Diagnostic accuracy of the vegetative and minimally conscious state: Clinical consensus versus standardized neurobehavioral assessment

Caroline Schnakers,Melanie Boly,Steve Majerus,Steven Laureys,Audrey Vanhaudenhuyse,Joseph Giacino,Gustave Moonen,Manfredi Ventura

doi:10.1186/1471-2377-9-35

Abstract

BackgroundPreviously published studies have reported that up to 43% of patients with disorders of consciousness are erroneously assigned a diagnosis of vegetative state (VS). However, no recent studies have investigated the accuracy of this grave clinical diagnosis. In this study, we compared consensus-based diagnoses of VS and MCS to those based on a well-established standardized neurobehavioral rating scale, the JFK Coma Recovery Scale-Revised (CRS-R).MethodsWe prospectively followed 103 patients (55 ± 19 years) with mixed etiologies and compared the clinical consensus diagnosis provided by the physician on the basis of the medical staff's daily observations to diagnoses derived from CRS-R assessments performed by research staff. All patients were assigned a diagnosis of 'VS', 'MCS' or 'uncertain diagnosis.'ResultsOf the 44 patients diagnosed with VS based on the clinical consensus of the medical team, 18 (41%) were found to be in MCS following standardized assessment with the CRS-R. In the 41 patients with a consensus diagnosis of MCS, 4 (10%) had emerged from MCS, according to the CRS-R. We also found that the majority of patients assigned an uncertain diagnosis by clinical consensus (89%) were in MCS based on CRS-R findings.ConclusionDespite the importance of diagnostic accuracy, the rate of misdiagnosis of VS has not substantially changed in the past 15 years. Standardized neurobehavioral assessment is a more sensitive means of establishing differential diagnosis in patients with disorders of consciousness when compared to diagnoses determined by clinical consensus.

Highlights

Published studies have reported that up to 43% of patients with disorders of consciousness are erroneously assigned a diagnosis of vegetative state (VS)
Differentiating the vegetative (VS) from minimally conscious state (MCS) is often one of the most challenging tasks facing clinicians involved in the care of patients with disorders of consciousness (DOC)
We recently showed that the proportion of patients diagnosed with MCS by the Coma Recovery Scale-Revised (CRS-R) was significantly higher as compared to other neurobehavioral scales such as the Glasgow Coma Scale [13], the Full Outline of UnResponsiveness [14] and the Wessex Head Injury Matrix [15]

Summary

Introduction

Published studies have reported that up to 43% of patients with disorders of consciousness are erroneously assigned a diagnosis of vegetative state (VS). We recently showed that the proportion of patients diagnosed with MCS by the CRS-R was significantly higher as compared to other neurobehavioral scales such as the Glasgow Coma Scale [13], the Full Outline of UnResponsiveness [14] and the Wessex Head Injury Matrix [15]. These results suggest that the type of assessment tool used is crucial to accurate diagnosis [16,17]. We compared consensusbased diagnoses of VS and MCS to those based on the CRS-R, a well-established standardized neurobehavioral rating scale

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