[Xingnao Kaiqiao acupuncture on promoting wake-up of vegetative state after brain injury].

OBJECTIVE: To observe the clinical effect of Xingnao Kaiqiao acupuncture on promoting wake-up of vegetative state after brain injury on the basis of comprehensive rehabilitation training. METHODS: A total of 100 patients with vegetative state after brain injury were randomly divided into an observation group (50 cases, 2 cases dropped off) and a control group (50 cases). Both groups were treated with routine clinical treatment. The patients in the control group were treated with rehabilitation and hyperbaric oxygen; on the basis of the control group treatment, the patients in the observation group were treated with Xingnao Kaiqiao acupuncture at Neiguan (PC 6), Shuigou (GV 26), Sanyinjiao (SP 6), Chize (LU 5), Weizhong (BL 40), Hegu (LI 4) and Taichong (LR 3). The acupuncture was given once a day, 5 days per week, for continuous 30 days. The Glasgow coma scale (GCS) and coma recovery scale-revised (CRS-R) scores were observed before treatment and 10, 20 and 30 days into treatment. The wake-up rate of the two groups was compared after treatment. RESULTS: On 10, 20 and 30 days into treatment, the GCS and CRS-R scores in the two groups were higher than those before treatment (P<0.01), and the scores in the observation group were higher than those in the control group (P<0.01). After treatment, the wake-up rate was 16.7% (8/48) in the observation group, which was higher than 12.0% (6/50) in the control group (P<0.01). CONCLUSION: On the basis of comprehensive rehabilitation and wake-up promotion therapy, the Xingnao Kaiqiao acupuncture could promote the recovery of consciousness level in patients with vegetative state after brain injury.

Behavioural improvement in a minimally conscious state after caloric vestibular stimulation: evidence from two single case studies.

OBJECTIVE: To investigate whether caloric vestibular stimulation, a non-invasive form of neuro-modulation, alters the level of awareness in people residing in a minimally conscious state. DESIGN: Single-case ( n = 2), prospective, controlled (ABAB) efficacy study. SETTING: Tertiary, neuro-rehabilitation inpatient ward within a university hospital. PARTICIPANTS: Two individuals in a minimally conscious state. INTERVENTION: Left ear caloric vestibular stimulation was performed in two four/five-week blocks interleaved with two four/five-week blocks of sham stimulation. Session duration and frequency gradually increased within each block from once per day for 10 minutes (Week 1) to once per day for 20 minutes (Week 2) to 20 minutes twice per day in the remaining weeks. MEASURES: Wessex Head Injury Matrix, JFK Coma Recovery Scale - Revised. RESULTS: Both participants' Wessex Head Injury Matrix scores indicated a transition from involuntary (i.e. mechanical vocalization) to voluntary (i.e. gesture making, selective responses to family members) behaviour that was time-locked to the onset of active stimulation. In one participant, this improvement persisted for at least four weeks after active stimulation, while in the other it diminished two weeks after stimulation. Allied, although less dramatic, changes were seen on the arousal and auditory subscales of the JFK Coma Recovery Scale - Revised. CONCLUSION: The data provide the first evidence that vestibular stimulation may help improve outcome in a low awareness state, although further studies are needed to replicate effect and determine longer-term benefit.

Effectiveness of Sensory Stimulation to Improve Arousal and Alertness of People in a Coma or Persistent Vegetative State After Traumatic Brain Injury: A Systematic Review.

OBJECTIVE: This systematic review evaluates the effectiveness of sensory stimulation to improve arousal and alertness of people in a coma or persistent vegetative state after traumatic brain injury (TBI). METHOD: Databases searched included Medline, PsycINFO, CINAHL, OTseeker, and the Cochrane Database of Systematic Reviews. The search was limited to outcomes studies published in English in peer-reviewed journals between 2008 and 2013. RESULTS: Included studies provide strong evidence that multimodal sensory stimulation improves arousal and enhances clinical outcomes for people in a coma or persistent vegetative state after TBI. Moderate evidence was also provided for auditory stimulation, limited evidence was provided for complex stimuli, and insufficient evidence was provided for median nerve stimulation. CONCLUSION: Interventions should be tailored to client tolerance and premorbid preferences. Bimodal or multimodal stimulation should begin early, be frequent, and be sustained until more complex activity is possible.

Thalamic and extrathalamic mechanisms of consciousness after severe brain injury.

OBJECTIVE: What mechanisms underlie the loss and recovery of consciousness after severe brain injury? We sought to establish, in the largest cohort of patients with disorders of consciousness (DOC) to date, the link between gold standard clinical measures of awareness and wakefulness, and specific patterns of local brain pathology-thereby possibly providing a mechanistic framework for patient diagnosis, prognosis, and treatment development. METHODS: Structural T1-weighted magnetic resonance images were collected, in a continuous sample of 143 severely brain-injured patients with DOC (and 96 volunteers), across 2 tertiary expert centers. Brain atrophy in subcortical regions (bilateral thalamus, basal ganglia, hippocampus, basal forebrain, and brainstem) was assessed across (1) healthy volunteers and patients, (2) clinical entities (eg, vegetative state, minimally conscious state), (3) clinical measures of consciousness (Coma Recovery Scale-Revised), and (4) injury etiology. RESULTS: Compared to volunteers, patients exhibited significant atrophy across all structures (p < 0.05, corrected). Strikingly, we found almost no significant differences across clinical entities. Nonetheless, the clinical measures of awareness and wakefulness upon which differential diagnosis rely were systematically associated with tissue atrophy within thalamic and basal ganglia nuclei, respectively; the basal forebrain was atrophied in proportion to patients' response to sensory stimulation. In addition, nontraumatic injuries exhibited more extensive thalamic atrophy. INTERPRETATION: These findings provide, for the first time, a grounding in pathology for gold standard behavior-based clinical measures of consciousness, and reframe our current models of DOC by stressing the different links tying thalamic mechanisms to willful behavior and extrathalamic mechanisms to behavioral (and electrocortical) arousal.

[Dog-based multi-sensorial therapy of a patient with a "persistent vegetative state"--a case report]. / Hundgestützte multisensorische Therapie bei einer Patientin mit "persistierendem vegetativen Zustand"--ein Fallbericht.

AIM: There is evidence that animal-assisted therapy can have beneficial effects in patients with cognitive disorders. In the present case study, the influence of animal-assisted therapy was to be investigated in a patient with most severe cerebral lesions. METHODS: A 27 year old patient with a persistent vegetative state since 5 years after severe traumatic brain injury received long term treatment by 54 sessions of animal-assisted therapy. RESULTS: During the course of the therapeutic interventions, the patient showed more and more signs of vegetative, emotional and motor reactions. The latter were increasingly target-bound and at last allowed a simple type of non-verbal communication. CONCLUSION: The present case indicates that animal-assisted therapy can be a reasonable option to treat patients with most severe cerebral lesions. Furthermore, the results illustrate that the usual diagnostic classification such as "persistent vegetative state" based on a neurological investigation alone may be questionable. Possible reasons for the impact of animal-assisted therapy are complex and comprise e.g. multiple sensory stimuli.

Integration of intensive care treatment and neurorehabilitation in patients with disorders of consciousness: a program description and case report.

Severe brain injuries frequently result in disorders of consciousness, requiring intensive care unit treatment. We present a rehabilitative system that integrates neurorehabilitation into intensive care treatment. The system will be described using the case report of a young man who was in a vegetative state after a severe traumatic brain injury that resulted in major medical problems and complications. Despite these challenges, interdisciplinary therapies can be applied throughout the rehabilitative process. The patient in our case report showed significant improvements and functional gains during the course of treatment. Additional data from other patients support the feasibility of this system and show that integrating neurorehabilitation into intensive care treatment is possible and can lead to improved outcomes in this patient population. We will discuss the advantages, special features, and limitations of the system. Additional studies are needed to further demonstrate the efficacy of this approach compared with standard treatment.

Central thalamic deep brain stimulation to promote recovery from chronic posttraumatic minimally conscious state: challenges and opportunities.

BACKGROUND: Central thalamic deep brain stimulation (CT-DBS) may have therapeutic potential to improve behavioral functioning in patients with severe traumatic brain injury (TBI), but its use remains experimental. Current research suggests that the central thalamus plays a critical role in modulating arousal during tasks requiring sustained attention, working memory, and motor function. The aim of the current article is to review the methodology used in the CT-DBS protocol developed by our group, outline the challenges we encountered and offer suggestions for future DBS trials in this population. RATIONAL FOR CT-DBS IN TBI: CT-DBS may therefore be able to stimulate these functions by eliciting action potentials that excite thalamocortical and thalamostriatal pathways. Because patients in chronic minimally conscious state (MCS) have a very low probability of regaining functional independence, yet often have significant sparing of cortical connectivity, they may represent a particularly appropriate target group for CT-DBS. PIlOT STUDY RESULTS: We have conducted a series of single-subject studies of CT-DBS in patients with chronic posttraumatic MCS, with 24-month follow-up. Outcomes were measured using the Coma Recovery Scale-Revised as well as a battery of secondary outcome measures to capture more granular changes. Findings from our index case suggest that CT-DBS can significantly increase functional communication, motor performance, feeding, and object naming in the DBS on state, with performance in some domains remaining above baseline even after DBS was turned off. CONCLUSIONS: The use of CT-DBS in patients in MCS, however, presents challenges at almost every step, including during surgical planning, outcome measurement, and postoperative care. Additionally, given the difficulties of obtaining informed consent from patients in MCS and the experimental nature of the treatment, a robust, scientifically rooted ethical framework is resented for pursuing this line of work.

Atrioesophageal fistula after cryoballoon pulmonary vein isolation.

The risk of atrioesophageal fistula after cryoballoon pulmonary vein isolation is thought to be much lower than after radiofrequency ablation, seeing that no data exist on this complication so far. We report for the first time on the occurrence of an atrioesophageal fistula 4 weeks after cryoballoon ablation at the site of the left inferior pulmonary vein. We suggest that even when using cryothermal ablation technique, an imaging modality to assess the proximity of esophagus and left atrium should be routinely performed to avoid this fatal complication.

Relationship between etiology and covert cognition in the minimally conscious state.

OBJECTIVES: Functional neuroimaging has shown that the absence of externally observable signs of consciousness and cognition in severely brain-injured patients does not necessarily indicate the true absence of such abilities. However, relative to traumatic brain injury, nontraumatic injury is known to be associated with a reduced likelihood of regaining overtly measurable levels of consciousness. We investigated the relationships between etiology and both overt and covert cognitive abilities in a group of patients in the minimally conscious state (MCS). METHODS: Twenty-three MCS patients (15 traumatic and 8 nontraumatic) completed a motor imagery EEG task in which they were required to imagine movements of their right-hand and toes to command. When successfully performed, these imagined movements appear as distinct sensorimotor modulations, which can be used to determine the presence of reliable command-following. The utility of this task has been demonstrated previously in a group of vegetative state patients. RESULTS: Consistent and robust responses to command were observed in the EEG of 22% of the MCS patients (5 of 23). Etiology had a significant impact on the ability to successfully complete this task, with 33% of traumatic patients (5 of 15) returning positive EEG outcomes compared with none of the nontraumatic patients (0 of 8). CONCLUSIONS: The overt behavioral signs of awareness (measured with the Coma Recovery Scale-Revised) exhibited by nontraumatic MCS patients appear to be an accurate reflection of their covert cognitive abilities. In contrast, one-third of a group of traumatically injured patients in the MCS possess a range of high-level cognitive faculties that are not evident from their overt behavior.

Pattern classification of volitional functional magnetic resonance imaging responses in patients with severe brain injury.

BACKGROUND: Recent neuroimaging investigations have explored the use of mental imagery tasks as proxies for an overt motor response, in which patients are asked to imagine performing a task, such as "Imagine yourself swimming." OBJECTIVES: To detect covert volitional brain activity in patients with severe brain injury using pattern classification of the blood oxygenation level-dependent (BOLD) response during mental imagery and to compare these results with those of a univariate functional magnetic resonance imaging analysis. DESIGN: Case-control study. SETTING: Academic research. PARTICIPANTS: Experiments were performed in 8 healthy control subjects and in 5 patients with severe brain injury. The patients with severe brain injury constituted a convenience sample. MAIN OUTCOME MEASURES: Functional magnetic resonance imaging data were acquired as the patients were asked to follow commands or to answer questions using motor imagery as a proxy response. RESULTS: In the controls, the responses were accurately classified. In the patient group, the responses of 3 of 5 patients were correctly classified. The remaining 2 patients showed no significant BOLD response in a standard univariate analysis, suggesting that they did not perform the task. In addition, we showed that a classifier trained on command-following data can be used to evaluate a later communication run. This technique was used to successfully disambiguate 2 potential BOLD responses to a single question. CONCLUSIONS: Pattern classification in functional magnetic resonance imaging is a promising technique for advancing the understanding of volitional brain responses in patients with severe brain injury and may serve as a powerful complement to traditional general linear model-based univariate analysis methods.

Microswitch technology and contingent stimulation to promote adaptive engagement in persons with minimally conscious state: a case evaluation.

This study assessed whether a post-coma woman functioning at the lower end of the minimally conscious state would (a) develop adaptive responding through the use of microswitch technology and contingent stimulation, (b) consolidate and maintain her responding over time, and (c) show evidence of response-consequences awareness (learning and discrimination). The study involved an ABABB1CB1 sequence in which the A represented baseline phases, the B and B1 intervention phases, and the C a control phase with continuous stimulation. Results indicated that the woman developed adaptive responding and consolidated it over the intervention phases of the study. The woman also showed evidence of being aware of response-consequences links. Potential implications and limitations of these findings are discussed.

A voxel-based analysis of FDG-PET in traumatic brain injury: regional metabolism and relationship between the thalamus and cortical areas.

The objective was to study the correlations and the differences in glucose metabolism between the thalamus and cortical structures in a sample of severe traumatic brain injury (TBI) patients with different neurological outcomes. We studied 49 patients who had suffered a severe TBI and 10 healthy control subjects using 18F-fluorodeoxyglucose positron emission tomography (18F-FDG-PET). The patients were divided into three groups: a vegetative or minimally-conscious state (MCS&VS) group (n=17), which included patients who were in a vegetative or a minimally conscious state; an In-post-traumatic amnesia (In-PTA) group (n=12), which included patients in PTA; and an Out-PTA group (n=20), which included patients who had recovered from PTA. SPM5 software was used to determine the metabolic differences between the groups. FDG-PET images were normalized and four regions of interest were generated around the thalamus, precuneus, and the frontal and temporal lobes. The groups were parameterized using Student's t-test. Principal component analysis was used to obtain an intensity-estimated-value per subject to correlate the function between the structures. Differences in glucose metabolism in all structures were related to the neurological outcome, and the most severe patients showed the most severe hypometabolism. We also found a significant correlation between the cortico-thalamo-cortical metabolism in all groups. Voxel-based analysis suggests a functional correlation between these four areas, and decreased metabolism was associated with less favorable outcomes. Higher levels of activation of the cortico-cortical connections appear to be related to better neurological condition. Differences in the thalamo-cortical correlations between patients and controls may be related to traumatic dysfunction due to focal or diffuse lesions.

[Selection criteria for parameters of electric current in trans-CSF brain stimulation in patients with posttraumatic vegetative state].

Trans-CSF brain stimulation is on of applied methods of stimulation in posttraumatic vegetative state. The paper analyzes application of this technique under the control by different methods of electrophysiological monitoring. Authors suggest principles of selection of stimulation parameters and detectable criteria of its effectiveness.

Measuring interconnection of the residual cortical functional islands in persistent vegetative state and minimal conscious state with EEG nonlinear analysis.

OBJECTIVES: The aim of the study is to investigate the cortical response to painful and auditory stimuli for subjects in persistent vegetative state (PVS) and minimal conscious state (MCS), and measure the interconnection of the residual cortical functional islands with electroencephalographic (EEG) nonlinear dynamic analysis (NDA). METHODS: Thirty PVS subjects, 20 MCS subjects and 30 subjects in normal conscious state (NCS) were involved in the study. EEG was recorded under three conditions: eyes closed, auditory stimuli and painful stimuli. EEG nonlinear index of cross-approximate entropy (C-ApEn) was calculated for all subjects. RESULTS: Interconnection of local and distant cortical networks of patients in PVS was generally suppressed, and painful or auditory stimulation could hardly cause any activation of associative cortices. Instead, interconnection of local cortical networks of patients in MCS improved significantly. The only significant difference with the NCS existed in the unaffected distant cortical networks. CONCLUSIONS: Interconnection of local and distant cortical networks in MCS is superior to that of PVS. NDA could measure interconnection of the residual cortical functional islands with associative cortices in the unconscious patients. SIGNIFICANCE: NDA can characterise the interconnection of cortical networks for the unconscious state and provide some information of unconsciousness at the awareness level.

Aetiological differences in neuroanatomy of the vegetative state: insights from diffusion tensor imaging and functional implications.

BACKGROUND: An improved in vivo understanding of variations in neuropathology in the vegetative state (VS) may aid diagnosis, improve prognostication and help refine the selection of patients for particular treatment regimes. The authors have used diffusion tensor imaging (DTI) to characterise the extent and location of white matter loss in VS secondary to traumatic brain injury (TBI) and ischaemic-hypoxic injury. METHODS: Twelve patients with VS (seven TBI, five ischaemic/hypoxic injuries) underwent MRI including DTI at a minimum of 3 months postinjury. Mean apparent diffusion coefficient, fractional anisotropy and eigenvalues were obtained for whole-brain grey and white matter, the pons, thalamus, ventral midbrain, dorsal midbrain and the corpus callosum. DTI measures of supratentorial damage were compared with a summed measure from the JFK modified Coma Recovery Scale (CRS-R) and with a three-point scale of functional magnetic resonance imaging (fMRI) response to an auditory paradigm to assess whether residual integrity of supratentorial white matter connectivity correlated with cortical processing. RESULTS: Conventional radiological approaches did not detect lesions in regions where quantitative DTI demonstrated abnormalities. There was evidence of marked, broadly similar, abnormalities in the supratentorial grey- and white-matter compartments from both aetiologies. In contrast, discordant findings were found in the infratentorial compartment, with DTI abnormalities in the brainstem confined to the TBI group. Supratentorial DTI abnormalities correlated with the CRS-R as well as responses to an fMRI paradigm that detected convert cognitive processing. CONCLUSIONS: DTI may help to characterise differences in patients in VS. These findings may have implications for response to therapies, and should be taken into account in trials of interventions aimed at arousal in VS.

Towards the routine use of brain imaging to aid the clinical diagnosis of disorders of consciousness.

Clinical audits have highlighted the many challenges and dilemmas faced by clinicians assessing persons with disorders of consciousness (vegetative state and minimally conscious state). The diagnostic decision-making process is highly subjective, dependent upon the skills of the examiner and invariably dictated by the patients' ability to move or speak. Whilst a considerable amount has been learnt since Jennett and Plum coined the term 'vegetative state', the assessment process remains largely unchanged; conducted at the bedside, using behavioural assessment tools, which are susceptible to environmental and physiological factors. This has created a situation where the rate of misdiagnosis is unacceptably high (up to 43%). In order to address these problems, various functional brain imaging paradigms, which do not rely upon the patient's ability to move or speak, have been proposed as a source of additional information to inform the diagnostic decision making process. Although accumulated evidence from brain imaging, particularly functional magnetic resonance imaging (fMRI), has been encouraging, the empirical evidence is still based on relatively small numbers of patients. It remains unclear whether brain imaging is capable of informing the diagnosis beyond the behavioural assessment and whether brain imaging has any prognostic utility. In this study, we describe the functional brain imaging findings from a group of 41 patients with disorders of consciousness, who undertook a hierarchical speech processing task. We found, contrary to the clinical impression of a specialist team using behavioural assessment tools, that two patients referred to the study with a diagnosis of vegetative state did in fact demonstrate neural correlates of speech comprehension when assessed using functional brain imaging. These fMRI findings were found to have no association with the patient's behavioural presentation at the time of investigation and thus provided additional diagnostic information beyond the traditional clinical assessment. Notably, the utility of brain imaging was further underlined by the finding that the level of auditory processing revealed by functional brain imaging, correlated strongly (rs = 0.81, P < 0.001) with the patient's subsequent behavioural recovery, 6 months after the scan, suggesting that brain imaging may also provide valuable prognostic information. Although further evidence is required before consensus statements can be made regarding the use of brain imaging in clinical decision making for disorders of consciousness, the results from this study clearly highlight the potential of imaging to inform the diagnostic decision-making process for persons with disorders of consciousness.

Minimally conscious state after ruptured giant basilar aneurysm.

OBJECTIVE: To report the clinical and radiologic findings in a case of transient minimally conscious state after rupture and coiling of a giant basilar aneurysm. DESIGN: Case report. SETTING: Neuroscience intensive care unit. PATIENT: A 44-year-old man who developed a transient minimally conscious state in association with perianeurysmal edema in the rostral brainstem and thalamus after rupture and coiling of a giant basilar artery aneurysm. MAIN OUTCOME MEASURE: Correlation of clinical and magnetic resonance imaging findings. RESULTS: A minimally conscious state and bilaterally symmetric vasogenic edema of the rostral brainstem and thalamus developed 2 days after endovascular aneurysm coiling. The clinical and radiologic abnormalities improved significantly and in parallel during the following 4 weeks. CONCLUSIONS: Perianeurysmal vasogenic edema in the brainstem and thalamus can develop after rupture and coiling of a giant basilar artery aneurysm. This process can be transient and can produce dramatic alterations in consciousness that later resolve.