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Abstract Background The rate of recovery from the vegetative state (VS) is low. Currently, little is known of the mechanisms and cerebral changes that accompany those relatively rare cases of good recovery. Here, we combined functional magnetic resonance imaging (fMRI) and diffusion tensor imaging (DTI) to study the evolution of one VS patient at one month post-ictus and again twelve months later when he had recovered consciousness. Methods fMRI was used to investigate cortical responses to passive language stimulation as well as task-induced deactivations related to the default-mode network. DTI was used to assess the integrity of the global white matter and the arcuate fasciculus. We also performed a neuropsychological assessment at the time of the second MRI examination in order to characterize the profile of cognitive deficits. Results fMRI analysis revealed anatomically appropriate activation to speech in both the first and the second scans but a reduced pattern of task-induced deactivations in the first scan. In the second scan, following the recovery of consciousness, this pattern became more similar to that classically described for the default-mode network. DTI analysis revealed relative preservation of the arcuate fasciculus and of the global normal-appearing white matter at both time points. The neuropsychological assessment revealed recovery of receptive linguistic functioning by 12-months post-ictus. Conclusions These results suggest that the combination of different structural and functional imaging modalities may provide a powerful means for assessing the mechanisms involved in the recovery from the VS.

Despite our constant need to flexibly balance internal and external information, research on cognitive flexibility has focused solely on shifts between externally oriented tasks. In contrast, switches across internally oriented processes (and self-referential cognition specifically) and between internal and external domains have never been investigated. Here, we report a novel task-switching paradigm developed to explore the behavioural signatures associated with cognitive flexibility when self-referential processes, as well as more traditional external processes, are involved. Two hundred healthy volunteers completed an online task. In each trial, participants performed one of four possible tasks on written words, as instructed by a pre-stimulus cue. These included two externally and two internally oriented tasks: assessing whether the third letter was a consonant or the penultimate letter was a vowel versus assessing whether the adjective applied to their personality or if it described a bodily sensation they were currently experiencing. In total, 40% of trials involved switches to another task, and these were equally distributed across within-external, within-internal, internal-to-external and external-to-internal switches. We found higher response times for switches compared to repetitions both in the external and internal domains, thus demonstrating the presence of switch costs in self-referential tasks for the first time. We also found higher response times for between-domain switches compared to switches within each domain. We propose that these effects originate from the goal-directed engagement of different domain-specific cognitive systems that flexibly communicate and share domain-general control features. [ABSTRACT FROM AUTHOR]

Objective: Some patients diagnosed with disorders of consciousness retain sensory and cognitive abilities beyond those apparent from their overt behavior. Characterizing these covert abilities is crucial for diagnosis, prognosis, and medical ethics. This multimodal study investigates the relationship between electroencephalographic evidence for perceptual/cognitive preservation and both overt and covert markers of awareness.Methods: Fourteen patients with severe brain injuries were evaluated with an electroencephalographic vibrotactile attention task designed to identify a hierarchy of residual somatosensory and cognitive abilities: (1) somatosensory steady-state evoked responses, (2) bottom-up attention orienting (P3a event-related potential), and (3) top-down attention (P3b event-related potential). Each patient was also assessed with a clinical behavioral scale and 2 functional magnetic resonance imaging assessments of covert command following.Results: Six patients produced only sensory responses, with no evidence of cognitive event-related potentials. A further 8 patients demonstrated reliable bottom-up attention-orienting responses (P3a). No patient showed evidence of top-down attention (P3b). Only those patients who followed commands, whether overtly with behavior or covertly with functional neuroimaging, also demonstrated event-related potential evidence of attentional orienting.Interpretation: Somatosensory attention-orienting event-related potentials differentiated patients who could follow commands from those who could not. Crucially, this differentiation was irrespective of whether command following was evident through overt external behavior, or through covert functional neuroimaging methods. Bedside electroencephalographic methods may corroborate more expensive and challenging methods such as functional neuroimaging, and thereby assist in the accurate diagnosis of awareness. Ann Neurol 2016;80:412-423. [ABSTRACT FROM AUTHOR]

Patients in a vegetative state are considered to lack awareness of themselves or the environment, but preserve respiratory and cardiac functions, as well as sleep/wake cycles. These patients are incapable of producing intentional responses to external stimulation and do not demonstrate any communication skills. Recent studies have shown that around 40% of vegetative state patients have been misdiagnosed. However, in recent years there has been a revolution in the tools that are available for the assessment of these patients. The objective of this article is to discuss the role of behavioural scales, as well as advanced neuroimaging techniques, in reducing the misdiagnosis rate. We review the scope and limitations of these approaches for the identification of overt and covert signs of awareness, and we present evidence to support a multimodal assessment that combines information from behavioural, structural, and functional imaging tools to ensure an accurate diagnosis for each individual patient. [ABSTRACT FROM AUTHOR]

Patients in a vegetative state are considered to lack awareness of themselves or the environment, but preserve respiratory and cardiac functions, as well as sleep/wake cycles. These patients are incapable of producing intentional responses to external stimulation and do not demonstrate any communication skills. Recent studies have shown that around 40% of vegetative state patients have been misdiagnosed. However, in recent years there has been a revolution in the tools that are available for the assessment of these patients. The objective of this article is to discuss the diagnostic role of behavioural scales, as well as advanced neuroimaging techniques in reducing the misdiagnosis rate. We review the scope and limitations of these approaches for the identification of overt and covert signs of awareness, and we present evidence to support a multimodal assessment that combines information from behavioural, structural, and functional imaging tools to ensure an accurate diagnosis for each individual patient. [ABSTRACT FROM AUTHOR]

Minimal or inconsistent behavioral responses to command make it challenging to accurately diagnose the level of awareness of a patient with a Disorder of consciousness (DOC). By identifying markers of mental imagery being covertly performed to command, functional neuroimaging (fMRI), electroencephalography (EEG) has shown that some of these patients are aware despite their lack of behavioral responsiveness. We report the findings of behavioral, fMRI, and EEG approaches to detecting command-following in a group of patients with DOC. From an initial sample of 14 patients, complete data across all tasks was obtained in six cases. Behavioral evaluations were performed with the Coma Recovery Scale--Revised. Both fMRI and EEG evaluations involved the completion of previously validated mental imagery tasks--i.e., motor imagery (EEG and fMRI) and spatial navigation imagery (fMRI). One patient exhibited statistically significant evidence of motor imagery in both the fMRI and EEG tasks, despite being unable to follow commands behaviorally. Two behaviorally non-responsive patients produced appropriate activation during the spatial navigation fMRI task. However, neither of these patients successfully completed the motor imagery tasks, likely due to specific motor area damage in at least one of these cases. A further patient demonstrated command following only in the EEG motor imagery task, and two patients did not demonstrate command following in any of the behavioral, EEG, or fMRI assessments. Due to the heterogeneity of etiology and pathology in this group, DOC patients vary in terms of their suitability for some forms of neuroimaging, the preservation of specific neural structures, and the cognitive resources that may be available to them. Assessments of a range of cognitive abilities supported by spatially-distinct brain regions and indexed by multiple neural signatures are therefore required in order to accurately characterize a patient's level of residual cognition and awareness. [ABSTRACT FROM AUTHOR]