Clinical and neurophysiological effects of central thalamic deep brain stimulation in the minimally conscious state after severe brain injury.

Deep brain stimulation (DBS) of the central thalamus is an experimental treatment for restoration of impaired consciousness in patients with severe acquired brain injury. Previous results of experimental DBS are heterogeneous, but significant improvements in consciousness have been reported. However, the mechanism of action of DBS remains unknown. We used magnetoencephalography to study the direct effects of DBS of the central thalamus on oscillatory activity and functional connectivity throughout the brain in a patient with a prolonged minimally conscious state. Different DBS settings were used to improve consciousness, including two different stimulation frequencies (50 Hz and 130 Hz) with different effective volumes of tissue activation within the central thalamus. While both types of DBS resulted in a direct increase in arousal, we found that DBS with a lower frequency (50 Hz) and larger volume of tissue activation was associated with a stronger increase in functional connectivity and neural variability throughout the brain. Moreover, this form of DBS was associated with improvements in visual pursuit, a reduction in spasticity, and improvement of swallowing, eight years after loss of consciousness. However, after DBS, all neurophysiological markers remained significantly lower than in healthy controls and objective increases in consciousness remained limited. Our findings provide new insights on the mechanistic understanding of neuromodulatory effects of DBS of the central thalamus in humans and suggest that DBS can re-activate dormant functional brain networks, but that the severely injured stimulated brain still lacks the ability to serve cognitive demands.

[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.

Effect of acupuncture method of removing-stasisand resuscitating on the consciousness of patients with severe traumatic brain injury: A randomized clinical trial.

INTRODUCTION: With the development of social economy, transportation and various infrastructures have also developed, but it has objectively increased the number of patients with head injury. Although the current craniocerebral medicine technology continues to advance, long-term bed rest and other complications have led to an insignificant decrease in the mortality rate of coma patients. It is not uncommon for patients with disturbance of consciousness caused by head injury in major hospitals. METHODS/DESIGN: This will be a retrospective, single-blind clinical observational study. We will select 50 cases that meet the subject's selection criteria. According to whether they received acupuncture treatment or not, they will be randomly divided into 2 groups, namely treatment group and control group. The control group will be given conventional Western medicine treatment, and the treatment group will be given acupuncture method of removing-stasis and resuscitating treatment on the basis of the control group. DISCUSSION: Our purpose is to observe the role of acupuncture method of removing-stasis and resuscitating in promoting the recovery of patients with severe head injury. We aim to provide more evidence-based medical evidence for acupuncture treatment of this disease. TRIAL REGISTRATION: ClinicalTrials.gov, ChiCTR2000034732, Registered on 19 July 2020.

Music Interventions for Disorders of Consciousness: A Systematic Review and Meta-analysis.

BACKGROUND: Quantitative evidence for the effects of music on patients with disorders of consciousness (DOCs) was presented. This study was based on available studies to summarize the effect estimates of music for DOC patients. METHODS: Three electronic databases were searched for studies that investigated the effects of music for DOC patients from start to July 2018. The summary results included functional scale, general physical indexes, electroencephalogram indexes, and favorable outcomes. The weighted mean difference and odds ratio with a corresponding 95% confidence interval were used to calculate continuous and frequency data using a random-effects model. This report adheres to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. RESULTS: Randomized controlled trials (3) and cohort studies (8) involving 201 DOC patients were included. Patients with DOCs receiving music interventions were associated with high levels of California Verbal Learning Test (P = .038) and persistent vegetative state (P < .001), whereas no significant differences were detected for agitated behavior scale (P = .982), Glasgow Coma Scale (P = .216), Mini-Mental State Examination (P = .215), music therapy in a vegetative or minimally conscious state (P = .590), and Stroop (P = 1.000). Furthermore, DOC patients receiving music intervention showed a significantly increased facial expression (P = .003) and reduced systolic blood pressure (P = .036), whereas no significant effects were observed on diastolic blood pressure (P = .777), heart rate (P = .666), oxygen saturation (P = .911), pulse (P = .899), respiratory frequency (P = .427), and temperature (P = .864). Moreover, music did not contribute significantly to electroencephalogram indexes including alpha (α), beta (ß), delta (δ), and theta (θ) in the left and right hemispheres (P > .050). Finally, DOC patients receiving music intervention showed an increased incidence of favorable outcomes (P = .015). CONCLUSION: This quantitative meta-analysis indicated that music might play a critical role on the functional scale, general physical indexes, and favorable outcomes for DOC patients. Music therapy can easily be provided at the bedside by nurses working with DOC patients.

[Xiao's "xingnaofusu" needling for regaining consciousness and the influence on width of the third ventricle in patients with persistent vegetative state].

OBJECTIVE: To observe the influence of Xiao's "xingnaofusu" needling (the technique for resuscitation) on regaining consciousness in the patients with persistent vegetative state (PVS). METHODS: A total of 50 patients of PVS were randomized into an observation group and a control group, 25 cases in each. The patients in the control group were treated by the routine western medicine, and those in the observation group treated by Xiao's "xingnaofusu" needling and routine western medicine. Baihui (GV20), Dingshen (Extra) to Shangen (Extra) (penetrating technique), Fengchi (GB20) to GB20 (penetrating technique), Neiguan (PC6) to Waiguan (TE5) (penetrating technique), Hegu (LI4) to Laogong (HT8) (penetrating technique) and Taichong (LR3) to Yongquan (KI1) (penetrating technique) were selected. The treatment was given once a day, 10 days as one treatment course, 3 courses in total. The coma recovery scale-revised (CRS-R) score, the modified Ashworth scale (MAS) score and the Glasgow coma scale (GCS) were separately compared before and after the treatment. Additionally, CT scanning was adopted to measure the width of the third ventricle before and after treatment so as to evaluate the clinical therapeutic effect. RESULTS: After the treatment, the CRS-R and GCS scores in the two groups increased remarkably, and MAS score reduced obviously as compared with that before the treatment(P<0.05); and the CRS-R and GCS scores were higher, and MAS score lower in the observation group than those in the control group(P<0.05). Compared with the control group, the width of the third ventricle reduced obviously in the observation group after the treatment(P<0.05). At the end of the treatment courses, the effective rate was 79.2%(19/24)in the observation group and was 47.8%(11/23) in the control group. The effective rate of the observation group was obviously higher than that of the control group (P<0.05). CONCLUSION: Xiao's "xingnaofusu" needling can remarkably improve the central nerve function, promote the recovery of brain function and the motor function of limbs, reduce the width of the third ventricle and improve the clinical therapeutic effect of regaining consciousness in the patients with PVS.

Animal-assisted therapy for patients in a minimally conscious state: A randomized two treatment multi-period crossover trial.

OBJECTIVE: To investigate if animal-assisted therapy (AAT) leads to higher consciousness in patients in a minimally conscious state during a therapy session, measured via behavioral reactions, heart rate and heart rate variability. METHODS: In a randomized two treatment multi-period crossover trial, 10 patients in a minimally conscious state participated in eight AAT sessions and eight paralleled conventional therapy sessions, leading to 78 AAT and 73 analyzed control sessions. Patients' responses during sessions were assessed via behavioral video coding and the Basler Vegetative State Assessment (BAVESTA), heart rate and heart rate variability (SDNN, RMSSD, HF and LF). Data were analyzed with generalized linear mixed models. RESULTS: Patients showed more eye movements (IRR = 1.31, 95% CI: 1.23 to 1.40, p < 0.001) and active movements per tactile input during AAT compared to control sessions (IRR = 1.13, 95% CI: 1.02 to 1.25, p = 0.018). No difference was found for positive emotions. With BAVESTA, patients' overall behavioral reactions were rated higher during AAT (b = 0.11, 95% CI: 0.01 to 0.22, p = 0.038). AAT led to significantly higher LF (b = 5.82, 95% CI: 0.55 to 11.08, p = 0.031) and lower HF (b = -5.80, 95% CI: -11.06 to -0.57, p = 0.030), while heart rate, SDNN, RMSSD did not differ. CONCLUSIONS: Patients in a minimally conscious state showed more behavioral reactions and increased physiological arousal during AAT compared to control sessions. This might indicate increased consciousness during therapeutic sessions in the presence of an animal. TRIAL REGISTRATION: ClinicalTrials.gov NCT02629302.

Xingnao Kaiqiao acupuncture combined with Angong Niuhuang Wan for a patient under persistent vegetative state: a case report.

Persistent vegetative state (PVS) is a clinical condition wherein the cerebral cortex loses its function although brain stem function remains relatively intact. It has high mortality and disability rates. Although treatment for PVS is extensively studied in developed countries, little breakthrough has been made. In China, many PVS patients who were treated with traditional Chinese medicine (TCM) and acupuncture therapy were reported to have regained consciousness. In our department, we have been investigating TCM diagnosis and treatment methods for PVS for many years and have summarized a set of curative programs. Our patient is a male and 5 years and 3 months of age. He had traumatic brain injury and had been unconscious for three months on admission. Considering his condition, we adopted Xingnao Kaiqiao acupuncture, oral Angong Niuhuang Wan, and Xingnaojing intravenous drip. After the 50-day treatment, his health significantly improved and is nearly similar to that of a healthy child, indicating that the treatment is effective for PVS. Therefore, we decided to report the case and treatment methods.

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.

Results of a prospective study (CATS) on the effects of thalamic stimulation in minimally conscious and vegetative state patients.

OBJECTIVE Deep brain stimulation of the thalamus was introduced more than 40 years ago with the objective of improving the performance and attention of patients in a vegetative or minimally conscious state. Here, the authors report the results of the Cortical Activation by Thalamic Stimulation (CATS) study, a prospective multiinstitutional study on the effects of bilateral chronic stimulation of the anterior intralaminar thalamic nuclei and adjacent paralaminar regions in patients affected by a disorder of consciousness. METHODS The authors evaluated the clinical and radiological data of 29 patients in a vegetative state (unresponsive wakefulness syndrome) and 11 in a minimally conscious state that lasted for more than 6 months. Of these patients, 5 were selected for bilateral stereotactic implantation of deep brain stimulating electrodes into their thalamus. A definitive consensus for surgery was obtained for 3 of the selected patients. All 3 patients (2 in a vegetative state and 1 in a minimally conscious state) underwent implantation of bilateral thalamic electrodes and submitted to chronic stimulation for a minimum of 18 months and a maximum of 48 months. RESULTS In each case, there was an increase in desynchronization and the power spectrum of electroencephalograms, and improvement in the Coma Recovery Scale-Revised scores was found. Furthermore, the severity of limb spasticity and the number and severity of pathological movements were reduced. However, none of these patients returned to a fully conscious state. CONCLUSIONS Despite the limited number of patients studied, the authors confirmed that bilateral thalamic stimulation can improve the clinical status of patients affected by a disorder of consciousness, even though this stimulation did not induce persistent, clinically evident conscious behavior in the patients. Clinical trial registration no.: NCT01027572 ( ClinicalTrials.gov ).

Neurophysiological assessment for evaluating residual cognition in vegetative and minimally conscious state patients: a pilot study.

The aim of this study was to assess residual cognitive function and perform outcome evaluation in vegetative state (VS) and minimally conscious state (MCS) patients, using Neurowave, a system able to monitor event-related potentials (ERPs) induced by neurosensory stimulation. Eleven VS and five MCS patients underwent neurological examination and clinical evaluation performed using validated clinical and behavioral scales; they also underwent neurosensory stimulation, which consisted of administration of target images (rare stimuli), relevant to the patient's personal history and having emotional significance, alternated with nontarget images ("standard" stimuli), which had no emotional significance. All simultaneous ERP responses at baseline (T0) and at three months from T0 (T1) were recorded. At T0 we found significant differences between the VS and MCS patients for the N200 (p=0.02) and P300 (p=0.04) waves. The neurophysiological analysis at T1 showed a significant difference only for P300 (p=0.02), probably due to the improvements observed in the VS subjects for the N100 (p=0.009) and N200 (p=0.02) sensory components. Neurophysiological assessment for evaluating residual cognition in vegetative and minimally conscious state patients: a pilot study Our findings seem to show the value of ERP monitoring in VS and MCS patients as a means of investigating residual cognitive function. This approach could guide early therapeutic and rehabilitation interventions, and contribute to identifying better diagnostic and prognostic markers for use in unresponsive or low-responsive patients.

[Beneficial effect of preferred music on cognitive functions in minimally conscious state patients]. / Effets bénéfiques de la musique préférée sur les capacités cognitives des patients en état de conscience minimale.

Several studies have shown that music can boost cognitive functions in normal and brain-damaged subjects. A few studies have suggested a beneficial effect of music in patients with a disorder of consciousness but it is difficult to conclude since they did not use quantified measures and a control condition/group. The aim of the present study was to compare the effect of music to that of a continuous sound on the relational behavior of patients in a minimally conscious state (MCS). Behavioral responses of six MCS patients were evaluated using items from the Coma Recovery Scale-Revised. Weekly evaluation sessions were carried out, over four weeks, under two conditions: following the presentation of either the patient's preferred music, or following a continuous sound (control condition). Qualitative and quantitative analyses showed that twelve of the eighteen sessions (66.6%) showed a better result for the music condition than for the control condition. This new protocol suggests that preferred music has a beneficial effect on the cognitive abilities of MCS patients. The results further suggest that cerebral plasticity may be enhanced in autobiographical (emotional and familiar) contexts. These findings should now be further extended with an increased number of patients to further validate the hypothesis of the beneficial effect of music on cognitive recovery.

Análisis de la frecuencia cardiaca en hipertensos tras la manipulación con impulso en C7 / Analysis of heart frequency in hypertension after handling with a C7 impulse

Introducción: La hipertensión arterial es la principal causa de morbilidad de la mayoría de los países, afectando al 20% de la población adulta, causando elevados costes a la sociedad. En los últimos años el interés y la sensibilización social en este tema, particularmente en el campo de la osteopatía, han derivado en estudios sobre las variables de frecuencia cardiaca que permitan analizar sus causas y fomentar nuevas técnicas para su tratamiento. Objetivos: Determinar si la manipulación a alta velocidad en el séptimo nivel cervical (C7) en pacientes hipertensos es segura y no modifica la frecuencia cardiaca, tras la intervención. Material y métodos: Estudio aleatorio, experimental, cegado y controlado. Sesenta y uno (n=61) pacientes con hipertensión se distribuyeron aleatoriamente en dos grupos, experimental (n=32) y control (n=29). Se realizó una valoración inicial (Pre-intervención) y una final (Post-intervención) analizando los cambios de la frecuencia cardiaca. Se realizaron evaluaciones previas, mediante los Test de Mitchell, Jackson y Klein. La técnica de intervención aplicada fue la maniobra de impulso (thrust) C7-D1 en decúbito prono, para disfunción en ERS o FRS. Resultados: En los pacientes del grupo experimental, no observamos una reducción significativa tras la manipulación experimental, en la frecuencia cardiaca medida en el brazo izquierdo, en la frecuencia cardiaca pico, en la frecuencia cardiaca de pie, ni en la frecuencia cardiaca en descanso. Conclusiones: La técnica de thrust sobre el segmento cervical C7-D1 aplicada en pacientes hipertensos no reduce significativamente los valores de la frecuencia cardiaca y por tanto es una técnica segura, que podría aplicarse sobre estos pacientes (AU)

Introduction: High blood pressure is the main cause of morbidity in most countries, affecting 20% of the adult population and causing high costs to society. In recent years interest and social awareness in this area, particularly in the field of osteopathy, has led to studies on the variables of heart rate that allow them to analyze their causes and to promote new techniques for treatment. Objective: To determine if high speed manipulation at the seventh cervical level (C7) in hypertensive patients is safe and does not modify the heart rate after intervention. Material and methods: A randomized, experimental, blinded and controlled study. Sixty-one (n = 61) patients with hypertension were randomized into two groups; experimental (n = 32) and control (n = 29). An initial assessment (pre-intervention) and an end assessment (post-intervention) were performed, analyzing changes in heart rate. Previous evaluations were performed using the Mitchell, Jackson and Klein Test. The applied intervention technique was the C7-D1 thrust maneuver in the prone position for dysfunction in ERS or FSR. Results: In patients in the experimental group, we did not observe a significant reduction after experimental manipulation in the heart rate measured in the left arm, the peak heart rate, the standing heart rate, or the resting heart rate. Conclusions: The thrust technique on the cervical segment C7-D1 applied in hypertensive patients does not significantly reduce heart rate values and, therefore, is a safe technique that could be applied to these patients (AU)

[Vegetative state treated with acupoint injection combined with plum-blossom needle in children: a randomized controlled trial].

OBJECTIVE: To observe the clinical efficacy difference on vegetative state in children between acupoint injection combined with plum-blossom needle and western medication based on basic treatment. METHODS: Forty-eight children of vegetative state were randomized into an observation group and a control group, 24 cases in each one. On the basis of the treatment of transcranial magnetic stimulation apparatus, balancing treatment apparatus and massage, the acupoint injection and tapping method with plum-blossom needle were adopted in the observation group, in which Xingnaojing injection, mouse nerve growth factor (mNGF) injection, monosialotetrahexosylganglioside sodium injection (MSI), compound Danshen injection were divided in 6 pairs and were injected respectively in Baihui (GV 20), Yongquan (KI 1), Fengfu (GV 16), Yamen (GV 15) and the others, 0.5 mL in each acupoint, once a day for continuous 10 days. Additionally, the tapping method with plum-blossom needle was used on the Governor Vessel and Jiaji (EX-B 2) on the back. In the control group, the intravenous infusion was adopted with citicoline sodium injection, mannitol injection and dexamethasone injection. The treatment was given once a day, 20 days of treatment made one session and totally 3 sessions were required in the two groups. The clinical efficacy, the vegetative state score and the mean curing time were observed after 20 days, 40 days and 60 days of treatment between the two groups. RESULTS: The effective rates were 58.3% (14/24), 70.8% (17/24) and 79.2% (19/24) in 20 days, 40 days and 60 days of treatment in the observation group and 20.8% (5/24), 45.8% (11/24) and 58.3% (14/24) in the control group respectively. The efficacy in the observation group was superior to those in the control group (P < 0.01, P < 0.05). The vegetative state score was improved apparently after 20 days, 40 days and 60 days of treatment as compared with those before treatment separately (all P < 0.05). It was improved obviously at the each time point after treatment in the observation group as compared with that in the control group (3.34 +/- 2.41 vs 2.64 +/- 11.56, 6.20 +/- 1.46 vs 4.34 +/- 1.64, 11.26 +/- 2.63 vs 8.75 +/- 2.18, all P < 0.05). The mean curing time was (45.67 +/- 16.24) days in the observation group, which was shorter apparently than that of (55.34 +/- 4.57) days in the control group (P < 0.05). CONCLUSION: Based on basic treatment acupoint injection combined with tapping method of plum-blossom needle achieve the reliable efficacy on vegetative state in children.

Electrical modulation of neuronal networks in brain-injured patients with disorders of consciousness: a systematic review.

Six clinical studies of chronic electrical modulation of deep brain circuits published between 1968 and 2010 have reported effects in 55 vegetative or minimally conscious patients. The rationale stimulation was to activate the cortex through the reticular-thalamic complex, comprising the tegmental ascending reticular activating system and its thalamic targets. The most frequent intended target was the central intralaminar zone and adjacent nuclei. Hassler et al. also proposed to modulate the pallidum as part of the arousal and wakefulness system. Stimulation frequency varied from 8Hz to 250Hz. Most patients improved, although in a limited way. Schiff et al. found correlations between central thalamus stimulation and arousal and conscious behaviours. Other treatments that have offered some clinical benefit include drugs, repetitive magnetic transcranial stimulation, median nerve stimulation, stimulation of dorsal column of the upper cervical spinal cord, and stimulation of the fronto-parietal cortex. No one treatment has emerged as a gold standard for practice, which is why clinical trials are still on-going. Further clinical studies are needed to decipher the altered dynamics of neuronal network circuits in patients suffering from severe disorders of consciousness as a step towards novel therapeutic strategies.

Central thalamic deep brain stimulation for support of forebrain arousal regulation in the minimally conscious state.

This chapter considers the use of central thalamic deep brain stimulation (CT/DBS) to support arousal regulation mechanisms in the minimally conscious state (MCS). CT/DBS for selected patients in a MCS is first placed in the historical context of prior efforts to use thalamic electrical brain stimulation to treat the unconscious clinical conditions of coma and vegetative state. These previous studies and a proof of concept result from a single-subject study of a patient in a MCS are reviewed against the background of new population data providing benchmarks of the natural history of vegetative and MCSs. The conceptual foundations for CT/DBS in selected patients in a MCS are then presented with consideration of both circuit and cellular mechanisms underlying recovery of consciousness identified from empirical studies. Directions for developing future generalizable criteria for CT/DBS that focus on the integrity of necessary brain systems and behavioral profiles in patients in a MCS that may optimally response to support of arousal regulation mechanisms are proposed.

Neuromodulation of vegetative state through spinal cord stimulation: where are we now and where are we going?

BACKGROUND: Vegetative state (VS) is a complex condition that represents a challenging frontier for medicine and neuroscience research. Nowadays there is no scientifically validated treatment for VS patients, and their chronic long-term assistance is very demanding for healthcare systems worldwide. OBJECTIVES: The present paper is a systematic review of the role of spinal cord stimulation (SCS) as a treatment of patients with VS. METHODS: Published literature on this topic was analyzed systematically. Clinical and epidemiological characteristics of VS, present therapeutic options and social costs of VS were also evaluated. RESULTS: Only 10 papers have been published since 1988, and overall 308 VS patients have been treated with SCS worldwide; 51.6% displayed a clinical improvement and an amelioration of the environmental interaction. These effects are probably mediated by the stimulation of the reticular formation-thalamus-cortex pathway and by cerebral blood flow augmentation induced by SCS. CONCLUSIONS: The experience on this topic is still very limited, and on this basis it is still hard to make any rigorous assessment. However, the most recent experiments represent significant progress in the research on this topic and display SCS as a possible therapeutic tool in the treatment of VS.

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.

Focal increase in cerebral blood flow after treatment with near-infrared light to the forehead in a patient in a persistent vegetative state.

OBJECTIVE: This study aimed to quantify the cerebral blood flow (CBF) after bilateral, transcranial near-infrared light-emitting diode (LED) irradiation to the forehead in a patient in a persistent vegetative state following severe head injury. BACKGROUND DATA: Positive behavioral improvement has been observed following transcranial near-infrared light therapy in humans with chronic traumatic brain injury and acute stroke. METHODS: Single-photon emission computed tomography with N-isopropyl-[123I]p-iodoamphetamine (IMP-SPECT) was performed following a series of LED treatments. RESULTS: IMP-SPECT showed unilateral, left anterior frontal lobe focal increase of 20%, compared to the pre-treatment value for regional CBF (rCBF) for this area, following 146 LED treatments over 73 days from an array of 23×850 nm LEDs, 13 mW each, held 5 mm from the skin, 30 min per session, the power density 11.4 mW/cm(2); the energy density 20.5 J/cm(2) at the skin. The patient showed some improvement in his neurological condition by moving his left arm/hand to reach the tracheostomy tube, post-LED therapy. CONCLUSIONS: Transcranial LED might increase rCBF with some improvement of neurological condition in severely head-injured patients. Further study is warranted.

Use of hyperbaric oxygen in traumatic brain injury: retrospective analysis of data of 20 patients treated at a tertiary care centre.

Traumatic brain injury (TBI) related impact results in a permanent need for help in performing daily activities. Standard treatment consists of removing the cause, restore perfusion, support metabolic requirement and limit inflammatory and oxidative damage. Hyperbaric oxygen therapy (HBOT) is one such newer promising treatment that enhances neurological recovery to some extent. HBOT is intermittent inhalation of 100% oxygen at greater than normal atmospheric pressure and is internationally accepted for its role in well-defined indications. It is hypothesised that HBO has a role in reviving 'idling neurons', also called the ischemic penumbra defined as area of reduced cerebral blood flow, abolished synaptic activity but preserved structural integrity. We carried out a retrospective analysis of medical records of 20 patients of TBI who had been treated with HBOT in addition to standard management. These were placed in Group A (test group) and received at least 30 sessions of HBO along with standard treatment. The patients were assessed along the Disability Rating Scale (DRS), Glasgow coma scale (GCS) and Rancho Los Amigos Scale (RLAS). Another 20 patients of TBI, matched in age and severity of brain injury, who received standard treatment but not HBOT, were selected as the control group (Group B). Assessment on the DRS showed maximum improvement in patients with scores of 22-24 (vegetative state).The percentage of patients in the test group fell from 45% to 5% whereas only 20% patients in Group B had similar progress. After the treatment, a significantly higher proportion of HBOT treated subjects showed a good response in cognitive functions, as measured by RLA. In group A, 90% patients had a score of ≤ 3 and in Group B 95% had a similar score, which improved to ≥ 3 in 60% patients versus 30% patients respectively. In both groups maximum patients are in 1-6 months post-injury category and within the groups this category showed the greatest recovery, with a greater improvement in the test group as compared to control group.