Chronic Disorders Of Consciousness Research Articles

Clinical Outcome After Epidural Spinal Cord Stimulation in Patients With Severe Traumatic Brain Injury.

Epidural spinal cord stimulation is a minimally invasive procedure with a growing list of indications. It has a good safety profile and analgesic effect, reduces the severity of spasticity, and activates various brain regions. The purpose of this study is to evaluate the clinical outcome of epidural spinal cord stimulation in patients with spastic syndrome and chronic disorders of consciousness resulting from severe traumatic brain injury (sTBI). Between 2021 and 2023, an epidural spinal cord stimulation test was performed in 34 patients with central paresis, severe hypertonia, and chronically altered consciousness following sTBI. The severity of spastic syndrome was assessed using a modified Ashworth scale. All patients underwent implantation of a cylindrical eight-contact test epidural electrode at C3-C5 cervical level, followed by neurostimulation and selection of individual modes. Tonic stimulation at a frequency of 60 Hz, "burst" mode, or a combination of the two was used. Epidural spinal cord stimulation was administered for an average of 4 ± 1.5 days, with tonic stimulation mode applied in 15 (44.1%) patients, "burst" mode in 10 (29.4%), and a combination of two in nine (26.5%) patients. A reduction in spasticity with clinical improvement was observed in 21 patients (61.8%). The Ashworth scale scores for distal and proximal upper extremities decreased from 3 points to 2.5 points and from 3 points to 2 points, respectively. This was significant in the right upper limbs (p = 0.0152 distally and p = 0.0164 proximally). Significant improvements were also seen in the lower extremities. Active movements in paretic limbs increased or appeared in 12 patients (35.3%), while a heightened level of consciousness was observed in six patients (17.6%). Permanent neurostimulator implantation was performed in 12 patients (35.3%), with no reported surgical complications. Epidural spinal cord stimulation shows promise as an invasive rehabilitation method for patients with sTBI sequelae. Its use reduced the severity of spastic syndrome in over half of patients and increased active movements in paretic limbs in over a third. Notably, neuromodulation at the cervical level yielded pronounced effects on the upper extremities, both proximally and distally. Findings regarding consciousness level improvement are particularly intriguing but warrant further validation through randomized trials.

Conventional structural magnetic resonance imaging in differentiating chronic disorders of consciousness

Conventional structural magnetic resonance imaging in differentiating chronic disorders of consciousness

The ECG abnormalities in persons with chronic disorders of consciousness.

We aimed to investigate the electrocardiogram (ECG) features in persons with chronic disorders of consciousness (DOC, ≥ 29days since injury, DSI) resulted from the most severe brain damages. The ECG data from 30 patients with chronic DOC and 18 healthy controls (HCs) were recorded during resting wakefulness state for about five minutes. The patients were classified into vegetative state (VS) and minimally conscious state (MCS). Eight ECG metrics were extracted for comparisons between the subject subgroups, and regression analysis of the metrics were conducted on the DSI (29-593days). The DOC patients exhibit a significantly higher heart rate (HR, p = 0.009) and lower values for SDNN (p = 0.001), CVRR (p = 0.009), and T-wave amplitude (p < 0.001) compared to the HCs. However, there're no significant differences in QRS, QT, QTc, or ST amplitude between the two groups (p > 0.05). Three ECG metrics of the DOC patients-HR, SDNN, and CVRR-are significantly correlated with the DSI. The ECG abnormalities persist in chronic DOC patients. The abnormalities are mainly manifested in the rhythm features HR, SDNN and CVRR, but not the waveform features such as QRS width, QT, QTc, ST and T-wave amplitudes.

1049 Are the AASM Scoring Rules Fitting for the Sleep of Patients with Chronic Disorders of Consciousness?

1049 Are the AASM Scoring Rules Fitting for the Sleep of Patients with Chronic Disorders of Consciousness?

Posttraumatic epilepsy in chronic disorders of consciousness due to severe traumatic brain injury after traffic accidents

PurposeTo evaluate the clinical state of posttraumatic epilepsy (PTE) in patients with chronic disorders of consciousness (CDC) due to severe traumatic brain injury (STBI) after traffic accidents and clarify the risk factors for seizure occurrence in such patients. MethodsTwo hundred ninety-three patients with CDC due to STBI (mean age at admission [±standard deviation]: 36.4 ± 17.9 years; men: 71.7 %; mean duration of injury to admission: 416 ± 732 days; mean hospitalization time: 899 ± 319 days) were enrolled in this study. We retrospectively investigated the relationship between seizure conditions (type and frequency) and clinical data, including age, sex, pathological types of brain injury, with/without surgical intervention, degree of CDC, and administration of antiseizure medications (ASMs). ResultsOverall, 52.9 % (n = 155/293) and 64.2 % of the patients (n = 183/of 285 patients surviving at discharge) were administered ASMs at admission and discharge, respectively. One hundred thirty-two patients (45.1 %) experienced epileptic seizures during hospitalization, and the mean seizure frequency was 4.0 ± 0.4 times per year. In multivariate analysis, significant and independent risk factors of seizure occurrence were revealed to be male sex, high National Agency for Automotive Safety and Victims’ Aid score, hypoxic encephalopathy, and history of the neurosurgical operations. ConclusionThe high prevalence of PTE in patients with CDC due to STBI, and the significant and independent risk factors for seizure occurrence in the chronic clinical phase were revealed. We expect that this study will aid toward improving clinical assessment and management of epileptic seizures in the population.

Brain-Computer Interfaces for Communication in Patients with Disorders of Consciousness: A Gap Analysis and Scientific Roadmap.

We developed a gap analysis that examines the role of brain-computer interfaces (BCI) in patients with disorders of consciousness (DoC), focusing on their assessment, establishment of communication, and engagement with their environment. The Curing Coma Campaign convened a Coma Science work group that included 16 clinicians and neuroscientists with expertise in DoC. The work group met online biweekly and performed a gap analysis of the primary question. We outline a roadmap for assessing BCI readiness in patients with DoC and for advancing the use of BCI devices in patients with DoC. Additionally, we discuss preliminary studies that inform development of BCI solutions for communication and assessment of readiness for use of BCIs in DoC study participants. Special emphasis is placed on the challenges posed by the complex pathophysiologies caused by heterogeneous brain injuries and their impact on neuronal signaling. The differences between one-way and two-way communication are specifically considered. Possible implanted and noninvasive BCI solutions for acute and chronic DoC in adult and pediatric populations are also addressed. We identify clinical and technical gaps hindering the use of BCI in patients with DoC in each of these contexts and provide a roadmap for research aimed at improving communication for adults and children with DoC, spanning the clinical spectrum from intensive care unit to chronic care.

Nutritional status and nutritional support of patients with chronic disorders of consciousness at the stage of medical rehabilitation

Chronic disturbances of consciousness (CDC) are a consequence of severe brain damage and are conditions that arise after emerging from a coma with the preservation of the sleep-wake cycle in the absence of signs of conscious behavior. When conducting inpatient medical rehabilitation of this group of patients, the state of nutritional status is not always taken into account and, as a rule, there is no nutritional support with an assessment of metabolic needs, including the introduction of various modes of physical activity during physical therapy and an increase in physical load on the patient's body. The purpose of the study was to assess the nutritional status and optimize the nutritional support system in patients with CDC at the inpatient stage of medical rehabilitation (MR). Material and methods. The study analyzed the results of examination and treatment of 152 patients with CDC of traumatic origin who received medical rehabilitation from 2016 to 2022 in the Department of Physical and Rehabilitation Medicine of the Nikiforov Russian Center of Emergency and Radiation Medicine, Ministry of Russian Federation for Civil Defense, Emergencies and Elimination of Consequences of Natural Disasters. Results. In patients with CDC of traumatic genesis, signs of malnutrition (objective, anthropometric, laboratory) were diagnosed at the inpatient stage of MR, and there were also risks of malnutrition progression with the introduction of additional physical activity. Conclusion. To create an effective and adequate nutritional support system during inpatient MR, metabolic monitoring (indirect calorimetry) is of fundamental importance, taking into account the influence of additional physical activity. The use of a calculation method for estimating energy requirements can lead to hyperalimentation.

Neuromodulatory pharmacotherapy individualization in prolonged and chronic consciousness disorders after severe traumatic brain injury

One of the most probable causes of effective therapy for post-comatose disorders of consciousness is the lack of individualization of drug prescriptions. In this observational study, we analyzed 48 courses of neuromodulatory therapy in 28 patients with prolonged and chronic disorders of consciousness following severe traumatic brain injury. Comparison of 24 effective and 24 ineffective courses demonstrated higher effectiveness of pharmacotherapy through its individualization, i.e. the choice of a drug whose neuromodulatory spectrum would correspond to neurological syndromes of neurotransmitter dysfunction. In this approach, 74% of therapy courses were effective while opposite management resulted only 34% of effective courses.

Extracellular Matrix Alterations in Human Soleus Muscle under Conditions of Chronic Disorder of Consciousness

Extracellular Matrix Alterations in Human Soleus Muscle under Conditions of Chronic Disorder of Consciousness

Covert cognition as a predictor of a favorable outcome in patients with chronic disorders of consciousness

Covert cognition as a predictor of a favorable outcome in patients with chronic disorders of consciousness

How to diagnose cognitive-motor dissociation in patients with chronic disorders of consciousness? Development of a novel set of fMRI paradigms for the Russian patient population

How to diagnose cognitive-motor dissociation in patients with chronic disorders of consciousness? Development of a novel set of fMRI paradigms for the Russian patient population

Functional hub disruption emphasizes consciousness recovery in severe traumatic brain injury.

Severe traumatic brain injury can lead to transient or even chronic disorder of consciousness. To increase diagnosis and prognosis accuracy of disorder of consciousness, functional neuroimaging is recommended 1 month post-injury. Here, we investigated brain networks remodelling on longitudinal data between 1 and 3 months post severe traumatic brain injury related to change of consciousness. Thirty-four severe traumatic brain-injured patients were included in a cross-sectional and longitudinal clinical study, and their MRI data were compared to those of 20 healthy subjects. Long duration resting-state functional MRI were acquired in minimally conscious and conscious patients at two time points after their brain injury. The first time corresponds to the exit from intensive care unit and the second one to the discharge from post-intensive care rehabilitation ward. Brain networks data were extracted using graph analysis and metrics at each node quantifying local (clustering) and global (degree) connectivity characteristics. Comparison with brain networks of healthy subjects revealed patterns of hyper- and hypo-connectivity that characterize brain networks reorganization through the hub disruption index, a value quantifying the functional disruption in each individual severe traumatic brain injury graph. At discharge from intensive care unit, 24 patients' graphs (9 minimally conscious and 15 conscious) were fully analysed and demonstrated significant network disruption. Clustering and degree nodal metrics, respectively, related to segregation and integration properties of the network, were relevant to distinguish minimally conscious and conscious groups. At discharge from post-intensive care rehabilitation unit, 15 patients' graphs (2 minimally conscious, 13 conscious) were fully analysed. The conscious group still presented a significant difference with healthy subjects. Using mixed effects models, we showed that consciousness state, rather than time, explained the hub disruption index differences between minimally conscious and conscious groups. While severe traumatic brain-injured patients recovered full consciousness, regional functional connectivity evolved towards a healthy pattern. More specifically, the restoration of a healthy brain functional segregation could be necessary for consciousness recovery after severe traumatic brain injury. For the first time, extracting the hub disruption index directly from each patient's graph, we were able to track the clinical alteration and subsequent recovery of consciousness during the first 3 months following a severe traumatic brain injury.

Detection of the “Covert Cognition” Phenomenon in Patients with Chronic Disorders of Consciousness: A Review of fMRI Data with Paradigms

Detection of the “Covert Cognition” Phenomenon in Patients with Chronic Disorders of Consciousness: A Review of fMRI Data with Paradigms

Three-year survival rate and changes in the level of consciousness in outpatients after severe brain injuries

Introduction. There is a worldwide lack of statistical data about the patients with chronic disorders of consciousness (DOC). In Russia, there are no such data at all.&#x0D; Objective: to perform the first study in Russia to assess the survival rate and changes in the level of consciousness in outpatients with the chronic DOC after their hospital discharge as well as to identify the predictors of survival and improvement in the level of consciousness.&#x0D; Materials and methods. All the participants (n = 142) underwent their treatment and rehabilitation in Federal Research and Clinical Center of Intensive Care Medicine and Rehabilitology from January 2016 to January 2020. We recorded the changes in patient's vital status and their level of consciousness at the endpoints of 3, 6, 12, 24, and 36 months from the brain injury (both for hospital and outpatient stages). We used the KaplanMeier method to assess the survival rate. We also used the logistic regression model to determine the correlation between the predictors of the survival and the improvement in the level of consciousness at baseline and 36 months after the injury.&#x0D; Results. The mortality rate in the study group 3 years after the brain injury was 86.6%. Regardless of the survival rate, the level of consciousness had significantly improved (i.e., they regained communication) in 22.5% of patients within 3 years after the index event. The statistically significant final model of the regression analysis (for 142 patients) showed that younger age and higher overall CRS-R score improved the survival rate. The logistic regression model used to determine the predictors of the improvement in the level of consciousness among the survivors gave no significant results.&#x0D; Conclusions. High mortality rate among the outpatients, whose level of consciousness had improved at discharge, proves the ineffectiveness of the outpatient rehabilitation. Thus, we need to find a way to improve it. The authors hope that the data obtained in this study will form the basis of their research.

Prognostication in Prolonged and Chronic Disorders of Consciousness.

Patients with prolonged disorders of consciousness (DOCs) longer than 28 days may continue to make significant gains and achieve functional recovery. Occasionally, this recovery trajectory may extend past 3 (for nontraumatic etiologies) and 12 months (for traumatic etiologies) into the chronic period. Prognosis is influenced by several factors including state of DOC, etiology, and demographics. There are several testing modalities that may aid prognostication under active investigation including electroencephalography, functional and anatomic magnetic resonance imaging, and event-related potentials. At this time, only one treatment (amantadine) has been routinely recommended to improve functional recovery in prolonged DOC. Given that some patients with prolonged or chronic DOC have the potential to recover both consciousness and functional status, it is important for neurologists experienced in prognostication to remain involved in their care.

Algorithm for the classification of phases and stages of sleep in patients with chronic disorders of consciousness based on logical artificial intelligence

BACKGROUND: The analysis of sleep patterns in patients with chronic disorders of consciousness is attracting increasing attention in terms of diagnosis, prognosis, and treatment of severe brain damage. The study describes a software package based on an artificial intelligence (AI) expert system designed to classify the phases and stages of sleep, taking into account the characteristics of impaired cortical rhythm in such patients.&#x0D; AIM: To develop a specialized AI-based software package focused on patients with chronic impairment of consciousness for automatic classification of sleep phases and stages, with an emphasis on identifying sleep spindles and non-rapid eye movement (REM) and REM sleep phases.&#x0D; MATERIALS AND METHODS: To ensure the correct operation of the software package, receiver operating characteristic (ROC) curves were analyzed considering the binary classification of slow sleep, REM sleep, and wakefulness.&#x0D; RESULTS: The average sensitivity and specificity of the algorithm were 87.9 and 70.1, respectively. The average area under the ROC curve was 0.790. The algorithm for determining the REM phase demonstrates low specificity with high sensitivity, and its graph was similar to that of wakefulness, as well as the irregularity of the presence of REMs in the REM sleep phase in patients with CNS and the frequent presence of nystagmus in the waking state. Information about the presence of nystagmus, entered at the start of the program, allowed us to slightly increase the efficiency of the algorithm; however, this aspect probably needs further improvement.&#x0D; CONCLUSION: A software package that takes into account the features of electroencephalography of patients with chronic disorders of consciousness and analyzes sleep and wakefulness automatically is not only useful as a diagnostic tool for neurologists and somnologists but also contributes to a wider dissemination of this technique in clinical practice.

Multimodal Prediction of 3- and 12-Month Outcomes in ICU Patients with Acute Disorders of Consciousness

BackgroundIn intensive care unit (ICU) patients with coma and other disorders of consciousness (DoC), outcome prediction is key to decision-making regarding prognostication, neurorehabilitation, and management of family expectations. Current prediction algorithms are largely based on chronic DoC, whereas multimodal data from acute DoC are scarce. Therefore, the Consciousness in Neurocritical Care Cohort Study Using Electroencephalography and Functional Magnetic Resonance Imaging (i.e. CONNECT-ME; ClinicalTrials.gov identifier: NCT02644265) investigates ICU patients with acute DoC due to traumatic and nontraumatic brain injuries, using electroencephalography (EEG) (resting-state and passive paradigms), functional magnetic resonance imaging (fMRI) (resting-state) and systematic clinical examinations.MethodsWe previously presented results for a subset of patients (n = 87) concerning prediction of consciousness levels in the ICU. Now we report 3- and 12-month outcomes in an extended cohort (n = 123). Favorable outcome was defined as a modified Rankin Scale score ≤ 3, a cerebral performance category score ≤ 2, and a Glasgow Outcome Scale Extended score ≥ 4. EEG features included visual grading, automated spectral categorization, and support vector machine consciousness classifier. fMRI features included functional connectivity measures from six resting-state networks. Random forest and support vector machine were applied to EEG and fMRI features to predict outcomes. Here, random forest results are presented as areas under the curve (AUC) of receiver operating characteristic curves or accuracy. Cox proportional regression with in-hospital death as a competing risk was used to assess independent clinical predictors of time to favorable outcome.ResultsBetween April 2016 and July 2021, we enrolled 123 patients (mean age 51 years, 42% women). Of 82 (66%) ICU survivors, 3- and 12-month outcomes were available for 79 (96%) and 77 (94%), respectively. EEG features predicted both 3-month (AUC 0.79 [95% confidence interval (CI) 0.77–0.82]) and 12-month (AUC 0.74 [95% CI 0.71–0.77]) outcomes. fMRI features appeared to predict 3-month outcome (accuracy 0.69–0.78) both alone and when combined with some EEG features (accuracies 0.73–0.84) but not 12-month outcome (larger sample sizes needed). Independent clinical predictors of time to favorable outcome were younger age (hazard ratio [HR] 1.04 [95% CI 1.02–1.06]), traumatic brain injury (HR 1.94 [95% CI 1.04–3.61]), command-following abilities at admission (HR 2.70 [95% CI 1.40–5.23]), initial brain imaging without severe pathological findings (HR 2.42 [95% CI 1.12–5.22]), improving consciousness in the ICU (HR 5.76 [95% CI 2.41–15.51]), and favorable visual-graded EEG (HR 2.47 [95% CI 1.46–4.19]).ConclusionsOur results indicate that EEG and fMRI features and readily available clinical data predict short-term outcome of patients with acute DoC and that EEG also predicts 12-month outcome after ICU discharge.

The Comorbidities Coma Scale (CoCoS): Assessment of Psychometric Properties

INTRODUCTION An increase in the survival rate of patients with severe brain injuries of various origins determines the relevance of the search for approaches to assessing the prognosis of changes in the state of patients with chronic disorders of consciousness (CDC). Concomitant diseases are predictors of the recovery of consciousness and functional independence of patients with CDC. To assess the impact of the level of comorbidity on the prognosis of the patient state, the Comorbidities Coma Scale (CoCoS) is used abroad. However, the lack of a Russian-language version of this scale limits the practical and scientific areas of work with this category of patients.THE AIM of the study was to evaluate the psychometric properties of the developed Russian version of the Comorbidities Coma Scale (CoCoS).MATERIALS AND METHODS As part of the validation study, an assessment of psychometric properties (reliability, validity, sensitivity) was performed on a group of 52 adult patients with traumatic (18/52) and non-traumatic (34/52) brain damage.RESULTS High levels of validity and reliability were obtained (the Spearman’s Rank Correlation Coefficient r=0.98 (p&lt;0.0001), Cronbach’s alpha α=0.73 (p&lt;0.001), Cohen’s kappa κ=0.72 (p&lt;0.0001)). However, when evaluating the CoCoS sensitivity, there were no statistically significant changes in the parameters (p=0.316).CONCLUSION In the present study, a sufficient level of psychometric properties of the Russian-language version of the CoCoS was obtained, which opens up the possibility of a quantitative assessment of comorbidities in unresponsive patients both in scientific research and clinical practice. The scale is available for download on the website of the Group for Validation of International Scales and Questionnaires of the Research Center of Neurology.

Chronic Disorders of Consciousness: guidelines of the All-Russian public organization “Federation of Anesthesiologists and Reanimatologists”

Chronic disorders of consciousness (DOC) represent severe central nervous system damage resulting in long-term disability and a significant burden to healthcare institutions and patientsʼ families. DOC develop in patients after coma and are characterized by the presence of wakefulness with complete or almost complete absence of signs of awareness. DOC include vegetative state (VS) and minimally conscious state (MCS). The term prolonged disorders of consciousness (pDOC) is also used in the Russian literature to describe the initial stages of chronic DOC. Another clinical entity, exit from MCS, is used to characterize the stage of recovery of cognitive functions. Diagnosis of DOC is based on repeated structured clinical examination using specific scales, provided that reversible causes of impaired consciousness are excluded. Treatment of DOC patients includes maintenance of vital functions and optimal nutrition and control of typical complications and concomitant conditions (pressure sores, spasticity, pain, paroxysmal sympathetic hyperactivity, etc.). Rehabilitation of DOC patients should involve a multidisciplinary rehabilitation team, the extent of which is determined by the individual problems and capabilities of the patient. Rehabilitation is most effective if started early. To date, there is no robust evidence on the effectiveness of specific methods for restoring consciousness, while a number of pharmacological and non-pharmacological interventions are being studied; however, they should be applied provided that the maximum possible level of correction of the patientʼs somatic problems is achieved. The family plays a key role in rehabilitation. They need practical information about their loved oneʼs condition, guidance in rehabilitation, and psychological support.

Possibilities and prospects for assessing pain nociception in patients with chronic disorders of consciousness

The objective was to study the possibilities of assessing pain nociception in patients with chronic disorders of consciousness (CDC) using the ANI index and to identify differences depending on the level of CDC, to create systems for objectification of pain sensations of patients with CDC. Materials and methods. The study included 29 patients with CDC. Group 1 (9 patients) – vegetative state / unresponsive wakefulness syndrome (VS/UWS), group 2 (20 patients) – minimally conscious state (MCS) – “plus”. The pain stimulus (PS) consisted in pressing on the nail phalanx of the hand with a reflex hammer. The ANI index was recorded three times: at rest (ANI 1), during the application of PS (ANI 2), 30 minutes after the application of PS (ANI 3). The assessment on the pain scale (NCS-R) was performed once during the application of PS. Statistical processing was carried out using the R programming language, a package of applied statistical programs SPSS STATISTICS.Results. The average values of the index difference ANI 2 and ANI 1 in group 1 differed, ANI 2 – ANI 3 had no differences. The average values of the ANI 3 index in groups 1 and 2 differed statistically significantly. A rank correlation between the ANI index and the NCS-R score existed in group 1 in the period after the application of BS. A statistically significant negative correlation was found in group 1 during the application of BS. When comparing the ANI index and the difference between the CRS-R index at discharge and admission, it was found that in group 2, the greater the difference between the CRS-R index at discharge and admission, the lower the value of the ANI index at all stages of the study, and in group 1 the opposite relationship was obtained. In group 1, there was a statistical relationship between the Kerdo index (IR) and the difference between the indices ANI 2 and ANI 1, ANI 2 and ANI 1 and IR, for group 2, the relationship could not be established.Conclusion. The data obtained during the study indicate that there are certain differences in the response to PS in patients in the VS / UWS and MCS ≪plus≫. Сreation of systems for objectification of pain sensations of patients in the VS / UWS will contribute to improving their quality of life.