Early detection of consciousness in patients with acute severe traumatic brain injury
Early detection of consciousness in patients with acute severe traumatic brain injury
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DOI：
10.1093/brain/awx176
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发表时间：
2017-09-01
期刊：
影响因子：
14.5
通讯作者：
Wu, Ona
中科院分区：
文献类型：
--
作者：
Edlow, Brian L.;Chatelle, Camille;Wu, Ona
急性重型颅脑损伤患者在自我表达之前可能会恢复意识。如果在床边没有意识的行为证据，临床医生可能会做出不准确的预后，增加了拒绝维持生命治疗或拒绝康复服务的可能性。基于任务的功能性磁共振成像和脑电图技术已经揭示了慢性环境中的隐蔽意识，但这些技术尚未在重症监护室中进行测试。我们前瞻性地招募了16名因急性严重创伤性脑损伤而入住重症监护室的患者，以检验两个假设：（i）在缺乏语言表达和理解的行为证据的患者中，功能性磁共振成像和脑电图检测运动想象任务期间的命令遵循（i）。e.认知运动分离）和在语言和音乐刺激期间的关联皮层反应（即，e.高阶皮质运动分离）;（ii）对这些范例的早期反应与格拉斯哥结局量表扩展的6个月结局较好相关。患者在损伤后第9.2 +/- 5.0天接受功能性磁共振成像，在第9.8 +/- 4.6天接受脑电图。在成像时，使用昏迷恢复量表-修订版进行的行为评价表明昏迷（n = 2）、植物人状态（n = 3）、无语言的最低意识状态（n = 3）、有语言的最低意识状态（n = 4）或创伤后意识模糊状态（n = 4）。在四名患者中发现了认知运动分离，其中三名患者的行为诊断表明处于植物人状态。在另外两名患者中发现了高阶皮层运动分离。完全没有反应的语言，音乐和运动想象只观察到昏迷患者。在有语言功能行为证据的患者中，对语言和音乐的反应比对运动想象的反应更频繁（62.5-80%对33.3-42.9%）。同样，在16名匹配的健康受试者中，对语言和音乐的反应比对运动想象的反应更频繁（87.5-100%对68.8-75.0%）。除1例患者在重症监护室死亡外，所有认知运动分离和高级皮质运动分离患者均在6个月内恢复至意识模糊状态。然而，6个月的结果与整个队列的早期功能性磁共振成像和脑电图反应无关。这些观察结果表明，功能性磁共振成像和脑电图可以检测急性严重创伤性脑损伤患者的命令遵循和高阶皮层功能。在重症监护室中早期发现内隐意识和皮层反应可以改变对时间敏感的决定，即拒绝维持生命的治疗。
Patients with acute severe traumatic brain injury may recover consciousness before self-expression. Without behavioural evidence of consciousness at the bedside, clinicians may render an inaccurate prognosis, increasing the likelihood of withholding life-sustaining therapies or denying rehabilitative services. Task-based functional magnetic resonance imaging and electroencephalography techniques have revealed covert consciousness in the chronic setting, but these techniques have not been tested in the intensive care unit. We prospectively enrolled 16 patients admitted to the intensive care unit for acute severe traumatic brain injury to test two hypotheses: (i) in patients who lack behavioural evidence of language expression and comprehension, functional magnetic resonance imaging and electroencephalography detect command-following during a motor imagery task (i. e. cognitive motor dissociation) and association cortex responses during language and music stimuli (i. e. higher-order cortex motor dissociation); and (ii) early responses to these paradigms are associated with better 6-month outcomes on the Glasgow Outcome Scale-Extended. Patients underwent functional magnetic resonance imaging on post-injury Day 9.2 +/- 5.0 and electroencephalography on Day 9.8 +/- 4.6. At the time of imaging, behavioural evaluation with the Coma Recovery Scale-Revised indicated coma (n = 2), vegetative state (n = 3), minimally conscious state without language (n = 3), minimally conscious state with language (n = 4) or post-traumatic confusional state (n = 4). Cognitive motor dissociation was identified in four patients, including three whose behavioural diagnosis suggested a vegetative state. Higher-order cortex motor dissociation was identified in two additional patients. Complete absence of responses to language, music and motor imagery was only observed in coma patients. In patients with behavioural evidence of language function, responses to language and music were more frequently observed than responses to motor imagery (62.5-80% versus 33.3-42.9%). Similarly, in 16 matched healthy subjects, responses to language and music were more frequently observed than responses to motor imagery (87.5-100% versus 68.8-75.0%). Except for one patient who died in the intensive care unit, all patients with cognitive motor dissociation and higher-order cortex motor dissociation recovered beyond a confusional state by 6 months. However, 6-month outcomes were not associated with early functional magnetic resonance imaging and electroencephalography responses for the entire cohort. These observations suggest that functional magnetic resonance imaging and electroencephalography can detect command-following and higher-order cortical function in patients with acute severe traumatic brain injury. Early detection of covert consciousness and cortical responses in the intensive care unit could alter time-sensitive decisions about withholding life-sustaining therapies.