Abstract
Background: advanced paraclinical approaches using functional neuroimaging and electroencephalography (EEG) allow identifying patients who are covertly aware despite being diagnosed as unresponsive wakefulness syndrome (UWS). Bedside detection of covert awareness employing motor imagery tasks (MI), which is a universally accepted clinical indicator of awareness in the absence of overt behavior, may miss some of these patients, as they could still have a certain level of awareness. We aimed at assessing covert awareness in patients with UWS using a visuomotor-guided motor imagery task (VMI) during EEG recording. Methods: nine patients in a minimally conscious state (MCS), 11 patients in a UWS, and 15 healthy individuals (control group—CG) were provided with an VMI (imagine dancing while watching a group dance video to command), a simple-MI (imagine squeezing their right hand to command), and an advanced-MI (imagine dancing without watching a group dance video to command) to detect command-following. We analyzed the command-specific EEG responses (event-related synchronization/desynchronization—ERS/ERD) of each patient, assessing whether these responses were appropriate, consistent, and statistically similar to those elicited in the CG, as reliable markers of motor imagery. Results: All patients in MCS, all healthy individuals and one patient in UWS repeatedly and reliably generated appropriate EEG responses to distinct commands of motor imagery with a classification accuracy of 60–80%. Conclusions: VMI outperformed significantly MI tasks. Therefore, patients in UWS may be still misdiagnosed despite a rigorous clinical assessment and an appropriate MI assessment. It is thus possible to suggest that motor imagery tasks should be delivered to patients with chronic disorders of consciousness in visuomotor-aided modality (also in the rehabilitation setting) to greatly entrain patient’s participation. In this regard, the EEG approach we described has the clear advantage of being cheap, portable, widely available, and objective. It may be thus considered as, at least, a screening tool to identify the patients who deserve further, advanced paraclinical approaches.
Highlights
The JFK Coma Recovery Scale-Revised (CRS-R) is considered as the gold standard in the assessment of behavioral responsiveness of patients with chronic disorder of consciousness (DOC), including the differential diagnosis of unresponsive wakefulness syndrome (UWS) and the minimally conscious state (MCS) [1,2,3,4,5]
Patients in UWS may be still misdiagnosed despite a rigorous clinical assessment and an appropriate motor imagery tasks (MI) assessment
There were no significant differences between patients with UWS and MCS concerning clinical-demographic characteristics, but CRS-R as foreseeable (Table 1)
Summary
The JFK Coma Recovery Scale-Revised (CRS-R) is considered as the gold standard in the assessment of behavioral responsiveness of patients with chronic disorder of consciousness (DOC), including the differential diagnosis of unresponsive wakefulness syndrome (UWS) and the minimally conscious state (MCS) [1,2,3,4,5]. Brain Sci. 2020, 10, 746 patients in MCS—only demonstrate non-reflex behaviors, whereas patients in MCS+ show command following [4]. The different degree of behavioral responsiveness of patients with DoC is hypothesized to mainly depend on the severity of cortical-thalamo-cortical connectivity breakdown, which affects the capacity of the brain to operationally switch from the external awareness network (EAN) and the default-mode network (DMN) [6,7,8,9,10,11]. DoC is still misdiagnosed, i.e., some patients apparently in UWS are instead in MCS. Some patients may be aware despite their inability to manifest it behaviorally [4,12,13,14,15,16,17,18,19,20,21]
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