged Disorders of Consciousness (Case Report)

The paper describes two patients with prolonged disorders of consciousness (PDC) because of non-traumatic brain injury, in whom a clear neurodynamic response to Zolpidem was observed.In order to illustrate systemic cerebral responses to administration of this drug in LIC patients, an analysis of clinical and electrophysiological changes has been undertaken.It has been shown that the result of Zolpidem applications in patients with prolonged disorders of consciousness (PDC) should be assessed not only by consciousness dynamics, but with the help of electroencephalogram (EEG) monitoring, too. Distinct response to Zolpidem during different periods of recovery in one patients was found.Zolpidem can render various effects in patients in vegetative state/with unresponsive wakefulness syndrome (VS/UWS) and in minimally conscious state (MCS). In one patient, sedation with EEG activation was observed, which was a sign of favorable prognosis. The other patient developed more than once local convulsions after Zolpidem administration followed by contact augmentation on the next day.The mechanism of action, necessary doses of drugs, and markers of forecasting the successful effect of that drug are yet to be further studied.

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Mindsight: Diagnostics in Disorders of Consciousness

Critical Care Research and Practice ◽

10.1155/2012/624724 ◽

2012 ◽

Vol 2012 ◽

pp. 1-13 ◽

Cited By ~ 7

Author(s):

P. Guldenmund ◽

J. Stender ◽

L. Heine ◽

S. Laureys

Keyword(s):

Brain Activity ◽

Vegetative State ◽

Activity Patterns ◽

Minimally Conscious State ◽

Conscious State ◽

Disorders Of Consciousness ◽

High Rate ◽

Healthy Controls ◽

Unresponsive Wakefulness Syndrome ◽

Minimally Conscious

Diagnosis of patients with disorders of consciousness (comprising coma, vegetative state/unresponsive wakefulness syndrome, and minimally conscious state) has long been dependent on unstandardized behavioral tests. The arrival of standardized behavioral tools, and especially the Coma Recovery Scale revised, uncovered a high rate of misdiagnosis. Ancillary techniques, such as brain imaging and electrophysiological examinations, are ever more often being deployed to aid in the search for remaining consciousness. They are used to look for brain activity patterns similar to those found in healthy controls. The development of portable and cheaper devices will make these techniques more widely available.

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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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Covert Cognition in Disorders of Consciousness: A Meta-Analysis

Brain Sciences ◽

10.3390/brainsci10120930 ◽

2020 ◽

Vol 10 (12) ◽

pp. 930

Author(s):

Caroline Schnakers ◽

Michaela Hirsch ◽

Enrique Noé ◽

Roberto Llorens ◽

Nicolas Lejeune ◽

...

Keyword(s):

Observational Studies ◽

Functional Neuroimaging ◽

Vegetative State ◽

Meta Analysis ◽

Minimally Conscious State ◽

Conscious State ◽

Demographic Variables ◽

Disorders Of Consciousness ◽

Minimally Conscious ◽

Increase Sample Size

Covert cognition in patients with disorders of consciousness represents a real diagnostic conundrum for clinicians. In this meta-analysis, our main objective was to identify clinical and demographic variables that are more likely to be associated with responding to an active paradigm. Among 2018 citations found on PubMed, 60 observational studies were found relevant. Based on the QUADAS-2, 49 studies were considered. Data from 25 publications were extracted and included in the meta-analysis. Most of these studies used electrophysiology as well as counting tasks or mental imagery. According to our statistical analysis, patients clinically diagnosed as being in a vegetative state and in a minimally conscious state minus (MCS−) show similar likelihood in responding to active paradigm and responders are most likely suffering from a traumatic brain injury. In the future, multi-centric studies should be performed in order to increase sample size, with similar methodologies and include structural and functional neuroimaging in order to identify cerebral markers related to such a challenging diagnosis.

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All things considered: Surrogate decision-making on behalf of patients in the minimally conscious state

Clinical Ethics ◽

10.1177/1477750920927177 ◽

2020 ◽

Vol 15 (3) ◽

pp. 111-119

Author(s):

L Syd M Johnson ◽

Kathy L Cerminara

Keyword(s):

Decision Making ◽

Medical Decision Making ◽

Vegetative State ◽

Minimally Conscious State ◽

Conscious State ◽

Disorders Of Consciousness ◽

Medical Decision ◽

Surrogate Decision Making ◽

Surrogate Decision ◽

Minimally Conscious

The minimally conscious state presents unique ethical, legal, and decision-making challenges because of the combination of diminished awareness, phenomenal experience, and diminished or absent communication. As medical expertise develops and technology advances, it is likely that more and more patients with disorders of consciousness will be recognized as being in the minimally conscious state, with minimal to no ability to participate in medical decision-making. Here we provide guidance useful for surrogates and medical professionals at any medical decision point, not merely for end-of-life decision-making. We first consider the legal landscape: precedent abounds regarding unconscious patients in coma or the vegetative state/Unresponsive Wakefulness Syndrome (VS/UWS), but there is little legal precedent involving patients in the minimally conscious state. Next we consider surrogates’ ethical authority to make medical decisions on behalf of patients with disorders of consciousness. In everyday medical decision-making, surrogates generally encounter few, if any, restrictions so long as they adhere to an idealized hierarchy of decision-making standards designed to honor patient autonomy as much as possible while ceding to the reality of what may or may not be known about a patient’s wishes. We conclude by proposing an ethically informed, practical guide for surrogate decision-making on behalf of patients in the minimally conscious state.

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Prolonged Disorders of Consciousness

Journal of the Korean Neurological Association ◽

10.17340/jkna.2020.1.2 ◽

2020 ◽

Vol 38 (1) ◽

pp. 9-15

Author(s):

Daeyoung Kim

Keyword(s):

Vegetative State ◽

Minimally Conscious State ◽

Conscious State ◽

Disorders Of Consciousness ◽

Assessment Tools ◽

Impaired Consciousness ◽

Transitional State ◽

Impaired Awareness ◽

Minimally Conscious ◽

Recovery Of Consciousness

Prolonged disorders of consciousness comprise a spectrum of impaired consciousness where arousal is preserved with impaired awareness, which last more than 4 weeks. Vegetative state is a prototype of the prolonged disorders of consciousness. A patient in the vegetative state has no signs of awareness. The minimally conscious state is characterized by inconsistent but reproducible signs of awareness and is regarded as a transitional state of recovery of consciousness. Differentiating patients in minimally conscious state from those in vegetative state is still challenging. Utilizing standardized neurobehavioral assessment tools could improve diagnostic accuracy. Recent advances in neuroimaging and electrophysiologic tools may aid the diagnosis and prognostication. Treatment for recovery of consciousness is still limited. More research on the diagnosis and treatment of prolonged disorders of consciousness is needed not only for improved care of patients with prolonged disorders of consciousness but also a greater understanding of human consciousness.

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The misdiagnosis of prolonged disorders of consciousness by a clinical consensus compared with repeated Coma-Recovery Scale-Revised assessment

10.21203/rs.2.17802/v3 ◽

2020 ◽

Author(s):

Jing Wang ◽

Xiaohua Hu ◽

Zhouyao Hu ◽

Ziwei Sun ◽

Steven Laureys ◽

...

Keyword(s):

Minimally Conscious State ◽

Conscious State ◽

Disorders Of Consciousness ◽

Behavior Assessment ◽

Unresponsive Wakefulness Syndrome ◽

Behavior Scale ◽

Minimally Conscious ◽

Consensus Diagnosis ◽

The Relationship ◽

Repeated Evaluation

Abstract Background: Previous studies have shown that a single Coma-Recovery Scale-Revision (CRS-R) assessment can identify high rates of misdiagnosis by clinical consensus. The aim of this study was to investigate the proportion of misdiagnosis by clinical consensus compared to repeated behavior-scale assessments in patients with prolonged disorders of consciousness (DOC). Methods: Patients with prolonged DOC during hospitalization were screened by clinicians, and the clinicians formed a clinical-consensus diagnosis. Trained professionals used the CRS-R to evaluate the consciousness levels of the enrolled patients repeatedly (≥5 times) within a week. Based on the repeated evaluation results, the enrolled patients with prolonged DOC were divided into unresponsive wakefulness syndrome (UWS), minimally conscious state (MCS), and emergence from MCS (EMCS). Finally, the relationship between the results of the CRS-R and the clinical consensus were analyzed. Results: In this study, 137 patients with a clinical-consensus diagnosis of prolonged DOC were enrolled. It was found that 24.7% of patients with clinical UWS were actually in MCS after a single CRS-R behavior evaluation, while the repeated CRS-R evaluation results showed that the proportion of misdiagnosis of MCS was 38.2%. A total of 16.7% of EMCS patients were misdiagnosed with clinical MCS, and 1.1% of EMCS patients were misdiagnosed with clinical UWS. Conclusions: The rate of the misdiagnosis by clinical consensus is still relatively high. Therefore, clinicians should be aware of the importance of the bedside CRS-R behavior assessment and should apply the CRS-R tool in daily procedures.

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Judicial oversight of life-ending withdrawal of assisted nutrition and hydration in disorders of consciousness in the United Kingdom: A matter of life and death

Medico-Legal Journal ◽

10.1177/0025817217702289 ◽

2017 ◽

Vol 85 (3) ◽

pp. 148-154 ◽

Cited By ~ 6

Author(s):

Mohamed Y Rady ◽

Joseph L. Verheijde

Keyword(s):

Vegetative State ◽

Minimally Conscious State ◽

Conscious State ◽

Disabled Persons ◽

Disorders Of Consciousness ◽

Best Interests ◽

Life And Death ◽

Decision Making Capacity ◽

Nutrition And Hydration ◽

Minimally Conscious

Mr Justice Baker delivered the Oxford Shrieval Lecture ‘A Matter of Life and Death’ on 11 October 2016. The lecture created public controversies about who can authorise withdrawal of assisted nutrition and hydration (ANH) in disorders of consciousness (DOC). The law requires court permission in ‘best interests’ decisions before ANH withdrawal only in permanent vegetative state and minimally conscious state. Some clinicians favour abandoning the need for court approval on the basis that clinicians are already empowered to withdraw ANH in other common conditions of DOC (e.g. coma, neurological disorders, etc.) based on their best interests assessment without court oversight. We set out a rationale in support of court oversight of best interests decisions in ANH withdrawal intended to end life in any person with DOC (who will lack relevant decision-making capacity). This ensures the safety of the general public and the protection of vulnerable disabled persons in society.

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Information processing in severe disorders of consciousness: Vegetative state and minimally conscious state

Clinical Neurophysiology ◽

10.1016/j.clinph.2005.03.028 ◽

2005 ◽

Vol 116 (10) ◽

pp. 2441-2453 ◽

Cited By ~ 213

Author(s):

B. Kotchoubey ◽

S. Lang ◽

G. Mezger ◽

D. Schmalohr ◽

M. Schneck ◽

...

Keyword(s):

Information Processing ◽

Vegetative State ◽

Minimally Conscious State ◽

Conscious State ◽

Disorders Of Consciousness ◽

Minimally Conscious

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Is Period3 Genotype Associated With Sleep and Recovery in Patients With Disorders of Consciousness?

Neurorehabilitation and Neural Repair ◽

10.1177/1545968315604398 ◽

2015 ◽

Vol 30 (5) ◽

pp. 461-469 ◽

Cited By ~ 4

Author(s):

Gloria Bedini ◽

Anna Bersano ◽

Davide Rossi Sebastiano ◽

Davide Sattin ◽

Francesca Ciaraffa ◽

...

Keyword(s):

Slow Wave Sleep ◽

Total Sleep Time ◽

Vegetative State ◽

Minimally Conscious State ◽

Sleep Time ◽

Conscious State ◽

Disorders Of Consciousness ◽

Sleep Quantity ◽

Minimally Conscious ◽

Post Hoc

Background. Sleep evaluation is increasingly being used as prognostic tool in patients with disorders of consciousness, but, surprisingly, the role of Period3 (Per3) gene polymorphism has never been evaluated. Objective. The aim of this study was to investigate the contribution of Per3 genotype on sleep quantity and consciousness recovery level in patients with disorders of consciousness (DOC). Methods. In this observational study, we evaluated 71 patients with DOC classified as vegetative state/unresponsive wakefulness syndrome or minimally conscious state. Demographic and clinical data were collected and a standardised diagnostic workup, including a polysomnographic record, was applied. After informed consent provided by proxy, genomic DNA was obtained and Per3 polymorphism was analysed by polymerase chain reaction to identify 5/5, 4/5, or 4/4 genotype. Results. Per35/5genotype was found in 12.7% of our DOC patients. The median total Coma Recovery Scale–revised score in Per35/5carriers was significantly higher than 4/4 genotype (10, range 5-16 vs 7, range 4-11; post hoc P = .036). Moreover, total sleep time seemed to be higher in 5/5 genotype ( 5/5, 221 minutes, range 88-515 minutes; 4/4, 151.5 minutes, range 36-477 minutes; and 4/5, 188 minutes, range 44-422 minutes). Conclusion. For the first time we have shown a possible association between Per3 polymorphism and consciousness recovery level in DOC patients. Even though the exact molecular mechanism has not been defined, we speculate that its effect is mediated by higher total sleep time and slow wave sleep, which would improve the preservation of main cerebral connections.

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Prognosis for patients with cognitive motor dissociation identified by brain-computer interface

Brain ◽

10.1093/brain/awaa026 ◽

2020 ◽

Vol 143 (4) ◽

pp. 1177-1189 ◽

Cited By ~ 6

Author(s):

Jiahui Pan ◽

Qiuyou Xie ◽

Pengmin Qin ◽

Yan Chen ◽

Yanbin He ◽

...

Keyword(s):

Patient Group ◽

Brain Computer Interface ◽

Minimally Conscious State ◽

Conscious State ◽

Disorders Of Consciousness ◽

The Other ◽

Computer Interface ◽

Unresponsive Wakefulness Syndrome ◽

Minimally Conscious ◽

Command Following

Abstract Cognitive motor dissociation describes a subset of patients with disorders of consciousness who show neuroimaging evidence of consciousness but no detectable command-following behaviours. Although essential for family counselling, decision-making, and the design of rehabilitation programmes, the prognosis for patients with cognitive motor dissociation remains under-investigated. The current study included 78 patients with disorders of consciousness who showed no detectable command-following behaviours. These patients included 45 patients with unresponsive wakefulness syndrome and 33 patients in a minimally conscious state, as diagnosed using the Coma Recovery Scale-Revised. Each patient underwent an EEG-based brain-computer interface experiment, in which he or she was instructed to perform an item-selection task (i.e. select a photograph or a number from two candidates). Patients who achieved statistically significant brain-computer interface accuracies were identified as cognitive motor dissociation. Two evaluations using the Coma Recovery Scale-Revised, one before the experiment and the other 3 months later, were carried out to measure the patients’ behavioural improvements. Among the 78 patients with disorders of consciousness, our results showed that within the unresponsive wakefulness syndrome patient group, 15 of 18 patients with cognitive motor dissociation (83.33%) regained consciousness, while only five of the other 27 unresponsive wakefulness syndrome patients without significant brain-computer interface accuracies (18.52%) regained consciousness. Furthermore, within the minimally conscious state patient group, 14 of 16 patients with cognitive motor dissociation (87.5%) showed improvements in their Coma Recovery Scale-Revised scores, whereas only four of the other 17 minimally conscious state patients without significant brain-computer interface accuracies (23.53%) had improved Coma Recovery Scale-Revised scores. Our results suggest that patients with cognitive motor dissociation have a better outcome than other patients. Our findings extend current knowledge of the prognosis for patients with cognitive motor dissociation and have important implications for brain-computer interface-based clinical diagnosis and prognosis for patients with disorders of consciousness.

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