Severe Disorders Of Consciousness Research Articles

Does amantadine improve cognitive recovery in severe disorders of consciousness after aneurysmal subarachnoid hemorrhage? A double-blind placebo‐controlled study

BackgroundSevere disorders of consciousness (sDoC) are a common sequela of aneurysmal subarachnoid hemorrhages (aSAH), and amantadine has been used to improve cognitive recovery after traumatic brain injury. ObjectiveThis study evaluated the effect of amantadine treatment on consciousness in patients with sDoC secondary to aSAH. MethodsThis double-center, randomized, prospective, cohort study included patients ≥ 18 years old with sDoC after aSAH from February 2020 to September 2023. Individual patient data of patients were pooled to determine the effect of amantadine, in comparison to placebo. The primary outcomes at 3 and 6 months after the ictus were evaluated using the modified Rankin scale (mRS) and Glasgow outcome scale (GOS). In addition to all-cause mortality, secondary endpoints were assessed weekly during intervention by scores on Rappaport's Disability Rating Scale (RDRS) and Coma Recovery Scale-Revised (CRSR). ResultsOverall, 37 patients with sDoC and initial Glasgow Coma Scale (GCS) varying between 3 and 11 were recruited and randomized to amantadine (test group, n = 20) or placebo (control group, n = 17). The average age was 59.5 years (28 to 81 year-old), 24 (65%) were women, and the mean GCS at the beginning of intervention was 7.1. Most patients evolved to vasospasm (81%), with ischemia in 73% of them. The intervention was started between 30 to 180 days after the ictus, and administered for 6 weeks, with progressively higher doses. Neither epidemiological characteristics nor considerations regarding the treatment of the aneurysm and its complications differed between both arms. Overall mortality was 10.8% (4 deaths). During the study, four patients had potential adverse drug effects: two presented seizures, one had paralytic ileus, and another evolved with tachycardia; the medication was not suspended, only the dose was not increased. At data opening, 2 were taking amantadine and 2 placebo. ConclusionDespite some good results associated with amantadine in the literature, this study did not find statistically significant positive effects in cognitive recovery in patients with delayed post-aSAH sDoC. Further large randomized clinical trials in patients’ subgroups are needed to better define its effectiveness and clarify any therapeutic window where it can be advantageous.

Ethical issues of nosology in disorders of consciousness.

The current classification scheme for severe disorders of consciousness (DoC) has several shortcomings. First, there is no consensus on how to incorporate patients with covert consciousness. Second, there is a mismatch between the definitions of severe DoC, based on consciousness, and the diagnosis of these same DoC, which is based on observable motoric responsiveness. Third, current categories are grouped into large heterogeneous syndromes which share phenotype, but do not incorporate underlying pathophysiology. Here we discuss several ethical issues pertaining to the current nosology of severe DoC. We conclude by proposing a revised nosology which addresses these shortcomings.

Clinical characteristics of and treatment strategy for hydrocephalus in patients with severe disorders of consciousness.

Making an appropriate diagnosis and effective treatment for hydrocephalus in patients with severe disorders of consciousness (DOC) remains controversial and difficult. Given that the typical symptoms are usually concealed by the limited behavioral responsiveness of patients with severe DOC, hydrocephalus diagnosis is likely to be missed in the clinic. Even if not, the presence of hydrocephalus may reduce the likelihood of DOC recovery, posing a conundrum for clinicians. From December 2013 to January 2023, the clinical data and therapeutic schedule of hydrocephalus in patients with severe DOC at Huashan Hospital's Neurosurgical Emergency Center were studied retrospectively. Sixty-eight patients [mean age (± SD) 52.53 ± 17.03 years, 35 males and 33 females] with severe DOC had been included. The hydrocephalus was discovered after computerized tomography (CT) or magnetic resonance imaging (MRI) revealed enlarged ventricles in the patients. During the hospitalization, the patient underwent a surgical treatment that included a ventriculoperitoneal (V-P) shunt and/or cranioplasty (CP) implantation. Following the surgery, an individualized V-P pressure was established based on the patient's ventricle size and neurological function variation. To account for the improvement in consciousness in patients with severe DOC, the Glasgow Coma Scale (GCS) and the Coma Recovery Scale-Revised (CRS-R) assessments were performed before and after hydrocephalus treatment. All severe DOC patients have varying degrees of ventricular enlargement, deformation, and poor brain compliance. Approximately 60.3% (41/68) of them had low- or negative-pressure hydrocephalus (LPH or NegPH). 45.5% (31/68) of the patients had a one-stage V-P shunt and CP operation performed concurrently, while the remaining 37 patients had a single V-P shunt operation performed independently. Beside of two DOC patients developed surgical complications, 92.4% (61/66) of the survivors showed an improvement in consciousness after hydrocephalus treatment. In patients with severe DOC, LPH or NegPH was common. Secondary hydrocephalus in DOC patients had been largely ignored, hampering their neurological rehabilitation. Even months or years after the onset of severe DOC, active treatment of hydrocephalus can significantly improve patients' consciousness and neurological function. Meanwhile, this study summarized several evidence-based treatment experiences of hydrocephalus in patients with DOC.

The signs of computer tomography combined with artificial intelligence can indicate the correlation between status of consciousness and primary brainstem hemorrhage of patients

For patients of primary brainstem hemorrhage (PBH), it is crucial to find a method that can quickly and accurately predict the correlation between status of consciousness and PBH. To analyze the value of computer tomography (CT) signs in combination with artificial intelligence (AI) technique in predicting the correlation between status of consciousness and PBH. A total of 120 patients with PBH were enrolled from August 2011 to March 2021 according to the criteria. Patients were divided into three groups [consciousness, minimally conscious state (MCS) and coma] based on the status of consciousness. Then, first, Mann-Whitney U test and Spearman rank correlation test were used on the factors: gender, age, stages of intracerebral hemorrhage, CT signs with AI or radiology physicians, hemorrhage involving the midbrain or ventricular system. We collected hemorrhage volumes and mean CT values with AI. Second, those significant factors were screened out by the Mann-Whitney U test and those highly or moderately correlated by Spearman's rank correlation test, and a further ordinal multinomial logistic regression analysis was performed to find independent predictors of the status of consciousness. At last, receiver operating characteristic (ROC) curves were drawn to calculate the hemorrhage volume for predictively assessing the status of consciousness. Preliminary meaningful variables include hemorrhage involving the midbrain or ventricular system, hemorrhage volume, grade of hematoma shape and density, and CT value from Mann-Whitney U test and Spearman rank correlation test. It is further shown by ordinal multinomial logistic regression analysis that hemorrhage volume and hemorrhage involving the ventricular system are two major predictors of the status of consciousness. It showed from ROC that the hemorrhage volumes of <3.040 mL, 3.040 ~ 6.225 mL and >6.225 mL correspond to consciousness, MCS or coma, respectively. If the hemorrhage volume is the same, hemorrhage involving the ventricular system should be correlated with more severe disorders of consciousness (DOC). CT signs combined with AI can predict the correlation between status of consciousness and PBH. Hemorrhage volume and hemorrhage involving the ventricular system are two independent factors, with hemorrhage volume in particular reaching quantitative predictions.

Outcome Prediction of Unconscious Patients Based on Weighted Sparse Brain Network Construction.

It is quite challenging to establish a prompt and reliable prognosis assessment for acquired brain injury (ABI) patients with persistent severe disorders of consciousness (DOC) like unconscious comatose and unresponsive wakefulness syndrome (a.k.a., vegetative state). Recent advances in brain functional imaging and functional net-work analysis have demonstrated its potential in determining the consciousness level and prognostic outcome for ABI patients with DOC. However, the diagnostic and prognostic usefulness of the whole-brain functional connectome based on advanced machine learning techniques has not been fully evaluated. The first aim of this study is to predict the outcome of individual unconscious ABI patients during a three-month follow-up. The second aim is to conduct precise individualized differentiation among different consciousness levels for exploring the neurobiological mechanisms underlying DOC. Based on resting-state fMRI, we construct large-scale functional networks by using a weighted sparse model, which ensures sparsity and interpretability by preserving strong functional connections. The functional connection strengths are exploited as features for outcome prediction and consciousness level differentiation. We achieve significantly improved consciousness level classification (accuracy: 84.78%) and recovery outcome prediction (accuracy: 89.74%) compared to other network construction methods. More importantly, we reveal the contributive connections across the entire brain in both tasks. These connections could serve as the potential biomarkers for better understanding of consciousness and further provide new insight into the development of diagnostic, prognostic, and effective therapeutic guidelines for ABI patients with DOC.

SWALLOWING ACTIVATION USING SENSORY STIMULATION IN PATIENTS WITH SEVERE DISORDERS OF CONSCIOUSNESS.

ObjectiveSwallowing disorders are systematically present in patients with severe brain injury, disorders of consciousness, and subsequently poor quality of life. The study hypothesis was that taste and smell could improve swallowing function and quality of life in such patients, who are fed by gastrostomy tube.MethodsEight patients with unresponsive wakefulness syndrome were included in this study. All patients had been in a stable state for at least 2 years, and the delay between the neurological event and the study was always more than 2 years. Strong tastes and smells were selected using the Pfister olfactory classification. Taste and smell stimulations were performed every weekday, Monday to Friday, for 1 week (5 sessions) by a speech and language therapist. Evaluation of swallowing was performed before the first session and after the fifth session, and included the number of spontaneous swallows during 10 min, the presence of drooling, and spontaneous tongue and velum mobility.ResultsThe number of spontaneous swallows at the initial evaluation was 6.8 ± 5.1 n/min. At the final evaluation there was a significant increase in the number of spontaneous swallows (9.1 ± 4.1 n/min, p < 0.01).ConclusionThis clinical observation has shown that taste and smell stimulations are relevant in clinical practice to improve spontaneous swallowing.LAY ABSTRACTSwallowing disorders are systematically present in patients with severe brain injury, disorders of consciousness, and subsequent poor quality of life. The study hypothesis was that taste and smell could improve swallowing function in such patients who require exclusive feeding by gastrostomy tube. The study showed that, in patients with severe DoC, taste and smell stimulations increased the number of spontaneous swallows. Based on these findings, taste and smell stimulations could be used in clinical practice to improve swallowing function and overall quality of life.

Residual Cognitive Capacities in Patients With Cognitive Motor Dissociation, and Their Implications for Well-Being.

Patients with severe disorders of consciousness are thought to be unaware of themselves or their environment. However, research suggests that a minority of patients diagnosed as having a disorder of consciousness remain aware. These patients, designated as having “cognitive motor dissociation” (CMD), can demonstrate awareness by imagining specific tasks, which generates brain activity detectable via functional neuroimaging. The discovery of consciousness in these patients raises difficult questions about their well-being, and it has been argued that it would be better for these patients if they were allowed to die. Conversely, I argue that CMD patients may have a much higher level of well-being than is generally acknowledged. It is far from clear that their lives are not worth living, because there are still significant gaps in our understanding of how these patients experience the world. I attempt to fill these gaps, by analyzing the neuroscientific research that has taken place with these patients to date. Having generated as comprehensive a picture as possible of the capacities of CMD patients, I examine this picture through the lens of traditional philosophical theories of well-being. I conclude that the presumption that CMD patients do not have lives worth living is not adequately supported.

Clinical Value of EEG Epileptiform Abnormalities on Predicting the Risk of Seizure Attacks and Prognosis in Severe Disorders of Consciousness

Clinical Value of EEG Epileptiform Abnormalities on Predicting the Risk of Seizure Attacks and Prognosis in Severe Disorders of Consciousness

Addressing Pain for a Proper Rehabilitation Process in Patients With Severe Disorders of Consciousness.

Consciousness constitutes a fundamental prerequisite in the individual appraisal and experience of pain. In the same way, a person needs to be able to report on pain perception. Patients who suffered a severe brain injury with disorders of consciousness (DOC) represent a spectrum of pathologies affecting patients' capacity to interact with the external world. In these patients, the most relevant aspects in response to pain are physiologic and behavioral. The treatments and management of pain are challenging issues in these patients, arising serious ethical concerns and bringing emotional load among medical staff, caregivers, and relatives. In this review, we report the importance of having a correct pain management in DOC patients, to individuate the best pharmacological treatment that can make the difference in detecting a behavioral response, indicative of a change in the level of consciousness, and in planning a more effective rehabilitative approach.

Clinical Diagnosis and Treatment in Emergency Medical Department to Rescue Unconscious Patients

Coma is a common and critical illness in emergency medicine. It is mainly caused by abnormal metabolism of the cerebral cortex and brainstem network structure that maintains normal conditions, causing the patient to lose consciousness, consciousness, etc. If the patient fails to receive timely and effective diagnosis and treatment after the onset of disease , Will threaten the lives of patients. However, because the patient was in a coma or impaired consciousness after admission, he was unable to describe his condition, medical history, etc., which increased the difficulty of clinical diagnosis. Coma is a common emergency and critical illness with a high fatality rate in the emergency department. It is more common in acute cardiovascular and cerebrovascular diseases, poisoning, and trauma. Because the patient presented with a severe disorder of consciousness, unable to provide relevant medical history and cooperate with diagnosis and treatment, and the etiology involved multi-disciplinary and multi-professional knowledge, it brought great difficulties to diagnosis, rescue and treatment. Therefore, how to quickly determine the cause of the disease in a short time and implement the correct rescue measures in the first time has become a great challenge for emergency medical staff. Medical research has shown that the diagnosis and treatment of coma patients must clarify the cause of the patient, understand the factors that cause the coma, and formulate targeted diagnosis and treatment measures. Therefore, clinically, it is necessary to strengthen the rapid diagnosis and timely examination of patients with coma in emergency medicine, understand the cause of the patient's coma, and adopt effective treatment methods, so as to stabilize the patient's vital signs and avoid further development of the disease.

Positive effects of music therapist's selected auditory stimulation on the autonomic nervous system of patients with disorder of consciousness: a randomized controlled trial.

The current randomized controlled trial was performed at the China Rehabilitation Science Institute, China to test the hypothesis that musical auditory stimulation has positive effects on the autonomic nervous system of patients with disorder of consciousness. Although past studies have recommended that patients with disorder of consciousness listen to patient-preferred music, this practice is not universally accepted by researchers. Twenty patients with severe disorder of consciousness listened to either therapist-selected (n = 10, 6 males and 4 females; 43.33 ± 18.76 years old) or patient-preferred (n = 10, 5 males and 5 females, 48.83 ± 18.79 years old) musical therapy, 30 minutes/day, 5 times/week for 6 weeks. The results showed no obvious differences in heart rate variability-related parameters including heart rate, standard deviation of normal-to-normal R-R intervals, and the root-mean-square of successive heartbeat interval differences of successive heartbeat intervals between the two groups of patients. However, percentage of differences exceeding 50 ms between adjacent normal number of intervals, low-frequency power/high-frequency power, high-frequency power norm, low-frequency power norm, and total power were higher in patients receiving therapist-selected music than in patients receiving their own preferred music. In contrast, this relationship was reversed for the high-frequency power and very-low-frequency band. These results suggest that compared with preferred musical stimulation, therapist-selected musical stimulation resulted in higher interactive activity of the autonomic nervous system. Therefore, therapist-selected musical stimulation should be used to arouse the autonomic nervous system of patients with disorder of consciousness. This study was approved by the Institutional Ethics Committee of China Rehabilitation Research Center, China (approval No. 2018-022-1) on March 12, 2018 and registered with the Chinese Clinical Trial Registry (registration number ChiCTR1800017809) on August 15, 2018.

P.595 Day and night variation of sleep differentiates patients in severe disorders of consciousness

P.595 Day and night variation of sleep differentiates patients in severe disorders of consciousness

Personhood and Disorders of Consciousness: Finding Room in Person-Centered Healthcare

Advocates of the Person-Centered Healthcare (PCH) approach say that PCH is a response to a failure of caring for patients as persons. Nevertheless, there are many human subjects falling to fulfill the requirements of a traditional philosophical definition of personhood. Hence, if we take, PCH seriously, a greater clarification of the key terminology of PCH is urgently needed. It seems necessary, for instance, that the concept of the person should be extended in order to include those individuals with insipient or immature levels of consciousness, as well as those who are severely and permanently mentally handicapped. In this article, we will depart from some well-known philosophical concepts of what it means to be a person and try to offer a broader and more inclusive meaning. We suggest that persons are human beings with a socially recognized biography, which implies to recognize as persons individuals with necessities, but also with narratives about their interests and claims, expressed sometimes by other people related to them. This is particularly the case of individuals that suffer from severe disorders of consciousness. For those, is not only care that matters; respect matters too. Caregivers should therefore not only sympathetically care for the well-being of these people; they should also be concerned to respect their interests and claims by interpreting them empathetically, in the light of their biographical story. Our conclusion is that, in order to be coherent, PCH must consider individuals with severe disorders of consciousness as persons and we think that our revised concept of personhood fits with this requirement.

Effects of intrathecal baclofen therapy in subjects with disorders of consciousness: a reappraisal

Baclofen is a structural analogue of gamma-amino-butyric acid (GABA), which reduces spastic hypertonia of striated muscle due to a mechanism of GABAB-ergic inhibition of mono- and polysynaptic reflexes at the spinal level. There are reports of patients with severe disorders of consciousness that presented a substantial improvement following intrathecal baclofen (ITB) administration for severe spasticity. The neural mechanisms underlying the clinical recovery after ITB have not yet been clarified. Baclofen could modulate sleep-wake cycles that may be dysregulated and thus interfere with alertness and awareness. The diminished proprioceptive and nociceptive sensory inputs may relieve thalamo-cortical neural networks involved in maintaining the consciousness of the self and the world. ITB treatment might also promote the recovery of an impaired GABAergic cortical tone, restoring the balance between excitatory and inhibitory cortical activity. Furthermore, glutamatergic synapses are directly or indirectly modulated by GABAB-ergic receptors. Neurophysiological techniques (such as transcranial magnetic stimulation, electroencephalography, or the combination of both) can be helpful to explore the effects of intrathecal or oral baclofen on the modulation of neural cortical circuits in humans with disorders of consciousness.

Clinical application of Chinese Nanjing persistent vegetative state scale

BackgroundIt is a challenge to characterize the consciousness level of patients with severe disturbance of consciousness and predict their prognosis effectively for Chinese doctors. We aimed to investigate the psychometric property and the diagnostic practicality of severe disturbance of consciousness by Chinese Nanjing persistent vegetative state scale (CNPVSS) which was first set up in 1996 and modified in 2001 and 2011.MethodsThe concurrent validity, inter-rater consistency and diagnostic accuracy of CNPVSS and Chinese version of coma recovery scale-revised (CRS-R) were investigated by assessment of 380 patients with severe disorders of consciousness.ResultsTotal scores of the CNPVSS were correlated significantly with that of the CRS-R, indicating acceptable concurrent validity. Sub-scale analysis showed moderate to high inter-rater reliability and test-retest reliability. CNPVSS was superior to CRS-R on the diagnosis sensitivity. The CNPVSS was able to distinguish 65 patients in emergence from minimal consciousness state who were misclassified as in minimal consciousness state (MCS) by the CRS-R, and it could also distinguish two patients in MCS who were misclassified as in vegetative state by the CRS-R.ConclusionThe CNPVSS is an appropriate measurement and is sensitive to distinguish the MCS patients from the VS patients.

Serum BDNF Levels Are Reduced in Patients with Disorders of Consciousness and Are Not Modified by Verticalization with Robot-Assisted Lower-Limb Training.

Little is known about plastic changes occurring in the brains of patients with severe disorders of consciousness (DOCs) caused by acute brain injuries at rest and during rehabilitative treatment. Brain-derived neurotrophic factor (BDNF) is a neurotrophin involved in neurogenesis and synaptic plasticity whose production is powerfully modulated by physical exercise. In this study, we compared serum BDNF levels in 18 patients with unresponsive wakefulness syndrome (UWS) and in a minimally conscious state (MCS) with those in 16 sex- and age-matched healthy controls. In 12 patients, serum BDNF levels before and after verticalization with ErigoPro robot-assisted lower-limb training were compared. Serum BDNF levels were significantly lower in patients (median, 1141 pg/ml; 25th and 75th percentiles, 1016 and 1704 pg/ml) than in controls (median, 2450 pg/ml; 25th and 75th percentiles, 2100 and 2875 pg/ml; p < 0.001). BDNF levels measured before and after verticalization with robot-assisted lower-limb training did not change (p = 0.5). Moreover, BDNF levels did not differ between patients with UWS and MCS (p = 0.2), or between patients with traumatic and nontraumatic brain injuries (p = 0.6). BDNF level correlated positively with the time since brain injury (p = 0.025). In conclusion, serum BDNF levels are reduced in patients with UWS and MCS and cannot be improved by verticalization associated with passive lower-limb training. Additional studies are needed to better understand the mechanisms underlying BDNF reduction in patients with DOCs and to determine the best rehabilitative strategies to promote restorative plastic changes in these patients.

Respeitando biografias até o fim: uma concepção de personalidade mais adequada ao cuidado centrado na pessoa de indivíduos com transtornos graves da consciência

A abordagem conhecida como Saúde Centrada na Pessoa (SCP) tem seu foco nos indivíduos tomados como pessoas e não apenas como pacientes. Contudo, em filosofia, segundo as abordagens tradicionais, nem todos os seres humanos são (estritamente) “pessoas”. Ora, se para a SCP, importa tomar a todos os pacientes como pessoas, é preciso repensar as definições e conceitos propostos pelas mais diferentes abordagens ontológicas sobre a personalidade. Afinal, não são apenas os indivíduos com um self maduro e racional que demandam cuidados em saúde. Para a SCP, recém-nascidos, bebês, crianças, deficientes mentais e idosos com demência, e mesmo as pessoas portadoras de transtornos graves de consciência (TGC), também são pessoas com direitos a cuidados de saúde. Portanto, levando a SCP a sério, parece necessário que o conceito de pessoa seja estendido para incluir indivíduos com níveis de consciência insipientes ou imaturos, bem como aqueles com deficiências mentais graves ou permanentes. Neste artigo, discutiremos criticamente alguns conceitos filosóficos influentes sobre o que entendemos ou devemos entender por “pessoa”, buscando uma abordagem mais ampla e inclusiva. Propomos uma abordagem ontológica segundo a qual pessoas são compreendidas como seres dotados de uma biografia socialmente reconhecida, o que implica reconhecer esses indivíduos como portadores não apenas de necessidades em saúde, mas de interesses e demandas legítimas. Tais interesses e demandas, além das necessidades em bem-estar, não são expressos diretamente por elas devido, dadas suas deficiências graves, como ocorre com os indivíduos com TGC. Disso resulta que, no âmbito de uma SCP, para os pacientes que padecem de TGC, não é apenas o cuidado que importa, mas também o respeito. Os cuidadores, portanto, devem não apenas cuidar, movidos por simpatia ou compaixão, do bem-estar desses indivíduos, mas também devem se preocupar em respeitar seus interesses e direitos, interpretando-os de forma empática, à luz de sua história pessoal ou biográfica. Nossa conclusão é que, para ser coerente, a SCP deve considerar pessoas com TGC como pessoas, e que nosso conceito revisado de personalidade se adapta perfeitamente a essa exigência.

Sensory stimulation to improve arousal in comatose patients after traumatic brain injury: a systematic review of the literature.

No standard rehabilitative treatment for coma arousal after traumatic brain injury (TBI) exists. Based on our clinical experience, we hypothesized that sensory stimulation (SS) is a promising protocol to improve outcomes in these patients. We performed a literature review on the progress of sensory stimulation to enhance coma arousal after traumatic brain injury. We searched the databases on Medline, Embase, and Cochrane to gain access to relevant publications using the key words "traumatic brain injury," "disorders of consciousness," "sensory stimulation," and "coma scale." We included all original studies published in English with patients presenting severe disorders of consciousness due to traumatic brain injury who had received SS and whose behavioral/neural responses had been measured. We compared data on ten selected studies and analyzed the SS effects in comatose patient outcomes after TBI. Our review outlines the role of SS in patients with TBI and provides guidance for its implementation in the clinical practice. The literature suggests the SS program improves coma arousal after TBI. However, high-quality clinical trials are needed to establish standard SS protocols.

EEG and Coma Recovery Scale-Revised prediction of neurological outcome in Disorder of Consciousness patients.

According to electroencephalogram (EEG) descriptors included in the American Clinical Neurophysiology Society (ACNS) terminology, we generated a score, and we compared it to the EEG scores previously proposed in order to identify the one with the best prognostic power for neurological outcome at post-acute stages in patients with severe disorders of consciousness (DoC). Patients included in the analysis were clinically evaluated with the Coma Recovery Scale-Revised (CRS-R). An EEG was performed within the first week after admission to Intensive Rehabilitation Unit (IRU). EEGs were classified according to the ACNS terminology and to the scores of Bagnato and Estraneo. A total of 260 patients admitted to the IRU were analysed. A total of 160 patients (61%) improved their consciousness level during IRU stay. EEG score based on the ANCS terminology showed higher overall performance (receiver-operating area under the curve=0.79) and greater sensitivity (65%), at comparable specificities (80%), for clinical improvement as compared to both CRS-R admission score and other EEG scores. Combining our EEG score with CRS-R score at admission, the cumulative sensitivity increased to 76% when at least one good prognostic index test was present in the same patient, whereas specificity increased up to 93% if both the good prognostic patterns of clinical and instrumental parameters were simultaneously present. The EEG scored according to the ACNS terminology is the best among those looked at for the prediction of short-term clinical improvement in patients with DoC and represents a useful instrumental test, complementary to clinical evaluation at admission, to be added in post-acute neurological prognostication methods.

Joint Neuropsychological Assessment through Coma/Near Coma and Level of Cognitive Functioning Assessment Scales Reduces Negative Findings in Pediatric Disorders of Consciousness.

The present study aimed to: (a) characterize the emergence to a conscious state (CS) in a sample of children and adolescents with severe brain injury during the post-acute rehabilitation and through two different neuropsychological assessment tools: the Rappaport Coma/Near Coma Scale (CNCS) and Level of Cognitive Functioning Assessment Scale (LOCFAS); (b) compare the evolution in patients with brain lesions due to traumatic and non-traumatic etiologies; and (c) describe the relationship between the emergence to a CS and some relevant clinical variables. In this observational prospective longitudinal study, 92 consecutive patients were recruited. Inclusion criteria were severe disorders of consciousness (DOC), Glasgow Coma Scale (GCS) score ≤8 at insult, age 0 to 18 years, and direct admission to inpatient rehabilitation from acute care. The main outcome measures were CNCS and LOCFAS, both administered three and six months after injury. The cohort globally shifted towards milder DOC over time, moving from overall ‘moderate/near coma’ at three months to ‘near/no coma’ at six months post-injury. The shift was captured by both CNCS and LOCFAS. CNCS differentiated levels of coma at best, while LOCFAS was superior in characterizing the emergence from coma. Agreement between scales was fair, and reduced negative findings at less than 10%. Patients with traumatic brain injury (TBI) vs. non-traumatic brain injury (NTBI) were older and had neurosurgical intervention more frequently. No relation between age and the level of consciousness was found overall. Concurrent administration of CNCS and LOCFAS reduced the rate of false negatives and better detected signs of arousal and awareness. This provides indication to administer both tools to increase measurement precision.