BACKGROUND: The vegetative state (VS) after severe acute brain injury (SABI) is associated with significant prognostic uncertainty and poor long-term functional outcomes. However, it is generally distinguished from imminent death and is exempt from the Life-Sustaining Treatment (LST) Decisions Act in Korea. Here, we aimed to examine the perspectives of the general population (GP) and clinicians regarding decisions on mechanical ventilator withdrawal in patients in a VS after SABI.
METHODS: A cross-sectional survey was undertaken, utilizing a self-reported online questionnaire based on a case vignette. Nationally selected by quota sampling, the GP comprised 500 individuals aged 20 to 69 years. There were 200 doctors from a tertiary university hospital in the clinician sample. Participants were asked what they thought about mechanical ventilator withdrawal in patients in VS 2 months and 3 years after SABI.
RESULTS: Two months after SABI in the case, 79% of the GP and 83.5% of clinicians had positive attitudes toward mechanical ventilator withdrawal. In the GP, attitudes were associated with spirituality, household income, religion, the number of household members. On the other hand, clinicians\' attitudes were related to their experience of completing advance directives (AD) and making decisions about LST. In this case, 3 years after SABI, 92% of the GP and 94% of clinicians were more accepting of ventilator withdrawal compared to previous responses, based on the assumption that the patient had written AD. However, it appeared that the proportion of positive responses to ventilator withdrawal decreased when the patients had only verbal expressions (82% of the GP; 75.5% of clinicians) or had not previously expressed an opinion regarding LST (58% of the GP; 39.5% of clinicians).
CONCLUSIONS: More than three quarters of both the GP and clinicians had positive opinions regarding ventilator withdrawal in patients in a VS after SABI, which was reinforced with time and the presence of AD. Legislative adjustments are needed to ensure that previous wishes for those patients are more respected and reflected in treatment decisions.

BACKGROUND: In recent years, prolonged states of impaired consciousness became widespread among patients with aneurysmal subarachnoid hemorrhage. Treatment and maintenance of vital functions in such patients represent a complex medical, economic and social problem. In this regard, searching for the causes of prolonged states of impaired consciousness and predicting the outcomes are important.
OBJECTIVE: To analyze available literature data on prevention and treatment of prolonged states of impaired consciousness after aneurysmal subarachnoid hemorrhage.
RESULTS: We reviewed the PubMed database using the keywords «unresponsive wakefulness syndrome», «persistent vegetative state2, «minimal consciousness state» and «outcome of subarachnoid hemorrhage». Only 4 reports devoted to the causes and treatment outcomes in patients with prolonged impairment of consciousness after aneurysmal subarachnoid hemorrhage were found. At the same time, patients with aneurysmal subarachnoid hemorrhage comprise up to 11% among all cases of prolonged states of impaired consciousness. Examination, management and treatment of patients with prolonged impairment of consciousness after aneurysmal subarachnoid hemorrhage are carried out according to general principles without taking into account specific etiological and pathogenetic factors.
CONCLUSIONS: Increased number of patients with prolonged impairment of consciousness after aneurysmal subarachnoid hemorrhage necessitates analysis of etiopathogenesis and outcomes of these disorders based on modern clinical, instrumental and laboratory assessment of the brain.
В последние годы среди больных, перенесших аневризматическое субарахноидальное кровоизлияние (аСАК), наблюдается неуклонный рост исходов с формированием состояний длительного нарушения сознания (ДНС). Лечение и поддержание жизнедеятельности таких больных представляет сложную медицинскую, экономическую и социальную проблему. В связи с этим поиск причин развития ДНС и прогнозирование его исходов становится все более актуальным.
UNASSIGNED: Анализ публикаций по проблеме профилактики развития и лечения ДНС у больных после аСАК.
UNASSIGNED: При поисковом запросе в PubMed по ключевым словам «unresponsive wakefulness syndrome», «persistent vegetative state», «minimal consciousness state», «outcome of subarachnoid hemorrhage» обнаружено только 4 публикации, анализирующие причины и исходы лечения пациентов с ДНС исключительно у больных после аСАК. В то же время пациенты с аСАК составляют до 11% в группах больных с ДНС различной этиологии. Обследование, ведение и лечение больных с ДНС после аСАК проводится в целом по общим принципам, без учета специфики этипатогенетических факторов.
UNASSIGNED: Увеличение доли больных с аСАК с исходом в ДНС обосновывает необходимость отдельного анализа этиопатогенеза и исходов ДНС в этой группе на основе современных методов клинической, инструментальной и лабораторной оценки состояния мозга.

BACKGROUND: Caregivers\' involvement in the diagnostic and monitoring processes of the level of consciousness of patients with Disorders of Consciousness (DoC) is strongly encouraged by international guidelines, as current literature suggests a better chance to detect behavioural responses when caregivers are involved in clinical assessments. Since caregivers\' involvement during clinical assessments can be difficult, the Social And Family Evaluation (SAFE) scale has been recently proposed as a standardised tool that caregivers can autonomously use to collect their opinions about the level of consciousness of patients with DoC, based on the behaviours manifested by the patients in a given time-window.
OBJECTIVE: Providing preliminary results concerning SAFE adoption.
METHODS: 22 patients with DoC were assessed through the Coma Recovery Scale-revised (CRS-r), while their caregivers filled-in the SAFE.
RESULTS: The SAFE showed a very high internal consistency, very high test-retest reliability, and high criterion validity when correlated to the CRS-r total score. Moreover, in line with the literature, the SAFE allowed the detection of some behaviours indicative of a higher level of consciousness than those detected by clinicians through the CRS-r in more than half of the sample.
CONCLUSIONS: Overall, these preliminary data are promising for the adoption of the SAFE to collect the opinions of the caregivers about the level of consciousness of patients with DoC, especially in those settings where it would be otherwise difficult to monitor the patients, such as long-term care structures and at home, as a tool for telemedicine allowing the monitoring of patients in remote settings.

One of the most probable causes of effective therapy for post-comatose disorders of consciousness is the lack of individualization of drug prescriptions. In this observational study, we analyzed 48 courses of neuromodulatory therapy in 28 patients with prolonged and chronic disorders of consciousness following severe traumatic brain injury. Comparison of 24 effective and 24 ineffective courses demonstrated higher effectiveness of pharmacotherapy through its individualization, i.e. the choice of a drug whose neuromodulatory spectrum would correspond to neurological syndromes of neurotransmitter dysfunction. In this approach, 74% of therapy courses were effective while opposite management resulted only 34% of effective courses.
Одной из наиболее вероятных причин неудач поиска эффективной терапии посткоматозных расстройств сознания является отсутствие индивидуализации лекарственных назначений. В настоящем наблюдательном исследовании проанализировано 48 курсов нейромодуляторной терапии у 28 пациентов с продленными и хроническими нарушениями сознания вследствие тяжелой черепно-мозговой травмы. Сопоставление 24 эффективных и 24 неэффективных курсов продемонстрировало возможность повышения эффективности фармакотерапии путем ее индивидуализации — выбора препарата, нейромодуляторный спектр действия которого соответствовал бы неврологическим синдромам нейромедиаторной дисфункции. При таком соответствии эффективными были 74% курсов терапии, при несоответствии — 34%.

Disorders of consciousness (DoC) are generally diagnosed by clinical assessment, which is a predominantly motor-driven process and accounts for up to 40 % of non-communication being misdiagnosed as unresponsive wakefulness syndrome (UWS) (previously known as prolonged/persistent vegetative state). Given the consequences of misdiagnosis, a more reliable and objective multimodal protocol to diagnosing DoC is needed, but has not been produced due to concerns regarding their interpretation and reliability. Of the techniques commonly used to detect consciousness in DoC, task-based paradigms (active paradigms) produce the most unequivocal result when findings are positive. It is well-established that command following (CF) reliably reflects preserved consciousness. Task-based electroencephalography (EEG) and functional magnetic resonance imaging (fMRI) can detect motor-independent CF and reveal preserved covert consciousness in up to 14 % of UWS patients. Accordingly, to improve the diagnostic accuracy of DoC, we propose a practical multimodal clinical decision framework centered on task-based EEG and fMRI, and complemented by measures like transcranial magnetic stimulation (TMS-EEG).

BACKGROUND: Research on disorders of consciousness in children is scarce and includes disparate and barely comparable participants and assessment instruments and therefore provides inconclusive information on the clinical progress and recovery in this population. This study retrospectively investigated the neurobehavioral progress and the signs of transition between states of consciousness in a group of children admitted to a rehabilitation program either with an unresponsive wakefulness syndrome (UWS) or in a minimally conscious state (MCS).
METHODS: Systematic weekly assessments were conducted with the Coma Recovery Scale-Revised (CRS-R) until emergence from MCS, discharge, or death.
RESULTS: Twenty-one children, nine admitted with a UWS and 12 admitted in an MCS, were included in the study. Four children with a UWS transitioned to an MCS with a CRS-R of 10 (9.2 to 12.2) by showing visual pursuit, visual fixation, or localization to noxious stimulation. Twelve children emerged from the MCS with a CRS-R of 20.5 (19 to 21.7). Children who emerged from the MCS had had a shorter time postinjury and higher CRS-R at admission, compared with those who did not emerge.
CONCLUSIONS: Almost half of the children who were admitted with a UWS transitioned to an MCS, and almost all who were admitted in an MCS emerged from this state. Children who emerged had shorter times since injury and higher scores on the CRS-R at admission, compared with those who did not emerge.

Non-invasive brain stimulation is considered as a promising technology for treating patients with disorders of consciousness (DOC). Various approaches and protocols have been proposed; however, few of them have shown potential effects on patients with vegetative state (VS). This study aimed to explore the neuro-modulation effects of intermittent theta burst stimulation (iTBS) on the brains of patients with VS and to provide a pilot investigation into its possible role in treating such patients.
We conducted a sham-controlled crossover study, a real and a sham session of iTBS were delivered over the left dorsolateral prefrontal cortex of such patients. A measurement of an electroencephalography (EEG) and a behavioral assessment of the Coma Recovery Scale-Revised (CRS-R) were applied to evaluate the modulation effects of iTBS before and after stimulation.
No meaningful changes of CRS-R were found. The iTBS altered the spectrum, complexity and functional connectivity of the patients. The real stimulation induced a trend of decreasing of delta power at T1 and T2 in the frontal region, significant increasing of permutation entropy at the T2 in the left frontal region. In addition, brain functional connectivity, particularly inter-hemispheric connectivity, was strengthened between the electrodes of the frontal region. The sham stimulation, however, did not induce any significant changes of the brain activity.
One session of iTBS significantly altered the oscillation power, complexity and functional connectivity of brain activity of VS patients. It may be a valuable tool on modulating the brain activities of patients with VS.

National guidelines provide advice for end-of-life care in patients with prolonged disorders of consciousness (PDOC). Following a Supreme Court judgment in July 2018, updated guidelines set out requirements to ensure that decisions to withdraw clinically assisted nutrition and hydration (CANH) are made responsibly in the absence of a mandatory application to the court. This retrospective 8-year cohort analysis of prospectively collected clinical data examines the experience and lessons learned from implementing the guidelines in the 80 PDOC patients who have died in one tertiary centre since 2014. It also reports performance against the standards for elective withdrawal of CANH outside of court since July 2018. CANH was withdrawn in 39/80 (49%) of the patients, over half of whom were already imminently dying. Even in a centre where patients are referred for this purpose, elective CANH withdrawal is comparatively rare (just 14 patients since 2018). The requirements were met in all cases.

Historically, clinical evaluation of unresponsive patients following brain injury has relied principally on serial behavioral examination to search for emerging signs of consciousness and track recovery. Advances in neuroimaging and electrophysiologic techniques now enable clinicians to peer into residual brain functions even in the absence of overt behavioral signs. These advances have expanded clinicians\' ability to sub-stratify behaviorally unresponsive and seemingly unaware patients following brain injury by querying and classifying covert brain activity made evident through active or passive neuroimaging or electrophysiologic techniques, including functional MRI, electroencephalography (EEG), transcranial magnetic stimulation-EEG, and positron emission tomography. Clinical research has thus reciprocally influenced clinical practice, giving rise to new diagnostic categories including cognitive-motor dissociation (i.e. \'covert consciousness\') and covert cortical processing (CCP). While covert consciousness has received extensive attention and study, CCP is relatively less understood. We describe that CCP is an emerging and clinically relevant state of consciousness marked by the presence of intact association cortex responses to environmental stimuli in the absence of behavioral evidence of stimulus processing. CCP is not a monotonic state but rather encapsulates a spectrum of possible association cortex responses from rudimentary to complex and to a range of possible stimuli. In constructing a roadmap for this evolving field, we emphasize that efforts to inform clinicians, philosophers, and researchers of this condition are crucial. Along with strategies to sensitize diagnostic criteria and disorders of consciousness nosology to these vital discoveries, democratizing access to the resources necessary for clinical identification of CCP is an emerging clinical and ethical imperative.

The current classification scheme for severe disorders of consciousness (DoC) has several shortcomings. First, there is no consensus on how to incorporate patients with covert consciousness. Second, there is a mismatch between the definitions of severe DoC, based on consciousness, and the diagnosis of these same DoC, which is based on observable motoric responsiveness. Third, current categories are grouped into large heterogeneous syndromes which share phenotype, but do not incorporate underlying pathophysiology. Here we discuss several ethical issues pertaining to the current nosology of severe DoC. We conclude by proposing a revised nosology which addresses these shortcomings.