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Objective:To investigate the factors affecting postoperative short-term improvement of consciousness level in patients with prolonged disorders of consciousness after severe traumatic brain injury (sTBI).Methods:A case-control study was conducted to analyze the clinical data of 55 patients with prolonged disorders of consciousness after sTBI admitted to Beijing Tiantan Hospital Affiliated to Capital Medical University and Seventh Medical Center of PLA General Hospital from September 2021 to September 2022. There were 33 males and 22 females, with the age range of 13-68 years [(43.0±15.5)years]. All patients were assessed for the consciousness level using the coma recovery scale-revision (CRS-R) preoperatively and within 48 hours postoperatively. A total of 33 patients were observed in vegetative state and 22 in minimally conscious state preoperatively. The consciousness level was found to be improved in 26 patients (consciousness- improved group), but not improved in the remaining 29 patients (consciousness-unimproved group). Indicators were documented including gender, age, cause of injury, Glasgow coma score (GCS) on admission, course of injury, preoperative consciousness level, operation mode, operation time, intraoperative fluid replenishment, intraoperative urine volume, intraoperative bleeding volume, American Society of Anesthesiologists grade, analgesic regimen and sedation maintenance drugs. A univariate analysis was conducted first to assess those indicators′ correlation with postoperative short-term improvement of consciousness level in patients with prolonged disorders of consciousness after sTBI. Multivariate Logistic regression analysis was then used to determine the independent risk factors for their postoperative short-term improvement of consciousness level.Results:Univariate analysis showed that GCS on admission, course of injury, preoperative consciousness level and analgesic regimen were correlated with short-term improvement of postoperative consciousness level in patients with prolonged disorders of consciousness after sTBI (all P<0.05), whereas gender, age, cause of injury, operation mode, operation time, intraoperative fluid replenishment, intraoperative urine volume, intraoperative bleeding volume, American Society of Anesthesiologists grade and sedation maintenance drugs showed no relation to the improvement of postoperative consciousness level (all P>0.05). Multivariate Logistic regression analysis showed that the GCS ≥7 points on admission ( OR=0.06, 95% CI 0.01, 0.36, P<0.01), preoperative minimally conscious state ( OR=0.09, 95% CI 0.02, 0.40, P<0.01) and intraoperative use of Sufentanil combined with Remifentanil ( OR=0.07, 95% CI 0.01, 0.43, P<0.01) were significantly correlated with postoperative improvement of consciousness level. Conclusion:The GCS on admission (≥7 points), preoperative minimally conscious state and intraoperative use of Sufentanil combined with Remifentanil are independent risk factors affecting short-term postoperative improvement of consciousness level in patients with prolonged disorders of consciousness after sTBI.
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Spasticity is a kind ofdyskinesia that often occurs after central nervous system injury.The reason for its occurrence is caused by lack of control and recombination of pyramidal system and extrapyramidal nerve fibers,and often leads to increased tension and hyperreflexia of affected muscle groups.For patients with chronic disorders of consciousness (DoC) after brain injury,the occurrence of such symptoms is very common,but effective treatment is rarely reported.The current treatment mainly includes intrathecal injection of baclofen and soft splint to solve joint contracture.Other therapeutic schemes still need further research,including acupuncture,botulinum toxin injection,and deep brain electrical stimulation.This article is summarized as follows.
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Disorders of consciousness (DOCs) is a kind of special brain disease. At present, scientific research and clinical workers are committed to explore scientific and effective neuromodulation, so as to better improve level of consciousness of patients. Repetitive transcranial magnetic stimulation (rTMS) and transcranial direct current stimulation (tCDS) have been applied to the field of DOCs and have produced positive regulatory effects. The author summarizes the research results of noninvasive neuromodulation in DOCs in recent years, and summarizes the effective stimulation parameters of different neuromodulation methods, hoping to guide the scientific research on mechanism of noninvasive neuromodulation and optimal selection of noninvasive neuromodulation in clinical practice in the future.
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With the development of first aid and severe medical technology,more and more patients are turning from severe coma to chronic disorder of consciousness (DOC),and the incidence rate of children is high.The treatments and prognoses of DOC in children are important issues related to family and society.This article reviews the diagnoses and scales,the research status of clinical drug therapy and non-invasive,invasive nerve stimulation therapies and hyperbaric oxygen therapy of DOC in childem.
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Objective To investigate the application value of auditory mismatch negativity (aMMN) in evaluating the brain function of patients with chronic disorders of consciousness (DOC). Methods Thirty-three patients with DOC or escaped minimally conscious state (eMCS), admitted to our hospital from April to June 2018, were selected in this study. Based on the levels of consciousness assessed by Coma Recovery Scale-Revised (CRS-R), they were divided into vegetative state (VS) group, micro-consciousness state (MCS) group and eMCS group; 14 healthy subjects were included as control group. The differences of aMMN amplitude and latency in patients from different groups, patients with different etiologies and different lateral cerebra were compared. Pearson correlation analysis was used to determine the correlation between CRS-R scores and aMMN. Results (1) There was statistically significant difference in aMMN amplitude between patients from any two groups (P<0.05); as compared with that in the control group, the latency of VS group and MCS group was significantly increased (P<0.05). (2) According to the etiology, the aMMN amplitude of brain injury group, cerebral hemorrhage group and hypoxic encephalopathy group was significantly lower than that of control group (P<0.05). (3) There was significant difference in the amplitude of aMMN between lesion side and contralateral side in 11 patients (t=5.798, P=0.000). (4) Statistical results showed that CRS-R scores were positively correlated with aMMN amplitude (R=0.876, P=0.000), but not with the latency (r=0.018, P=0.922). Conclusion The amplitude of aMMN is significantly positively correlated with levels of consciousness in DOC patients, which can be used as an important tool to assess the levels of consciousness and dynamically estimate the outcomes of consciousness in DOC patients.
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Mismatch negativity is a kind of event-related evoked potential (ERP),which is an automatic response of the brain to relevant events without active participation,especially suitable for uncoordinated patients with disorders of consciousness.In recent years,it has been more and more widely used in the diagnosis and prognosis prediction of disorders of consciousness.This is a review about the latest progress of the clinical application of mismatch negativity in the area of disorders of consciousness.
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Treatment for disorders of consciousness (DOCs) is still a Gordian knot. Evidence-based guidelines on the treatment of DOC patients are not currently available, while neuromodulation techniques are seen as a potential treatment. Multiple neuromodulation therapies have been applied. This article reviews the most relevant studies in the literature in order to describe a clear picture of the current state of neuromodulation therapies that could be used to treat DOC patients. Both invasive and non-invasive brain stimulation is discussed. Significant behavioral improvements in prolonged DOCs under neuromodulation therapies are rare. The efficacy of various such therapies remains a matter of debate. Further clinical investigations of existing techniques in larger samples properly controlling for spontaneous recovery are needed, and new approaches are awaited.
Subject(s)
Humans , Brain , General Surgery , Consciousness , Physiology , Consciousness Disorders , Therapeutics , Neurotransmitter Agents , Therapeutic Uses , Transcranial Magnetic Stimulation , Methods , Treatment OutcomeABSTRACT
In recent decades, event-related potentials have been used for the clinical electrophysiological assessment of patients with disorders of consciousness (DOCs). In this paper, an oddball paradigm with two types of frequency-deviant stimulus (standard stimuli were pure tones of 1000 Hz; small deviant stimuli were pure tones of 1050 Hz; large deviant stimuli were pure tones of 1200 Hz) was applied to elicit mismatch negativity (MMN) in 30 patients with DOCs diagnosed using the JFK Coma Recovery Scale-Revised (CRS-R). The results showed that the peak amplitudes of MMN elicited by both large and small deviant stimuli were significantly different from baseline. In terms of the spatial properties of MMN, a significant interaction effect between conditions (small and large deviant stimuli) and electrode nodes was centered at the frontocentral area. Furthermore, correlation coefficients were calculated between MMN amplitudes and CRS-R scores for each electrode among all participants to generate topographic maps. Meanwhile, a significant negative correlation between the MMN amplitudes elicited by large deviant stimuli and the CRS-R scores was also found at the frontocentral area. In consequence, our results combine the above spatial properties of MMN in patients with DOCs, and provide a more precise location (frontocentral area) at which to evaluate the correlation between clinical electrophysiological assessment and the level of consciousness.
Subject(s)
Adolescent , Adult , Aged , Female , Humans , Male , Middle Aged , Acoustic Stimulation , Auditory Perception , Physiology , Brain Injuries , Consciousness Disorders , Electroencephalography , Evoked Potentials , Neuropsychological Tests , Severity of Illness Index , Wavelet AnalysisABSTRACT
Spinal cord stimulation (SCS) is a promising technique for treating disorders of consciousness (DOCs). However, differences in the spatio-temporal responsiveness of the brain under varied SCS parameters remain unclear. In this pilot study, functional near-infrared spectroscopy was used to measure the hemodynamic responses of 10 DOC patients to different SCS frequencies (5 Hz, 10 Hz, 50 Hz, 70 Hz, and 100 Hz). In the prefrontal cortex, a key area in consciousness circuits, we found significantly increased hemodynamic responses at 70 Hz and 100 Hz, and significantly different hemodynamic responses between 50 Hz and 70 Hz/100 Hz. In addition, the functional connectivity between prefrontal and occipital areas was significantly improved with SCS at 70 Hz. These results demonstrated that SCS modulates the hemodynamic responses and long-range connectivity in a frequency-specific manner (with 70 Hz apparently better), perhaps by improving the cerebral blood volume and information transmission through the reticular formation-thalamus-cortex pathway.
Subject(s)
Adolescent , Adult , Female , Humans , Male , Middle Aged , Young Adult , Brain , Consciousness , Physiology , Consciousness Disorders , Therapeutics , Hemodynamics , Physiology , Pilot Projects , Spinal Cord , General Surgery , Spinal Cord Stimulation , MethodsABSTRACT
Stroke is one of the major diseases leading to human death and disability,and prevention and treatment of stroke have become difficult medical problems.A large number of studies have shown that estrogen has significant neuroprotective effect against stroke,but its clinical application has encountered many obstacles.Long-term use of estrogen,especially the activation of estrogen receptor α (ERα) will increase the risk of reproductive system tumors.Recent studies abroad and our previous research have found that activation of estrogen receptor β (ERβ) can significantly alleviate cerebral ischemic injury.In addition,activation of ERβ can also improve the learning and memory abilities of ovariectomized rats.At the same time,ERβ selective agonists lack the ability to stimulate the proliferation of breast or endometrial tissue as compared with estrogen or ERa agonists,so activation of ERβ is expected to be a more safe and effective method for the prevention and treatment of stroke in menopause women.In this paper,we briefly reviewed the neuroprotective effects associated with ERβ signaling pathway in order to provide new ideas and molecular targets for the clinical transformation of estrogen in prevention and treatment against stroke.
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Paroxysmal sympathetic hyperactivity (PSH),which recognized in a subgroup of survivors of severe acquired brain injury,is a syndrome of simultaneous,paroxysmal transient increases in sympathetic (elevated heart rate,blood pressure,respiratory rate,temperature,sweating) and motor (posturing) activity.These symptoms are not specific and can occur in sepsis,epilepsy,malignant hyperthermia,hydrocephalus and many other complications,which is related to confused diagnosis and delayed treatment of PSH.In addition,Patients with PSH have prolonged ICU stays and added healthcare costs.This article discusses the pathophysiological mechanism,clinical diagnostic criteria,and current drug treament measures of PSH,so as to guide rapid diagnosis.
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Assessment of consciousness in patients with disorders of consciousness (DOC) remains a clinical challenge.It is now mainly based on behavioral evaluation,which brings lots of misdiagnoses.Objective measures of the level of consciousness are still needed.Transcranial magnetic stimulation-electroencephalogram (TMS-EEG) allows the stimulation of any given cortical areas and the recording of the immediate electrical cortical response.This technique has been successfully employed to measure the changes in brain complexity under physiological,pharmacological and pathological conditions.TMS-EEG might be a reliable tool to discriminate between conscious and unconscious patients at the single subject level.
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Objective To review systematically the clinical curative effects and time window of hyperbaric oxygen treatment of persistent vegetative state (PVS).Methods All the clinical research articles about hyperbaric oxygen for PVS from January 1990 to December 2013 were retrieved from China national knowledge internet,Wanfang Database and Vip Database (the Chinese key words:vegetative state,the vegetable,or hyperbaric oxygen),and then,a Meta-analysis was conducted.Results Search terms yielded 165 pieces of articles and 19 were included in the final analysis for treatment efficacy;the treatment group included 939 patients and the control group included 659 patients.Totally,17 pieces of articles of time window were included;the patients with onset＜60 d group included 700 patients and the patients with onset＞ 60 d group included 330 patients.The Jadad scores of included articles were not high in general,and the highest scores were two points.Comparable baseline data were demonstrated in all of the articles.Data from articles were pooled and analyzed,and the results showed that the effective rate of treatment group and control group were 67.51％ and 34.45％,with significant difference (Z=12.16,P=0.000,odd ratio=0.25,95％ confidence interval=0.20-0.31).The effective rate of patients with onset＜60 d group and patients with onset≥60 d group was 22.73％ and 63.29％ (Z=9.72,P=0.000,odd ratio=5.21,95％ confidence interval=3.74-7.27) Conclusion Hyperbaric oxygen treatment enjoys better treatment efficacy than conventional treatment;patients with onset＜60 d have better prognosis than patients with onset≥ 60 d.