Recovery from disorders of consciousness: mechanisms, prognosis and emerging therapies.
Recovery from disorders of consciousness: mechanisms, prognosis and emerging therapies.
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从意识障碍中恢复：机制，预后和新兴疗法。
DOI：
10.1038/s41582-020-00428-x
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发表时间：
2021-03
期刊：
影响因子：
--
通讯作者：
Greer DM
中科院分区：
文献类型：
--
作者：
Edlow BL;Claassen J;Schiff ND;Greer DM
过去二十年来，在检测、预测和促进严重脑损伤引起的意识障碍（DoC）患者的意识恢复方面取得了实质性进展。先进的神经影像学和电生理学技术揭示了意识恢复的生物学机制的新见解，并使人们能够识别那些似乎没有反应的患者中保存的大脑网络，从而为更准确的诊断和预后带来希望。新出现的证据表明，高达15-20%的DoC患者存在隐蔽意识或认知运动分离（CMD），并且重症监护室中CMD的检测可以预测损伤后1年的功能恢复。虽然关于DoC患者有恢复潜力的基本问题仍然存在，但新的药理学和电生理学疗法已显示出重新激活受损神经网络并促进意识重新出现的潜力。在这篇综述中，我们专注于从DoC的急性和亚急性到慢性阶段的恢复机制，我们讨论了最近的进展，在检测和预测意识的恢复。我们还描述了药理学和电生理学治疗的发展，这些治疗为改善DoC患者的生活创造了新的机会。在这篇综述中，作者讨论了检测和预测严重脑损伤所致意识障碍患者意识恢复的最新进展。他们描述了旨在促进恢复的药理学和电生理学疗法的持续发展。意识障碍（DoC）的常见病理生理机制是由新皮层、丘脑和纹状体神经元的去传入或去便利化产生的跨大脑的兴奋性突触活动的撤回。从昏迷中恢复涉及各种机制，最终恢复兴奋性神经传递的长距离皮质，丘脑皮质和丘脑纹状体连接。意识的重新出现与皮质丘脑系统中神经元活动模式的转变有关，这种转变可以用EEG、PET或静息态功能性MRI来测量。基于任务的功能性MRI和EEG可以揭示高达15-20%的在行为检查中似乎无反应的患者的认知运动分离，并且新出现的证据表明，在重症监护室中早期检测到认知运动分离可预测1年的功能结局。金刚烷胺是唯一一种在亚急性创伤性DoC患者的随机对照试验中与加速意识恢复相关的疗法，但目前正在测试多种药理学和神经调节疗法。诊断和预后技术的新进展提供了新的机会，以检测意识，监测其恢复，阐明其神经元底物，并确定治疗潜力，促进意识的重新出现在一个子集的DoC患者。
Substantial progress has been made over the past two decades in detecting, predicting and promoting recovery of consciousness in patients with disorders of consciousness (DoC) caused by severe brain injuries. Advanced neuroimaging and electrophysiological techniques have revealed new insights into the biological mechanisms underlying recovery of consciousness and have enabled the identification of preserved brain networks in patients who seem unresponsive, thus raising hope for more accurate diagnosis and prognosis. Emerging evidence suggests that covert consciousness, or cognitive motor dissociation (CMD), is present in up to 15–20% of patients with DoC and that detection of CMD in the intensive care unit can predict functional recovery at 1 year post injury. Although fundamental questions remain about which patients with DoC have the potential for recovery, novel pharmacological and electrophysiological therapies have shown the potential to reactivate injured neural networks and promote re-emergence of consciousness. In this Review, we focus on mechanisms of recovery from DoC in the acute and subacute-to-chronic stages, and we discuss recent progress in detecting and predicting recovery of consciousness. We also describe the developments in pharmacological and electrophysiological therapies that are creating new opportunities to improve the lives of patients with DoC. In this Review, the authors discuss recent progress in the detection and prediction of recovery of consciousness in patients with disorders of consciousness caused by severe brain injuries. They describe the ongoing development of pharmacological and electrophysiological therapies designed to enhance recovery. A common pathophysiological mechanism underlying disorders of consciousness (DoC) is the withdrawal of excitatory synaptic activity across the cerebrum produced by deafferentation or disfacilitation of neocortical, thalamic and striatal neurons. Recovery from coma involves various mechanisms, culminating in the restoration of excitatory neurotransmission across long-range corticocortical, thalamocortical and thalamostriatal connections. The re-emergence of consciousness is associated with a shift in patterns of neuronal activity across the corticothalamic system that can be measured with EEG, PET or resting-state functional MRI. Task-based functional MRI and EEG can reveal cognitive motor dissociation in up to 15–20% of patients who seem unresponsive on behavioural examination, and emerging evidence suggests that early detection of cognitive motor dissociation in the intensive care unit predicts 1-year functional outcomes. Amantadine is the only therapy that has been associated with the acceleration of recovery of consciousness in a randomized controlled trial of patients with subacute traumatic DoC, but multiple pharmacological and neuromodulatory therapies are now being tested. Emerging advances in diagnostic and prognostic techniques provide new opportunities to detect consciousness, monitor its recovery, elucidate its neuronal substrate and identify the therapeutic potential of promoting re-emergence of consciousness in a subset of patients with DoC.
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DOI：
10.1007/s10334-016-0546-3
发表时间：
2016-06-01
影响因子：
2.3
作者：
Bianciardi, Marta;Toschi, Nicola;Wald, Lawrence L.
通讯作者：
Wald, Lawrence L.
DOI：
10.1056/nejmra0808281
发表时间：
2010-12-30
期刊：
The New England journal of medicine
影响因子：
--
作者：
Brown EN;Lydic R;Schiff ND
通讯作者：
Schiff ND
DOI：
10.1073/pnas.0809667106
发表时间：
2009-02-03
影响因子：
11.1
作者：
Bekinschtein, Tristan A.;Dehaene, Stanislas;Naccache, Lionel
通讯作者：
Naccache, Lionel
影响因子：
2.9
作者：
Brooks JC;Faull OK;Pattinson KT;Jenkinson M
通讯作者：
Jenkinson M
影响因子：
5.3
作者：
Bonnelle, Valerie;Leech, Robert;Sharp, David J.
通讯作者：
Sharp, David J.