Network Localization of Unconscious Visual Perception in Blindsight.

OBJECTIVE: Blindsight is a disorder where brain injury causes loss of conscious but not unconscious visual perception. Prior studies have produced conflicting results regarding the neuroanatomical pathways involved in this unconscious perception. METHODS: We performed a systematic literature search to identify lesion locations causing visual field loss in patients with blindsight (n = 34) and patients without blindsight (n = 35). Resting state functional connectivity between each lesion location and all other brain voxels was computed using a large connectome database (n = 1,000). Connections significantly associated with blindsight (vs no blindsight) were identified. RESULTS: Functional connectivity between lesion locations and the ipsilesional medial pulvinar was significantly associated with blindsight (family wise error p = 0.029). No significant connectivity differences were found to other brain regions previously implicated in blindsight. This finding was independent of methods (eg, flipping lesions to the left or right) and stimulus type (moving vs static). INTERPRETATION: Connectivity to the ipsilesional medial pulvinar best differentiates lesion locations associated with blindsight versus those without blindsight. Our results align with recent data from animal models and provide insight into the neuroanatomical substrate of unconscious visual abilities in patients. ANN NEUROL 2022;91:217-224.

Associations among civilian mild traumatic brain injury with loss of consciousness, posttraumatic stress disorder symptom trajectories, and structural brain volumetric data.

Posttraumatic stress disorder (PTSD) is prevalent and associated with significant morbidity. Mild traumatic brain injury (mTBI) concurrent with psychiatric trauma may be associated with PTSD. Prior studies of PTSD-related structural brain alterations have focused on military populations. The current study examined correlations between PTSD, acute mTBI, and structural brain alterations longitudinally in civilian patients (N = 504) who experienced a recent Criterion A traumatic event. Participants who reported loss of consciousness (LOC) were characterized as having mTBI; all others were included in the control group. PTSD symptoms were assessed at enrollment and over the following year; a subset of participants (n = 89) underwent volumetric brain MRI (M = 53 days posttrauma). Classes of PTSD symptom trajectories were modeled using latent growth mixture modeling. Associations between PTSD symptom trajectories and cortical thicknesses or subcortical volumes were assessed using a moderator-based regression. mTBI with LOC during trauma was positively correlated with the likelihood of developing a chronic PTSD symptom trajectory. mTBI showed significant interactions with cortical thickness in the rostral anterior cingulate cortex (rACC) in predicting PTSD symptoms, r = .461-.463. Bilateral rACC thickness positively predicted PTSD symptoms but only among participants who endorsed LOC, p < .001. The results demonstrate positive correlations between mTBI with LOC and PTSD symptom trajectories, and findings related to mTBI with LOC and rACC thickness interactions in predicting subsequent chronic PTSD symptoms suggest the importance of further understanding the role of mTBI in the context of PTSD to inform intervention and risk stratification.

Opportunities for reducing college drinking: The roles of drinking attitudes and blackout experience.

BACKGROUND: As many as 35% of college students report having been drunk in the past month, and greater alcohol use and alcohol-related problems are associated with a positive attitude toward heavy drinking. One serious consequence of heavy drinking is alcohol-induced blackout. When they occur, alcohol-induced blackouts present a unique opportunity to increase motivation to change drinking. However, it is unclear under what conditions an alcohol-related heavy drinking attitude and experiencing a blackout represent an opportunity to change and how experiencing a blackout(s) influences an individual's motivation to reduce drinking and actual behavior. METHODS: This study tested the interplay between one's positive attitude toward heavy drinking and experiencing a blackout in the past year in predicting motivation to reduce drinking (Study 1) and its impact on drinking over time (Study 2). Data were derived from complementary datasets collected at two universities (Study 1 n = 703, mean age = 20.63 years, 44% male, 52% White; Study 2 n = 568, mean age = 19.18 years, 72% male, 84% White). Drinking behavior was measured using a modified Daily Drinking Questionnaire, the Drinking Norms Rating Form, the Alcohol Use Disorders Identification Test (AUDIT), and estimated peak blood alcohol concentration (BAC). Regression analyses were conducted to determine whether a blackout would moderate the association between attitude and motivation to reduce drinking (Study 1) and drinking over time (Study 2). RESULTS: Results revealed a significant interaction between attitude and blackout, such that individuals who experience a blackout (vs. those who do not) and positively evaluate heavy drinking evidenced lower motivation to reduce drinking (Study 1) and higher levels of estimated peak BAC (Study 2). CONCLUSIONS: Drinkers with a negative attitude toward heavy drinking who have experienced a blackout have the strongest motivation to reduce drinking and the greatest reductions in peak drinking behavior over time. These effects are over and above that related to the level of alcohol consumed. For young adults who do not positively endorse heavy drinking, blackouts may present a "moment of opportunity" for intervention.

Perioperative Electroencephalogram Spectral Dynamics Related to Postoperative Delirium in Older Patients.

BACKGROUND: Intraoperative electroencephalography (EEG) signatures related to the development of postoperative delirium (POD) in older patients are frequently studied. However, a broad analysis of the EEG dynamics including preoperative, postinduction, intraoperative and postoperative scenarios and its correlation to POD development is still lacking. We explored the relationship between perioperative EEG spectra-derived parameters and POD development, aiming to ascertain the diagnostic utility of these parameters to detect patients developing POD. METHODS: Patients aged ≥65 years undergoing elective surgeries that were expected to last more than 60 minutes were included in this prospective, observational single center study (Biomarker Development for Postoperative Cognitive Impairment [BioCog] study). Frontal EEGs were recorded, starting before induction of anesthesia and lasting until recovery of consciousness. EEG data were analyzed based on raw EEG files and downloaded excel data files. We performed multitaper spectral analyses of relevant EEG epochs and further used multitaper spectral estimate to calculate a corresponding spectral parameter. POD assessments were performed twice daily up to the seventh postoperative day. Our primary aim was to analyze the relation between the perioperative spectral edge frequency (SEF) and the development of POD. RESULTS: Of the 237 included patients, 41 (17%) patients developed POD. The preoperative EEG in POD patients was associated with lower values in both SEF (POD 13.1 ± 4.6 Hz versus no postoperative delirium [NoPOD] 17.4 ± 6.9 Hz; P = .002) and corresponding γ-band power (POD -24.33 ± 2.8 dB versus NoPOD -17.9 ± 4.81 dB), as well as reduced postinduction absolute α-band power (POD -7.37 ± 4.52 dB versus NoPOD -5 ± 5.03 dB). The ratio of SEF from the preoperative to postinduction state (SEF ratio) was ~1 in POD patients, whereas NoPOD patients showed a SEF ratio >1, thus indicating a slowing of EEG with loss of unconscious. Preoperative SEF, preoperative γ-band power, and SEF ratio were independently associated with POD (P = .025; odds ratio [OR] = 0.892, 95% confidence interval [CI], 0.808-0.986; P = .029; OR = 0.568, 95% CI, 0.342-0.944; and P = .009; OR = 0.108, 95% CI, 0.021-0.568, respectively). CONCLUSIONS: Lower preoperative SEF, absence of slowing in EEG while transitioning from preoperative state to unconscious state, and lower EEG power in relevant frequency bands in both these states are related to POD development. These findings may suggest an underlying pathophysiology and might be used as EEG-based marker for early identification of patients at risk to develop POD.

Similar or dissimilar? Influence of similarity between distraction tasks and target tasks on unconscious thought.

Distraction tasks are known to affect the unconscious-thought (UT) effect. However, the relationship between two task types, namely distraction and target tasks, and their effect on UT effect have not been examined in previous studies. In this study, we assessed whether simultaneously performing dissimilar distraction and target tasks are beneficial to information processing by UT. In Experiment 1, the target task was an Alternate Use Task (speech task). For the similar-task test, the UT group was assigned the speech 1-back task (speech task) as the distraction task; for the dissimilar-task test, the UT group was assigned the spatial 1-back task (spatial task) as the distraction task. The results of the experiment revealed that under dissimilar tasks, the UT group not only provided more answers but also provided answers that were more novel. For Experiment 2, the target task was changed to Creative Mental Synthesis Task (spatial task) to replicate the results of Experiment 1. The results demonstrated that the dissimilarity between the distraction and target tasks facilitates the UT.

Granger Causality of the Electroencephalogram Reveals Abrupt Global Loss of Cortical Information Flow during Propofol-induced Loss of Responsiveness.

BACKGROUND: It is a commonly held view that information flow between widely separated regions of the cerebral cortex is a necessary component in the generation of wakefulness (also termed "connected" consciousness). This study therefore hypothesized that loss of wakefulness caused by propofol anesthesia should be associated with loss of information flow, as estimated by the effective connectivity in the scalp electroencephalogram (EEG) signal. METHODS: Effective connectivity during anesthesia was quantified by applying bivariate Granger to multichannel EEG data recorded from 16 adult subjects undergoing a slow induction of, and emergence from, anesthesia with intravenous propofol. During wakefulness they were conducting various auditory and motor tasks. Functional connectivity using EEG coherence was also estimated. RESULTS: There was an abrupt, substantial, and global decrease in effective connectivity around the point of loss of responsiveness. Recovery of behavioral responsiveness was associated with a comparable recovery in information flow pattern (expressed as normalized values). The median (interquartile range) change was greatest in the delta frequency band: decreasing from 0.15 (0.21) 2 min before loss of behavioral response, to 0.06 (0.04) 2 min after loss of behavioral response (P < 0.001). Regional decreases in information flow were maximal in a posteromedial direction from lateral frontal and prefrontal regions (0.82 [0.24] 2 min before loss of responsiveness, decreasing to 0.17 [0.05] 2 min after), and least for information flow from posterior channels. The widespread decrease in bivariate Granger causality reflects loss of cortical coordination. The relationship between functional connectivity (coherence) and effective connectivity (Granger causality) was inconsistent. CONCLUSIONS: Propofol-induced unresponsiveness is marked by a global decrease in information flow, greatest from the lateral frontal and prefrontal brain regions in a posterior and medial direction. Loss of information flow may be a useful measure of connected consciousness.

Dignity at stake: Caring for persons with impaired autonomy.

Dignity, usually considered an essential ethical value in healthcare, is a relatively complex, multifaceted concept. However, healthcare professionals often have only a vague idea of what it means to respect dignity when providing care, especially for persons with impaired autonomy. This article focuses on two concepts of dignity, human dignity and dignity of identity, and aims to analyse how these concepts can be applied in the care for persons with impaired autonomy and in furthering the practice of respect and protection from harm. Three vignettes were designed to illustrate typical caring situations involving patients with mild to severely impaired autonomy, including patients with cognitive impairments. In situations like these, there is a risk of the patient's dignity being disrespected and violated. The vignettes were then analysed with respect to the two concepts of dignity to find out whether this approach can illuminate what is at stake in these situations and to provide an understanding of which measures could safeguard the dignity of these patients. The analysis showed that there are profound ethical challenges in the daily care of persons with impaired autonomy. We suggest that these two concepts of human dignity could help guide healthcare professionals to develop practical skills in person-centred, ethically grounded care, where the patient's wishes and needs are the starting point.

Suspiciously slow: timed digit span as an embedded performance validity measure in a sample of veterans with mTBI.

OBJECTIVE: To explore the utility of Timed Digit Span (TDS) as an embedded performance validity test (PVT) in a sample of veterans with mild traumatic brain injury (mTBI). We hypothesize that TDS will predict PVT failure on an established stand-alone measure (Trial 1 of the Test of Memory Malingering; TOMM). METHODS: TDS was compared to Digit Span accuracy (DS), using TOMM as a criterion measure, in a sample of 99 veterans with mTBI. Correlation and regression were used to characterize associations between PVTs. Logistic regression was utilized to examine the relationship between embedded PVTs and the odds of TOMM failure. Classification accuracy of TDS was examined using receiver operating characteristic (ROC) curves. Predictive power of TDS to estimate TOMM failure was calculated for the current sample and for hypothetical populations with common base rates (BRs). OUTCOMES: TDS significantly predicted failure on the TOMM and added greater incremental predictive value to the model compared to DS accuracy. Estimates of the predictive power of TDS were calculated using observed and hypothetical BRs. Sensitivity to stand-alone PVT, failure was 38% when specificity was set at 90%. CONCLUSION: TDS offers a promising embedded PVT method, given its strong convergence with an established stand-alone PVT.

Loss of consciousness and altered mental state predicting depressive and post-concussive symptoms after mild traumatic brain injury.

Objective: Limited studies exist on the association between loss of consciousness (LOC) and altered mental state (AMS) and development of depressive and post-concussive symptoms within six months after mild traumatic brain injury (mTBI). We tested the hypothesis that presence of both LOC and AMS predict the highest risk of symptoms within the first six months post-mTBI compared to either variable alone, and that LOC alone is more strongly associated with these symptoms. Research design: We analyzed data from 407 subjects with mTBI from the Head injury Serum Markers for Assessing Response to Trauma (HeadSMART) cohort, a prospective cohort of patients post-TBI presenting to two urban emergency departments. Results: There were higher rates of depressive (44%) and post-concussive symptoms (54%) at 1 month post-injury, among participants with both LOC and AMS compared to other groups. AMS was associated with depressive symptoms at one and six months (OR = 1.59, p = .038; OR = 1.60; p = .060) and post-concussive symptoms at one month (OR = 1.56, p = .053). LOC was associated only with post-concussive symptoms at one month (OR = 1.55;p = .048). Among those without LOC, AMS was associated with depressive symptoms at one month (OR = 2.24; p = .028). Conclusions: AMS predicts post-mTBI depressive symptoms both in the acute and chronic mTBI phases whereas LOC is a more sensitive predictor of post-concussive symptoms in the acute mTBI period.

Dreaming and awareness during dexmedetomidine- and propofol-induced unresponsiveness.

BACKGROUND: Experiences during anaesthetic-induced unresponsiveness have previously been investigated by interviews after recovery. To explore whether experiences occur during drug administration, we interviewed participants during target-controlled infusion (TCI) of dexmedetomidine or propofol and after recovery. METHODS: Healthy participants received dexmedetomidine (n=23) or propofol (n=24) in stepwise increments until loss of responsiveness (LOR1). During TCI we attempted to arouse them for interview (return of responsiveness, ROR1). After the interview, if unresponsiveness ensued with the same dose (LOR2), the procedure was repeated (ROR2). Finally, the concentration was increased 1.5-fold to achieve presumable loss of consciousness (LOC), infusion terminated, and the participants interviewed upon recovery (ROR3). An emotional sound stimulus was presented during LORs and LOC, and memory for stimuli was assessed with recognition task after recovery. Interview transcripts were content analysed. RESULTS: Of participants receiving dexmedetomidine, 18/23 were arousable from LOR1 and LOR2. Of participants receiving propofol, 10/24 were arousable from LOR1 and two of four were arousable from LOR2. Of 93 interviews performed, 84% included experiences from periods of unresponsiveness (dexmedetomidine 90%, propofol 74%). Internally generated experiences (dreaming) were present in 86% of reports from unresponsive periods, while externally generated experiences (awareness) were rare and linked to brief arousals. No within drug differences in the prevalence or content of experiences during infusion vs after recovery were observed, but participants receiving dexmedetomidine reported dreaming and awareness more often. Participants receiving dexmedetomidine recognised the emotional sounds better than participants receiving propofol (42% vs 15%), but none reported references to sounds spontaneously. CONCLUSION: Anaesthetic-induced unresponsiveness does not induce unconsciousness or necessarily even disconnectedness. CLINICAL TRIAL REGISTRATION: NCT01889004.

Non-alcoholic Wernicke's encephalopathy with cortical involvement and polyneuropathy following gastrectomy.

In this study, we present the clinical manifestations, brain magnetic resonance imaging (MRI) and concurrent polyneuropathies in two patients with non-alcoholic Wernicke's encephalopathy (WE) after gastrojejunostomy (Billroth II) anastomosis procedures. These patients developed sub-acute onset of disorientation and disturbance of consciousness following several weeks of poor intake. Peripheral neuropathy of varying severity was noted before and after the onset of WE. Brain MRI of the patients showed cerebellar vermis and symmetric cortical abnormalities in addition to typical WE changes. Electrophysiological studies demonstrated axonal sensorimotor polyneuropathy. Prompt thiamine supplement therapy was initiated and both patients gradually recovered, however mild amnesia was still noted 6 months later. We reviewed non- alcoholic WE with atypical cortical abnormalities in English language literatures and identified 29 more cases. Eight out of 31 (25.8%) patients died during follow-up. Nine patients with gait disturbance or motor paresis had showed hyporeflexia in neurological examinations. In addition to classic triad, seizure was recorded in seven patients. Dietary deprivation is a risk factor for non-alcoholic WE among elderly patients receiving gastrointestinal surgery. The prognosis is good after thiamine supplement therapy. Recognizing the MRI features and predisposing factors in patients who have undergone gastrectomy can aid in the diagnosis and management.

Disentangling conscious from unconscious cognitive processing with event-related EEG potentials.

By looking for properties of consciousness, cognitive neuroscience studies have dramatically enlarged the scope of unconscious cognitive processing. This emerging knowledge inspired the development of new approaches allowing clinicians to probe and disentangle conscious from unconscious cognitive processes in non-communicating brain-injured patients both in terms of behaviour and brain activity. This information is extremely valuable in order to improve diagnosis and prognosis in such patients both at acute and chronic settings. Reciprocally, the growing observations coming from such patients suffering from disorders of consciousness provide valuable constraints to theoretical models of consciousness. In this review we chose to illustrate these recent developments by focusing on brain signals recorded with EEG at bedside in response to auditory stimuli. More precisely, we present the respective EEG markers of unconscious and conscious processing of two classes of auditory stimuli (sounds and words). We show that in both cases, conscious access to the corresponding representation (e.g.: auditory regularity and verbal semantic content) share a similar neural signature (P3b and P600/LPC) that can be distinguished from unconscious processing occurring during an earlier stage (MMN and N400). We propose a two-stage serial model of processing and discuss how unconscious and conscious signatures can be measured at bedside providing relevant informations for both diagnosis and prognosis of consciousness recovery. These two examples emphasize how fruitful can be the bidirectional approach exploring cognition in healthy subjects and in brain-damaged patients.

Loss of consciousness, collapse and associated driving restrictions: a retrospective case note review - an important reminder regarding driving restrictions.

Background and aims National guidelines outlining medical standards for fitness to drive are provided by The Driver and Vehicle Licensing Agency. We aimed to establish whether patients presenting with collapse or loss of consciousness received documented advice regarding driving restrictions, if appropriate for their working diagnosis. Methods and results A retrospective case note review was undertaken over a four-month period for emergency patients clinically coded as seizure/convulsion (R568) and collapse/syncope (R55X); 163 patients had a primary or working diagnosis on discharge that suggested driving status and restrictions could have been reviewed. Six groupings of diagnoses were noted, and variation was seen amongst documentation for each. Current driving status was documented for 32 patients, and 34 had restriction advice documented; 73% (119 patients) had further investigations or clinic review planned. Conclusion Documentation of driving status and restrictions is poor. This audit serves to remind clinicians of the importance of considering driving status when discharging patients who have presented with collapse or loss of consciousness. Recent high-profile media coverage regarding medical driving restrictions, both locally and nationally, have emphasised the need for knowledge of The Driver and Vehicle Licensing Agency guidance.

Neurophysiological correlates of sevoflurane-induced unconsciousness.

BACKGROUND: Recent studies of anesthetic-induced unconsciousness in humans have focused predominantly on the intravenous drug propofol and have identified anterior dominance of alpha rhythms and frontal phase-amplitude coupling patterns as neurophysiological markers. However, it is unclear whether the correlates of propofol-induced unconsciousness are generalizable to inhaled anesthetics, which have distinct molecular targets and which are used more commonly in clinical practice. METHODS: The authors recorded 64-channel electroencephalograms in healthy human participants during consciousness, sevoflurane-induced unconsciousness, and recovery (n = 10; n = 7 suitable for analysis). Spectrograms and scalp distributions of low-frequency (1 Hz) and alpha (10 Hz) power were analyzed, and phase-amplitude modulation between these two frequencies was calculated in frontal and parietal regions. Phase lag index was used to assess phase relationships across the cortex. RESULTS: At concentrations sufficient for unconsciousness, sevoflurane did not result in a consistent anteriorization of alpha power; the relationship between low-frequency phase and alpha amplitude in the frontal cortex did not undergo characteristic transitions. By contrast, there was significant cross-frequency coupling in the parietal region during consciousness that was not observed after loss of consciousness. Furthermore, a reversible disruption of anterior-posterior phase relationships in the alpha bandwidth was identified as a correlate of sevoflurane-induced unconsciousness. CONCLUSION: In humans, sevoflurane-induced unconsciousness is not correlated with anteriorization of alpha and related cross-frequency patterns, but rather by a disruption of phase-amplitude coupling in the parietal region and phase-phase relationships across the cortex.

Do injury characteristics predict the severity of acute neuropsychological deficits following sports-related concussion? A meta-analysis.

The utility of injury characteristics for predicting the severity of post-concussion outcomes remains equivocal. The purpose of this meta-analysis was to quantify the predictive relationship between these variables to inform classification of acute injury severity. Thirty-one empirical samples of concussed athletes, for which rates of loss of consciousness and/or amnesia were reported, were included in a meta-analysis evaluating acute outcomes following sports-related concussion. Outcome measures of interest were neuropsychological tests first administered 1-10 days post-injury. Loss of consciousness and anterograde amnesia significantly predicted more severe neuropsychological deficits within 10 days of concussion in studies using pre-injury baseline, but not control group, comparisons. Retrograde amnesia significantly predicted acute neuropsychological dysfunction (d = -1.03) irrespective of comparison group. Although small sample sizes require conservative interpretation and future replication, the evidence suggests that retrograde amnesia, rather than loss of consciousness, may be used to classify the acute severity of concussion.

White matter integrity in veterans with mild traumatic brain injury: associations with executive function and loss of consciousness.

OBJECTIVE: We investigated using diffusion tensor imaging (DTI) and the association between white matter integrity and executive function (EF) performance in postacute mild traumatic brain injury (mTBI). In addition, we examined whether injury severity, as measured by loss of consciousness (LOC) versus alterations in consciousness (AOC), is related to white matter microstructural alterations and neuropsychological outcome. PARTICIPANTS: Thirty Iraq and Afghanistan War era veterans with a history of mTBI and 15 healthy veteran control participants. RESULTS: There were no significant overall group differences between control and mTBI participants on DTI measures. However, a subgroup of mTBI participants with EF decrements (n = 13) demonstrated significantly decreased fractional anisotropy of prefrontal white matter, corpus callosum, and cingulum bundle structures compared with mTBI participants without EF decrements (n = 17) and control participants. Participants having mTBI with LOC were more likely to evidence reduced EF performances and disrupted ventral prefrontal white matter integrity when compared with either mTBI participants without LOC or control participants. CONCLUSIONS: Findings suggest that altered white matter integrity contributes to reduced EF in subgroups of veterans with a history of mTBI and that LOC may be a risk factor for reduced EF as well as associated changes to ventral prefrontal white matter.

Glasgow Coma Scores, early opioids, and posttraumatic stress disorder among combat amputees.

A recent study found that combat amputees had a reduced prevalence of posttraumatic stress disorder (PTSD) compared with nonamputees with serious extremity injuries. We hypothesized that an extended period of impaired consciousness or early treatment with morphine could prevent consolidation of traumatic memory and the development of PTSD. To examine this hypothesis, we retrospectively reviewed 258 combat casualty records from the Iraq or Afghanistan conflicts from 2001-2008 in the Expeditionary Medical Encounter Database, including medications and Glasgow Coma Scale (GCS) scores recorded at in-theater facilities within hours of the index injury. All patients sustained amputations from injuries. Psychological diagnoses were extracted from medical records for 24 months postinjury. None of 20 patients (0%) with GCS scores of 12 or lower had PTSD compared to 20% of patients with GCS scores of 12 or greater who did have PTSD. For patients with traumatic brain injury, those treated with intravenous morphine within hours of injury had a significantly lower prevalence of PTSD (6.3%) and mood disorders (15.6%) compared to patients treated with fentanyl only (prevalence of PTSD = 41.2%, prevalence of mood disorder = 47.1%). GCS scores and morphine and fentanyl treatments were not significantly associated with adjustment, anxiety, or substance abuse disorders.

Blast-related mild traumatic brain injury in the acute phase: acute stress reactions partially mediate the relationship between loss of consciousness and symptoms.

PRIMARY OBJECTIVE: The objective was to compare symptoms in service members diagnosed with a blast-related mTBI (mild traumatic brain injury) with a loss of consciousness (LOC) to those without LOC. RESEARCH DESIGN: Clinicians saw US military personnel within 72 hours of sustaining a blast-related mTBI and at a follow-up visit 48-72 hours later (n = 210). METHODS AND PROCEDURES: Demographics, post-concussive symptoms, diagnosis of acute stress reaction (ASR) and simple reaction time data from the Automated Neuropsychological Assessment Metric (ANAM) were collected. MAIN OUTCOMES AND RESULTS: ASRs were significantly more likely in patients reporting LOC versus patients reporting no LOC. At the first post-injury visit, LOC was associated with difficulty sleeping, hearing loss, memory problems and reporting more symptoms. A follow-up analysis explored if symptomatic differences were influenced by ASR. Adjusting for ASR, the statistical relationships between LOC and symptoms were weaker (i.e. reduced Odds Ratios). At the follow-up visit, difficulty sleeping was associated with LOC before and after adjusting for ASR. Patients with both ASR and LOC had the slowest simple reaction times. CONCLUSIONS: Results suggest ASR may partially mediate symptom presentation and cognitive dysfunction in the acute phase following blast-related mTBI. Future research is warranted.

[Brain injury: existential view to the restoration of the patient's contact with the self and the world].

We present conceptual changes in psychological rehabilitation after severe brain injury. Traditional clinical approach reduces the person's inner life to level of consciousness, considers psychological processes only from the deficit point of view. We consider the experience of coming out of coma (non-existence) from the point of fundamental components of existence, i.e. anchoring with the world, with life, with self, with the future (Langle, 2003). In aspect of experience these components form the matrix of Patient-World and Patient-Self recovery phases. While working with BI patients, we have defined following phases: 0-phase: experiencing existence, the feeling "I exist here". The main target of psychotherapy is consolidation and reinforcement of the feeling of existence through the feeling of one's body boundaries (and extension), and finding resources for surviving. 1-phase: "be-able-to-exist-in-the world". The patient comes across reality of external world. We mean first of all the perception of the factual side of the world. 2-phase: loving life. The work is concentrated on the recovery of patient's ability to address himself and others so as to be able to experience emotions and live through his own wishes. 3-phase: restoration of patient's self-image and substantiation of own value. It means self-perception and selfrespect despite all the losses and deficits because of trauma. 4-phase: finding the sense. It is necessary to help the patient to make the existential change to avoid dependent position, don't consider himself as the victim of circumstances. This conception is used on different stages of recovery starting from severe disordered consciousness to socialization stage.