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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 ).

The activities of a care providers' team need to be coordinated within a process properly designed on the basis of available best practice medical knowledge. It requires a rethinking of the management of care processes within health care organizations. The current workflow technology seems to offer the most convenient solution to build such cooperative systems. However, some of its present weaknesses still require an intense research effort to find solutions allowing its exploitation in real medical practice. This paper presents an approach to design and build evidence-based careflow management systems, which can be viewed as components of a knowledge management infrastructure each health care organization should be provided with to increase its performance in delivering high quality care by efficiently exploiting the available knowledge resources. The post-stroke rehabilitation process has been taken as a challenging care problem to assess our methodology for designing and developing careflow management systems. Then a system was co-developed with a team of rehabilitation professionals who will be committed to use it in their daily work. The system's main goal is to deliver a full array of rehabilitation services provided by an interdisciplinary team. They are related to identify which patients are most likely to benefit from rehabilitation, manage a rehabilitation treatment plan, and monitor progress both during rehabilitation and after return to a community residence. A model of the rehabilitation process was derived from an international guideline and adapted to the local organization of work. It involves different organizational units, such as wards, rehabilitation units, clinical laboratories, and imaging services. Several organizational agents work within them and play one or more roles. Each role is defined by the goals' set that she/he must fulfill. Special effort has been given to the design and development of a knowledge-based system for managing exceptions, which may occur in daily medical work as any deviation from the normal flow of activities. It allows either avoiding or recovering automatically from expected exceptions. When they are not expected, organizational agents, with enough power to do that, are allowed to modify the scheduled flow of activities for an individual patient under the only constraint of justifying their decision. After an intensive testing in a research laboratory, the system is now in the process of being transferred in a real working setting with the full support of its future users.

Objective: To investigate functional connectivity between the default mode network (DMN) and other networks in disorders of consciousness. Methods:We analyzed MRI data from 11 patients in a vegetative state and 7 patients in a minimally conscious state along with age-and sex-matched healthy control subjects. MRI data analysis included nonlinear spatial normalization to compensate for disease-related anatomical distortions. We studied brain connectivity data from resting-state MRI temporal series, combining noninferential (independent component analysis) and inferential (seed-based general linear model) methods.Results: In DMN hypoconnectivity conditions, a patient's DMN functional connectivity shifts and paradoxically increases in limbic structures, including the orbitofrontal cortex, insula, hypothalamus, and the ventral tegmental area. Conclusions:Concurrently with DMN hypoconnectivity, we report limbic hyperconnectivity in patients in vegetative and minimally conscious states. This hyperconnectivity may reflect the persistent engagement of residual neural activity in self-reinforcing neural loops, which, in turn, could disrupt normal patterns of connectivity. Patients in a vegetative state (VS) (also called "unresponsive wakefulness syndrome" 1 ) exhibit apparent dissociation between wakefulness and awareness, the 2 cardinal elements of consciousness.2 Onset of a VS, in which awareness is negatively affected, typically follows a coma and can be chronic and may evolve into a minimally conscious state (MCS).3 The current literature assumes a "passive" model of unawareness in both the VS and MCS, which is associated with widespread cerebral connectivity loss.In severe brain injury and postcomatose states, the default mode network (DMN), a major frontoparietal connectivity network of the resting brain connecting anterior and posterior cingulate with parietal and hippocampal regions, shows a breakdown of connectivity depending on the level of consciousness.4 Similar findings were found in healthy controls during altered states of consciousness such as anesthesia and sleep. 5The DMN 6 has been proposed as a correlate of the baseline cognitive state of a subject, and its link to memory and executive functions in normal and pathologic conditions suggests profound implications for consciousness. 7To date, interplay between the DMN and other brain networks has not been well explored in disorders of consciousness. We hypothesized that neural connectivity measured by resting-state From the Department of Neuroradiology (C.D.P., A.P., P.V.),