Clinical Cognitive Motor Dissociation: A Case Report Showing How Pitfalls Can Hinder Early Clinical Detection of Awareness

Abstract

This study presents the case of a brain-injured patient whose pathological awakening after coma and absence of interaction led to a diagnosis of lack of consciousness when standard clinical scales were administered. However, we were able to demonstrate conscious perception in this patient from initial clinical assessments using the Motor Behaviour Tool in the acute stage, complemented by a systematic search for potential obstacles blocking his execution of motor responses (pitfalls). This refinement of the diagnosis enabled prediction of a favourable outcome despite the severity of the lesions, with the patient’s evolution confirming our prediction. Faced with an unresponsive patient, every specialist should go beyond the absence of response with the standard scores, consider the possibility of a hidden consciousness and look for rigorous ways of proving it.

Structural connectivity in recovery after coma: Connectome atlas approach

“…(Schiff, 2015;Edlow et al, 2017) exact underlying pathology of the CMD is not yet understood, although recent research has pointed to the possible involvement of lesions to the somatomotor-striato-thalamic network in the CMD patients, blocking the motor output or its initiation, and producing neurological disorders that hinder interaction with the environment, such as akinetic mutism, aphasia, or abulia. (Pincherle et al, 2021;Jöhr et al, 2022;Fernández-Espejo et al, 2015;Ghoshal et al, 2011) our findings are in contrast with the study of Tan et al (Tan et al, 2022) who reported significant correlation between the CRS-R scores and FA values of the mostly right hemisphere white mater tracts. The authors associated this hemispheric asymmetry with the role of the right hemisphere in the bodily self-awareness and its disorders (Ronchi et al, 2018), although they have not excluded a possible effect of neural compensation after brain injury.…”

A Focus on Subtle Signs and Motor Behavior to Unveil Awareness in Unresponsive Brain-Impaired Patients

“…10 Bringing all this together, we created a flowchart that considers clinical, pathophysiologic, radiologic, and electrophysiologic aspects to establish an early diagnosis of either a true disorder of consciousness or CMD (Figure 1). 11 We propose using the suggested flowchart as soon as possible, that is, in the intensive care unit 24 hours after sedation withdrawal, always considering residual anesthesia as a potential confounder. A comprehensive clinical assessment should be conducted at least 3 times a week in conjunction with pathophysiologic considerations and paraclinical investigations if necessary.…”