Novel approaches to prediction in severe brain injury.

PURPOSE OF REVIEW: Recovery after severe brain injury is variable and challenging to accurately predict at the individual patient level. This review highlights new developments in clinical prognostication with a special focus on the prediction of consciousness and increasing reliance on methods from data science. RECENT FINDINGS: Recent research has leveraged serum biomarkers, quantitative electroencephalography, MRI, and physiological time-series to build models for recovery prediction. The analysis of high-resolution data and the integration of features from different modalities can be approached with efficient computational techniques. SUMMARY: Advances in neurophysiology and neuroimaging, in combination with computational methods, represent a novel paradigm for prediction of consciousness and functional recovery after severe brain injury. Research is needed to produce reliable, patient-level predictions that could meaningfully impact clinical decision making.

Divergent neural responses to narrative speech in disorders of consciousness.

Objective: Clinical assessment of auditory attention in patients with disorders of consciousness is often limited by motor impairment. Here, we employ intersubject correlations among electroencephalography responses to naturalistic speech in order to assay auditory attention among patients and healthy controls. Methods: Electroencephalographic data were recorded from 20 subjects with disorders of consciousness and 14 healthy controls during of two narrative audio stimuli, presented both forwards and time-reversed. Intersubject correlation of evoked electroencephalography signals were calculated, comparing responses of both groups to those of the healthy control subjects. This analysis was performed blinded and subsequently compared to the diagnostic status of each patient based on the Coma Recovery Scale-Revised. Results: Subjects with disorders of consciousness exhibit significantly lower intersubject correlation than healthy controls during narrative speech. Additionally, while healthy subjects had higher intersubject correlation values in forwards versus backwards presentation, neural responses did not vary significantly with the direction of playback in subjects with disorders of consciousness. Increased intersubject correlation values in the backward speech condition were noted with improving disorder of consciousness diagnosis, both in cross-sectional analysis and in a subset of patients with longitudinal data. Interpretation: Intersubject correlation of neural responses to narrative speech audition differentiates healthy controls from patients and appears to index clinical diagnoses in disorders of consciousness.

Clinical, hemispheric, and autonomic changes associated with use of closed-loop, allostatic neurotechnology by a case series of individuals with self-reported symptoms of post-traumatic stress.

BACKGROUND: The objective of this pilot study was to explore the use of a closed-loop, allostatic, acoustic stimulation neurotechnology for individuals with self-reported symptoms of post-traumatic stress, as a potential means to impact symptomatology, temporal lobe high frequency asymmetry, heart rate variability (HRV), and baroreflex sensitivity (BRS). METHODS: From a cohort of individuals participating in a naturalistic study to evaluate use of allostatic neurotechnology for diverse clinical conditions, a subset was identified who reported high scores on the Posttraumatic Stress Disorder Checklist (PCL). The intervention entailed a series of sessions wherein brain electrical activity was monitored noninvasively at high spectral resolutions, with software algorithms translating selected brain frequencies into acoustic stimuli (audible tones) that were delivered back to the user in real time, to support auto-calibration of neural oscillations. Participants completed symptom inventories before and after the intervention, and a subset underwent short-term blood pressure recordings for HRV and BRS. Changes in temporal lobe high frequency asymmetry were analyzed from baseline assessment through the first four sessions, and for the last four sessions. RESULTS: Nineteen individuals (mean age 47, 11 women) were enrolled, and the majority also reported symptom scores that exceeded inventory thresholds for depression. They undertook a median of 16 sessions over 16.5 days, and 18 completed the number of sessions recommended. After the intervention, 89% of the completers reported clinically significant decreases in post-traumatic stress symptoms, indicated by a change of at least 10 points on the PCL. At a group level, individuals with either rightward (n = 7) or leftward (n = 7) dominant baseline asymmetry in temporal lobe high frequency (23-36 Hz) activity demonstrated statistically significant reductions in their asymmetry scores over the course of their first four sessions. For 12 individuals who underwent short-term blood pressure recordings, there were statistically significant increases in HRV in the time domain and BRS (Sequence Up). There were no adverse events. CONCLUSION: Closed-loop, allostatic neurotechnology for auto-calibration of neural oscillations appears promising as an innovative therapeutic strategy for individuals with symptoms of post-traumatic stress. TRIALS REGISTRATION: ClinicalTrials.gov #NCT02709369 , retrospectively registered on March 4, 2016.

Executive attention deficits after traumatic brain injury reflect impaired recruitment of resources.

Deficits in attention are a common and devastating consequence of traumatic brain injury (TBI), leading to functional impairments, rehabilitation barriers, and long-term disability. While such deficits are well documented, little is known about their underlying pathophysiology hindering development of effective and targeted interventions. Here we evaluate the integrity of brain systems specific to attentional functions using quantitative assessments of electroencephalography recorded during performance of the Attention Network Test (ANT), a behavioral paradigm that separates alerting, orienting, and executive components of attention. We studied 13 patients, at least 6 months post-TBI with cognitive impairments, and 24 control subjects. Based on performance on the ANT, TBI subjects showed selective impairment in executive attention. In TBI subjects, principal component analysis combined with spectral analysis of the EEG after target appearance extracted a pattern of increased frontal midline theta power (2.5-7.5 Hz) and suppression of frontal beta power (12.5-22.5 Hz). Individual expression of this pattern correlated (r = - 0.67, p < 0.001) with executive attention impairment. The grading of this pattern of spatiotemporal dynamics with executive attention deficits reflects impaired recruitment of anterior forebrain resources following TBI; specifically, deafferentation and variable disfacilitation of medial frontal neuronal populations is proposed as the basis of our findings.

Neural correlates of intentional switching from ternary to binary meter in a musical hemiola pattern.

Musical rhythms are often perceived and interpreted within a metrical framework that integrates timing information hierarchically based on interval ratios. Endogenous timing processes facilitate this metrical integration and allow us using the sensory context for predicting when an expected sensory event will happen ("predictive timing"). Previously, we showed that listening to metronomes and subjectively imagining the two different meters of march and waltz modulated the resulting auditory evoked responses in the temporal lobe and motor-related brain areas such as the motor cortex, basal ganglia, and cerebellum. Here we further explored the intentional transitions between the two metrical contexts, known as hemiola in the Western classical music dating back to the sixteenth century. We examined MEG from 12 musicians while they repeatedly listened to a sequence of 12 unaccented clicks with an interval of 390 ms, and tapped to them with the right hand according to a 3 + 3 + 2 + 2 + 2 hemiola accent pattern. While participants listened to the same metronome sequence and imagined the accents, their pattern of brain responses significantly changed just before the "pivot" point of metric transition from ternary to binary meter. Until 100 ms before the pivot point, brain activities were more similar to those in the simple ternary meter than those in the simple binary meter, but the pattern was reversed afterwards. A similar transition was also observed at the downbeat after the pivot. Brain areas related to the metric transition were identified from source reconstruction of the MEG using a beamformer and included auditory cortices, sensorimotor and premotor cortices, cerebellum, inferior/middle frontal gyrus, parahippocampal gyrus, inferior parietal lobule, cingulate cortex, and precuneus. The results strongly support that predictive timing processes related to auditory-motor, fronto-parietal, and medial limbic systems underlie metrical representation and its transitions.

Detecting perturbations in polyrhythms: effects of complexity and attentional strategies.

Jones et al. in Journal of Experimental Psychology Human Perception and Performance 21:293-307, 1995, showed that a temporal perturbation is easier to detect in a 3:2 polyrhythm than in a single-stream isochronous baseline condition if the two isochronous pulse streams forming the polyrhythm are perceptually integrated: integration creates shorter inter-onset interval (IOI) durations that facilitate perturbation detection. The present study examined whether this benefit of integration outweighs the potential costs imposed by the greater IOI heterogeneity and memory demands of more complex polyrhythms. In "Experiment 1", musically trained participants tried to detect perturbations in 3:5, 4:5, 6:5, and 7:5 polyrhythms having one of two different pitch separations between pulse streams, as well as in an isochronous baseline condition. "Experiment 2" included an additional 2:5 polyrhythm, additional pitch separations, and instructions to integrate or segregate the two pulse streams. In both experiments, perturbation detection scores for polyrhythms were below baseline, decreased as polyrhythm complexity increased, and tended to be lower at a smaller pitch separation, with little effect of instructions. Clearly, polyrhythm complexity was the main determinant of detection performance, which is attributed to the interval heterogeneity and/or memory demands of the pattern formed by the integrated pulse streams. In this task, perceptual integration was disadvantageous, but apparently could not be avoided.