Diagnostic Developments in Differentiating Unresponsive Wakefulness Syndrome and the Minimally Conscious State

When treating patients with a disorder of consciousness (DOC), it is essential to obtain an accurate diagnosis as soon as possible to generate individualized treatment programs. However, accurately diagnosing patients with DOCs is challenging and prone to errors when differentiating patients in a Vegetative State/Unresponsive Wakefulness Syndrome (VS/UWS) from those in a Minimally Conscious State (MCS). Upwards of ~40% of patients with a DOC can be misdiagnosed when specifically designed behavioral scales are not employed or improperly administered. To improve diagnostic accuracy for these patients, several important neuroimaging and electrophysiological technologies have been proposed. These include Positron Emission Tomography (PET), functional Magnetic Resonance Imaging (fMRI), Electroencephalography (EEG), and Transcranial Magnetic Stimulation (TMS). Here, we review the different ways in which these techniques can improve diagnostic differentiation between VS/UWS and MCS patients. We do so by referring to studies that were conducted within the last 10 years, which were extracted from the PubMed database. In total, 55 studies met our criteria (clinical diagnoses of VS/UWS from MCS as made by PET, fMRI, EEG and TMS- EEG tools) and were included in this review. By summarizing the promising results achieved in understanding and diagnosing these conditions, we aim to emphasize the need for more such tools to be incorporated in standard clinical practice, as well as the importance of data sharing to incentivize the community to meet these goals.

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Zolpidem Action During Prolonged Disorders of Consciousness (Case Report)

General Reanimatology ◽

10.15360/1813-9779-2019-5-44-60 ◽

2019 ◽

Vol 15 (5) ◽

pp. 44-60 ◽

Cited By ~ 1

Author(s):

E. A. Kondratyeva ◽

M. V. Sinkin ◽

E. V. Sharova ◽

S. Laureys ◽

A. N. Kondratyev

Keyword(s):

Vegetative State ◽

Minimally Conscious State ◽

Conscious State ◽

Disorders Of Consciousness ◽

Eeg Monitoring ◽

Unresponsive Wakefulness Syndrome ◽

Favorable Prognosis ◽

Eeg Activation ◽

Minimally Conscious ◽

Electroencephalogram Eeg

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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Dissecting the coma spectrum using Bayesian classification

10.1101/832824 ◽

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.

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

Canadian Journal of Neurological Sciences / Journal Canadien des Sciences Neurologiques ◽

10.1017/cjn.2018.315 ◽

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.

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

Journal of Neurosurgery ◽

10.3171/2015.7.jns15700 ◽

2016 ◽

Vol 125 (4) ◽

pp. 972-981 ◽

Cited By ~ 29

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)

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The Timecourse of Electrophysiological Brain–Heart Interaction in DoC Patients

Brain Sciences ◽

10.3390/brainsci11060750 ◽

2021 ◽

Vol 11 (6) ◽

pp. 750

Author(s):

Francesco Riganello ◽

Martina Vatrano ◽

Simone Carozzo ◽

Miriam Russo ◽

Lucia Francesca Lucca ◽

...

Keyword(s):

Vegetative State ◽

Minimally Conscious State ◽

External World ◽

Conscious State ◽

Unresponsive Wakefulness Syndrome ◽

Alpha Blocking ◽

Significant Difference ◽

Healthy Control ◽

Minimally Conscious ◽

Stimulation Of

Disorders of Consciousness (DOC) are a spectrum of pathologies affecting one’s ability to interact with the external world. Two possible conditions of patients with DOC are Unresponsive Wakefulness Syndrome/Vegetative State (UWS/VS) and Minimally Conscious State (MCS). Analysis of spontaneous EEG activity and the Heart Rate Variability (HRV) are effective techniques in exploring and evaluating patients with DOC. This study aims to observe fluctuations in EEG and HRV parameters in the morning/afternoon resting-state recording. The study enrolled 13 voluntary Healthy Control (HC) subjects and 12 DOC patients (7 MCS, 5 UWS/VS). EEG and EKG were recorded. PSDalpha, PSDtheta powerband, alpha-blocking, alpha/theta of the EEG, Complexity Index (CI) and SDNN of EKG were analyzed. Higher values of PSDalpha, alpha-blocking, alpha/theta and CI values and lower values of PSD theta characterized HC individuals in the morning with respect to DOC patients. In the afternoon, we detected a significant difference between groups in the CI, PSDalpha, PSDtheta, alpha/theta and SDNN, with lower PSDtheta value for HC. CRS-R scores showed a strong correlation with recorded parameters mainly during evaluations in the morning. Our finding put in evidence the importance of the assessment, as the stimulation of DOC patients in research for behavioural response, in the morning.

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Disorders of Consciousness: Is a Dichotomous Legal Approach Justified?

European Journal of Health Law ◽

10.1163/15718093-12520369 ◽

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.

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

10.21203/rs.2.96/v1 ◽

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.

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Visual Control System Based on Nociception-Analgesia Index for Patients in a Vegetative State/Unresponsive Wakefulness Syndrome and Minimally Conscious State

10.51130/graphicon-2020-2-4-21 ◽

2020 ◽

pp. short21-1-short21-7

Author(s):

Svetlana Degtiareva ◽

Ivan Polukhin ◽

Irina Smirnova ◽

Ekaterina Kondratieva ◽

Vladislav Bougrov

Keyword(s):

Control System ◽

Vegetative State ◽

Minimally Conscious State ◽

Conscious State ◽

Visual Control ◽

Monitoring Systems ◽

Visual Object ◽

Unresponsive Wakefulness Syndrome ◽

Minimally Conscious ◽

Range Of Values

Considering people who are in a coma, doctors have to rely on physical clues and information provided by monitoring systems. It is commonly used for patients in a vegetative state, as contact with them is difficult. Taking into account the typical workload of the doctor, they require several tools to monitor the coma depth, since it is hard to perform a clinical evaluation hourly. Therefore, visual perception and monitoring of physical state for coma personnel proved to be more convenient for prompt decision-making. In a number of cases, it would be possible to make a prognosis for their recovery and monitor effectiveness of treatment courses. Visual control system based on RGB led strips according to the ANI range of values was created. In conclusion, the connecting scheme of ANI monitor with the implementation of visual object was presented.

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

10.1093/med/9780190208875.001.0001 ◽

2019 ◽

Cited By ~ 8

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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