Practice guideline update recommendations summary: Disorders of consciousness

Abstract

Clinicians should identify and treat confounding conditions, optimize arousal, and perform serial standardized assessments to improve diagnostic accuracy in adults and children with prolonged DoC (Level B). Clinicians should counsel families that for adults, MCS (vs vegetative state [VS]/unresponsive wakefulness syndrome [UWS]) and traumatic (vs nontraumatic) etiology are associated with more favorable outcomes (Level B). When prognosis is poor, long-term care must be discussed (Level A), acknowledging that prognosis is not universally poor (Level B). Structural MRI, SPECT, and the Coma Recovery Scale-Revised can assist prognostication in adults (Level B); no tests are shown to improve prognostic accuracy in children. Pain always should be assessed and treated (Level B) and evidence supporting treatment approaches discussed (Level B). Clinicians should prescribe amantadine (100-200 mg bid) for adults with traumatic VS/UWS or MCS (4-16 weeks post injury) to hasten functional recovery and reduce disability early in recovery (Level B). Family counseling concerning children should acknowledge that natural history of recovery, prognosis, and treatment are not established (Level B). Recent evidence indicates that the term chronic VS/UWS should replace permanent VS, with duration specified (Level B). Additional recommendations are included.

“DoC-feeling”: a new behavioural tool to help diagnose the Minimally Conscious State

“…First, as for all study on consciousness disorders, we faced a typical situation of imperfect gold standard. Although CRS-R is still the more widely accepted reference, the optimal number of assessments remain unknow[14]. According to a recent study, using 3 CRS-R assessments can lead to a 17% rate of misdiagnoses [13].…”

“…Even when using dedicated clinical tools such as the Coma Recovery Scale Revised (CRS-R; [10]), a unique assessment remains associated with a high frequency of diagnostic error [11,12]. To circumvent this limitation, repeated clinical assessments have been proposed but this can be limited by the availability of trained clinicians [13,14].…”

Automated pupillometry to detect command following in neurological patients: A proof-of-concept study

“…Five unconscious and deeply sedated/comatose patients in the ICU were recruited for negative control. Levels of consciousness were estimated following standard neurological bedside examination by a board-certified neurologist experienced in neurocritical care and according to established criteria (Giacino et al, 2018). Twenty healthy volunteers served as positive controls.…”

Clinical Decision‐Making for Patients with Disorders of Consciousness

“…Neurologists should follow the recent American Academy of Neurology (AAN) practice guidelines for the care of patients with disorders of consciousness . These guidelines include making diagnoses using validated examination techniques and counseling families about prognosis citing reliable evidence.…”

“…10 Neurologists should follow the recent American Academy of Neurology (AAN) practice guidelines for the care of patients with disorders of consciousness. 11 These guidelines include making diagnoses using validated examination techniques and counseling families about prognosis citing reliable evidence. In the early phase, neurologists should avoid making statements suggesting a uniformly poor prognosis but should identify patient and family preferences for treatment.…”