Abstract
Bedside assessment of consciousness and awareness after a severe brain injury might be hampered by confounding clinical factors (i.e., pitfalls) interfering with the production of behavioral or motor responses to external stimuli. Despite the use of validated clinical scales, a high misdiagnosis rate is indeed observed. We retrospectively analyzed a cohort of 49 patients with severe brain injury admitted to an acute neuro-rehabilitation program. Patients’ behavior was assessed using the Motor Behavior Tool and Coma Recovery Scale Revised. All patients underwent systematic assessment for pitfalls including polyneuropathy and/or myopathy and/or myelopathy, major cranial nerve palsies, non-convulsive status epilepticus, aphasia (expressive or comprehensive), cortical blindness, thalamic involvement and frontal akinetic syndrome. A high prevalence (75%) of pitfalls potentially interfering with sensory afference (polyneuropathy, myopathy, myelopathy, and sensory aphasia), motor efference (polyneuropathy, myopathy, motor aphasia, and frontal akinetic syndrome), and intrinsic brain activity (thalamic involvement and epilepsy) was found. Nonetheless, the motor behavior tool identified residual cognition (i.e. a cognitive motor dissociation condition) regardless of the presence of these pitfalls in 70% of the patients diagnosed as unresponsive using the Coma Recovery Scale Revised. On one hand, pitfalls might contribute to misdiagnosis. On the other, it could be argued that they are clues for diagnosing cognitive motor dissociation rather than true disorders of consciousness given their prominent effect on the sensory–motor input–output balance.
Highlights
Alessandro Pincherle and Frederic Rossi have contributed .Acute Neuro‐rehabilitation Unit, Department of ClinicalNeurosciences, Lausanne University Hospital and University of Lausanne, Bâtiment Champ de l’Air, Rue du Bugnon 21, Lausanne, SwitzerlandNeurology Unit, Department of Medicine, Hopitaux RobertSchuman, Luxembourg, LuxembourgDepartment of Diagnostic and Interventional Radiology, Lausanne University Hospital and University of Lausanne, Intensive Care Unit, Lausanne University Hospital and University of Lausanne, Lausanne, SwitzerlandFeil Family Brain and Mind Research Institute, Weill CornellMedicine, New York, NY, USAVol:.(1234567890)One of the main challenges in neurology, often implying serious ethical consequences, is the reliable bedside clinical identification of consciousness in patients with severe brain injury [1, 2]
Using the motor behavior tool (MBT), patients were diagnosed as true disorders of consciousness (DOC) and 38 as clinical cognitive motor dissociation (CMD)
Of the 37 patients classified as coma/UWS using the Coma Recovery Scale Revised (CRS-R), 26 (70%) showed signs of residual cognition based on the MBT
Summary
Neurology Unit, Department of Medicine, Hopitaux Robert. One of the main challenges in neurology, often implying serious ethical consequences, is the reliable bedside clinical identification of consciousness in patients with severe brain injury [1, 2]. Functional neuroimaging can help detect residual cognitive function and awareness in some patients who appear entirely unresponsive at the bedside [3], pointing to the so-called cognitive motor dissociation (CMD). This approach has, a limited feasibility in the neuro-intensive-care setting. Assessment of motor/verbal/visual responses to external stimuli remains the current standard in clinical practice [4], with the Coma Recovery Scale Revised (CRS-R) regarded as the gold-standard for diagnosis of disorders of consciousness (DOC) [5]. Despite the use of validated clinical scales, an unacceptably high rate of clinical misdiagnosis is observed [6]
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