Coma Recovery Scale Research Articles

Conventional structural magnetic resonance imaging in differentiating chronic disorders of consciousness

BACKGROUND: Differential diagnosis of chronic disorders of consciousness remains one of the most difficult problems even for experienced clinicians. AIM: To evaluate the inter-expert consistency and capacity of the researcher-developed structural scale based on magnetic resonance imaging to differentiate chronic disorders of consciousness, named, DOC-MRIDS, on a larger sample of patients. MATERIALS AND METHODS: Sixty patients with a clinically stable status diagnosed with consciousness disorders (vegetative state, n=32; minimally conscious state, n=28) were enrolled. The revised coma recovery scale (CRS-R) was included in the clinical assessment. All patients underwent structural magnetic resonance imaging with 3.0-T Siemens scanners including T2 and T1 sequences. Structural changes were assessed using the DOC-MRIDS scale and included the following features: diffuse cortical atrophy, ventricular enlargement, gyri dilatation, leukoaraiosis, brainstem and/or thalamic degeneration, corpus callosum degeneration, and focal corpus callosum lesions. A total score was calculated. Magnetic resonance imaging data were analyzed by three neuroradiologists, and inter-observer agreement (Krippendorf’s alpha) was assessed. RESULTS: A high inter-examiner agreement of the DOC-MRIDS scale score was found, with α=0.806 (95% confidence interval 0.757–0.849). The vegetative state group had a higher DOC-MRIDS score than the minimally conscious state group (p 0.005). A negative correlation was obtained between CRS-R and DOC-MRIDS scale scores (ρ=–0.457, p 0.0001), individual clinical scale domains, and magnetic resonance imaging features. CONCLUSION: When assessing structural changes in patients with chronic consciousness disorders, the use of the DOC-MRIDS scale helps differentiate the type of such disorders with sufficient specificity, sensitivity, and inter-rater agreement. This scale can be used in clinical practice as an additional differential diagnostic tool.

Perturbational complexity index in assessing responsiveness to rTMS treatment in patients with disorders of consciousness: a cross-over randomized controlled trial study

BackgroundDisorders of Consciousness (DoC) caused by severe brain injuries represent a challenging clinical entity, which is easy to misdiagnosis and lacks effective treatment options. Repetitive Transcranial Magnetic Stimulation (rTMS) is a non-invasive neuroelectric stimulation method that shows promise in improving consciousness for DoC, especially in minimally conscious state (MCS). However, there is little evidence of its effectiveness, especially in RCT studies.MethodsTwenty MCS patients participated in a double-blind, randomized, crossover, sham-controlled clinical study to evaluate the safety and efficacy of rTMS for MCS. Subjects were randomized into two groups: one group received rTMS-active for 10 consecutive days (n = 10), and the other group received rTMS-sham for 10 consecutive days (n = 10). After a 10-day washout period, the two groups were crossed over and received the opposite treatment. the rTMS protocol consisted of 2,000 pulses per day in the left dorsolateral prefrontal cortex (L-DLPFC), sent at 10 Hz. The stimulation intensity was 90% of the resting motor threshold. Coma Recovery Scale Revised (CRS-R), the main evaluation index, was evaluated before and after each phase in a double-blind manner. Meanwhile RS-EEG and TMS-EEG data were acquired and relative alpha power (RAP), and perturbational complexity index based on state transitions (PCIst) were caculated.ResultsOne-way ANOVA revealed significantly higher scores in rTMS-active treatment compared to rTMS-sham across various measures, including CRS-R total score, RAP, PCIst (all P < 0.05). Among the 20 MCS patients, 7 (35%) were identified as responders following rTMS treatment. Compared to rTMS-sham, responder scores for CRS-R, RAP, and PCIst (all P < 0.05) were significantly elevated after rTMS-active treatment. Conversely, there was no significant difference observed in non-responders. Furthermore, post-hoc analysis revealed that baseline PCIst was significantly higher in responders than non-responders. Upon a 6-month follow-up, CRS-R scores significantly increased in all 20 patients (P = 0.026). However, the responder group exhibited a more favorable prognosis compared to the non-responder group (P = 0.031).ConclusionsApplying 10 Hz rTMS to L-DLPFC significantly increased consciousness level in MCS patients. PCIst is a neurophysiological index that has the potential to evaluate and predict therapeutic efficacy.Trial registrationwww.ClinicalTrials.gov, identifier: NCT05187000.

Cognitive Motor Dissociation in Disorders of Consciousness

BackgroundPatients with brain injury who are unresponsive to commands may perform cognitive tasks that are detected on functional magnetic resonance imaging (fMRI) and electroencephalography (EEG). This phenomenon, known as cognitive motor dissociation, has not been systematically studied in a large cohort of persons with disorders of consciousness.MethodsIn this prospective cohort study conducted at six international centers, we collected clinical, behavioral, and task-based fMRI and EEG data from a convenience sample of 353 adults with disorders of consciousness. We assessed the response to commands on task-based fMRI or EEG in participants without an observable response to verbal commands (i.e., those with a behavioral diagnosis of coma, vegetative state, or minimally conscious state–minus) and in participants with an observable response to verbal commands. The presence or absence of an observable response to commands was assessed with the use of the Coma Recovery Scale–Revised (CRS-R).ResultsData from fMRI only or EEG only were available for 65% of the participants, and data from both fMRI and EEG were available for 35%. The median age of the participants was 37.9 years, the median time between brain injury and assessment with the CRS-R was 7.9 months (25% of the participants were assessed with the CRS-R within 28 days after injury), and brain trauma was an etiologic factor in 50%. We detected cognitive motor dissociation in 60 of the 241 participants (25%) without an observable response to commands, of whom 11 had been assessed with the use of fMRI only, 13 with the use of EEG only, and 36 with the use of both techniques. Cognitive motor dissociation was associated with younger age, longer time since injury, and brain trauma as an etiologic factor. In contrast, responses on task-based fMRI or EEG occurred in 43 of 112 participants (38%) with an observable response to verbal commands.ConclusionsApproximately one in four participants without an observable response to commands performed a cognitive task on fMRI or EEG as compared with one in three participants with an observable response to commands. (Funded by the James S. McDonnell Foundation and others.)

The integrity of thalamo-dorsolateral prefrontal cortex tract: a key factor in residual consciousness in disorders of consciousness patients.

The mesocircuit model describes a complex network that includes the prefrontal cortical-striatopallidal-thalamo-cortical loop systems and is involved in the mechanism underlying consciousness in patients with disorders of consciousness (DoC). Inhibitory signals to the thalamus become hyperactive in DoC patients, leading to a loss of consciousness. Reactivating this mesocircuit system is important for recovering consciousness in these patients. We investigated how the residual integrity of the thalamo-dorsolateral prefrontal cortex tract (TDLPFCT) influences consciousness in patients with DoC. This retrospective case-control study included three groups: prolonged DoC (n = 20), stroke without DoC (n = 20), and healthy controls (n = 20). Diffusion tensor imaging (DTI) was performed at least 4 weeks after the onset. Thalamo-DLPFC tracts were reconstructed using diffusion tensor tractography, and fractional anisotropy (FA) and tract volume (TV) were measured for each hemisphere. Consciousness was assessed using the revised coma recovery scale (CRS-R) within a week of brain imaging. Significant differences in DLPFCT TV were observed across all three groups, in both affected and less-affected lobes, with the DoC group showing the greatest reduction. A significant correlation was found between the TV of the less-affected TDLPFCT and CRS-R score. The integrity of the TDLPFCT, particularly in the less affected hemisphere, is associated with consciousness levels in patients with prolonged DoC. This finding suggests its potential importance in assessing prognosis and further developing therapeutic strategies for patients with DoC.

Examining the Motor Scale Items From the Coma Recovery Scale–Revised

Abstract Date Presented 03/23/24 We provide an empirical evaluation of the item hierarchy within the Coma Recover Scale–Revised (CRS–R), an assessment used with patients with disorders of consciousness.This evaluation is critical for determining whether the challenge of the items aligns with the order in which they are presented in the assessment. Primary Author and Speaker: Jill Calvani Additional Authors and Speakers: Trudy Mallinson, Jennifer Weaver Contributing Authors: Katherine O’Brien

Prognosis of patients with prolonged disorders of consciousness after brain injury: a longitudinal cohort study.

The findings regarding the prognosis of prolonged disorders of consciousness (PDOC) vary widely among different studies. This study aims to investigate the mortality, consciousness recovery and disabilities of patients with PDOC after brain injury. A total of 204 patients with PDOC were included in a longitudinal cohort study, including 129 males and 75 females. There were 112 cases of traumatic brain injury (TBI), 62 cases of cerebral hemorrhage (CH), 13 cases of cerebral infarction (CI) and 17 cases of ischemic hypoxic encephalopathy (IHE). The status of consciousness at 1, 2, 3, 6, 12, 18, 24, 36, 48 months of the disease course was assessed or followed up using the Revised Coma Recovery Scale (CRS-R). If the patients were conscious, the disability Rating Scale (DRS) was also performed. The prognosis of different PDOC including coma, vegetative state (VS) and minimal conscious state (MCS) was analyzed. The survival patients were screened for variables and included in multivariate binary Logistic regression to screen the factors affecting the recovery of consciousness. The mortality rates at 12, 24, 36, and 48 months were 10.7, 23.4, 38.9, and 68.4%, respectively. The median time of death was 18 months (8.75, 29). The probability of MCS regaining consciousness was higher than VS (p < 0.05), with the degree of disability left lower than VS (p < 0.05). There was no significant difference between MCS- and MCS+ groups in terms of the probability of regaining consciousness, the extent of residual disability, and mortality rates (p > 0.05). The mortality rate of coma was higher than that of other PDOC (p < 0.05). The mortality rate of MCS was lower than that of VS, but the difference was not statistically significant (p > 0.05). The probability of consciousness recovery after TBI was the highest and the mortality rate was the lowest. The possibility of consciousness recovery in IHE was the least, and the mortality rate of CI was the highest. The cause of brain injury and initial CRS-R score were the factors affecting the consciousness recovery of patients (p < 0.05). The prognosis of MCS is more favorable than VS, with comparable outcomes between MCS- and MCS+, while comatose patients was the poorest. TBI has the best prognosis and IHE has the worst prognosis.

Indices of Responsiveness for the Coma Recovery Scale - Revised in a Clinical Trial of Amantadine for Patients with Disorders of Consciousness

Indices of Responsiveness for the Coma Recovery Scale - Revised in a Clinical Trial of Amantadine for Patients with Disorders of Consciousness

Assessment of Frequency and Predictive Value of Comorbidities in Patients With Disorders of Consciousness in the Acute Setting.

Medical comorbidities are frequent in patients with disorders of consciousness (DoC) and their impact on outcomes is under investigation. The aim of this study was to investigate patients with DoC in the acute stage and the influence of comorbidities. Patients admitted to intensive care units and neurological units with a diagnosis of coma, vegetative state/unresponsive wakefulness syndrome (VS/UWS), and minimally conscious state (MCS) were investigated through the Glasgow Coma Scale (GCS), the Coma Recovery Scale - Revised (CRS-R) and the Comorbidities Coma Scale (CoCos). Forty-three patients (21 men and 22 women; mean age at admission: 60.4 ± 21.0) were included in the study. The most frequent diagnosis at admission was coma (72%) followed by VS/UWS (14%) and MCS (14%). The most frequent brain injury was subarachnoid hemorrhage (46%). At the 6-month follow-up, 19 patients had died (44%), 15 showed a full recovery of consciousness (35%), 7 were in a condition of emergence from MCS (16%), and 2 showed a persistent VS/UWS (5%). Forty-two (98%) patients showed at least one comorbidity: presence of life-support device (92.9%), anemia (76.2%), arterial hypertension (66,7%), hydrocephalus (45.3%), and respiratory infections (45.2%) were those most frequently reported. At the Multivariable Cox regression, the presence of renal disease (hazard ratio [HR] 33.37; p = 0.033) and malnutrition (HR 14.52; p = 0.001) were predictors of missed recovery of full consciousness. Although adverse outcomes are generally predicted by the severity of brain damage, the presence of medical comorbidities in an acute phase could influence outcomes and long-term prognosis.

Neck muscle spasticity in patients with disorder of consciousness: a pilot study.

Disorder of consciousness (DOC) is a state of prolonged altered consciousness due to severe acquired brain injury (ABI). DOC can be differentiated into coma, unresponsive wakefulness syndrome (UWS), or minimally conscious state (MCS) depending on the behavioral features observed and their relationship to the level of consciousness. Spasticity is one of the most frequently reported medical comorbidities in DOC patients. Since there is a critical lack of spasticity-focused studies and, in turn, of target treatment, we designed this pilot prospective study to evaluate cervical spine muscle spasticity and its effect on rehabilitation outcome in a large cohort of patients followed from the post-acute phase to 6 months after severe ABI. To evaluate neck muscle spasticity and investigate its impact on neurological and functional outcome in a large cohort of adult patients with DOC followed from post-acute to 6 months after severe ABI. Single-center prospective pilot study. Highly specialized inpatient neurorehabilitation clinic. Patients with severe ABI admitted within 3 months after the acute event to our Neurorehabilitation Unit between May 21st, 2019 and April 23rd, 2020 for treatment of DOC as a part of their rehabilitation program. In this single-center prospective pilot study demographic data, etiology of ABI (traumatic versus non-traumatic), DOC evaluated with the revised Coma Recovery Scale (CRS-R), and neurological and functional outcome assessed respectively with the Glasgow Coma Scale (GCS) and Functional Independence Measure (FIM) were considered. During cervical examination, we assessed spasticity with the Modified Ashworth Scale (MAS), deviation of head alignment with a goniometer, and pain with the Nociception Coma Scale-Revised (NCS-R). Of the 48 patients, 41.7% were diagnosed with UWS and 58.3% were in a minimally conscious state (MCS). We found spasticity of neck muscles in 91.7% of patients, with no difference in severity (assessed with MAS) between UWV and MCS. The NCS-R score at cervical spine examination was lower in UWS than MCS. Spasticity was severer in patients with traumatic brain injury (TBI) compared to non-traumatic. At multiple linear regression analysis, younger age, hemisyndrome, and tetraparesis were independent predictors of severity of neck muscle spasticity in MCS. More severe spasticity was a predictor of worse neurological and functional outcome at discharge in UWS patients, independently of the other confounding variables at admission (e.g., age, severity of brain injury, functional assessment, and pain). Spasticity of neck muscles frequently develops in patients with DOC and is more severe in those after TBI. UWV and MCS have different spasticity profiles as regards risk factors and neurological and functional outcome. Severity of neck muscle spasticity in UWV patients may represent an early indicator of worse neurological and functional outcome after inpatient rehabilitation. Our findings could prompt clinicians to redefine the rehabilitation aims regarding spasticity and to estimate the functional outcome in patients undergoing intensive rehabilitation after severe ABI.

Feasibility of overground exoskeleton gait training during inpatient rehabilitation after severe acquired brain injury

ABSTRACT Objective To describe the safety, feasibility, and tolerability of overground exoskeleton gait training (OEGT) integrated into clinical practice for patients after severe acquired brain injury (ABI). Setting Inpatient rehabilitation hospital. Participants Eligible patients with severe ABI met the following criteria: age > 18, medically stable, met exoskeleton frame limitations, and a score of ≤ 3 on the motor function portion of the Coma Recovery Scale – Revised (CRS-R). Presence of consciousness disorder was not exclusionary. Design Prospective observational study. Main Measures Outcomes examined safety (adverse events), feasibility (session count and barriers to session completion), and tolerability of OEGT (session metrics and heart rate). Results Ten patients with ABI completed 10.4 ± 4.8 OEGT sessions with no adverse events. Barriers to session completion included clinical focus on prioritized interventions. Sessions [median up time = 17 minutes, (IQR: 7); walk time = 13 minutes, (IQR: 9); step count = 243, (IQR: 161); device assist = 74, (IQR: 28.0)] were primarily spent in Very Light to Light heart rate intensities [89%, (IQR: 42%) and 9%, (IQR: 33%), respectively]. Conclusion OEGT incorporated into the rehabilitation plan of care during inpatient rehabilitation after severe ABI was observed to be safe, feasible, and tolerable. However, intentional steps must be taken to facilitate patient safety.

Effect of transcranial direct current stimulation on the level of arousal in hypoglycemic ischemic encephalopathy: A case study

Abstract: The current study presents the use of transcranial direct current stimulation (tDCS) as a novel intervention for improving the level of arousal in a patient with hypoglycemic ischemic encephalopathy (HIE). HIE is a rare but potentially devastating condition that can lead to impaired consciousness, coma, and profound neurological deficits. The Coma Recovery Scale was utilized as the primary outcome measure for arousal, along with the Oral Motor Assessment Scale for the assessment of oromotor functions as a secondary outcome to assess the effectiveness of tDCS in promoting neurological recovery.

Prognosis for Recovery from a Vegetative State

The prognosis for recovery from a vegetative state (VS) remains underdeveloped.Objective. To determine the feasibility of prognosis for recovery from a vegetative state based on clinical comparison of 18- fluorodeoxyglucose-PET (18FDGPET) and MRI (SCT) data.Materials and methods. We compared and analyzed retrospectively cerebral PET and MRI (SCT) scans and relevant prognostic criteria (including revised coma recovery scale — CRS-R scores) prospectively during 6–84 months of follow-up in a cohort of 39 VS patients. All VS cases were of different etiologies, lasting for more than 2 months after brain damage (including 18 patients in chronic VS).Pairwise comparison of groups was used (significance level P0.05) and multiple comparison for three groups with a Bonferroni correction at P0.017 was employed.Results. Three patterns were identified when comparing 18FDGPET and MRI (SCT) neuro-images: pattern I — the area of functional alterations was larger than the area of structural damage, pattern II — complete matching of areas of structural and functional alterations, III — mixed pattern. Pattern I (69% of cases) was more common than patterns II (18%), and III (13%), P0.001. There were no differences in VS etiology, VC duration, CRS-R scores, patients’ gender and age between the groups of patients each falling into one of patterns. The outcome in a group with pattern I patients (all of them recovered from VS) was better than in other two groups exhibiting patterns II or III, each, P0.001. In a group of patients with pattern III the recovery was better than in pattern II (all patients remained in VS), P=0.018. The increases in the total CRS-R score values were as follows: 12,1±4,46; Me=12 (4–19), N=27 (patients with a pattern I); 0±1,54 (–2–1, Me=0, N=7 (patients with a pattern II); and 5,20±4,09/ Me=4 (1 — 10), N=5 (patients with a pattern III). Significant increases in neurological improvement were revealed in pattern I patients with non-chronic VS versus chronic VS, P=0.003.Conclusion. Clinical comparison of PET/MRI (SCT) data showed certain potential to predict patient’s recovery from VS in 87% of cases. A retrospectively confirmed favorable prognosis in patients with pattern I was established in 69% cases, unfavorable (pattern II patients) was defined in 18% cases, regardless of other prognostic criteria, including chronic VS. Therefore, the data confirms the feasibility and clinical relevance of neurophysiological justification as a candidate approach for evaluating the prospect of recovering patients from VS.

Diagnosis and Prognosis in Disorders of Consciousness: An Active Paradigm fMRI Study

Diagnoses in patients with disorders of consciousness are prone to misdiagnosis; thus, research has sought approaches to increase reliability, for instance, with functional MRI. By applying a motor imagery task, patients showing covert command following despite the absence of behavioural signs of awareness can be identified as being in a cognitive motor dissociation. This study seeks to determine the proportion of patients, with unresponsive wakefulness syndrome and minimally conscious state, who display covert command following. Moreover, the prognostic value of the improved diagnosis and different methodical approaches to analyse the functional MRI data were evaluated. 73 disorder of consciousness patients (35 unresponsive, 35 minimally conscious, and three already recovered) underwent weekly standardized behavioural assessments with the coma-recovery scale—revised and one functional MRI examination comparing their brain activations in the supplementary motor area between phases of imaging playing tennis and rest. 27 healthy controls served as a control group. The data was evaluated using different region-of-interest analyses (one- and two-tailed small-volume correction and region-of-interest exploration approaches) and a whole-brain analysis. Based on the one-tailed small volume correction data, seven patients, all of nontraumatic aetiology, showed covert command following. The one-tailed region-of-interest exploration identified three additional responders. 10 patients showed significantly more activation during rest than during the imagery paradigm (negative responders). 40% of patients (minimally conscious patients being three times more likely) showed significant activations in the whole brain analysis. Besides, no significant further associations were found between covert command following and clinical parameters. The analyses showed that the tennis paradigm could identify patients with cognitive motor dissociation with a nontraumatic aetiology, but our data failed to show any short-term prognostic validity. The relevance of negative responders and activated regions outside of the region of interest should be further investigated.

35 Preliminary reliability of the Coma Recovery Scale, Revised (CRS-R) in children with a history of disorders of consciousness after acquired brain injury

Objective:The Coma Recovery Scale-Revised (CRS-R) is the gold standard assessment of adults with disorders of consciousness (DoC); however few studies have examined the psychometric properties of the CRS-R in pediatric populations. This study aimed to demonstrate preliminary intra-rater and inter-rater reliability of the CRS-R in children with acquired brain injury (ABI).Participants and Methods:Participants included 3 individuals (ages 10, 15, and 17 years) previously admitted to an inpatient pediatric neurorehabilitation unit with DoC after ABI who were followed in an outpatient brain injury clinic due to ongoing severe disability. ABI etiology included traumatic brain injury (TBI; n=2) and encephalitis (n=1). Study participation took place on average 4.6 years after injury (range 2-9). The Glasgow Outcome Scale-Extended, Pediatric Version (GOS-E Peds), a measure of outcome after pediatric brain injury, was administered as part of screening. Two participants were placed in the GOS-E Peds “lower severe disability” category (i.e., score of 6) and one was placed in the “upper severe disability” category (i.e., score of 5). The CRS-R includes 6 subscales measuring responsivity including Auditory (range 0-4), Visual (range 05), Motor (range 0-6), Oromotor/Verbal (range 03), Communication (range 0-2), and Arousal (range 0-3) with higher scores indicating higherlevel function. Subscales are totaled for a CRS-R Total score. Behaviors shown during the CRS-R are used to determine state of DoC [Vegetative State (VS), Minimally Conscious State (MCS) or emergence from a minimally conscious state (eMCS)] based on 2002 Aspen Guidelines. Participants were administered the CRS-R three consecutive times on the same day. Administrations were completed by two raters in this order: Rater 1 (1A), Rater 1 (1B) and Rater 2. Intra-rater reliability was deemed by percent agreement across the 6 subscales between Rater 1A and 1B. Inter-rater reliability was deemed by percent agreement across the 6 subscales between 1A and 2.Results:Mean CRS-R Total score for Rater 1A was 22 (SD=1.73, range 20-23), Rater 1B was 22 (SD=1.73, range 20-23), and Rater 2 was 21.33 (SD=2.08, range 19-23). Intra-rater reliability was 100% and inter-rater reliability was 94% across all subscales. All participants were deemed eMCS at all 3 ratings.Conclusions:Data from this very small sample of children suggests that the CRS-R demonstrates both intra-rater and inter-rater reliability in patients with a history of DoC after ABI. Given that all children were at the high end of the scale (eMCS), further research is needed with a larger sample of children with a range of states of DoC.

Effectiveness of sensory stimulation and early mobility on consciousness, mental state, RLA stage, and hospital stay in patients with Traumatic brain injury: A research protocol

TBI is the most difficult to treat and has the highest mortality and morbidity rates in ICU. The most common cause of neurological abnormalities and physical disabilities in people is traumatic brain injury (TBI). Brain injury occurs when an external force causes a change in brain function or other signs of brain pathology. TBI is a leading cause of epilepsy and is linked to a high morbidity and mortality rate. Over the last few decades, India has seen an increase in traumatic brain injury (TBI) as a result of increased transportation development, a rapidly growing construction industry, and urbanization. A total of 30 patients with traumatic brain injuries will be included in this experimental study, and they will be evenly divided into two groups. Sensory stimulation with early mobility will be delivered to Group A, while traditional physiotherapy will be given to Group B for two weeks at 40 minutes per session, two sessions per day, 5 days a week. The Coma Recovery scale, Mini-mental scale examination (MMSE), Glasgow Coma Scale (GCS), Ranchos Los Amigos scale for cognitive functioning, and length of stay in ICU will be used as outcome measures. The goal of this study is to see how early mobility exercises and sensory stimulation affect consciousness, mental state, RLA, and hospital stay when used in conjunction with physiotherapy. CTRI Reference Number CTRI/2022/07/044127

Investigating microRNAs as biomarkers in disorders of consciousness: a longitudinal multicenter study

MicroRNAs (miRNAs) are involved in gene regulation and may affect secondary brain injury and recovery in patients with disorders of consciousness (DoC). This study investigated the role of five miRNAs (150-5p, 132-3p, 23b-3p, 451a, and 16-5p) in prolonged DoC. miRNA levels were assessed in serum samples from 30 patients with unresponsive wakefulness syndrome or minimally conscious state due to traumatic or hypoxic-ischemic brain injury (TBI, HIBI) at baseline (1–3 months) and 6 months post-injury. Patients’ diagnoses were determined using the Coma Recovery Scale revised, and functional outcomes were evaluated 6 months after injury with the Glasgow Outcome Scale Extended (GOSE) and the Functional Independence Measure (FIM). Compared to healthy controls, patients with TBI had lower levels of miRNAs 150-5p, 132-3p, and 23b-3p at baseline, while patients with HIBI had lower levels of miRNA 150-5p at baseline and 6 months post-injury and a reduction of miRNA 451a at baseline. Higher levels of miRNAs 132-3p and 23b-3p were associated with better outcomes in TBI patients as indicated by GOSE and FIM scores. This study highlights distinct miRNA dysregulated patterns in patients with prolonged DoC, dependent on etiology and post-injury time, and suggests that miRNAs 132-3p and 23b-3p may serve as prognostic biomarkers.

Combined behavioral and EEG evidence for the 70 Hz frequency selection of short-term spinal cord stimulation in disorders of consciousness.

This study investigated the prognostic effect of electroencephalography (EEG) instant effects of single spinal cord stimulation (SCS) on clinical outcome in disorders of consciousness (DOC) and the time-dependent brain response during the recovery of consciousness prompted by SCS. Twenty three patients with DOC underwent short-term SCS (stSCS) implantation operation. Then, all patients received the postoperative EEG test including EEG record before (T1) and after (T2) single SCS session. Subsequently, 2 weeks stSCS treatment was performed and revised coma recovery scale (CRS-R) and EEG data were collected. Finally, they were classified into effective and ineffective groups at 3-month follow-up (T6). The parietal-occipital (PO) connectivity and clustering coefficients (CC) in the beta band of the effective group at the 1 week after the treatment (T5) were found to be higher than preoperative assessment (T0). Correlation analysis showed that the change in beta CC at T1/T2was correlated with the change in CRS-R at T0/T6. In addition, the change in PO connectivity and CC in the beta at T0/T5 were also correlated with the change in CRS-R at T0/T5. SCS may facilitate the recovery of consciousness by enhancing local information interaction in posterior brain regions. And the recovery can be predicted by beta CC in the EEG test.

Cortical responses to auditory stimulation predict the prognosis of patients with disorders of consciousness

ObjectiveThis study aimed to assess the prognosis of patients with disorders of consciousness (DoC) using auditory stimulation with electroencephalogram (EEG) recordings. MethodsWe enrolled 72 patients with DoC in the study, which involved subjecting patients to auditory stimulation while EEG responses were recorded. Coma Recovery Scale–Revised (CRS-R) scores and Glasgow Outcome Scale (GOS) were determined for each patient and followed up for three months. A frequency spectrum analysis was performed on the EEG recordings. Finally, the power spectral density (PSD) index was used to predict the prognosis of patients with DoC based on a support vector machine (SVM) model. ResultsPower spectral analyses revealed that the cortical response to auditory stimulation showed a decreasing trend with decreasing consciousness levels. Auditory stimulation-induced changes in absolute PSD at the delta and theta bands were positively correlated with the CRS-R and GOS scores. Furthermore, these cortical responses to auditory stimulation had a good ability to discriminate between good and poor prognoses of patients with DoC. ConclusionsAuditory stimulation-induced changes in the PSD were highly predictive of DoC outcomes. SignificanceOur findings showed that cortical responses to auditory stimulation may be an important electrophysiological indicator of prognosis in patients with DoC.

Long-term clinical evolution of patients with prolonged disorders of consciousness due to severe anoxic brain injury: a meta-analytic study.

The prognosis of prolonged (28 days to 3 months post-onset) Disorders of Consciousness (pDoC) due to anoxic brain injury is uncertain. The present study aimed to evaluate long-term outcome of post-anoxic pDoC and identify the possible predictive value of demographic and clinical information. Systematic review and meta-analysis. We evaluated the rates of mortality, any improvement in clinical diagnosis, and recovery of full consciousness at least 6 months after severe anoxic brain injury. A cross-sectional approach searched for differences in baseline demographic and clinical characteristics between survivors and non-survivors, patients improved vs. not-improved, and patients who recovered full consciousness vs. not-recovered. We identified 27 studies. The pooled rates of mortality, any clinical improvement, and recovery of full consciousness were 26%, 26%, and 17%, respectively. Younger age, baseline diagnosis of minimally conscious state vs. vegetative state/unresponsive wakefulness syndrome, higher Coma Recovery Scale-Revised total score, and earlier admission to intensive rehabilitation units were associated with a significantly higher likelihood of survival and clinical improvement. These same variables, except time of admission to rehabilitation, were also associated with recovery of full consciousness. Patients with anoxic pDoC might improve over time up to full recovery of consciousness and some clinical characteristics can help predict clinical improvement. These new insights could support clinicians and caregivers in the decision-making on patient management.

Effect of Transcranial Direct Current Stimulation on Patients With Disorders of Consciousness: A Systematic Review and Meta-analysis.

The aims of this study are to evaluate the efficacy of transcranial direct current stimulation for improving disorders of consciousness and to compare efficacy of the different etiologies of disorders of consciousness. Randomized controlled trials or crossover trials examining effects of transcranial direct current stimulation in patients with disorders of consciousness were searched in PubMed, Embase, Cochrane Library, and Web of Science. The sample characteristics, etiology, transcranial direct current stimulation treatment characteristics, and outcomes were extracted. Meta-analysis was performed using the RevMan software. We included nine trials providing data with 331 participants and found that transcranial direct current stimulation improved the Coma Recovery Scale-Revised score of disorders of consciousness patients. We found a significant improvement of Coma Recovery Scale-Revised score in the minimally conscious state group (weighted mean difference = 0.77, 95% confidence interval = 0.30-1.23, P = 0.001), but not in the vegetative state or unresponsive wakefulness syndrome group. The effects of transcranial direct current stimulation are related to etiology, as the Coma Recovery Scale-Revised score was improved in the traumatic brain injury group (weighted mean difference = 1.18, 95% confidence interval = 0.60-1.75, P < 0.001), but not in vascular accident and anoxia groups. This meta-analysis revealed the evidence for positive effects of transcranial direct current stimulation on disorders of consciousness without adverse effects observed in minimally conscious state patients. In particular, transcranial direct current stimulation may be an effective treatment in rehabilitating cognitive functions in people with traumatic brain injury.