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Severe brain injury can result in disorders of consciousness (DoC), including coma, vegetative state/unresponsive wakefulness syndrome, and minimally conscious state. Improved emergency and trauma medicine response, in addition to expanding efforts to prevent premature withdrawal of life-sustaining treatment, has led to an increased number of patients with prolonged DoC. High-quality bedside care of patients with DoC is key to improving long-term functional outcomes. However, there is a paucity of DoC-specific evidence guiding clinicians on efficacious bedside care that can promote medical stability and recovery of consciousness. This Viewpoint describes the state of current DoC bedside care and identifies knowledge and practice gaps related to patient care with DoC collated by the Care of the Patient in Coma scientific workgroup as part of the Neurocritical Care Society's Curing Coma Campaign. The gap analysis identified and organized domains of bedside care that could affect patient outcomes: clinical expertise, assessment and monitoring, timing of intervention, technology, family engagement, cultural considerations, systems of care, and transition to the post-acute continuum. Finally, this Viewpoint recommends future research and education initiatives to address and improve the care of patients with DoC. more...

BackgroundClinical management of persons with disorders of consciousness (DoC) is dedicated largely to optimizing recovery. However, selecting a measure to evaluate the extent of recovery is challenging because few measures are designed to precisely assess the full range of potential outcomes, from prolonged DoC to return of preinjury functioning. Measures that are designed specifically to assess persons with DoC are often performance-based and only validated for in-person use. Moreover, there are no published recommendations addressing which outcome measures should be used to evaluate DoC recovery. The resulting inconsistency in the measures selected by individual investigators to assess outcome prevents comparison of results across DoC studies. The National Institute of Neurological Disorders and Stroke (NINDS) common data elements (CDEs) is an amalgamation of standardized variables and tools that are recommended for use in studies of neurologic diseases and injuries. The Neurocritical Care Society Curing Coma Campaign launched an initiative to develop CDEs specifically for DoC and invited our group to recommend CDE outcomes and endpoints for persons with DoCs.MethodsThe Curing Coma Campaign Outcomes and Endpoints CDE Workgroup, consisting of experts in adult and pediatric neurocritical care, neurology, and neuroscience, used a previously established five-step process to identify and select candidate CDEs: (1) review of existing NINDS CDEs, (2) nomination and systematic vetting of new CDEs, (3) CDE classification, (4) iterative review and approval of panel recommendations, and (5) development of case report forms.ResultsAmong hundreds of existing NINDS outcome and endpoint CDE measures, we identified 20 for adults and 18 for children that can be used to assess the full range of recovery from coma. We also proposed 14 new outcome and endpoint CDE measures for adults and 5 for children.ConclusionsThe DoC outcome and endpoint CDEs are a starting point in the broader effort to standardize outcome evaluation of persons with DoC. The ultimate goal is to harmonize DoC studies and allow for more precise assessment of outcomes after severe brain injury or illness. An iterative approach is required to modify and adjust these outcome and endpoint CDEs as new evidence emerges. more...

Background: Efficient bedside neurofunctional monitoring is crucial for managing disorders of consciousness (DoC). Ultrafast Power Doppler Imaging (uPDI) outperforms traditional Ultrasound in bedside for assessing the microcirculatory system. However, intracranial blood flow imaging traditionally faces limitations due to the skull's impedance. This constraint is circumvented in common post-craniectomy DoC patients, who present a unique observational window for uPDI. Methods: We conducted uPDI scans on five DoC patients of different ages and consciousness levels who had undergone decompressive craniectomy. We compared the imaging results from uPDI with traditional PDI and identified the physiological and pathological conditions with uPDI. Results: Detailed microvascular images of both cortical and subcortical areas were obtained using uPDI through the craniectomy window. Notably, uPDI demonstrates high sensitivity and imaging depth, revealing microvessels as small as 320 μm in diameter at 4 cm depth, and detecting blood flow signals up to 6 cm beneath the scalp. Conclusion: Through the decompressive cranial windows of DoC patients, we obtained cerebral microvascular images with significantly higher sensitivity without the need for contrast agents. Significance: Our research provides a novel bedside cerebral microcirculation imaging method for patients with DoC, offering convenient neurofunctional assessment to improve the clinical management of DoC patients. [ABSTRACT FROM AUTHOR] more...

Introduction: Prognostication in patients with prolonged disorders of consciousness (pDoC) remains a challenging task. Electroencephalography (EEG) is a neurophysiological method that provides objective information for evaluating overall brain function. In this study, we aim to investigate the multiple features of pDoC using EEG and evaluate the prognostic values of these indicators. Methods: We analyzed the EEG features: (i) spectral power; (ii) microstates; and (iii) mismatch negativity (MMN) and P3a of healthy controls, patients in minimally conscious state (MCS), and unresponsive wakefulness syndrome (UWS). Patients were followed up for 6 months. A combination of machine learning and SHapley Additive exPlanations (SHAP) were used to develop predictive model and interpret the results. Results: The results indicated significant abnormalities in low-frequency spectral power, microstate parameters, and amplitudes of MMN and P3a in MCS and UWS. A predictive model constructed using support vector machine achieved an area under the curve (AUC) of 0.95, with the top 10 SHAP values being associated with transition probability (TP) from state C to F, time coverage of state E, TP from state D to F and D to F, mean duration of state A, TP from state F to C, amplitude of MMN, time coverage of state F, TP from state C to D, and mean duration of state E. Predictive models constructed for each component using support vector machine revealed that microstates had the highest AUC (0.95), followed by MMN and P3a (0.65), and finally spectral power (0.05). Discussion: This study provides preliminary evidence for the application of microstate-based multiple EEG features for prognosis prediction in pDoC. Clinical trial registration: chictr.org.cn , identifier ChiCTR2200064099. [ABSTRACT FROM AUTHOR] more...

Background: Advances in neuroimaging have significantly enhanced our understanding of brain function, providing critical insights into the diagnosis and management of disorders of consciousness (DoC). Functional near-infrared spectroscopy (fNIRS), with its real-time, portable, and noninvasive imaging capabilities, has emerged as a promising tool for evaluating functional brain activity and nonrecovery potential in DoC patients. This review explores the current applications of fNIRS in DoC research, identifies its limitations, and proposes future directions to optimize its clinical utility. Aim: This review examines the clinical application of fNIRS in monitoring DoC. Specifically, it investigates the potential value of combining fNIRS with brain-computer interfaces (BCIs) and closed-loop neuromodulation systems for patients with DoC, aiming to elucidate mechanisms that promote neurological recovery. Methods: A systematic analysis was conducted on 155 studies published between January 1993 and October 2024, retrieved from the Web of Science Core Collection database. Results: Analysis of 21 eligible studies on neurological diseases involving 262 DoC patients revealed significant findings. The prefrontal cortex was the most frequently targeted brain region. fNIRS has proven crucial in assessing brain functional connectivity and activation, facilitating the diagnosis of DoC. Furthermore, fNIRS plays a pivotal role in diagnosis and treatment through its application in neuromodulation techniques such as deep brain stimulation (DBS) and spinal cord stimulation (SCS). Conclusion: As a noninvasive, portable, and real-time neuroimaging tool, fNIRS holds significant promise for advancing the assessment and treatment of DoC. Despite limitations such as low spatial resolution and the need for standardized protocols, fNIRS has demonstrated its utility in evaluating residual brain activity, detecting covert consciousness, and monitoring therapeutic interventions. In addition to assessing consciousness levels, fNIRS offers unique advantages in tracking hemodynamic changes associated with neuroregulatory treatments, including DBS and SCS. By providing real-time feedback on cortical activation, fNIRS facilitates optimizing therapeutic strategies and supports individualized treatment planning. Continued research addressing its technical and methodological challenges will further establish fNIRS as an indispensable tool in the diagnosis, prognosis, and treatment monitoring of DoC patients. [ABSTRACT FROM AUTHOR] more...

Objectives: To investigate the characteristics of pharyngeal and laryngeal structure in patients with acquired brain injury (ABI), who were long time wearing nasogastric tube (NGT) with or without tracheostomy. Methods: 103 ABI patients with NGT indwelled for more than 1 month were retrospectively studied and divided into two groups by whether or not undergoing tracheostomy. Age, gender, types of brain injury, course of the disease, disorders of consciousness, activities of daily living (ADL) and fiberoptic endoscopic examination of swallowing (FEES) were evaluated. The structure and function of pharyngeal and laryngeal were assessed by FEES, focusing on the morphology of the arytenoid cartilage, epiglottis, vocal folds, tongue base, and pharyngeal cavity. Results: Prolonged indwelling nasogastric tubes and tracheostomy tubes might lead to abnormal alterations of the structure and function in the arytenoid cartilage, epiglottis, tongue base, and pharyngeal cavity. Epiglottis shape abnormality, glossoptosis and pharyngeal stenosis were present in a larger proportion of the NGT–TRACH (nasogastric tube with tracheostomy) group than the NGT group (p < 0.05). Conclusions: This study highlights potential physiological changes associated with prolonged placement of nasogastric tubes and tracheostomy tubes, which could impede the recovery of swallowing function and decannulation. We hope to provide valuable evidence to develop effective management strategies for ABI patients with NGT or tracheostomy. [ABSTRACT FROM AUTHOR] more...

Disorders of consciousness (DoC) resulting from severe brain injury present substantial challenges in rehabilitation due to disruptions in brain network connectivity, particularly within the frontal-parietal network critical for awareness. Transcutaneous auricular vagus nerve stimulation (taVNS) has emerged as a promising non-invasive intervention; however, the precise mechanisms through which it influences cortical function in DoC patients remain unclear. This study describes the effects of taVNS on fronto-parietal network connectivity and arousal in a 77-year-old female patient with unresponsive wakefulness syndrome (UWS). The patient received bilateral taVNS for 1 h daily over 3 months, with functional connectivity (FC) in the frontoparietal network assessed using functional near-infrared spectroscopy (fNIRS) and behavioral responsiveness evaluated through the Coma Recovery Scale-Revised (CRS-R). After taVNS intervention, mean FC was enhanced from 0.06 (SD = 0.31) to 0.33 (SD = 0.28) in the frontal-parietal network. The frontal-parietal were subdivided into 12 regions of interest (ROIs) and it was determined that the FC between the left dorsolateral prefrontal cortex (DLPFC) and the left prefrontal ROIs was 0.06 ± 0.41 before the intervention and 0.55 ± 0.24 after the intervention. Behavioral improvements were evidenced by an increase in CRS-R scores from 2 to 14, marking the patient's transition from UWS to minimally conscious state plus (MCS+). Additionally, regions associated with auditory and sensory processing showed increased cortical engagement, supporting the positive impact of taVNS on cortical responsiveness. This suggests its value as a non-invasive adjunctive therapy in the rehabilitation of DoC patients. Further studies are necessary to confirm these effects in a wider patient population and to refine the strategy for clinical application of taVNS. [ABSTRACT FROM AUTHOR] more...

Introduction: The Coma Recovery Scale-Revised (CRS-R) is the recommended tool to assess consciousness in patients with prolonged Disorders of Consciousness (pDoC). However, the time needed to administer it may limit its use. A shorter tool has been validated: the Simplified Evaluation of CONsciousness Disorders (SECONDs). This multicentre study aimed to develop and validate a cross-cultural adaptation of the SECONDs into Italian. Methods: An interdisciplinary expert team, from both Fondazione Don Carlo Gnocchi and Istituto Neurologico Carlo Besta, led the translation processes. Independent certified translators were also involved in a blinded modality. Patients diagnosed with Unresponsive Wakefulness Syndrome (UWS) or Minimally Conscious State (MCS) admitted to 3 Italian rehabilitation units were enrolled. The CRS-R and SECONDs were administered in 5 sessions over two weeks by 3 blinded examiners at each center (3 times, with 2 sessions conducted by the same examiner). Weighted Fleiss' kappa and Spearman correlation coefficients were used to assess intrarater and interrater reliability and concurrent validity. Results: Sixty adults with pDoC were assessed: 23 women; median age: 64 years; 14 trauma, median post-onset time: 2 months. Intrarater and interrater reliability showed almost perfect agreement (kappa coefficients 0.968 and 0.935, respectively; p<0.001). The comparison of CRS-R vs. SECONDs on the same day or the best out of 5 SECONDs/CRS-R led to a substantial to almost perfect agreement both for the total score of the CRS-R and the SECONDs' Additional Index (ρ = 0.772–1.000; p<0.001) and for the consciousness diagnosis (k = 0.784–0.935; p<0.001). The disagreement rate between the overall best diagnosis of the SECONDs and the best CRS-R diagnosis was 6.7%. Conclusion: The Italian version of the SECONDs has been cross-culturally adapted to serve as a shorter assessment tool for the diagnosis of pDoC. Our study shows its excellent reliability and concurrent validity when compared to the CRS-R. [ABSTRACT FROM AUTHOR] more...