[Unconsciousness and clouded awareness]. / Bewusstseinsstörung oder -trübung.

Stupor and coma are clinical states in which patients have impaired responsiveness or are unresponsive to external stimulation and are either difficult to arouse or are unarousable. The term stupor refer to states between alertness and coma. An alteration in arousal represents an acute life-threatening emergency, requiring prompt intervention for preservation of life and brain function.

Consciousness as a useful concept in epilepsy classification.

Impaired consciousness has important practical consequences for people living with epilepsy. Recent pathophysiologic studies show that seizures with impaired level of consciousness always affect widespread cortical networks and subcortical arousal systems. In light of these findings and their clinical significance, efforts are underway to revise the International League Against Epilepsy (ILAE) 2010 report to include impaired consciousness in the classification of seizures. Lüders and colleagues have presented one such effort, which we discuss here. We then propose an alternative classification of impaired consciousness in epilepsy based on functional neuroanatomy. Some seizures involve focal cortical regions and cause selective deficits in the content of consciousness but without impaired overall level of consciousness or awareness. These include focal aware conscious seizures (FACS) with lower order cortical deficits such as somatosensory or visual impairment as well as FACS with higher cognitive deficits including ictal aphasia or isolated epileptic amnesia. Another category applies to seizures with impaired level of consciousness leading to deficits in multiple cognitive domains. For this category, we believe the terms "dyscognitive" or "dialeptic" should be avoided because they may create confusion. Instead we propose that seizures with impaired level of consciousness be described based on underlying pathophysiology. Widespread moderately severe deficits in corticothalamic function are seen in absence seizures and in focal impaired consciousness seizures (FICS), including many temporal lobe seizures and other focal seizures with impaired consciousness. Some simple responses or automatisms may be preserved in these seizures. In contrast, generalized tonic-clonic seizures usually produce widespread severe deficits in corticothalamic function causing loss of all meaningful responses. Further work is needed to understand and prevent impaired consciousness in epilepsy, but the first step is to keep this crucial practical and physiologic aspect of seizures front-and-center in our discussions.

A multicenter prospective study of interobserver agreement using the Full Outline of Unresponsiveness score coma scale in the intensive care unit.

OBJECTIVE: The classification of the comatose patient has been greatly improved with the use of coma scales. The Full Outline of Unresponsiveness score has emerged as an alternative to the Glasgow Coma Scale in that it incorporates essential information needed to assess the depth of coma. One set of patients for which the Full Outline of Unresponsiveness score could be particularly beneficial is those admitted to an intensive care unit, where approximately 30%-35% of all patients are intubated or ventilated. This manuscript reports on a study that examined the inter-rater reliability of the Full Outline of Unresponsiveness score in five intensive care units. SETTING: Seven intensive care units at five U.S. hospitals partici-pated. SUBJECTS: Patients admitted during parts of 2010 and 2011 had their Full Outline of Unresponsiveness score assessed independently by two nurses within 1 hr of admission. DESIGN: We evaluated the weighted kappa statistic of the Full Outline of Unresponsiveness score over all patients and stratified by mechanical ventilation status. Finally, we looked for evidence of heterogeneity in Full Outline of Unresponsiveness score agreement across hospitals. MEASUREMENTS AND MAIN RESULTS: A total of 907 adult critically ill patients had Full Outline of Unresponsiveness score assessments by two evaluators. The overall weighted kappa statistic was 0.92, and this did not differ by whether or not a patient was on a ventilator. Among hospitals there was modest heterogeneity for the weighted kappa; however, all of the values were >0.80. CONCLUSIONS: The Full Outline of Unresponsiveness score showed excellent inter-rater agreement overall and at each of the five hospitals. This demonstrates that the Full Outline of Unresponsiveness score can be utilized reliably in critically ill patients.

The assessment of consciousness during partial seizures.

A wide range of controversial definitions and dynamic components surround the multi-dimensional concept of consciousness, with important reflections on the phenomenological description of ictal states relevant to epileptic seizures. The inadequacies of terminology, the insufficient emphasis on the subjective nature of consciousness, as well as the intrinsic limitations of the simple versus complex dichotomy for partial seizures, are to be considered in view of a modern definition of consciousness. In this paper, we review the difficulties encountered by clinicians in assessing the ictal conscious state in patients with epilepsy, and illustrate how a more sophisticated bi-dimensional model of consciousness can prove a valuable conceptual tool for the clinical assessment of ictal consciousness and the categorization of seizures.

Neuroethics, neuroimaging, and disorders of consciousness: promise or peril?

The advent of powerful neuroimaging tools such as functional magnetic resonance imaging (fMRI) and positron emission tomography (PET) has begun to redefine how we diagnose, define, and understand disorders of consciousness such as the vegetative and minimally conscious states. In my paper, I review how research using these methods is both elucidating these brain states and creating diagnostic dilemmas related to their classification as the specificity and sensitivity of traditional behavior-based assessments are weighed against sensitive but not yet fully validated neuroimaging data. I also consider how these methods are being studied as potential communication vectors for therapeutic use in subjects who heretofore have been thought to be unresponsive or minimally conscious. I conclude by considering the ethical challenges posed by novel diagnostic and therapeutic neuroimaging applications and contextualize these scientific developments against the broader needs of patients and families touched by severe brain injury.

Video analysis of acute motor and convulsive manifestations in sport-related concussion.

OBJECTIVES: To describe the motor and convulsive manifestations in acute sports-related head injury. METHODS: A total of 234 cases of concussive injuries during the 1995 through 1997 football seasons were obtained from the Australian Football League Medical Officers Association injury survey. Of these, 102 cases were recorded adequately on television videotape and were analyzed by two independent observers using a standardized recording form detailing injury mechanics and clinical features of the episodes. Motor and convulsive features were correlated with mechanical variables and with duration of loss of consciousness using linear modeling techniques. RESULTS: Tonic posturing occurred in 25 subjects, clonic movements in 6, righting movement in 40, and gait unsteadiness in 42. In one subject the tonic and clonic features were sufficiently prolonged to be deemed a concussive convulsion. The only risk factor for tonic posturing using logistic regression was the presence of loss of consciousness (p = 0.0001). There was a trend toward facial impact being an independent predictor of tonic posturing but this did not reach significance. No other independent variable predicted the development of clonic movements, righting movements, or gait unsteadiness. CONCLUSIONS: Subtle motor manifestations such as tonic posturing and clonic movements commonly occur in concussion; the main predictive factor for tonic posturing is the presence of loss of consciousness. The authors speculate that these clinical features are due to brainstem dysfunction secondary to biomechanical forces inducing a transient functional decerebration.

Near-drowning and drowning classification: a proposal to stratify mortality based on the analysis of 1,831 cases.

STUDY OBJECTIVE: To establish an updated classification for near-drowning and drowning (ND/D) according to severity, based on mortality rate of the subgroups. MATERIALS AND METHODS: We reviewed 41,279 cases of predominantly sea water rescues from the coastal area of Rio de Janeiro City, Brazil, from 1972 to 1991. Of this total, 2,304 cases (5.5%) were referred to the Near-Drowning Recuperation Center, and this group was used as the study database. At the accident site, the following clinical parameters were recorded: presence of breathing, arterial pulse, pulmonary auscultation, and arterial BP. Cases lacking records of clinical parameters were not studied. The ND/D were classified in six subgroups: grade 1--normal pulmonary auscultation with coughing; grade 2--abnormal pulmonary auscultation with rales in some pulmonary fields; grade 3--pulmonary auscultation of acute pulmonary edema without arterial hypotension; grade 4--pulmonary auscultation of acute pulmonary edema with arterial hypotension; grade 5--isolated respiratory arrest; and grade 6--cardiopulmonary arrest. RESULTS: From 2,304 cases in the database, 1,831 cases presented all clinical parameters recorded and were selected for classification. From these 1,831 cases, 1,189 (65%) were classified as grade 1 (mortality=0%); 338 (18.4%) as grade 2 (mortality=0.6%); 58 (3.2%) as grade 3 (mortality=5.2%); 36 (2%) as grade 4 (mortality=19.4%); 25 (1.4%) as grade 5 (mortality=44%); and 185 (10%) as grade 6 (mortality=93%) (p<0.000001). CONCLUSION: The study revealed that it is possible to establish six subgroups based on mortality rate by applying clinical criteria obtained from first-aid observations. These subgroups constitute the basis of a new classification.

[Types of consciousness disorders in stroke]. / Formy narusheniia soznaniia pri mozgovom insul'te.

The peculiarities of consciousness disturbances in 289 patients with grave brain stroke were studied. Eight informative clinical syndromes, including the awakeness level, brain stem reflex functions as well as vegetative-visceral functions were described. Two levels and eleven corresponding to them phases of damaged consciousness were singled out. The scale of quantitative estimation of each phase of the consciousness damage was established for practical use by the computer method of plural step by step regression; dynamics of phases was shown also.

[Classification and definition of consciousness disorders]. / Einteilung und Definition der Bewusstseinsstörungen.

A classification of the disturbances of consciousness is given, and the possible causes are listed. The criteria used in Switzerland for the diagnosis of brain death are presented in detail.

[Examination and observation of the unconscious patient]. / Die Untersuchung und Uberwachung des Bewusstlosen.

The old neurological art of careful examination and detailed description of an unconscious patient delivers a vivid picture of cerebral functions and deficiencies. Daily medical practice, however, demands immediate information with measurable and easily comparable numerical values. This requirement is best satisfied by the current proven and universally accepted 'Glasgow Coma Scale'. Dispensing with the terms: somnolent, soporous and comatose, the GCS numerically marks the depth of the disturbances of consciousness, which, recorded in a graph, indicate the fluctuations of consciousness. The registration of the depth and duration of clouded consciousness is a decisive criterion for the prognosis.

Validation of the Italian version of a new coma scale: the FOUR score.

The Glasgow Coma Scale (GCS) is the most widely accepted tool for the evaluation of consciousness, despite several reported shortcomings. A new coma scale, named Full Outline of UnResponsiveness (FOUR) score, is now available. The aim of the present study is to provide and validate the Italian version of the FOUR score. The Italian version of the FOUR score was developed according to a standardized protocol, and thereafter validated in a series of patients with acute neurological illness. For each patient, the FOUR and the GCS scores were recorded by two physicians randomly selected. The inter-rater agreement for the FOUR and the GCS scores was evaluated using the weighted kappa (κ(w)). The receiving operating characteristic curve was also calculated to determine the ability of the scales to predict outcome. Eighty-seven consecutive patients with an acute brain injury were enrolled. The inter-rater agreement was excellent both for the FOUR (κ(w) = 0.953; P < 0.0001) and the GCS (κ(w) = 0.943; P < 0.01). The area under the curve for mortality was 0.935 for the FOUR and 0.953 for the GCS. The FOUR score provides greater neurological details than the GCS. Our data indicate that the Italian version of the FOUR score is a valid predictor of outcome, yielding reproducible findings across raters independent of their expertise.

Practical use of the Glasgow Coma Scale; a comprehensive narrative review of GCS methodology.

OBJECTIVE: Narrative review of Glasgow Coma Scale (GCS) methodology. DESIGN: Narrative review of published papers describing methodological aspects of the GCS, from Premedline, Medline, EMBASE, CINAHL and Ovid Nursing databases from 1950 to May 2012. RESULTS: Examination of 18,851 references limited to descriptions of GCS development, pathophysiological correlations, examination techniques, complications or clinician agreement gave a final set of 33, which were summarised in this review. CONCLUSION: The GCS was designed for the objective measurement of level of consciousness, assessment of trend, and to facilitate accurate and valid communication between clinicians. Concerns have been raised about the potential for misleading levels of precision engendered by the use of the GCS, and the use of simpler scales suggested. This review discusses the GCS and conditions affecting calculation of domain and summary scores, and recommends a method of implementation and interpretation.

Biomechanical correlates of mild diffuse brain injury in the rat.

The relationship between diffuse brain injury (DBI) occurrence and impact biomechanics is well documented. Previous studies attempted to develop injury thresholds based on various biomechanical parameters and have demonstrated inconsistent results. The spectral nature of DBI requires robust metrics capable of predicting injury occurrence and severity. In the present study impact biomechanics reported previously were correlated to rat unconsciousness time. Significant correlation was identified in three parameters including square angular velocity, change in rotational velocity, and Head Impact Power. Results suggest rotational loading of the rat head has similar correlates to the human condition. In addition, certain biomechanical parameters demonstrate capacity for predicting DBI severity.