RESUMEN
Prolonged disorders of consciousness (pDOC) are pathological conditions of alterations in consciousness caused by various severe brain injuries, profoundly affecting patients' life ability and leading to a huge burden for both the family and society. Exploring the mechanisms underlying pDOC and accurately assessing the level of consciousness in the patients with pDOC provide the basis of developing therapeutic strategies. Research of non-invasive functional neuroimaging technologies, such as functional magnetic resonance (fMRI) and scalp electroencephalography (EEG), have demonstrated that the generation, maintenance and disorders of consciousness involve functions of multiple cortical and subcortical brain regions, and their networks. Invasive intracranial neuroelectrophysiological technique can directly record the electrical activity of subcortical or cortical neurons with high signal-to-noise ratio and spatial resolution, which has unique advantages and important significance for further revealing the brain function and disease mechanism of pDOC. Here we reviewed the current progress of pDOC research based on two intracranial electrophysiological signals, spikes reflecting single-unit activity and field potential reflecting multi-unit activities, and then discussed the current challenges and gave an outlook on future development, hoping to promote the study of pathophysiological mechanisms related to pDOC and provide guides for the future clinical diagnosis and therapy of pDOC.
Asunto(s)
Trastornos de la Conciencia , Electroencefalografía , Humanos , Trastornos de la Conciencia/fisiopatología , Trastornos de la Conciencia/diagnóstico , Encéfalo/fisiopatología , Encéfalo/diagnóstico por imagen , Imagen por Resonancia Magnética , Lesiones Encefálicas/fisiopatología , Estado de Conciencia/fisiologíaRESUMEN
PURPOSE: The 2HELPS2B score is an invaluable tool for assessing seizure risk in critically ill patients with unconsciousness. However, this can be challenging for non-epileptologists to use owing to its reliance on electroencephalogram (EEG) analysis. Thus, identifying clinical manifestations associated with high 2HELPS2B scores is crucial. METHODS: We examined patients who underwent EEG for acute impaired consciousness in the emergency department between 2020 and 2022. We evaluated the clinical manifestations immediately prior to the EEG tests and identified those associated with a 2HELPS2B score ≥ 2. Additionally, we investigated clinical outcomes in accordance with these manifestations and the 2HELPS2B score. RESULTS: A total of 78 patients were included in this study. While the median 2HELPS2B score was 1 (range: 0-6), 13 patients (16.6%) showed electrographic/electroclinical seizures or status epilepticus and 16 patients (20.5%) showed ictal-interictal continuum in their EEGs. Abnormal muscle tonus (p = 0.034) and eye deviation (p = 0.021) were Significantly associated with a 2HELPS2B score ≥ 2. The presence of these manifestations (p < 0.001) and a 2HELPS2B score ≥ 2 (p < 0.001) were both significantly associated with a favorable response to anti-seizure medication. Conversely, patients with a 2HELPS2B score ≥ 2 who exhibited these clinical manifestations were more likely to be non-dischargeable (p = 0.053), have prolonged intensive care unit stays (p = 0.002), or require extended ventilator use (p = 0.082). CONCLUSION: Abnormal muscle tonus and eye deviation were significant manifestations compatible with a 2HELPS2B score ≥ 2 and may indicate an increased risk of seizures or the severity of the epileptic condition.
Asunto(s)
Trastornos de la Conciencia , Electroencefalografía , Convulsiones , Humanos , Masculino , Femenino , Persona de Mediana Edad , Electroencefalografía/métodos , Anciano , Trastornos de la Conciencia/diagnóstico , Trastornos de la Conciencia/fisiopatología , Trastornos de la Conciencia/etiología , Convulsiones/diagnóstico , Convulsiones/fisiopatología , Adulto , Anciano de 80 o más Años , Estudios Retrospectivos , Índice de Severidad de la Enfermedad , Enfermedad Crítica , Inconsciencia/diagnósticoRESUMEN
Accurate prediction of the recovery of Disorders of Consciousness (DoC) is of paramount significance for clinicians and families. Serum total bilirubin (TBIL) formed by activation of heme oxygenase 2, is associated with incidence and prognosis of cardiovascular and cerebrovascular diseases. However, studies that based TBIL and DoC are limited. The study attempted to examine the association between serum TBIL levels and prognosis in patients with DoC. One hundred and sixty-eight patients with DoC in the Second hospital of Shandong University from June 2021 to June 2023 were recruited. The clinical characteristics and venous blood samples were collected within 24 h after admission. The diagnosis of DoC was determined by two skilled investigators employing various behavioral evaluations along the coma recovery scale-revised (CRS-R) and the investigators conducted follow-up assessments of diagnosis at 1, 3, and 6 months after admission. For statistical analysis, we categorized patients with an improvement in clinical diagnosis from study entry as having a "good outcome". In total, 139 individuals enrolled in the study. The median TBIL level was 8.2 µmol/L. Good recovery of DoC at 1, 3, and 6 months occurred in 25 (18.0%), 41 (29.5%), and 56 (40.3%) patients, respectively. After full adjustment, a significant association was found between TBIL levels and the prognosis of DoC at 1, 3, and 6 months. When TBIL levels were analyzed as categorical variables, an increasing trend in the tertiles of TBIL levels demonstrated a significant positive association with the recovery of DoC at 1, 3, and 6 months. Stratified analysis revealed that the association between serum TBIL levels and the recovery of DoC remained consistent across different sub-populations. A high serum TBIL level is associated with an improved likelihood of recovery of DoC. Additional research is required to elucidate the underlying pathophysiological causal association between TBIL levels and DoC.
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Bilirrubina , Trastornos de la Conciencia , Humanos , Bilirrubina/sangre , Masculino , Femenino , Pronóstico , Persona de Mediana Edad , Trastornos de la Conciencia/sangre , Trastornos de la Conciencia/diagnóstico , Adulto , Anciano , Biomarcadores/sangreRESUMEN
BACKGROUND: There is no diagnostic assessment procedure with moderate or strong evidence of use, and evidence for current means of treating prolonged disorders of consciousness (pDOC) is sparse. This may be related to the fact that the mechanisms of pDOC have not been studied deeply enough and are not clear enough. Therefore, the aim of this study was to explore the mechanism of pDOC using functional near-infrared spectroscopy (fNIRS) to provide a basis for the treatment of pDOC, as well as to explore preclinical markers for determining the arousal of pDOC patients. METHODS: Five minutes resting-state data were collected from 10 pDOC patients and 13healthy adults using fNIRS. Based on the concentrations of oxyhemoglobin (HbO) and deoxyhemoglobin (HbR) in the time series, the resting-state cortical brain functional connectivity strengths of the two groups were calculated, and the functional connectivity strengths of homologous and heterologous brain networks were compared at the sensorimotor network (SEN), dorsal attention network (DAN), ventral attention network (VAN), default mode network (DMN), frontoparietal network (FPN), and visual network (VIS) levels. Univariate binary logistic regression analyses were performed on brain networks with statistically significant differences to identify brain networks associated with arousal in pDOC patients. The receiver operating characteristic (ROC) curves were further analyzed to determine the cut-off value of the relevant brain networks to provide clinical biomarkers for the prediction of arousal in pDOC patients. RESULTS: The results showed that the functional connectivity strengths of oxyhemoglobin (HbO)-based SENâ¼SEN, VISâ¼VIS, DANâ¼DAN, DMNâ¼DMN, SENâ¼VIS, SENâ¼FPN, SENâ¼DAN, SENâ¼DMN, VISâ¼FPN, VISâ¼DAN, VISâ¼DMN, HbR-based SENâ¼SEN, and SENâ¼DAN were significantly reduced in the pDOC group and were factors that could reflect the participants' state of consciousness. The cut-off value of resting-state functional connectivity strength calculated by ROC curve analysis can be used as a potential preclinical marker for predicting the arousal state of subjects. CONCLUSION: Resting-state functional connectivity strength of cortical networks is significantly reduced in pDOC patients. The cut-off values of resting-state functional connectivity strength are potential preclinical markers for predicting arousal in pDOC patients.
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Nivel de Alerta , Trastornos de la Conciencia , Espectroscopía Infrarroja Corta , Humanos , Espectroscopía Infrarroja Corta/métodos , Masculino , Proyectos Piloto , Femenino , Adulto , Trastornos de la Conciencia/fisiopatología , Trastornos de la Conciencia/diagnóstico por imagen , Nivel de Alerta/fisiología , Persona de Mediana Edad , Red Nerviosa/fisiopatología , Red Nerviosa/diagnóstico por imagen , Oxihemoglobinas/metabolismo , Oxihemoglobinas/análisis , Encéfalo/fisiopatología , Encéfalo/diagnóstico por imagen , Biomarcadores , Conectoma/métodos , Descanso/fisiología , Adulto Joven , HemoglobinasRESUMEN
We investigated differences in subcortical white matter according to the presence disorders of consciousness (DOC) in patients with hypoxic-ischemic brain injury (HI-BI), using tract-based spatial statistics (TBSS). Thirty-two consecutive patients with HI-BI were recruited. The patients were assigned in group A [preserved consciousness (Glasgow Coma Scale: 15 and Coma Recovery Scale-revised (CRS-R): 23, 9 patients)] or group B [DOC present (Glasgow Coma Scale <15 and CRS-Râ <â 23, 20 patients)]. Voxel-wise statistical analysis of fractional anisotropy data was performed by using TBSS as implemented in the FMRIB Software Library. We calculated mean fractional anisotropy values across the white matter skeleton and within 48 regions of interest (ROIs) based on intersections between the skeleton and the probabilistic Johns Hopkins University white matter atlases. Among the 48 ROIs examined, the fractional anisotropy values of two ROIs (the left superior corona radiata, and left tapetum) were significantly lower in group B than in group A ( P â <â 0.05). No significant differences were observed, however, in the other 46 ROIs ( P â >â 0.05). Our results suggest that abnormalities of the superior corona radiata and tapetum may be critical for DOC presence in patients with HI-BI.
Asunto(s)
Trastornos de la Conciencia , Hipoxia-Isquemia Encefálica , Sustancia Blanca , Humanos , Hipoxia-Isquemia Encefálica/diagnóstico por imagen , Hipoxia-Isquemia Encefálica/patología , Hipoxia-Isquemia Encefálica/complicaciones , Femenino , Sustancia Blanca/diagnóstico por imagen , Sustancia Blanca/patología , Masculino , Persona de Mediana Edad , Trastornos de la Conciencia/diagnóstico por imagen , Trastornos de la Conciencia/etiología , Trastornos de la Conciencia/patología , Adulto , Imagen de Difusión Tensora/métodos , Anciano , Anisotropía , Adulto JovenRESUMEN
Background: 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. Methods: 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. Results: 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). Conclusion: 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.
Asunto(s)
Trastornos de la Conciencia , Humanos , Femenino , Masculino , Estudios Longitudinales , Pronóstico , Persona de Mediana Edad , Adulto , Trastornos de la Conciencia/etiología , Anciano , Lesiones Encefálicas/mortalidad , Lesiones Encefálicas/complicaciones , Recuperación de la Función , Estado de Conciencia/fisiología , Coma/mortalidad , Coma/etiologíaRESUMEN
BACKGROUND: Clinical management of persons with disorders of consciousness (DoC) is dedicated largely to optimizing recovery. However, selecting a measure to evaluate the extent of recovery is challenging because few measures are designed to precisely assess the full range of potential outcomes, from prolonged DoC to return of preinjury functioning. Measures that are designed specifically to assess persons with DoC are often performance-based and only validated for in-person use. Moreover, there are no published recommendations addressing which outcome measures should be used to evaluate DoC recovery. The resulting inconsistency in the measures selected by individual investigators to assess outcome prevents comparison of results across DoC studies. The National Institute of Neurological Disorders and Stroke (NINDS) common data elements (CDEs) is an amalgamation of standardized variables and tools that are recommended for use in studies of neurologic diseases and injuries. The Neurocritical Care Society Curing Coma Campaign launched an initiative to develop CDEs specifically for DoC and invited our group to recommend CDE outcomes and endpoints for persons with DoCs. METHODS: The Curing Coma Campaign Outcomes and Endpoints CDE Workgroup, consisting of experts in adult and pediatric neurocritical care, neurology, and neuroscience, used a previously established five-step process to identify and select candidate CDEs: (1) review of existing NINDS CDEs, (2) nomination and systematic vetting of new CDEs, (3) CDE classification, (4) iterative review and approval of panel recommendations, and (5) development of case report forms. RESULTS: Among hundreds of existing NINDS outcome and endpoint CDE measures, we identified 20 for adults and 18 for children that can be used to assess the full range of recovery from coma. We also proposed 14 new outcome and endpoint CDE measures for adults and 5 for children. CONCLUSIONS: The DoC outcome and endpoint CDEs are a starting point in the broader effort to standardize outcome evaluation of persons with DoC. The ultimate goal is to harmonize DoC studies and allow for more precise assessment of outcomes after severe brain injury or illness. An iterative approach is required to modify and adjust these outcome and endpoint CDEs as new evidence emerges.
Asunto(s)
Elementos de Datos Comunes , Trastornos de la Conciencia , Evaluación de Resultado en la Atención de Salud , Humanos , Trastornos de la Conciencia/terapia , Trastornos de la Conciencia/diagnóstico , Evaluación de Resultado en la Atención de Salud/normas , National Institute of Neurological Disorders and Stroke (U.S.)/normasRESUMEN
BACKGROUND: Patients 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. METHODS: In 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). RESULTS: Data 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. CONCLUSIONS: Approximately 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.).
Asunto(s)
Lesiones Encefálicas , Trastornos de la Conciencia , Trastornos Disociativos , Estado Vegetativo Persistente , Adulto , Femenino , Humanos , Masculino , Persona de Mediana Edad , Adulto Joven , Encéfalo/diagnóstico por imagen , Encéfalo/fisiopatología , Lesiones Encefálicas/fisiopatología , Lesiones Encefálicas/complicaciones , Lesiones Encefálicas/diagnóstico por imagen , Cognición/fisiología , Trastornos de la Conciencia/diagnóstico por imagen , Trastornos de la Conciencia/etiología , Trastornos de la Conciencia/fisiopatología , Electroencefalografía , Imagen por Resonancia Magnética , Estado Vegetativo Persistente/diagnóstico por imagen , Estado Vegetativo Persistente/etiología , Estado Vegetativo Persistente/fisiopatología , Estudios Prospectivos , Trastornos Disociativos/diagnóstico por imagen , Trastornos Disociativos/etiología , Trastornos Disociativos/fisiopatologíaRESUMEN
Numerous studies have shown that musical stimulation can activate corresponding functional brain areas. Electroencephalogram (EEG) activity during musical stimulation can be used to assess the consciousness states of patients with disorders of consciousness (DOC). In this study, a musical stimulation paradigm and verifiable criteria were used for consciousness assessment. Twenty-nine participants (13 healthy subjects, 6 patients in a minimally conscious state (MCS) and 10 patients in a vegetative state (VS)) were recruited, and EEG signals were collected while participants listened to preferred and relaxing music. Fusion features based on differential entropy (DE), common spatial pattern (CSP), and EEG-based network pattern (ENP) features were extracted from EEG signals, and a convolutional neural network-long short-term memory (CNN-LSTM) model was employed to classify preferred and relaxing music.The results showed that the average classification accuracy for healthy subjects reached 85.58%. For two of the patients in the MCS group, the classification accuracies reached 78.18% and 66.14%, and they were diagnosed with emergence from MCS (EMCS) two months later. The accuracies of three patients in the VS group were 58.18%, 64.32% and 62.05%, with two patients showing slight increases in scale scores. Our study suggests that musical stimulation could be an effective method for consciousness detection, with significant diagnostic implications for patients with DOC.
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Estimulación Acústica , Trastornos de la Conciencia , Estado de Conciencia , Electroencefalografía , Música , Redes Neurales de la Computación , Estado Vegetativo Persistente , Humanos , Masculino , Femenino , Adulto , Estado Vegetativo Persistente/fisiopatología , Estado Vegetativo Persistente/diagnóstico , Electroencefalografía/métodos , Persona de Mediana Edad , Trastornos de la Conciencia/fisiopatología , Trastornos de la Conciencia/diagnóstico , Estado de Conciencia/fisiología , Adulto Joven , Algoritmos , Anciano , Entropía , Voluntarios Sanos , Memoria a Corto Plazo/fisiologíaRESUMEN
BACKGROUND: In recent years, prolonged states of impaired consciousness became widespread among patients with aneurysmal subarachnoid hemorrhage. Treatment and maintenance of vital functions in such patients represent a complex medical, economic and social problem. In this regard, searching for the causes of prolonged states of impaired consciousness and predicting the outcomes are important. OBJECTIVE: To analyze available literature data on prevention and treatment of prolonged states of impaired consciousness after aneurysmal subarachnoid hemorrhage. RESULTS: We reviewed the PubMed database using the keywords «unresponsive wakefulness syndrome¼, «persistent vegetative state2, «minimal consciousness state¼ and «outcome of subarachnoid hemorrhage¼. Only 4 reports devoted to the causes and treatment outcomes in patients with prolonged impairment of consciousness after aneurysmal subarachnoid hemorrhage were found. At the same time, patients with aneurysmal subarachnoid hemorrhage comprise up to 11% among all cases of prolonged states of impaired consciousness. Examination, management and treatment of patients with prolonged impairment of consciousness after aneurysmal subarachnoid hemorrhage are carried out according to general principles without taking into account specific etiological and pathogenetic factors. CONCLUSION: Increased number of patients with prolonged impairment of consciousness after aneurysmal subarachnoid hemorrhage necessitates analysis of etiopathogenesis and outcomes of these disorders based on modern clinical, instrumental and laboratory assessment of the brain.
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Hemorragia Subaracnoidea , Humanos , Hemorragia Subaracnoidea/complicaciones , Hemorragia Subaracnoidea/fisiopatología , Hemorragia Subaracnoidea/diagnóstico , Trastornos de la Conciencia/etiología , Trastornos de la Conciencia/fisiopatología , Trastornos de la Conciencia/diagnósticoRESUMEN
BACKGROUND: A considerable portion of acutely intoxicated patients is presented with impaired consciousness. Early identification of those patients who require advanced medical care, such as mechanical ventilation (MV), can improve their prognosis. METHODS: This study included 330 acutely intoxicated patients who were presented with impaired consciousness and admitted to Tanta University Poison Control Center, Egypt, in the period from January 2021 to December 2023. Patients were enrolled in derivation (257 patients) and validation (73 patients) cohorts. Patients' data were analyzed to develop and validate a predictive nomogram to determine the probability of MV need in acutely intoxicated patients. RESULTS: Significant predictors for MV need were mean arterial blood pressure (OR = 0.96, p = .014), PaO2 (OR = 0.96, p = .001), pH (OR = 0.00, p < . 001), and glucose/potassium ratio (OR = 1.59, p = .030). These four parameters were used to formulate a bedside nomogram. Receiver-operating characteristic (ROC) analysis for the proposed nomogram shows that area under the curve (AUC) = 95.7%, accuracy = 93.4%, sensitivity = 88.9%, and specificity = 95.1%. The internal validation for the developed nomogram was assessed using a bootstrapping method and calibration curve. Regarding external validation, AUCs for the developed nomogram probability was 96.5%, and for predicted probability using the developed nomogram was 97.8%. CONCLUSION: The current study provides a validated nomogram that could be used as a reliable tool for the accurate prediction of MV need among acutely intoxicated patients with impaired consciousness. It could assist in the early identification of patients who will require MV, especially in low-income countries with limited resources.
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Nomogramas , Respiración Artificial , Humanos , Masculino , Femenino , Adulto , Trastornos de la Conciencia , Persona de Mediana Edad , Adulto Joven , Egipto , Intoxicación Alcohólica/complicacionesRESUMEN
OBJECTIVES: For critically ill patients with acute severe brain injuries, consciousness may reemerge before behavioral responsiveness. The phenomenon of covert consciousness (i.e., cognitive motor dissociation) may be detected by advanced neurotechnologies such as task-based functional MRI (fMRI) and electroencephalography (EEG) in patients who appear unresponsive on the bedside behavioral examination. In this narrative review, we summarize the state-of-the-science in ICU detection of covert consciousness. Further, we consider the prognostic and therapeutic implications of diagnosing covert consciousness in the ICU, as well as its potential to inform discussions about continuation of life-sustaining therapy for patients with severe brain injuries. DATA SOURCES: We reviewed salient medical literature regarding covert consciousness. STUDY SELECTION: We included clinical studies investigating the diagnostic performance characteristics and prognostic utility of advanced neurotechnologies such as task-based fMRI and EEG. We focus on clinical guidelines, professional society scientific statements, and neuroethical analyses pertaining to the implementation of advanced neurotechnologies in the ICU to detect covert consciousness. DATA EXTRACTION AND DATA SYNTHESIS: We extracted study results, guideline recommendations, and society scientific statement recommendations regarding the diagnostic, prognostic, and therapeutic relevance of covert consciousness to the clinical care of ICU patients with severe brain injuries. CONCLUSIONS: Emerging evidence indicates that covert consciousness is present in approximately 15-20% of ICU patients who appear unresponsive on behavioral examination. Covert consciousness may be detected in patients with traumatic and nontraumatic brain injuries, including patients whose behavioral examination suggests a comatose state. The presence of covert consciousness in the ICU may predict the pace and extent of long-term functional recovery. Professional society guidelines now recommend assessment of covert consciousness using task-based fMRI and EEG. However, the clinical criteria for patient selection for such investigations are uncertain and global access to advanced neurotechnologies is limited.
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Estado de Conciencia , Electroencefalografía , Unidades de Cuidados Intensivos , Imagen por Resonancia Magnética , Humanos , Electroencefalografía/métodos , Estado de Conciencia/fisiología , Lesiones Encefálicas/diagnóstico , Lesiones Encefálicas/terapia , Pronóstico , Trastornos de la Conciencia/diagnóstico , Enfermedad CríticaRESUMEN
A variety of drugs have been known to induce disulfiram-like reactions in individuals exposed to ethanol, including certain cephalosporin antibiotics with methylthiotetrazole (MTT) substituents or methylthiodioxotriazine (MTDT) rings. Among cephalosporins, cefixime is known to cause fewer disulfiram-like reactions. This case report, the first involving a pediatric patient, presents the scenario of a 14-year-old female who exhibited drowsiness, loss of consciousness, and cold extremities within an hour after ingesting 9 cefixime capsules. Upon admission, drug intoxication was considered, prompting immediate gastric lavage and toxicology tests, which revealed the presence of both cefixime and alcohol. Subsequent monitoring of vital signs, rehydration, and symptomatic treatments aimed at facilitating toxic excretion were administered during hospitalization. Following initial assessment by a clinical pharmacist, drug intoxication was deemed improbable, though an atypical disulfiram-like reaction or alcohol intoxication could not be ruled out. Further evaluation, coupled with the child's cefixime overdose, suggested an atypical disulfiram-like reaction. This case underscores the potential for disulfiram reactions even with cephalosporins lacking MTT substituents or MTDT rings. Notably, it is the first report of an atypical disulfiram-like reaction triggered by alcohol consumption following cefixime overdose, emphasizing the importance of caution in cefixime usage and avoidance of alcohol or alcohol-containing substances.
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Antibacterianos , Cefixima , Humanos , Femenino , Cefixima/efectos adversos , Cefixima/administración & dosificación , Adolescente , Antibacterianos/efectos adversos , Antibacterianos/administración & dosificación , Consumo de Bebidas Alcohólicas/efectos adversos , Disulfiram/efectos adversos , Trastornos de la Conciencia/inducido químicamente , Etanol/efectos adversosRESUMEN
The progress in neuroimaging and electrophysiological techniques has shown substantial promise in improving the clinical assessment of disorders of consciousness (DOC). Through the examination of both stimulus-induced and spontaneous brain activity, numerous comprehensive investigations have explored variations in brain activity patterns among patients with DOC, yielding valuable insights for clinical diagnosis and prognostic purposes. Nonetheless, reaching a consensus on precise neuroimaging biomarkers for patients with DOC remains a challenge. Therefore, in this review, we begin by summarizing the empirical evidence related to neuroimaging biomarkers for DOC using various paradigms, including active, passive, and resting-state approaches, by employing task-based fMRI, resting-state fMRI (rs-fMRI), electroencephalography (EEG), and positron emission tomography (PET) techniques. Subsequently, we conducted a review of studies examining the neural correlates of consciousness in patients with DOC, with the findings holding potential value for the clinical application of DOC. Notably, previous research indicates that neuroimaging techniques have the potential to unveil covert awareness that conventional behavioral assessments might overlook. Furthermore, when integrated with various task paradigms or analytical approaches, this combination has the potential to significantly enhance the accuracy of both diagnosis and prognosis in DOC patients. Nonetheless, the stability of these neural biomarkers still needs additional validation, and future directions may entail integrating diagnostic and prognostic methods with big data and deep learning approaches.
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Biomarcadores , Encéfalo , Trastornos de la Conciencia , Imagen por Resonancia Magnética , Neuroimagen , Humanos , Trastornos de la Conciencia/diagnóstico por imagen , Trastornos de la Conciencia/fisiopatología , Trastornos de la Conciencia/diagnóstico , Neuroimagen/métodos , Pronóstico , Encéfalo/diagnóstico por imagen , Encéfalo/fisiopatología , Imagen por Resonancia Magnética/métodos , Electroencefalografía/métodos , Tomografía de Emisión de Positrones/métodos , Estado de Conciencia/fisiologíaRESUMEN
Neuroimaging studies have suggested an important role for the default mode network (DMN) in disorders of consciousness (DoC). However, the extent to which DMN connectivity can discriminate DoC states-unresponsive wakefulness syndrome (UWS) and minimally conscious state (MCS)-is less evident. Particularly, it is unclear whether effective DMN connectivity, as measured indirectly with dynamic causal modelling (DCM) of resting EEG can disentangle UWS from healthy controls and from patients considered conscious (MCS+). Crucially, this extends to UWS patients with potentially "covert" awareness (minimally conscious star, MCS*) indexed by voluntary brain activity in conjunction with partially preserved frontoparietal metabolism as measured with positron emission tomography (PET+ diagnosis; in contrast to PET- diagnosis with complete frontoparietal hypometabolism). Here, we address this gap by using DCM of EEG data acquired from patients with traumatic brain injury in 11 UWS (6 PET- and 5 PET+) and in 12 MCS+ (11 PET+ and 1 PET-), alongside with 11 healthy controls. We provide evidence for a key difference in left frontoparietal connectivity when contrasting UWS PET- with MCS+ patients and healthy controls. Next, in a leave-one-subject-out cross-validation, we tested the classification performance of the DCM models demonstrating that connectivity between medial prefrontal and left parietal sources reliably discriminates UWS PET- from MCS+ patients and controls. Finally, we illustrate that these models generalize to an unseen dataset: models trained to discriminate UWS PET- from MCS+ and controls, classify MCS* patients as conscious subjects with high posterior probability (pp > .92). These results identify specific alterations in the DMN after severe brain injury and highlight the clinical utility of EEG-based effective connectivity for identifying patients with potential covert awareness.
Asunto(s)
Trastornos de la Conciencia , Estado de Conciencia , Electroencefalografía , Lóbulo Parietal , Humanos , Masculino , Femenino , Adulto , Electroencefalografía/métodos , Persona de Mediana Edad , Lóbulo Parietal/fisiopatología , Lóbulo Parietal/diagnóstico por imagen , Trastornos de la Conciencia/fisiopatología , Trastornos de la Conciencia/diagnóstico por imagen , Estado de Conciencia/fisiología , Tomografía de Emisión de Positrones , Lóbulo Frontal/diagnóstico por imagen , Lóbulo Frontal/fisiopatología , Lesiones Traumáticas del Encéfalo/fisiopatología , Lesiones Traumáticas del Encéfalo/diagnóstico por imagen , Estado Vegetativo Persistente/fisiopatología , Estado Vegetativo Persistente/diagnóstico por imagen , Estudios de Cohortes , Estudios de Casos y Controles , Adulto Joven , Red Nerviosa/fisiopatología , Red Nerviosa/diagnóstico por imagenRESUMEN
Chronic disturbances of consciousness (CDC) are a consequence of severe brain damage and are conditions that arise after emerging from a coma with the preservation of the sleep-wake cycle in the absence of signs of conscious behavior. When conducting inpatient medical rehabilitation of this group of patients, the state of nutritional status is not always taken into account and, as a rule, there is no nutritional support with an assessment of metabolic needs, including the introduction of various modes of physical activity during physical therapy and an increase in physical load on the patient's body. The purpose of the study was to assess the nutritional status and optimize the nutritional support system in patients with CDC at the inpatient stage of medical rehabilitation (MR). Material and methods. The study analyzed the results of examination and treatment of 152 patients with CDC of traumatic origin who received medical rehabilitation from 2016 to 2022 in the Department of Physical and Rehabilitation Medicine of the Nikiforov Russian Center of Emergency and Radiation Medicine, Ministry of Russian Federation for Civil Defense, Emergencies and Elimination of Consequences of Natural Disasters. Results. In patients with CDC of traumatic genesis, signs of malnutrition (objective, anthropometric, laboratory) were diagnosed at the inpatient stage of MR, and there were also risks of malnutrition progression with the introduction of additional physical activity. Conclusion. To create an effective and adequate nutritional support system during inpatient MR, metabolic monitoring (indirect calorimetry) is of fundamental importance, taking into account the influence of additional physical activity. The use of a calculation method for estimating energy requirements can lead to hyperalimentation.
Asunto(s)
Estado Nutricional , Apoyo Nutricional , Humanos , Masculino , Femenino , Apoyo Nutricional/métodos , Adulto , Persona de Mediana Edad , Trastornos de la Conciencia/rehabilitación , Enfermedad Crónica , Desnutrición/rehabilitaciónRESUMEN
Objective.To improve the understanding and diagnostic accuracy of disorders of consciousness (DOC) by quantifying transcranial magnetic stimulation (TMS) evoked electroencephalography connectivity using permutation conditional mutual information (PCMI).Approach.PCMI can characterize the functional connectivity between different brain regions. This study employed PCMI to analyze TMS-evoked cortical connectivity (TEC) in 154 DOC patients and 16 normal controls, focusing on optimizing parameter selection for PCMI (Data length, Order length, Time delay). We compared short-range and long-range PCMI values across different consciousness states-unresponsive wakefulness syndrome (UWS), minimally conscious state (MCS), and normal (NOR)-and assessed various feature selection and classification techniques to distinguish these states.Main results.(1) PCMI can quantify TEC. We found optimal parameters to be Data length: 500 ms; Order: 3; Time delay: 6 ms. (2) TMS evoked potentials (TEPs) for NOR showed a rich response, while MCS patients showed only a few components, and UWS patients had almost no significant components. The values of PCMI connectivity metrics demonstrated its usefulness for measuring cortical connectivity evoked by TMS. From NOR to MCS to UWS, the number and strength of TEC decreased. Quantitative analysis revealed significant differences in the strength and number of TEC in the entire brain, local regions and inter-regions among different consciousness states. (3) A decision tree with feature selection by mutual information performed the best (balanced accuracy: 87.0% and accuracy: 83.5%). This model could accurately identify NOR (100.0%), but had lower identification accuracy for UWS (86.5%) and MCS (74.1%).Significance.The application of PCMI in measuring TMS-evoked connectivity provides a robust metric that enhances our ability to differentiate between various states of consciousness in DOC patients. This approach not only aids in clinical diagnosis but also contributes to the broader understanding of cortical connectivity and consciousness.
Asunto(s)
Corteza Cerebral , Trastornos de la Conciencia , Electroencefalografía , Estimulación Magnética Transcraneal , Humanos , Estimulación Magnética Transcraneal/métodos , Trastornos de la Conciencia/fisiopatología , Trastornos de la Conciencia/diagnóstico , Femenino , Adulto , Masculino , Persona de Mediana Edad , Electroencefalografía/métodos , Adulto Joven , Corteza Cerebral/fisiopatología , Corteza Cerebral/diagnóstico por imagen , Corteza Cerebral/fisiología , Anciano , Adolescente , Red Nerviosa/fisiopatología , Red Nerviosa/diagnóstico por imagen , Algoritmos , Potenciales Evocados/fisiología , Reproducibilidad de los ResultadosRESUMEN
Assessing communication abilities in patients with disorders of consciousness (DOCs) is challenging due to limitations in the behavioral scale. Electroencephalogram-based brain-computer interfaces (BCIs) and eye-tracking for detecting ocular changes can capture mental activities without requiring physical behaviors and thus may be a solution. This study proposes a hybrid BCI that integrates EEG and eye tracking to facilitate communication in patients with DOC. Specifically, the BCI presented a question and two randomly flashing answers (yes/no). The subjects were instructed to focus on an answer. A multimodal target recognition network (MTRN) is proposed to detect P300 potentials and eye-tracking responses (i.e., pupil constriction and gaze) and identify the target in real time. In the MTRN, the dual-stream feature extraction module with two independent multiscale convolutional neural networks extracts multiscale features from multimodal data. Then, the multimodal attention strategy adaptively extracts the most relevant information about the target from multimodal data. Finally, a prototype network is designed as a classifier to facilitate small-sample data classification. Ten healthy individuals, nine DOC patients and one LIS patient were included in this study. All healthy subjects achieved 100% accuracy. Five patients could communicate with our BCI, with 76.1±7.9% accuracy. Among them, two patients who were noncommunicative on the behavioral scale exhibited communication ability via our BCI. Additionally, we assessed the performance of unimodal BCIs and compared MTRNs with other methods. All the results suggested that our BCI can yield more sensitive outcomes than the CRS-R and can serve as a valuable communication tool.