Activation of a residual cortical network during painful stimulation in long-term postanoxic vegetative state: a 15O–H2O PET study

Kassubek, Jan; Juengling, Freimut D.; Els, Thomas; Spreer, Joachim; Herpers, M.; Krause, Thomas; Moser, E.; Lücking, Carl Hermann

doi:10.1016/s0022-510x(03)00106-0

Cited by 114 publications

(67 citation statements)

References 24 publications

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“…Finally, Kassubek et al 23 observed activation to noxious stimuli in contralateral primary and secondary somatosensory, anterior cingulate and ipsilateral posterior insular cortices in seven hypoxic VS patients studied three months to four years post-insult. This study is in contrast with Laureys et al 's results showing solely primary cortical activation during noxious stimulation.…”

Section: Clinical Medicine Vol 8 No 5 October 2008mentioning

confidence: 95%

“…All in all, eight PET studies including 32 patients [6][7][8][9][10][11]16,18,23 and six fMRI studies including 17 patients 12,13,15,[17][18][19][20][21] (one patient was studied by both PET and fMRI) have been reviewed (Table 1). Among these 48 patients (16 of whom were traumatic), 25 patients (52%; 8 traumatic) showed typical activation patterns, five patients (10%; 1 traumatic) showed no activation and 18 patients (38%; 7 traumatic) showed atypical activation patterns.…”

Section: Does Cerebral Activation Predict Clinical Recovery?mentioning

confidence: 99%

“…In eight patients no outcome data were available (seven atypical activations 23 and one absence of activation 11 ). Nine out of the 11 patients with atypical 'higher order' associative cortical activation patterns (82%; 6 traumatic) recovered consciousness.…”

Section: Does Cerebral Activation Predict Clinical Recovery?mentioning

confidence: 99%

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Neuroimaging activation studies in the vegetative state: predictors of recovery?

Boly

Weng

et al. 2008

Clinical Medicine

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-The vegetative state (VS) is a devastating clinical condition characterised by wakefulness without awareness. Functional neuroimaging permits to objectively measure brain responsiveness to external stimuli in VS. The literature on functional magnetic resonance imaging and positron emission tomography studies in these patients has been reviewed. Results from 15 studies were classified in: absent cortical activation or 'typical' activation of 'low level' primary sensory cortices and 'atypical' activation spreading to 'higher level' associative cortices. This descriptive review on 48 published cases suggests that 'atypical' activation patterns seem to herald recovery from VS with a 93% specificity and 69% sensitivity. Passive stimulation paradigms, however, do not permit to make strong claims about the absence or presence of consciousness. Recently proposed mental imagery paradigms permit to identify signs of consciousness in non-communicative brain damaged patients. The clinical application of these functional neuroimaging techniques awaits validation from ongoing multi-centric cohort studies in these challenging patients with chronic disorders of consciousness. KEY WORDS: brain injury, coma, functional magnetic resonance imaging, minimally conscious state, positron emission tomography, vegetative statePatients in a vegetative state (VS) present sleep-wake cycles but show no sign of awareness of the environment or of self. An accurate and reliable judgment of VS patients' awareness is of paramount importance for their diagnosis and prognosis. In clinical practice, the evidence for the existence of VS patients' awareness comes from bedside behavioural assessment. However, theoretically, awareness is a multifaceted concept. It mainly refers to the subject's own subjective experience, which is not equal to its communicable behavioural expression. Furthermore, for disorders of consciousness like VS, motor dysfunction and arousal fluctuations render the bedside assessment of awareness challenging. 1 Misdiagnosis in VS has been shown to be as high as 37-43%. 2,3,4 Diagnosing the VS is more difficult than diagnosing brain death (ie irreversible coma with absent brainstem reflexes). For the latter, complimentary examinations exist to confirm the clinical diagnosis (eg the absence of electrical cerebral activity as shown by an electroencephalogram (EEG) or of cerebral blood flow as shown by echo Doppler, angiography or scanning techniques). 5 Such objective diagnostic markers are also needed to confirm the clinical diagnosis of VS.Ongoing developments and validation in healthy subjects of brain mapping techniques, such as functional magnetic resonance imaging (fMRI) and positron emission tomography (PET) now permit the use of brain 'activation studies' in clinical settings. Detecting residual brain function in VS by use of functional neuroimaging may provide useful information to the diagnosis and prognosis of these challenging patients. Such studies also provide an opportunity to study the neural correlates of c...

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Section: Clinical Medicine Vol 8 No 5 October 2008mentioning

confidence: 95%

Section: Does Cerebral Activation Predict Clinical Recovery?mentioning

confidence: 99%

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Neuroimaging activation studies in the vegetative state: predictors of recovery?

Boly

Weng

et al. 2008

Clinical Medicine

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“…Kassubek et al [25] performed a H 2 O PET scan when administering an electrical noxious stimulus in seven post-anoxic patients in a VS/UWS. A group analysis revealed a pain-induced activation in S1 but also in S2 and in the cingulate cortex which is involved in the affective pain network.…”

Section: Pain Processing and Disorders Of Consciousnessmentioning

confidence: 99%

Pain issues in disorders of consciousness

Chatelle¹,

Thibaut²,

Whyte³

et al. 2014

Brain Injury

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Background: The assessment of pain and nociception in non-communicative patients with disorders of consciousness (DOC) is a real challenge for clinicians. It is, therefore, important to develop sensitive standardized tools usable at the bedside. Objectives: This review aims to provide an overview of the current knowledge about pain processing and assessment in patients with DOC. Methods: A search was performed on PubMed using MeSH terms including vegetative state, unresponsive wakefulness syndrome, minimally conscious state, consciousness disorders, pain, nociception, neuroimaging and pain assessment. Results: Neuroimaging studies investigating pain processing in patients with DOC and their implication for clinicians are reviewed. Current works on the development of standardized and sensitive tools for assessing nociception are described. Conclusion: The suggested pain perception capacity highlighted by neuroimaging studies in patients in a MCS and in some patients in a VS/UWS supports the idea that these patients need analgesic treatment and monitoring. The first tool which has been developed to assess nociception and pain in patients with DOC is the NCS. Its revised version represents a rapid, standardized and sensitive scale which can be easily implemented in a clinical setting. Complementary pain assessments are also under validation in order to offer more options to clinicians.

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“…Instead, cortical activation subsisted as an island, dissociated from higherorder associative cortices that are currently thought to be necessary for conscious awareness [e.g., 43,44]. However, another study reported additional activation of secondary somatosensory and insular cortices in VS/ UWS patients [45], suggesting the possibility of affective experiences of pain in these patients. As opposed to VS/UWS patients, noxious stimulation in MCS patients measured with PET elicited cerebral responses not only in the midbrain, thalamus, and primary somatosensory cortex but also more widespread activation in secondary somatosensory, insular, posterior parietal, and anterior cingulate cortices, comparable to healthy controls [46,47], strongly suggesting preserved capacity of pain experience in these patients.…”

Section: Functional Neuroimaging and Electrophysiology Of Negative Anmentioning

confidence: 99%

Pain Perception in Disorders of Consciousness: Neuroscience, Clinical Care, and Ethics in Dialogue

et al. 2012

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Pain, suffering and positive emotions in patients in vegetative state/unresponsive wakefulness syndrome (VS/UWS) and minimally conscious states (MCS) pose clinical and ethical challenges. Clinically, we evaluate behavioural responses after painful stimulation and also emotionally-contingent behaviours (e.g., smiling). Using stimuli with emotional valence, neuroimaging and electrophysiology technologies can detect subclinical remnants of preserved capacities for pain which might influence decisions about treatment limitation. To date, no data exist as to how healthcare providers think about end-of-life options (e.g., withdrawal of artificial nutrition and hydration) in the presence or absence of pain in non-communicative patients. Here, we aimed to better clarify this issue by re-analyzing previously published data on pain perception (Prog Brain Res 2009 177, 329-38) and end-of-life decisions (J Neurol 2010 258, 1058-65) in patients with disorders of consciousness. In a sample of 2259 European healthcare professionals we found that, for VS/UWS more respondents agreed with treatment withdrawal when they considered that VS/UWS patients did not feel pain (77%) as compared to those who thought VS/UWS did feel pain (59%). This interaction was influenced by religiosity and professional background. For MCS, end-of-life attitudes were not Neuroethics (2013) Author's personal copy influenced by opinions on pain perception. Within a contemporary ethical context we discuss (1) the evolving scientific understandings of pain perception and their relationship to existing clinical and ethical guidelines; (2) the discrepancies of attitudes within (and between) healthcare providers and their consequences for treatment approaches, and (3) the implicit but complex relationship between pain perception and attitudes toward life-sustaining treatments.6:37-50 DOI 10.1007/s12152-011-9149-

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Activation of a residual cortical network during painful stimulation in long-term postanoxic vegetative state: a 15O–H2O PET study

Cited by 114 publications

References 24 publications

Neuroimaging activation studies in the vegetative state: predictors of recovery?

Neuroimaging activation studies in the vegetative state: predictors of recovery?

Pain issues in disorders of consciousness

Pain Perception in Disorders of Consciousness: Neuroscience, Clinical Care, and Ethics in Dialogue

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