Flowchart for Implementing Advanced Imaging and Electrophysiology in Patients With Disorders of Consciousness

Abstract

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 ethical and clinical imperatives to meet standards of care, 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 that is based on the new guidelines and can be used to determine the appropriateness of AIEs for any given DOC patient and ensure that evidence-based best practices are being followed. We also provide a brief context for understanding the main categories of AIEs available to clinicians, their advantages, and their limitations.

What names for covert awareness? A systematic review

“…On the other hand, the clinical management of this population will certainly have to include serial state-of-the-art behavioral assessments as recommended by the American and European Academy Neurology to optimize the detection of consciousness at the bedside (Giacino et al, 2018;Kondziella et al, 2020). Tools such as flowcharts have recently been published to help clinicians implement recent guidelines and ensure high quality behavioral assessments before making a decision regarding the need of multi-modal assessments (Monti and Schnakers, 2022). Future studies should also address the risk of misinterpretation of multi-modal results (false positive) and develop protocols for clinicians to decrease this risk.…”

The importance of instrumental assessment in disorders of consciousness: a comparison between American, European, and UK International recommendations

“…Nevertheless, the three international guidelines do not clarify when specific instrumental tools should be adopted in clinical routine case-by-case. To fill this gap, previous works provided decision trees taking into account the patients’ stage, their behavioral responsiveness (i.e., diagnosis), the clinical status, confounding factors [ 39 , 40 ], and even the costs associated with the use of different instrumental tools [ 41 ]. Notwithstanding these efforts, it remains to be determined a shared algorithm that can consider the peculiarities of each National Health System, the different national care pathways, legislations, economics, cultural, and moral attitudes toward very frail patients, along with the availability of instrumental tools in both acute and post-acute care settings.…”

“…Indeed, the use of instrumental tools should be differently grounded on DOC patients' clinical stage and condition. For example, EEG, TMS-EEG, PET, and fMRI seem to be useful to detect consciousness in behaviorally unresponsive patients [13,[37][38][39]. Conversely, the use of these techniques seems to be poorly useful with patients who already show at least minimal behavioral responsiveness [37,39].…”

“…For example, EEG, TMS-EEG, PET, and fMRI seem to be useful to detect consciousness in behaviorally unresponsive patients [13,[37][38][39]. Conversely, the use of these techniques seems to be poorly useful with patients who already show at least minimal behavioral responsiveness [37,39]. Nevertheless, the three international guidelines do not clarify when specific instrumental tools should be adopted in clinical routine case-by-case.…”

Neuroethics across the Disorders of Consciousness Care Continuum

“…140 Advanced neuroimaging and electrophysiologic techniques in the acute care setting could help establish a clearer diagnosis and inform which patients will experience positive versus poor outcomes. 203 Yet, there may be barriers to the use of these techniques for some patients. The AAN/ACRM/NIDILRR guideline specifies that advanced neuroimaging can be used in acute care if it is "feasible" and its "benefit outweighs costs."…”