To fMRI or not to fMRI? A flowchart translating guidelines for management of patients with Disorders of Consciousness into routine practice
The American Academy of Neurology and the European Academy of Neurology have now recognized, for the very first time, the value of advanced neuroimaging and electrophysiology techniques (AIEs) in the context of diagnosing patients with a disorder of consciousness (DOC). This recognition is part of an important agenda of promoting evidence-based competency in the management of DOC patients. Nonetheless, considering these techniques (and the required know-how) are seldom available outside of advanced medical centers, it is important to provide physicians with a framework for balancing risks and benefits and deciding, on a single patient basis, whether AIEs are suitable. This issue is all the more urgent considering that family members are increasingly aware of the use of AIEs in DOC patients, that pressure for these assessments is likely to increase in the context of legal proceedings, and that pathways for reimbursement for such assessments in DOC are yet to be established. The new guidelines, however, provide no guiding principle for physicians to decide when such assessments are appropriate, a limitation that impedes their wide adoption. We address this important gap by proposing an easy to use algorithmic flowchart, tightly based on the new guidelines, to evaluate the appropriateness of AIEs for any given DOC patient in the context of routine care and to help ensure that evidence-based best practices are being followed in the diagnostic process. In addition, we also provide a brief context for understanding the main categories of AIEs available to clinicians, their advantages, and their limitations.