Practice Guideline Update Recommendations Summary: Disorders of Consciousness

Giacino, Joseph T.; Katz, Douglas I.; Schiff, Nicholas D.; Whyte, John; Ashman, Eric; Ashwal, Stephen; Barbano, Richard L.; Hammond, Flora M.; Laureys, Steven; Ling, Geoffrey; Nakase‐Richardson, Risa; Seel, Ronald T.; Yablon, Stuart A.; Getchius, Thomas S.D.; Gronseth, Gary S.; Armstrong, Melissa J.

doi:10.1016/j.apmr.2018.07.001

Cited by 170 publications

(103 citation statements)

References 38 publications

(37 reference statements)

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“…Reflexive withdrawal can be behaviorally congruent per se, but its association to painful experience is often uncertain in this context [42]. This has important implications for analgesic treatment [43], as emphasized in recent recommendations [1].…”

Section: Discussionmentioning

confidence: 99%

“…The assessment of the state of consciousness (CS) in patients emerging from coma is a major challenge for all centers delivering acute and post-acute inpatient rehabilitation to victims of acquired brain injury (ABI). Due to the need for frequent inspection of the CS at the bedside and in optimal arousal state, behavioral assessment remains essential [1], despite a high rate of misdiagnoses [2]. A number of tools specifically designed for accurate behavioral assessment of the CS [3] have been validated [4][5][6][7][8], and some have become a standard [1,3].…”

Section: Introductionmentioning

confidence: 99%

“…Due to the need for frequent inspection of the CS at the bedside and in optimal arousal state, behavioral assessment remains essential [1], despite a high rate of misdiagnoses [2]. A number of tools specifically designed for accurate behavioral assessment of the CS [3] have been validated [4][5][6][7][8], and some have become a standard [1,3]. In parallel, the availability of unprecedentedly refined diagnostic resources has fostered deeper exploration of the disorders of consciousness (DOC).…”

Section: Introductionmentioning

confidence: 99%

“…Validation in children remains sporadic, sized on small samples and aimed to the 'wide' pediatric age [13,14]. A recent survey and the most updated guidelines have both highlighted a lack of appropriate tools and standards for pediatrics [1,15]. Additionally, the behavioral assessment is intrinsically harder, due to the yet limited behavioral repertoire of infants and very young children [16,17], the dependence of outcome on the age at injury [18,19], and the overlap of the evolution of the CS with the physiological growth curve [20][21][22].…”

Section: Introductionmentioning

confidence: 99%

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Joint Neuropsychological Assessment through Coma/Near Coma and Level of Cognitive Functioning Assessment Scales Reduces Negative Findings in Pediatric Disorders of Consciousness

et al. 2020

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The present study aimed to: (a) characterize the emergence to a conscious state (CS) in a sample of children and adolescents with severe brain injury during the post-acute rehabilitation and through two different neuropsychological assessment tools: the Rappaport Coma/Near Coma Scale (CNCS) and Level of Cognitive Functioning Assessment Scale (LOCFAS); (b) compare the evolution in patients with brain lesions due to traumatic and non-traumatic etiologies; and (c) describe the relationship between the emergence to a CS and some relevant clinical variables. In this observational prospective longitudinal study, 92 consecutive patients were recruited. Inclusion criteria were severe disorders of consciousness (DOC), Glasgow Coma Scale (GCS) score ≤8 at insult, age 0 to 18 years, and direct admission to inpatient rehabilitation from acute care. The main outcome measures were CNCS and LOCFAS, both administered three and six months after injury. The cohort globally shifted towards milder DOC over time, moving from overall ‘moderate/near coma’ at three months to ‘near/no coma’ at six months post-injury. The shift was captured by both CNCS and LOCFAS. CNCS differentiated levels of coma at best, while LOCFAS was superior in characterizing the emergence from coma. Agreement between scales was fair, and reduced negative findings at less than 10%. Patients with traumatic brain injury (TBI) vs. non-traumatic brain injury (NTBI) were older and had neurosurgical intervention more frequently. No relation between age and the level of consciousness was found overall. Concurrent administration of CNCS and LOCFAS reduced the rate of false negatives and better detected signs of arousal and awareness. This provides indication to administer both tools to increase measurement precision.

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Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

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Joint Neuropsychological Assessment through Coma/Near Coma and Level of Cognitive Functioning Assessment Scales Reduces Negative Findings in Pediatric Disorders of Consciousness

et al. 2020

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“…Восстановление бодрствования без признаков взаимодействия с окружающей средой свидетельствует о переходе в вегетативное состояние. Учитывая неоднородность группы пациентов, уровень содержания сознания которых характеризуется как «вегетативное состояние», и сформировавшуюся негативную, пессимистическую эмоциональную окраску этого термина, международным сообществом рекомендован более нейтральный, описательный термин -синдром безответного бодрствования (СББ) [1]. Пациенты с синдромом малого сознания (СМС) демонстрируют восстановление целенаправленного поведения, но остаются недоступными для полноценного общения.…”

Section: Locked-in Syndrome In Basilar Artery Thrombosis Is a Classicunclassified

Diagnosis of the phenomenon of cognitive-motor dissociation in patients with chronic consciousness disorders

Belkin

Pozdnyakov

Belkin

2019

RJTAO

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Locked-in syndrome in basilar artery thrombosis is a classic example of dissociation between preserved consciousness and complete deefferentation as total myoplegia with preserved vertical eye movement. Something similar is observed in post-comatose patients, described under the name “functional locked-in syndrome”, and is also a clinical reflection of the phenomenon of cognitive-motor dissociation (CMD). Diagnosis of this condition in a patient with chronic consciousness disorders indicates that there may be a cognitive imprint, which gives a chance for the maximum realization of the rehabilitation potential of latent consciousness as an exit to the clinical level of small consciousness or creation of a brain-interface. In any case, this patient should be given an extended rehabilitation program.Objective: to search for the optimal set of clinical and instrumental diagnostic methods, allowing the identification of CMD in patients with chronic consciousness disorder.Patients and methods. The 2016–2018 prospective single-center study enrolled patients with unresponsive wakefulness syndrome (UWS) who had received a treatment cycle at the Clinical Brain Institute (Yekaterinburg). The study included 39 patients (22 men, 17 women) aged 19 to 71 years who had sustained various cerebral injuries (traumatic, hypoxic, and acute vascular disease-associated) in different periods (from 32 to 2431 days) before being included in the study. All the patients underwent 5-fold clinical assessments according to the Coma Recovery ScaleRevised (CRS-R) and navigated transcranial magnetic stimulation (nTMS) in order to determine the time course of changes in the activity of the cortical motor centers at the time of presentation of verbal paradigms. Registration of the changes was assessed as the presence of a cognitive imprint and served as a criterion for diagnosing CMD as a positive predictor for the outcome of UWS. The outcome of the state was analyzed using the Glasgow Outcome Scale (GOS) at 180 days.Results and discussion. Positive changes (GOS >3) were noted in 10 (66%) patients with established CMD; the patients who had not diagnosed as having the cognitive potential showed a further increase in the level of cognition in 3 (12.5%) cases. Whether the identified sign could be used in the comprehensive prediction of chronic consciousness disorder was discussed.Conclusion. The use of TMS in diagnosing the phenomenon of CMD optimizes the routing of patients, for whom intensive rehabilitation can contribute to more favorable long-term outcomes.

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Translating the Discovery of Covert Consciousness Into Clinical Practice

2020

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In conditions of prognostic uncertainty, neurointensivists and families often struggle to make decisions for unresponsive patients with brain injuries. However, a new study demonstrates that after brain injury electrophysiological assessment (electroencephalography [EEG]) has potential prognostic value. 1 This could have profound implications for clinically and ethically consequential decisions, such as withdrawing life-sustaining treatment or managing potentially life-threatening events such as sepsis. Here, we outline 2 interrelated ethical considerations for neurointensivists who use these methods when communicating prognostic information to patients' families. Discovering Covert Consciousness in the Intensive Care UnitA 2019 study of 104 seemingly unconscious patients with brain injuries cared for in a neuro-intensive care unit (ICU) demonstrated that 16 patients responded to the command to open and close their hand. 1 Researchers did not observe this hand movement at the bedside. Instead, they witnessed EEG evidence of motor cortex activation.A machine learning algorithm identified latent evidence of brain responsiveness from multiple EEG test results. Six days after injury, half of the 16 patients with responsive brain activity recovered the ability to behaviorally follow commands, and follow-up showed that 7 patients recovered functional independence. Compared with patients who showed no evidence of motor cortex activation and recovered (12 of 84 [14%]), those with brain responsiveness recovered faster and with greater odds of a positive outcome.These results are similar to those of previous studies reporting brain activity in unresponsive patients with brain injuries. 2 Indeed, a significant proportion of unresponsive patients, estimated to be at least 15%, are able to modulate their brain activity to command. 3 These patients are correctly regarded as unconscious according to clinical criteria, yet their brain activity shows that they are aware. Such patients are variously described as having cognitive-motor dissociation or as being covertly conscious. Their consciousness is hidden until we discover it by measuring their brain activity.These findings have important implications for neurocritical care. The novel combination of machine learning with EEG can improve prognostic accuracy. The feasibility of these methods also suggests that they are likely to be used. In the days following brain injury, EEG is more practical for ICU patients compared with other costly and complex neuroimaging methods. 4 Despite the promise of these methods, little is known about how families will use test results to make VIEWPOINT

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Practice Guideline Update Recommendations Summary: Disorders of Consciousness

Cited by 170 publications

References 38 publications

Joint Neuropsychological Assessment through Coma/Near Coma and Level of Cognitive Functioning Assessment Scales Reduces Negative Findings in Pediatric Disorders of Consciousness

Joint Neuropsychological Assessment through Coma/Near Coma and Level of Cognitive Functioning Assessment Scales Reduces Negative Findings in Pediatric Disorders of Consciousness

Diagnosis of the phenomenon of cognitive-motor dissociation in patients with chronic consciousness disorders

Translating the Discovery of Covert Consciousness Into Clinical Practice

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