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Behavioral markers of recovery of consciousness after severe brain injury

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Behavioral Markers of Recovery of

Consciousness After Severe Brain Injury

13th World Congress on Brain Injury, March 2019

Géraldine Martens

1,2

, Yelena G. Bodien

1,3

, Joseph

T. Giacino

1

1 Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Harvard Medical School, Boston, MA 2 Coma Science Group, GIGA-Consciousness & Neurology Department, University and University Hospital of Liege, Liege, Belgium

(2)

Background

Laureys, Scientific American, 2007

?

Vegetative State/Unresponsive Wakefulness Syndrome

Visual pursuit

& Visual

Fixation

(Bagnato et al.

2016)

(3)

Background

Coma Recovery Scale-Revised (CRS-R)

11 signs of MCS * 2 signs of EMCS †

(4)

Aims

Primary: determine frequency of conscious

CRS-R behaviors emerging first in patients

transitioning from VS/UWS to MCS (or

EMCS)

Secondary: time to emergence; influence of

etiology (TBI vs. nTBI)

4 VS/UWS VS/UWS MCS MCS VS/UWS

CRS-R assessments (2-3/week)

(5)

Methods

Retrospective observational database study on

metrics collected by clinicians in an inpatient

rehabilitation setting with a specialized DOC

program (SRH).

Inclusion Criteria

≥16 y/o

Diagnosed coma or VS/UWS on admission

Transitioned to MCS or EMCS during

inpatient rehab on 2 consecutive CRS-R

obtained within the same week

(6)

Results: Study Sample

79/324 patients eligible admitted between

June 2012 and August 2017

(7)

Results: Primary Aim

57 patients showed only 1 sign of consciousness

(72%)

7

Visual Pursuit Reproducible Movement to Command Automatic Movement Intentional Communication Fixation Localization to Noxious Stimulation Intelligible Verbalization Object Manipulation Consistent Movement to Command Functional Object Use Object Localization Object Recognition Functional Communication 0 5 10 15 20 25 30 35 40 45 41 25 24 15 13 8 6 5 3 3 3 1 0 % C R S-R i te m s d e n o ti n g c o n sc io u sn e ss N=79

(8)

Results: TBI vs. nTBI

8

Visual Pursuit Reproducible Movement to Command Visual Fixation Intentional Communication Automatic Movement Object Manipulation Localization to Pain Consistent Movement to Command Intelligible Verbalization Object Recognition Object Localization Functional Object Use Functional Communication

0 5 10 15 20 25 30

TBI %non-TBI

*

(9)

Summary

9

Top 3 – Visual Pursuit, Reproducible Movement

to Command & Automatic Movement: consistent

with (few) previous findings

~44 days to transition from unconsciousness to

consciousness (TBI & nTBI)

At transition, TBI patients show significantly

more Automatic Movement

Limitations: low sample size, single-site study

(selection bias), retrospective analysis

(10)

Conclusion

10

Clinicians: behavioral assessment methods

should be sensitive to the detection of behaviors

that signal the transition to consciousness

Researchers: future studies should investigate

the association between time to emergence of

specific conscious behaviors and long-term

(11)
(12)

Disclosure

Presenter has no relevant financial or non-financial interest to disclose.

This continuing education activity is managed and accredited by AffinityCE in cooperation with the

International Brain Injury Association. AffinityCE, IBIA, and all accrediting organizations do not support or endorse any product or service mentioned in this activity. Disclosure will be made when a product is discussed for an unapproved use. AffinityCE staff, IBIA staff, planners, and reviewers have no relevant financial or non-financial interests to disclose.

(13)

13

72% of patients presented with

a single behavioral feature of

MCS or EMCS at time of

transition

(14)

14

These patients (72%) mainly presented visual pursuit

(15)

15

Supplementary

Table II: CRS-R assessments per subject

Days of CRS-R monitoring 60.5 [41.5 – 97.5]

a

Days between

consecutive assessments

4 [3 – 5]

Number of assessments

between admission and

discharge

16 [11 – 24.75]

Number of assessments

between admission and

transition to

consciousness

(16)

16

Figure

Table II: CRS-R assessments per subject

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