Increased Adrenocorticotropic Hormone Levels Predict Recovery of Consciousness in Patients With Disorders of Consciousness.

The potential influence of pituitary-related hormones (including both pituitary gland and target gland hormones) on functional recovery after traumatic brain injury has been observed. However, the relationship between these hormones and the recovery of consciousness in patients with disorders of consciousness (DOC) remains unclear. In this retrospective and observational study, 208 patients with DOC were recruited. According to the Glasgow Outcome Scale (GOS) scores after 6 months, patients with DOC were categorized into two subgroups: a favorable prognosis subgroup (n = 38) comprising those who regained consciousness (GOS score ≥3), and a poor prognosis subgroup (n = 156) comprising those who remained in DOC (GOS score <3). Comparative analyses of pituitary-related hormone levels between the two subgroups were conducted. Further, a binary logistic regression analysis was conducted to assess the predictive value of pituitary-related hormones for the patients' prognosis. The favorable prognosis subgroup showed a significant increase in adrenocorticotropic hormone (ACTH) levels (p = 0.036). Moreover, higher ACTH levels and shorter days since injury were significantly associated with a better prognosis, with odds ratios (ORs) of 0.928 (95% confidence interval [CI] = 0.873-0.985, p = 0.014) and 1.015 (95% CI = 1.005-1.026, p = 0.005), respectively. A subsequent receiver operating characteristic (ROC) analysis demonstrated the potential to predict patients' prognosis with an area under the curve value of 0.78, an overall accuracy of 75.5%, a sensitivity of 77.5%, and a specificity of 66.7%. Our findings indicate that ACTH levels could serve as a clinically valuable and convenient predictor for patients' prognosis.

In-Hospital Amantadine Does Not Improve Outcomes After Severe Traumatic Brain Injury: An 11-Year Propensity-Matched Retrospective Analysis.

BACKGROUND: Disruption of dopamine neurotransmission is associated with functional impairment after severe traumatic brain injury (sTBI). This has prompted the study of dopamine agonists, such as amantadine, to assist recovery of consciousness. Randomized trials have mostly addressed the posthospital setting, with inconsistent findings. Therefore, we evaluated the efficacy of early amantadine administration on recovery of consciousness after sTBI. METHODS: We searched the medical records of all patients with sTBI admitted to our hospital between 2010 and 2021 who survived 10 days postinjury. We identified all patients receiving amantadine and compared them with all patients not receiving amantadine and a propensity score-matched nonamantadine group. Primary outcome measures included discharge Glasgow Coma Scale, Glasgow Outcome Scale-Extended score, length of stay, mortality, recovery of command-following (CF), and days to CF. RESULTS: In our study population, 60 patients received amantadine and 344 did not. Compared with the propensity score-matched nonamantadine group, the amantadine group had no difference in mortality (86.67% vs. 88.33%, P = 0.783), rates of CF (73.33% vs. 76.67%, P = 0.673), or percentage of patients with severe (3-8) discharge Glasgow Coma Scale scores (11.11% vs. 12.28%, P = 0.434). In addition, the amantadine group was less likely to have a favorable recovery (discharge Glasgow Outcome Scale-Extended score 5-8) (14.53% vs. 16.67%, P < 0.001), had a longer length of stay (40.5 vs. 21.0 days, P < 0.001), and had a longer time to CF (11.5 vs. 6.0 days, P = 0.011). No difference in adverse events existed between groups. CONCLUSIONS: Our findings do not support the early administration of amantadine for sTBI. Larger inpatient randomized trials are necessary to further investigate amantadine treatment for sTBI.

General anesthesia globally synchronizes activity selectively in layer 5 cortical pyramidal neurons.

General anesthetics induce loss of consciousness, a global change in behavior. However, a corresponding global change in activity in the context of defined cortical cell types has not been identified. Here, we show that spontaneous activity of mouse layer 5 pyramidal neurons, but of no other cortical cell type, becomes consistently synchronized in vivo by different general anesthetics. This heightened neuronal synchrony is aperiodic, present across large distances, and absent in cortical neurons presynaptic to layer 5 pyramidal neurons. During the transition to and from anesthesia, changes in synchrony in layer 5 coincide with the loss and recovery of consciousness. Activity within both apical and basal dendrites is synchronous, but only basal dendrites' activity is temporally locked to somatic activity. Given that layer 5 is a major cortical output, our results suggest that brain-wide synchrony in layer 5 pyramidal neurons may contribute to the loss of consciousness during general anesthesia.

Thalamo-Prefrontal Connectivity Correlates With Early Command-Following After Severe Traumatic Brain Injury.

Recovery of consciousness after traumatic brain injury (TBI) is heterogeneous and difficult to predict. Structures such as the thalamus and prefrontal cortex are thought to be important in facilitating consciousness. We sought to investigate whether the integrity of thalamo-prefrontal circuits, assessed via diffusion tensor imaging (DTI), was associated with the return of goal-directed behavior after severe TBI. We classified a cohort of severe TBI patients (N = 25, 20 males) into Early and Late/Never outcome groups based on their ability to follow commands within 30 days post-injury. We assessed connectivity between whole thalamus, and mediodorsal thalamus (MD), to prefrontal cortex (PFC) subregions including dorsolateral PFC (dlPFC), medial PFC (mPFC), anterior cingulate (ACC), and orbitofrontal (OFC) cortices. We found that the integrity of thalamic projections to PFC subregions (L OFC, L and R ACC, and R mPFC) was significantly associated with Early command-following. This association persisted when the analysis was restricted to prefrontal-mediodorsal (MD) thalamus connectivity. In contrast, dlPFC connectivity to thalamus was not significantly associated with command-following. Using the integrity of thalamo-prefrontal connections, we created a linear regression model that demonstrated 72% accuracy in predicting command-following after a leave-one-out analysis. Together, these data support a role for thalamo-prefrontal connectivity in the return of goal-directed behavior following TBI.

Anterior precuneus related to the recovery of consciousness.

The neural mechanism that enables the recovery of consciousness in patients with unresponsive wakefulness syndrome (UWS) remains unclear. The aim of the current study is to characterize the cortical hub regions related to the recovery of consciousness. In the current fMRI study, voxel-wise degree centrality analysis was adopted to identify the cortical hubs related to the recovery of consciousness, for which a total of 27 UWS patients were recruited, including 13 patients who emerged from UWS (UWS-E), and 14 patients who remained in UWS (UWS-R) at least three months after the experiment performance. Furthermore, other recoverable unconscious states were adopted as validation groups, including three independent N3 sleep datasets (n = 12, 9, 9 respectively) and three independent anesthesia datasets (n = 27, 14, 6 respectively). Spatial similarity of the hub characteristic with the validation groups between the UWS-E and UWS-R was compared using the dice coefficient. Finally, with the cortical regions persistently shown as hubs across UWS-E and validation states, functional connectivity analysis was further performed to explore the connectivity patterns underlying the recovery of consciousness. The results identified four cortical hubs in the UWS-E, which showed significantly higher degree centrality for UWS-E than UWS-R, including the anterior precuneus, left inferior parietal lobule, left inferior frontal gyrus, and left middle frontal gyrus, of which the degree centrality value also positively correlated with the patients' Glasgow Outcome Scale (GOS) score that assessed global brain functioning outcome after a brain injury. Furthermore, the anterior precuneus was found with significantly higher similarity of hub characteristics as well as functional connectivity patterns between UWS-E and the validation groups. The results suggest that the recovery of consciousness may be relevant to the integrity of cortical hubs in the recoverable unconscious states, especially the anterior precuneus. The identified cortical hub regions could serve as potential treatment targets for patients with UWS.

Injury to thalamocortical projections following traumatic brain injury results in attractor dynamics for cortical networks.

Major theories of consciousness predict that complex electroencephalographic (EEG) activity is required for consciousness, yet it is not clear how such activity arises in the corticothalamic system. The thalamus is well-known to control cortical excitability via interlaminar projections, but whether thalamic input is needed for complexity is not known. We hypothesized that the thalamus facilitates complex activity by adjusting synaptic connectivity, thereby increasing the availability of different configurations of cortical neurons (cortical "states"), as well as the probability of state transitions. To test this hypothesis, we characterized EEG activity from prefrontal cortex (PFC) in traumatic brain injury (TBI) patients with and without injuries to thalamocortical projections, measured with diffusion tensor imaging (DTI). We found that injury to thalamic projections (especially from the mediodorsal thalamus) was strongly associated with unconsciousness and delta-band EEG activity. Using advanced signal processing techniques, we found that lack of thalamic input led to 1.) attractor dynamics for cortical networks with a tendency to visit the same states, 2.) a reduced repertoire of possible states, and 3.) high predictability of transitions between states. These results imply that complex PFC activity associated with consciousness depends on thalamic input. Our model implies that restoration of cortical connectivity is a critical function of the thalamus after brain injury. We draw a critical connection between thalamic input and complex cortical activity associated with consciousness.

Effects of different injection methods of propofol anesthesia on the behavior and electroencephalography recording in mice.

Propofol is commonly used in mice studies on the mechanism of general anesthesia. The administration routes of propofol include intraperitoneal injection, single tail vein injection, and continuous tail vein pumping. The aim of this study is to compare the effects of the three injection methods on the behavior and electroencephalography (EEG) recording in mice. Mice were divided into an intraperitoneal injection group, a single tail vein injection group, and a continuous tail vein pumping group according to the propofol administration route. The indexes for observation were: time of loss of righting reflex (LORR), time of resumption of righting reflex (RORR), and change in the number of EEG spindle waves during anesthesia. The LORR and RORR were detected again after 1 week to determine the repeatability of the three administration routes. Death and behavioral change after anesthesia recovery in mice were recorded in the three groups. For propofol administration in mice, intraperitoneal injection induced long-duration anesthesia, but the depth of anesthesia was shallow and there was a risk of anesthesia accidents. A small dose of propofol administered through a single tail vein can induce loss of consciousness but the LORR time was not recorded, hence the metrics during induction of anesthesia were not investigated. Continuous tail vein pumping produced stable behavior and EEG recording during anesthesia induction and recovery in mice, and the individual difference was small. Continuous tail vein pumping is an ideal administration route for studying the mechanism of loss of consciousness of propofol anesthesia in mice, which could provide reference data for future mice experiments using propofol.

Recognition of general anesthesia-induced loss of consciousness based on the spatial pattern of the brain networks.

Objective.Unconsciousness is a key feature related to general anesthesia (GA) but is difficult to be evaluated accurately by anesthesiologists clinically.Approach.To tracking the loss of consciousness (LOC) and recovery of consciousness (ROC) under GA, in this study, by investigating functional connectivity of the scalp electroencephalogram, we explore any potential difference in brain networks among anesthesia induction, anesthesia recovery, and the resting state.Main results.The results of this study demonstrated significant differences among the three periods, concerning the corresponding brain networks. In detail, the suppressed default mode network, as well as the prolonged characteristic path length and decreased clustering coefficient, during LOC was found in the alpha band, compared to the Resting and the ROC state. When to further identify the Resting and LOC states, the fused network topologies and properties achieved the highest accuracy of 95%, along with a sensitivity of 93.33% and a specificity of 96.67%.Significance.The findings of this study not only deepen our understanding of propofol-induced unconsciousness but also provide quantitative measurements subserving better anesthesia management.

One-Year Demographical and Clinical Indices of Patients with Chronic Disorders of Consciousness.

This work aims to evaluate the prognostic value of the demographical and clinical data on long-term outcomes (up to 12 months) in patients with severe acquired brain injury with vegetative state/unresponsive wakefulness syndrome (VS/UWS/UWS) or a minimally conscious state (MCS). Patients (n = 211) with VS/UWS/UWS (n = 123) and MCS (n = 88) were admitted to the Federal Research and Clinical Center of Intensive Care Medicine and Rehabilitology after anoxic brain injury (n = 53), vascular lesions (n = 59), traumatic brain injury (n = 93), and other causes (n = 6). At the beginning of the 12-month study, younger age and a higher score by the Coma Recovery Scale-Revised (CRS-R) predicted a survival. However, no reliable markers of significant positive dynamics of consciousness were found. Based on the etiology, anoxic brain injury has the most unfavorable prognosis. For patients with vascular lesions, the first three months after injury have the most important prognostic value. No correlations were found between survival, increased consciousness, and gender. The demographic and clinical characteristics of patients with chronic DOC can be used to predict long-term mortality in patients with chronic disorders of consciousness. Further research should be devoted to finding reliable predictors of recovery of consciousness.

Agitation Following Severe Traumatic Brain Injury Is a Clinical Sign of Recovery of Consciousness.

Objective: Severe traumatic brain injury (sTBI) often results in disorders of consciousness. Patients emerging from coma frequently exhibit aberrant behaviors such as agitation. These non-purposeful combative behaviors can interfere with medical care. Interestingly, agitation is associated with arousal and is often among the first signs of neurological recovery. A better understanding of these behaviors may shed light on the mechanisms driving the return of consciousness in sTBI patients. This study aims to investigate the association between posttraumatic agitation and the recovery of consciousness. Methods: A retrospective chart review was conducted in 530 adult patients (29.1% female) admitted to Stony Brook University Hospital between January 2011 and December 2019 with a diagnosis of sTBI and Glasgow Coma Scale (GCS) ≤8. Agitation was defined as a Richmond Agitation Sedation Scale (RASS) > +1, or any documentation of equivalently combative and violent behaviors in daily clinical notes. The ability to follow verbal commands was used to define the recovery of consciousness and was assessed daily. Results: Of 530 total sTBI patients, 308 (58.1%) survived. Agitation was present in 169 of all patients and 162 (52.6%) of surviving patients. A total of 273 patients followed commands, and 159 of them developed agitation. Forty patients developed agitation on hospital arrival whereas 119 developed agitation later during their hospital course. Presence of in-hospital agitation positively correlated with command-following (r = 0.315, p < 0.001). The time to develop agitation and time to follow commands showed positive correlation (r = 0.485, p < 0.001). These two events occurred within 3 days in 54 (44.6%) patients, within 7 days in 81 (67.8%) patients, and within 14 days in 96 (80.2%) patients. In 71 (59.7%) patients, agitation developed before command-following; in 36 (30.2%) patients, agitation developed after command-following; in 12 (10.1%) patients, agitation developed on the same day as command-following. Conclusion: Posttraumatic agitation in comatose patients following sTBI is temporally associated with the recovery of consciousness. This behavior indicates the potential for recovery of higher neurological functioning. Further studies are required to identify neural correlates of posttraumatic agitation and recovery of consciousness after sTBI.

Role of neurorehabilitative treatment using transcranial magnetic stimulation in disorders of consciousness.

Disorders of consciousness (DOC) result from brain injuries that cause functional changes in vigilance, awareness and behaviour. It is important to correctly diagnose DOC so that the most appropriate rehabilitation treatments can be initiated. Several studies in DOC patients have demonstrated that repetitive transcranial magnetic stimulation (rTMS) has an important role to play in the recovery of consciousness as highlighted by monitoring clinical scale scores. Although studies indicate that rTMS can be used to aid recovery, it is not combined with other rehabilitative cognitive treatments. As of December 2018, there have been no studies published that combined DOC cognitive rehabilitation with TMS. This current review describes the use of rTMS as a form of non-invasive brain stimulation, as distinct from its use as a tool to investigate residual cortical activity, in terms of its possible therapeutic effects including cognitive rehabilitation. Literature searches were undertaken to identify all relevant studies. The available evidence suggests that rTMS may have an important role to play in in monitoring brain function during recovery and making other intensive rehabilitation treatments more effective, such as sensorial stimulations and cognitive training in patients after a severe acquired brain injury. Further research is required to establish the usefulness of rTMS treatment in DOC rehabilitation.

Consciousness recovery after various periods in vegetative state.

BACKGROUND: Recent studies suggest that late recovery from vegetative state (VS) is more prevalent today than previously thought. This study examined the decline in the rate of recovery from VS with time after admission to rehabilitation, and established a new time frame, in which the odds of recovery from VS remain substantial. METHODS: Data of 206 patients with VS after traumatic and non-traumatic brain injuries (TBI and NTBI), who were treated at the Loewenstein Rehabilitation Hospital (LRH), in Raanana, Israel, between 2003 and 2015, and described in a previous publication, were further analysed. Rate of recovery from VS was monitored at several time points after admission to intensive care and consciousness rehabilitation (ICCR). RESULTS: The odds of consciousness recovery were at least 54% at admission to ICCR, and 48%, 33%, 19%, and 7% at 3, 6, 9, and 12 months after admission, respectively. CONCLUSIONS: The rate of recovery from VS decreases significantly with time, but contrary to previous consensus, 6-12 months after admission to ICCR, the odds of recovery from VS after TBI and NTBI remain substantial.

[Mental activity of the children during the early stage of rehabilitation after acute severe brain damage]. / Psikhicheskaia aktivnost' u detei na rannem étape reabilitatsii posle ostrykh tiazhelykh povrezhdenii golovnogo mozga.

INTRODUCTION: Children who have suffered brain damage form a large group of patients in need of rehabilitation. For rehabilitation, patients require not only surgical, neurosurgical, traumatological, pharmacological and other medical support, but also the creation of special conditions for psychiatric care, psychological and pedagogical correction of their psychophysical potential. Neurological, motor and mental consequences of severe injuries of the nervous system in children lead to a high degree of disability with a subsequent restriction of their life, where social maladaptation and a violation of the quality of life are the primary problems. An integrated approach with differentiated qualified help will increase the effectiveness of rehabilitation programs and help the children adapt when they return to their normal environment. AIM: To identify the characteristics of mental activity during the recovery of the level of consciousness in children after acute severe brain damage at an early stage of rehabilitation. MATERIAL AND METHODS: We examined 210 children under the age of 18 years with severe brain damage (traumatic brain injury, hypoxia, hydrocephalus) who were admitted for treatment and rehabilitation. Clinical-psychopathological, pedagogical methods were used for examination as well as diagnostic scales, questionnaires. RESULTS: The main differentiating signs were divided into three groups, depending on the mental activity of the child, the level of consciousness: Group 1 - 37 (18%) patients with mental activity with physical, cognitive and social abilities with the minimal '+' consciousness (a-/hyperkinetic mutism with emotional reactions, understanding of speech); 2-nd group - 67 (32%) patients with dominant manifestations of physical and cognitive abilities with the minimal '-' consciousness (a-/hyperkinetic mutism without emotional manifestations and understanding of speech); 3rd group - 106 (50%) children with a weak manifestation of mental activity (physical abilities) in a vegetative status/exit from a vegetative status. CONCLUSION: Three variants of mental activity in children after acute severe brain injuries were distinguished - from minimal involuntary reactions or their absence during the vegetative status/exit from the vegetative status to arbitrary actions according to the instructions of an adult with a minimum '+' consciousness. Understanding the dynamics of the recovery of children's mental activity after neurotrauma may make it possible to have a differentiated approach to psychiatric, psychological and pedagogical rehabilitation in order to correct the recovery of mental functions in pediatric patients, and to prevent the developmental disorders as the child grows.

[Magnetic resonance spectroscopy data in the prognosis of consciousness recovery in patients with vegetative state]. / Prognozirovanie vosstanovleniia soznaniia u patsientov v vegetativnom sostoianii s primeneniem metoda vodorodnoi magnitno-rezonansnoi spektroskopii.

AIM: To study the prognostic value of magnetic resonance spectroscopy (MRS) in patients with vegetative state/unresponsive wakefulness syndrome (VS/UWS). MATERIAL AND METHODS: Thirty-four patients with VS/UWS underwent multi-voxel MRS (thalamus, globus pallidus, putamen, internal capsules, fornix, brainstem, temporal and frontal cortex). Subjects were grouped according to etiology: 22 patients with traumatic brain injury (TBI) (group 1) and 12 patients with a hypoxia (group 2). The groups were matched by age and duration of UWS (mean 2, 3 months). The CRS-R was used to identify the first signs of consciousness during hospitalization and 6-12 months later. Outcomes of the patients with TBI were as follows: chronic VS/UWS (n=6), minimally conscious state (MCS) plus (n=9), emergence from MCS (EMCS) (n=7). Outcomes of the patients with hypoxia were: chronic vegetative state (n=10), minimally conscious state (MCS) (n=2). RESULTS: The decrease in the NAA/Cr ratio in thalamus, capsula interna, temporal cortex are correlated with poor outcome in both groups. Higher rates of NAA/Cr in these structures are correlated with further recovery of consciousness. The decrease in the ratio of NAA Cr and NAA/NAA+Cho+Cr in the midbrain is correlated with poor outcome only in UWS with hypoxia. CONCLUSION: The results suggest that the MRS allows to more accurately predicting the outcome in VS/UWS patients with hypoxic brain damage, as well as in UWS patients with TBI, who have recovered consciousness to the level of EMCS.

Impact of alternative electrical stunning parameters on the ability of broilers to recover consciousness and meat quality.

Broilers in the United States are typically electrically stunned using low voltage-high frequency (12-38 V, ≥400 Hz) DC or AC water bath stunners. In the European Union, however, broilers are required to be electrocuted using high voltage-low frequency (50-150 V, 50-350 Hz) AC. Low voltage stunned broilers regain consciousness in the absence of bleeding. In contrast, high voltage stunned broilers die due to induction of cardiac fibrillation. For birds stunned with low voltage systems, concerns have been raised regarding animal welfare during bleeding. This work evaluated the impact of extended DC stunning duration and alternative stunning methods (DC+AC combination) on the recovery of bird consciousness and meat quality. In the absence of bleeding, broilers that were DC stunned for extended times (60, 90, or 120 s), 63, 10, or 0% of broilers, respectively, were able to recover consciousness. Alternative stunning protocols included water bath stunning broilers at 15 or 25 V DC for 10 s followed by plate stunning at 100, 110, or 120 V AC for 5 s. Prior to shackling, live body weight and shank width were measured and during stunning, maximum mA for both DC and AC stuns were recorded. All of the alternative stunning protocols (DC+AC) resulted in non-recoverable stunning. The maximum mA recorded during both DC and AC stunning were moderately/strongly (r = 0.54-0.81) correlated to body weight and poorly/moderately (r = 0.27-0.74) correlated to shank width. No significant differences for carcass or meat quality characteristics (hemorrhages, red wing tips, broken clavicles, pH, cook loss, a* and b* color values, and MORS shear energy) were detected between control (15 or 25 V DC only) and treatment groups (DC+AC combination stunning). The only significant different meat quality parameter was L* values where the lowest voltage group (15 V DC) had the darkest fillets (53.27) and the 15 V DC+100 V AC group had the lightest fillets (55.61) with all other groups intermediate. These data indicate that stunning parameters combining DC and AC stunning may be viable protocols when a stun-to-death is desired.

The first sign of loss of consciousness.

The first clinically observable sign of an unconsciousness episode (UNCE) serves as the temporal sequence (kinetics) onset point for neurological events occurring during the loss of consciousness, unconsciousness and recovery of consciousness phases of the UNCE. The initial neurologic signs of 212 individuals exposed to gradual (N=114) and rapid (N=98) onset +Gz acceleration stress, inducing the ischemic LOC phase in 83.3±18.6s and 8.89±1.52s; p<0.001 respectively, were determined. The duration of the unconscious phase (considered absolute incapacitation) was 10.42±5.3s and 9.36±3.99s; p>0.1 for gradual and rapid onset +Gz-stress, respectively. Cerebral autoregulation may play a role in determination of ischemic UNCE induction and recovery. Five signs: loss of muscle control, eyelid closure, eye fixation, upward eye deviation, and muscular twitching occurred at LOC phase onset. The most frequent initial sign of LOC phase onset was loss of muscle control (84% of the episodes), followed by eye fixation (8.5%), and upward eye deviation (6.1%). Signs play a key role in differential diagnosis of syncopal, epileptic, psychogenic and other causes of UNCEs. Sign kinetics may provide insight into localization of the essential components and networks within the cephalic nervous system associated with UNCEs.

Lack of Responsiveness during the Onset and Offset of Sevoflurane Anesthesia Is Associated with Decreased Awake-Alpha Oscillation Power.

Anesthetic drugs are typically administered to induce altered states of arousal that range from sedation to general anesthesia (GA). Systems neuroscience studies are currently being used to investigate the neural circuit mechanisms of anesthesia-induced altered arousal states. These studies suggest that by disrupting the oscillatory dynamics that are associated with arousal states, anesthesia-induced oscillations are a putative mechanism through which anesthetic drugs produce altered states of arousal. However, an empirical clinical observation is that even at relatively stable anesthetic doses, patients are sometimes intermittently responsive to verbal commands during states of light sedation. During these periods, prominent anesthesia-induced neural oscillations such as slow-delta (0.1-4 Hz) oscillations are notably absent. Neural correlates of intermittent responsiveness during light sedation have been insufficiently investigated. A principled understanding of the neural correlates of intermittent responsiveness may fundamentally advance our understanding of neural dynamics that are essential for maintaining arousal states, and how they are disrupted by anesthetics. Therefore, we performed a high-density (128 channels) electroencephalogram (EEG) study (n = 8) of sevoflurane-induced altered arousal in healthy volunteers. We administered temporally precise behavioral stimuli every 5 s to assess responsiveness. Here, we show that decreased eyes-closed, awake-alpha (8-12 Hz) oscillation power is associated with lack of responsiveness during sevoflurane effect-onset and -offset. We also show that anteriorization-the transition from occipitally dominant awake-alpha oscillations to frontally dominant anesthesia induced-alpha oscillations-is not a binary phenomenon. Rather, we suggest that periods, which were defined by lack of responsiveness, represent an intermediate brain state. We conclude that awake-alpha oscillation, previously thought to be an idling rhythm, is associated with responsiveness to behavioral stimuli.

[Head trauma patients, towards a new life project]. / Patient traumatisé crânien, vers un nouveau projet de vie.

A real transition between intensive care and traditional rehabilitation, the post-intensive care rehabilitation service for patients with brain injuries aims to provide patients with early and intensive rehabilitation. Multi-disciplinary teams support the patients and their families on their journey towards new life projects.

Rehabilitation outcome of patients with severe and prolonged disorders of consciousness after aneurysmal subarachnoid hemorrhage (aSAH).

OBJECTIVES: Our objectives were to evaluate rehabilitation outcome of aSAH survivors with severe disorders of consciousness (DOC) and to examine potential predictors of long-term outcome. Severe DOC includes patients in a vegetative state (VS) and in a minimally conscious state (MCS). PATIENTS AND METHODS: This is a retrospective single-center cohort study of consecutive aSAH patients with severe and prolonged DOC upon admission to neurorehabilitation. Clinical assessments started right after discharge from ICU, a median of 26 days after the aSAH. Two different outcome criteria were used, one addressing the functional aspect (assessed by the Functional Independence Measure [FIM]) the other one addressing the level of consciousness ("behavioral outcome", assessed by the Coma Remission Scale [CRS]). Improved outcome was defined by an increase in FIM scores of at least 22 points (minimal clinically important difference) or by reaching a full score of 24 points on the CRS. Separate least square linear regression models were calculated to examine potential predictors for functional and behavioral outcome. RESULTS: Out of 63 patients, 19.0% and 39.7% of the patients achieved an improved functional and behavioral outcome, respectively. Age and level of consciousness upon admission to neurorehabilitation were independent prognostic factors for both outcome definitions. Both groups reached the better outcome category after a median of 11 and 9 weeks, respectively. In an individual patient, the longest delay to achievement of improved functional outcome was 30 weeks and to favorable behavioral outcome was 22 weeks after rehabilitation admission. CONCLUSION: About one-third of severely affected aSAH patients with DOC regained at least a favorable behavioral status during early neurorehabilitation. It is interesting to note that in our study population, the beginning of clinical improvement took up to 6 months after aSAH.

A Comparative Study of Propofol and Isoflurane Anaesthesia using Butorphanol in Neurosurgery.

SUMMARY: Propofol and isoflurane have well proven roles as intravenous and inhalational anaesthetics respectively in neurosurgery. We conducted this study to know the outcome using butorphanol as an intraoperative analgesic. Sixty craniotomy patients randomly divided into two groups of 30 each were included in this study. Group A patients were induced and maintained with propofol. Group B patients were induced with thiopentone and maintained with isoflurane. All patients were administered 30mug.kg(-1) butorphanol intravenously 10 minutes before induction of anaesthesia, followed by slow injection of 30mug.kg(-1) midazolam. All were assessed for sedation, respiratory insufficiency, postoperative nausea and vomiting (PONV) and other side effects in the recovery room. We found no difference in demographic parameters between the groups. The fall in HR was maintained in the post induction / intubation period and throughout the intraoperative period in Group A, unlike Group B patients in whom it rose significantly following intubation. Butorphanol was found to be a safe intraoperative analgesic in neurosurgical patients. In addition, it was associated with statistically better haemodynamics and earlier recovery when used with propofol as compared to thiopentone-isoflurane anaesthesia.