Vegetative State Research Articles

Efficacy of melatonin for prolonged disorders of consciousness: a double-blind, randomized clinical trial

BackgroundSleep is essential for the recovery of patients with disorders of consciousness (DoC). However, few approaches targeting sleep were applied. Melatonin has been shown to enhance sleep efficiency with virtually no side effects. This study explored melatonin’s benefits for patients with prolonged DoC, as well as the underlying mechanisms involved.MethodsA cohort of 46 patients with prolonged DoC were randomly assigned to either the melatonin treatment group or the placebo group. Assessments were conducted using the Coma Recovery Scale-Revised (CRS-R), electroencephalography (EEG), and polysomnography (PSG) before and after the intervention, with follow-up CRS-R evaluations performed 6 months post-treatment.ResultsCompared to the placebo, melatonin demonstrated a significant improvement in CRS-R scores after a 2-week period in patients with unresponsive wakefulness syndrome (UWS) (Fgroup*time = 6.86, P = 0.032; Fgroup = 4.03, P = 0.045) and this improvement was particularly pronounced in visual scores (Fgroup*time = 7.03, P = 0.030; Fgroup = 4.90, P = 0.027). Moreover, patients with UWS who received melatonin exhibited a higher relative spectral density of the alpha band in the frontal lobe compared to those who received placebo (Ftime-mel = 4.55, P = 0.033) and benefited for their prognosis after 6 months (Pseudo R2 = 0.370, F = 12.03, P = 0.034).ConclusionsOverall, melatonin intervention seems to have a better response in UWS patients with preserved sleep cycles. These positive effects may not be solely attributed to improvements in the patients’ sleep quality.Trail registrationClinicalTrials.gov: NCT05285124.

Comprehensive evaluation and diagnosis of persistent vegetative state after hypoxic-ischemic encephalopathy: a case report

ABSTRACT We report a case of a 39-year-old woman with persistent vegetative state (PVS) following cardiac arrest and a right lower extremity fracture. Despite comprehensive rehabilitation for over 4 months, there was no improvement. Neuroelectrophysiological and neuroimaging assessments showed poor brain function, and the coma recovery scale-revised scale results suggested low arousal probability. Furthermore, patients with PVS exhibit autonomic reactivity and physiological responses to external stimuli. It is important to note that while these reactions may manifest as responsiveness to external stimuli, they should be interpreted as automatic physiological responses rather than indicative of consciousness.

Exploring end-of-life decision-making in China for disorders of consciousness

Objectives We aim to investigate the ethical attitudes of the Chinese population toward withdrawal of life-sustaining treatment (WLST) in disorders of consciousness (DoC) patients. Methods A self-administered questionnaire concerning WLST was distributed to Chinese medical professionals and non-medical participants between February and July 2022. Statistical analysis included chi-square tests and logistic regressions. Results A total of 1223 Chinese participants responded to the questionnaire (39% of whom were medical professionals). Less than one third of participants reported positive attitudes towards withdrawing artificial nutrition and hydration (ANH), antibiotics, and do-not-resuscitation (DNR) orders in patients with unresponsive wakefulness syndrome (UWS) (30%, 24%, 24%) and minimally conscious state (MCS) (23%, 19%, 15%). More respondents agreed with WLST in UWS compared to MCS (p < 0.05). Positive attitudes toward DNR orders were associated with participants’ older age, religion, monthly income > 5000 RMB and medical profession (p < 0.05). Most participants deemed patient’s will (78%), families’ wishes (67%), and financial burden (63%) to be crucial factors when considering WLST. Conclusions Chinese respondents exhibit a relatively low propensity to accept WLST in DoC. Ethical attitudes toward WLST resulted to be affected by individual characteristics of responders. These results call for developing better regulations for identifying qualified surrogate decision-makers and reducing legal ambiguities.

Brain Function and Structure Changes in the Prognosis Prediction of Prolonged Disorders of Consciousness.

To observe the functional differences in the key brain areas in patients with different levels of consciousness after severe brain injury, and provide reference for confirming the objective diagnosis indicators for prolonged disorders of consciousness (pDoCs). This prospective study enrolled patients with pDoCs hospitalized in the department of rehabilitation medicine of our Hospital. Levels of consciousness and clinical outcomes were assessed according to diagnostic criteria and behavioral scales. Resting-state functional magnetic resonance imaging (rs-fMRI) and diffusion tensor imaging (DTI) of 30 patients with different levels of consciousness was performed. The patients were grouped as conscious or unconscious according to whether they regained consciousness during the 12-month follow-up. Thirty patients were enrolled, including eight with unresponsive wakefulness syndrome/vegetative state, eight with minimally conscious state, six with emergence from the minimally conscious state, and eight with a locked-in syndrome. There were 19 and 11 patients in the conscious and unconscious groups. Compared with the unconscious group, the left basal nucleus was activated in the conscious group, and there were significant differences in white matter fiber bundles. Correlations were observed between the regional homogeneity (ReHo) value of the cerebellum and the Glasgow coma scale score (r = 0.387, P = 0.038) and between the ReHo value of the left temporal and the coma recovery scale-revised score (r = 0.394, P = 0.035). The left insula and cerebellum might be important for regaining consciousness. The brain function activity and structural remodeling of the key brain regions and the activation level of the cerebellum are correlated with clinical behaviors and have potential application value for the prognosis prediction of pDoCs patients.

The Italian version of the Coma Recovery Scale for Pediatrics.

The Coma Recovery Scale for Pediatrics (CRS-P) is a modified version of the Coma Recovery Scale-Revised (CRS-R). This CRS-P looks at behavioral responses and diagnoses Coma, Vegetative State, MCS and E-MCS in pediatric age. It is an ordinal scale consisting of 29 items divided into 6 subscales. The CRS-R is a gold standard for the assessment of adults with disorders of consciousness (DOC) and is also recommended for children, following the American Guidelines. The CRS-P was translated and culturally adapted into Italian by two independent translators in order to test an adapted Italian version on Italian children. We found conceptual, semantic and content correspondence between the original version and the preliminary version of the CRS-P in Italian. The Italian CRS-P version can be tested on Italian children and then validated.

Identification of biallelic intronic EPM2A mutations in a Lafora disease kindred.

Lafora disease (LD) is a severe autosomal recessive disease, which usually presents as seizure and myoclonus, followed by behavioral changes, dysarthria, intellectual decline, and finally progressed to dementia and a vegetative state. The main cause of LD is the loss-of-function mutations in EPM2A and NHLRC1 that encode laforin and malin, respectively. Targeted genetic testing is the gold standard to confirm the diagnosis of LD. To describe the pathogenic role of biallelic EPM2A intronic mutations carried by patients in a family diagnosed as LD. Here, we present clinical findings in a patient presenting with epileptic seizures and Lafora bodies in muscle biopsy. Long-read DNA and RNA sequencing were performed to identify the causative mutation. Western blot and qPCR confirmed the pathogenic role of biallelic EPM2A intronic mutations. Genetic testing identified two intronic mutations in EPM2A which caused aberrant mRNA splicing. c.301+1 G > A in EPM2A caused aberrant splicing at donor site and resulted in intron retention in transcript NM_005670.4, while c.476+14860 C > A caused aberrant splicing in transcript NM_001368129.2 and NM_001368132.1. Our findings expand the spectrum of variants in LD disease, additionally providing evidence linking non-coding regulatory regions mutations to LD disease.

Abstract Su902: Ability of Composite Magnetic Resonance Brain Imaging Scores to Predict Functional Outcomes in Survivors of Cardiac Arrest

Background: Brain magnetic resonance imaging (MRI) has been examined for neuroprognostication (NP) after out-of-hospital cardiac arrest (OHCA). However, studies have focused on predicting poor outcomes of non-awakening and/or death. Recommendations for utilization of brain MRI in NP remain weak due to its subjective interpretation. Aim: We modified a previously published brain MRI score and examined our quantitated NP scores’ ability to predict good functional outcomes in OHCA survivors. Methods: We screened OHCA cases (2017-2023, Seattle Medic One registry) for patients who survived to hospital discharge and had brain MRIs performed 25 hours-7 days after arrest. Each MRI was reviewed by two adjudicators; a third reviewer served as tie-breaker. Reviewers were blinded to patient outcomes. Diffusion Weighted Imaging and Fluid Attenuated Inversion Recovery sequences were reviewed to score 35 neuroanatomical regions. Graded severity for estimated affected area (0 = zero; 1= &lt; 25%; 2 = 25-50%; 3 = 50-75%; 4 = &gt;75%) and binary (0 = not affected, 1 = affected) scores were tallied. Points were summed for a composite brain MRI score, “ NP score ”, possible range 0-214. Primary outcome was Cerebral Performance Categories (CPC) at hospital discharge (1-2: “independent”, 3: “dependent”, 4: “vegetative state”). Computational modeling employed folded normal distributions and Maximum Likelihood Estimation. Statistical analyses were Pearson’s, Spearman’s, ANOVA, Fisher LSD, t-tests. Results: Forty-two (42) adult patients were included (74% men, 55% Caucasian). Median NP score was 11.5 (IQR 41.5, n=42) overall, 2 (IQR=10, n=21) for independent versus 25.5 (IQR 36.5, n=10) for dependent patients, and 92 (IQR=81, n=11) for those in a vegetative state. NP scores strongly correlated with CPC [ r s (40) = .69, p&lt; .001 ], and were significantly different between CPC groups [F(2,39) = 32.66, p&lt; 0.001 ]. Interrater concordance for NP score was high (Pearson) r = .88 [r = .96; .95; .90; .71]. Conclusions: Our NP score correlated well with good functional outcomes in OHCA survivors, and (1) identified distinct thresholds that well-separate functional outcome groups and (2) had very strong concordance rate among four pairs of adjudicators. NP score-based predictive modeling differentiates functional outcomes beyond good versus poor dichotomy and may help providers and family anticipate recovery potential.

Early-onset subacute sclerosing panencephalitis and its rapid clinical course of progression to vegetative state: An atypical presentation

Early-onset subacute sclerosing panencephalitis and its rapid clinical course of progression to vegetative state: An atypical presentation

Hypotension and Adverse Outcomes in Moderate to Severe Traumatic Brain Injury

Traumatic brain injury (TBI) is a leading cause of death and disability worldwide. Hypotension in patients with TBI is associated with poorer outcomes. A comprehensive review examining adverse outcomes of hypotension in patients with TBI is needed. To investigate the mortality and incidence of hypotension in patients with TBI. A search of studies published before April 2024 was conducted using MEDLINE, MEDLINE In Process, ePubs, Embase, Classic+Embase, Cochrane Central Register of Controlled Trials, and Cochrane Database of Systematic Reviews for primary research articles in English, including randomized control trials, quasirandomized studies, prospective cohorts, retrospective studies, longitudinal studies, and cross-sectional surveys. Inclusion criteria were patients aged at least 10 years with moderate to severe TBI with hypotension. The exclusion criteria were mild TBI (due to the differences in management principles from moderate to severe TBI). Data were screened using Covidence software with multiple reviewers. This meta-analysis conforms to Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) and Meta-analysis of Observational Studies in Epidemiology (MOOSE) reporting guidelines for assessing data quality and validity. Primary outcomes (unadjusted and adjusted odds ratios [ORs]) were calculated using a random-effect model with 95% CIs. Incidence of hypotension was derived using logit transformation. Main outcomes were association of hypotension with death and/or vegetative state within 6 months and incidence of hypotension. Vegetative state was not reported due to lack of data from included studies. Hypothesis testing occurred before data collection. The search strategy identified 17 676 unique articles. The final review included 51 studies (384 329 patients). Pooled analysis of found a significant increase in mortality in patients with hypotension and moderate to severe TBI (crude OR, 3.82; 95% CI, 3.04-4.81; P < .001; I2 = 96.98%; adjusted OR, 2.22; 95% CI, 1.96-2.51; P < .001; I2 = 92.21%). The overall hypotension incidence was 18% (95% CI, 12%-26%) (P < .001; I2 = 99.84%). This meta-analysis of nearly 400 000 patients with TBI found a significant association of greater than 2-fold odds of mortality in patients with hypotension and TBI. This comprehensive analysis can guide future management recommendations, specifically with respect to blood pressure threshold management to reduce deaths when treating patients with TBI.

NIMG-68. A COMPREHENSIVE REVIEW OF THE USE OF FMRI IN EVALUATING FUNCTIONAL CONNECTIVITY AND ACTIVATION IN DISORDERS OF CONSCIOUSNESS

Abstract PURPOSE Disorders of consciousness (DoC) like vegetative and minimally conscious states pose significant diagnostic and prognostic challenges, compounded by the inherent limitations in communicating with affected patients. We performed a scoping review of the literature to examine the application of functional magnetic resonance imaging (fMRI) to the assessment of functional connectivity (FC) and activation in DoC. METHODS We searched the MEDLINE/PubMed, Web of Science, and Embase databases between the years 2004 and 2024 for English-language studies involving fMRI and DoC in adult populations, adhering to PRISMA guidelines. Included studies were evaluated for study design, DoC subtype, fMRI subtype, cohort size, and FC and/or activation findings. RESULTS Our initial search identified 17,475 results, of which 82 studies were ultimately included with a total of 3917 patients. Only one of the included studies was a randomized controlled trial, 24 were prospective cohort studies, three were retrospective cohort studies, and 54 were observational in design. The majority of studies utilized resting-state fMRI (n=54, 65.9%), and the most commonly investigated disorders of consciousness were minimally conscious states (31.9%), vegetative states (14.4%), and unresponsive wakefulness syndromes (12.9%). Among studies with higher levels of evidence like prospective and retrospective studies, FC and activation findings were heterogeneous, with several studies reporting abnormal connectivity in the default mode and auditory networks. Activation responses among patients also varied, with some patients of the same DoC displaying expected activation patterns while others did not. Normal patterns of connectivity and activation were associated with improved prognosis in eight prospective studies and one retrospective study. CONCLUSIONS These findings underscore the complexity of using fMRI to evaluate consciousness in DoC patients. Though fMRI has the potential to identify residual cognitive function, the variability in responses also indicates the need for personalized approaches and further research to standardize fMRI protocols for this purpose.

A new ICT system coupling electromyography and coma recovery scale-revised to support the diagnostic process in disorders of consciousness

The Coma Recovery Scale-revised (CRS-r) is the gold standard for the behavioral assessment of patients with Disorders of Consciousness (DoCs). However, the misdiagnosis rate is around 40%. For this reason, recent guidelines suggested enhancing the assessment with neurophysiological measures: among these, surface electromyography (sEMG) represents a convenient bedside solution. This work presents the use of the STRIVEfc system, a wearable device that allows CRS-r administration while recording four sEMG signals. STRIVEfc was employed in 40 sessions on 33 DoCs patients and the sEMG was analyzed to look for voluntary and consistent over threshold (OT) muscular activities. Their duration, amplitude, and number were retained and compared between patients in Unresponsive Wakefulness Syndrome (UWS) and Minimally Conscious State (MCS), revealing more numerous and significantly longer OTs in the latter group. Lastly, the EMG information was exploited to enrich the behavioral assessment by building the instrumented CRS-r score (ICRS-r). In 9/16 UWS sessions, the ICRS-r score suggested a higher-level functioning, not translated into a behavioral response, compatible with MCS diagnosis. Overall, the use of STRIVEfc allows to reveal hidden muscular patterns not detectable by the clinician, thus improving the characterization of DoCs patient’s functional capabilities and supporting the diagnostic process.

Genetic Enhancement and Problems of Personal Identity

There are various discussions on personal identity in philosophy. Some differences of opinions exist in western philosophy regarding the criteria that needs to be fulfilled for two different persons at two different times to be considered as identical. Some philosophers think if physical continuity exists between the persons before and after, then they are identical. Some philosophers go against this and think that only psychological continuity must exist between the persons before and after to be considered as identical. There are also some philosophers who think only if both physical and psychological continuity exist between two persons at two different times, then they can be considered identical. The answer to the question , which of the three criteria, i.e. physical, psychological or mixed, is acceptable as the criteria of personal identity - is entwined with a very important question : when an entity becomes a person. In this paper, personhood of an entity, whether a fetus and who are in vegetative state can be considered as a person etc will be discussed along with another issue on whether personal identity changes after genetic enhancement.

"I don't want hear about that": Treatment wishes/preferences of elderly patients regarding possible treatment goals in acute life-threatening illness or acute organ failure

Abstract Background In many people with acutely life-threatening illnesses, the will to undergo treatment is not known with sufficient precision. It is often unclear whether the person concerned would have consented to life-sustaining measures or would have preferred to die with palliative care. This applies in particular to the vulnerable group of elderly, chronically ill/fragile people. It is not uncommon for people to reject the risks/burdens of medical treatment, even if there is a chance of success. On the other hand, there are many people who fight to continue living, even if this can be associated with great burdens and the outcome is rather uncertain. Aim of the study is to determine the characteristics of cardiologic patients who refuse to discuss treatment wishes/preferences in case of acute emergencies, temporary (e.g. in the context of intensive care unit (ICU) treatment), or permanent (vegetative state) inability to consent. Methods Prospective, questionnaire-based cross-sectional study including Hospital Anxiety and Depression Scale (HADS) and assessment of quality of life using the 12-item Short Form Health Survey (SF-12) on normal cardiology wards. Results 455 cardiologic patients were interviewed (mean age 71.2 ± 12.9 years, 39.6% female), 76.1% had moderate-severe concomitant diseases according to the Carlsson Comorbidity Index (4.3 ± 2.4 points) (see Table I). 23.5 % of respondents did not wish to address the above-mentioned question, they were significantly older (74.6 ± 13.1 vs. 69.9 ± 12.8 years; p=0.0009), had more comorbidities, were less likely to have a high level of education (university degree: 13.0 % vs. 30.6 %; p=0.0021) and were less likely to be employed (11.7 % vs. 25.8 %; p=0.0026). Furthermore, these patients live alone more frequently (45.8% vs. 30.6%; p=0.0048) and are less likely to live in a partnership (52.0% vs. 68.0%; p=0.0043). Refusal of an advance directive was also more common (22.5% vs. 10.7%; p=0.05), quality of life was impaired (42.4 ± 9.8 vs. 45.9 ± 10.5 points; p=0.0022), and the HADS-score levels were higher (15.6 ± 7.3 vs. 12.7 ± 7.8 points; p=0.0007). Conclusions A relevant proportion of our patients refuse to discuss treatment wishes/preferences in case of acute emergencies, temporary or permanent inability to consent. Paradoxically, these were patients for whom it would make particular sense (older, sicker, and more socially isolated patients). Those patients are also prone to anxiety and depression, and have a reduced quality of life.

Predictive power of the eTBI score for 30 day outcome in elderly patients with traumatic brain Injury

Traumatic brain injury (TBI) is a common problem in elderly individuals, with significant morbidity and mortality. The elderly Traumatic Brain Injury (eTBI) score, a novel tool for predicting outcomes in elderly patients with TBI, has shown promising results in previous studies. This study aimed to validate the eTBI score in a larger cohort of elderly patients with TBI in the Middle East. We conducted a retrospective study on 337 TBI patients with a mean age of 73.04 ± 8.73, admitted to a tertiary care hospital between March 2021 and November 2022. Within 30 days of admission, the patients’ conditions, including mortality and entering a vegetative state, were evaluated. The study population was split into three groups based on eTBI score: low, medium, and high risk; then patients were divided into two subgroups based on their Glasgow Outcome Scale (GOS ≤ 2, GOS > 2) in 30 days from hospital admission. Poor outcomes (mortality and entering a vegetative state) occurred in 24.3% of the study population. Within 30 days of hospital admission, 88% of low-risk patients experienced some degree of improvement, while 100% of high-risk patients died or fell into a vegetative state. In the medium-risk group, there was a significant correlation between unresponsive pupil (P = 0.006), initial GCS score (P = 0.003), need for a ventilator device (P = 0.015), need for surgical treatment (P = 0.031) and poor outcomes. Despite having a low sensitivity (21% vs. 57%), the eTBI score performed well in terms of accuracy (81% vs. 88%), specificity (100 vs. 98%), positive predictive value (100% vs. 90%), and negative predictive value (80% vs. 88%) for both eTBI ≤ 0 and eTBI ≤ 3 thresholds. The eTBI score is a reliable tool for predicting outcomes in elderly patients with TBI. This scoring system has a positive predictive value of 100% in the eTBI ≤ 0 group, which shows that 100% of the patients who are predicted by the eTBI score to have a poor outcome will indeed have a poor outcome. Patients in the high-risk group should be closely monitored and provided with intensive care, while those in the low-risk group can be reassured about their prognosis. The eTBI score can also be used in conjunction with other clinical factors to inform treatment decisions for patients in the medium-risk group.

NSE and S100β as serum alarmins in predicting neurological outcomes after cardiac arrest

Cardiac arrest (CA) is a serious health concern that often results in mortality or severe neurological dysfunction in the case of survival. Our aim was to explore the neurological prognostic factors in patients with CA. This retrospective observational study included adult patients with CA. We investigated serum neuron-specific enolase (NSE), S100 calcium-binding protein β (S100β), and indices and parameters at 1, 3, 5, 7 and intensive care unit (ICU) discharge days after CA. The primary study endpoint was the Cerebral Performance Category (CPC) scale score at ICU discharge, which was dichotomized as good neurological outcome (CPC 1–2: full recovery or moderate disability) and poor neurological outcome (CPC 3–5: severe disability, vegetative state, or death). Of the 191 adult patients with CA, 42 (22%) had good neurological outcomes, and 149 (78%) had poor neurological outcomes. NSE at 1,3,5,7 and ICU discharge days showed excellent predictive accuracy for neurological outcomes (area under the curve [AUC]: 0.666, 0.716, 0.870, 0.739, and 0.901, respectively). However, S100β exhibited general predictive power (AUC: 0.666, 0.573, 0.607, 0.594, 0.727). Finally, the early warning model, which combined day 1 NSE, day 1 S100β, cardiac arrest time, SOFA scores, APACHE II scores, and age, was used to screen CA patients with poor neurological prognosis at early stages and had an AUC of 0.792. Serum concentrations of NSE and S100β were significantly elevated in CA patients and could be prognostic biomarkers to predict neurological outcomes. Day 1 NSE and S100β combined with multiple indicators could be a decent early warning model for poor neurological prognosis in patients with CA.

An AI-Driven Model of Consciousness, Its Disorders, and Their Treatment.

Understanding the neural signatures of consciousness and the mechanisms underlying its disorders, such as coma and unresponsive wakefulness syndrome, remains a critical challenge in neuroscience. In this study, we present a novel computational approach for the in silico discovery of neural correlates of consciousness, the mechanisms driving its disorders, and potential treatment strategies. Inspired by generative adversarial networks, which have driven recent advancements in generative artificial intelligence (AI), we trained deep neural networks to detect consciousness across multiple brain areas and species, including humans. These networks were then integrated with a genetic algorithm to optimize a brain-wide mean-field model of neural electrodynamics. The result is a realistic simulation of conscious brain states and disorders of consciousness (DOC), which not only recapitulates known mechanisms of unconsciousness but also predicts novel causes expected to lead to these conditions. Beyond simulating DOC, our model provides a platform for exploring therapeutic interventions, specifically deep brain stimulation (DBS), which has shown promise in improving levels of awareness in DOC in over five decades of study. We systematically applied simulated DBS to various brain regions at a wide range of frequencies to identify an optimal paradigm for reigniting consciousness in this cohort. Our findings suggest that in addition to previously studied thalamic and pallidal stimulation, high-frequency stimulation of the subthalamic nucleus, a relatively underexplored target in DOC, may hold significant promise for restoring consciousness in this set of disorders.

Survival and clinical characteristics of patients with disorders of consciousness in a developing country between 2002 and 2018

ABSTRACT Objective Describe the survival, sociodemographic and clinical characteristics of subjects with disorders of consciousness in a reference rehabilitation center, in a developing country. Methods Patients with disorders of consciousness (DoC) caused by acquired neurological injuries, admitted between the years 2002–2018 in a neurorehabilitation center. Extracted data covered demographics, clinical details, survival time, and discharge information. Cox proportional hazard model and Kaplan-Meier analysis were used to reveal, associations with survival. Result Out of 5064 neurological cases, 159 patients were diagnosed with DoC. The demographic data showed a male dominance (65%), with an average injury age of 42 years. The most common causes were traumatic (41%), anoxic (36%), and vascular (10%), with traffic accidents accounting for 71% of traumatic injuries. The study found that 75% of patients remained in a vegetative state (VS), and 25% in a minimally conscious state (MCS), with an average survival of 2110 days. Conclusion There were no significant differences in survival days between patients in MCS and VS. Patients with traumatic injuries showed a higher survival rate than those with non-traumatic injuries. Age and etiology were identified as factors associated with a higher risk of death.

Exploring bispectral index as an alternative to polysomnography for long-term sleep monitoring in disorders of consciousness.

Sleep plays a crucial role in neuroplasticity and recovery from brain injury, particularly in disorders of consciousness (DoC), including unresponsive wakefulness syndrome (UWS) and minimally conscious state (MCS). Traditional sleep monitoring methods like polysomnography (PSG) are complex and often impractical for long-term use in clinical settings. This study aimed to explore the utility of the Bispectral Index (BIS) as a more practical alternative for monitoring sleep patterns in DoC patients. We conducted simultaneous PSG and BIS monitoring on 38 DoC patients (19 UWS and 19 MCS). The study focused on analyzing sleep timing distribution, the effectiveness of BIS in differentiating sleep stages, and its correlation with consciousness levels. Our findings revealed that DoC patients exhibited irregular and fragmented sleep patterns, necessitating extended monitoring periods. The BIS effectively differentiated various sleep stages, with significant differences in BIS values observed across these stages. However, BIS values did not show significant differences between UWS and MCS patients, indicating that BIS primarily indicates wakefulness rather than cognitive awareness. DoC patients have disturbed sleep-wake cycles that require prolonged monitoring. BIS can well distinguish sleep stages in DoC patients, and the distribution of values is similar to that of normal subjects. However, BIS could not distinguish the level of consciousness of DoC patients. The study demonstrates the potential of BIS as a practical tool for long-term sleep monitoring in DoC patients, offering a less intrusive alternative to traditional methods.

Artificial intelligence and machine learning in disorders of consciousness.

As artificial intelligence and machine learning technologies continue to develop, they are being increasingly used to improve the scientific understanding and clinical care of patients with severe disorders of consciousness following acquired brain damage. We here review recent studies that utilized these techniques to reduce the diagnostic and prognostic uncertainty in disorders of consciousness, and to better characterize patients' response to novel therapeutic interventions. Most papers have focused on differentiating between unresponsive wakefulness syndrome and minimally conscious state, utilizing artificial intelligence to better analyze functional neuroimaging and electroencephalography data. They often proposed new features using conventional machine learning rather than deep learning algorithms. To better predict the outcome of patients with disorders of consciousness, recovery was most often based on the Glasgow Outcome Scale, and traditional machine learning techniques were used in most cases. Machine learning has also been employed to predict the effects of novel therapeutic interventions (e.g., zolpidem and transcranial direct current stimulation). Artificial intelligence and machine learning can assist in clinical decision-making, including the diagnosis, prognosis, and therapy for patients with disorders of consciousness. The performance of these models can be expected to be significantly improved by the use of deep learning techniques.

Neuroendoscopic surgery for brainstem hemorrhage: Technical notes and preliminary clinical results

BackgroundBrainstem hemorrhage accounts for a relatively small proportion of spontaneous intracerebral hemorrhages (∼10 %) but tends to occur earlier in life and has poorer prognosis. Numerous studies support the therapeutic potential of minimally invasive hematoma evacuation for intracerebral hemorrhage; however, there have been few assessments of the benefits for brainstem hemorrhage. MethodsWe evaluated the safety and efficacy of a minimally invasive approach under neuroendoscopic guidance with pneumatic arm fixation for removing the hematoma in severe brainstem hemorrhage patients. 14 patients diagnosed with primary brainstem hemorrhage and treated by neuroendoscopy-assisted evacuation at Suzhou Ninth Hospital affiliated to Soochow University were included in the study. Relevant clinical and prognostic date were collected and analyzed. ResultsHematoma volume ranged from 8 to 13 mL according to preoperative CT, while GCS at admission ranged from 4 to 6. The average operative time was 157 min and average intraoperative blood loss was 86 mL. All patients achieved satisfactory hematoma evacuation (over 90 %) according to immediate postoperative CT. Postoperative intensive care unit stay averaged 9.5 days and respiratory support averaged 7.5 days. 11 patients required tracheotomy due to pulmonary infection and absence of pharyngeal reflexes. 9 patients achieved satisfactory functional recovery (GOS score of 4 and 3), while 5 remained in a vegetative state (GOS score of 2). ConclusionNeuroendoscopy provides excellent direct visualization of brainstem hematomas for safe and reliable evacuation. Patients with a new PPH score of 2 or 3 are more likely to benefit from surgical treatment. Large-scale studies are required to identify patients most likely to benefit from this technique.