Coma, Stupor, and Related Disorders of Consciousness

1st Edition, Volume 207 - February 26, 2025
Editors: Peter W. Kaplan, Romergryko G. Geocadin
Language: English
Hardback ISBN:
9 7 8 - 0 - 4 4 3 - 1 3 4 0 8 - 1
eBook ISBN:
9 7 8 - 0 - 4 4 3 - 1 3 4 2 5 - 8

Coma, Stupor, and Related Disorders of Consciousness reviews recent research and best practice in the assessment and treatment of coma, stupor, and disorders of consci… Read more

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Coma, Stupor, and Related Disorders of Consciousness reviews recent research and best practice in the assessment and treatment of coma, stupor, and disorders of consciousness. It encompasses the neural circuits, anatomy & physiology of stupor and coma, differential diagnosis and clinical assessment, imagery, EEGs, therapy/intervention, decision making and prognosis.

Coma, Stupor, and Related Disorders of Consciousness
Cover image
Title page
Table of Contents
Series Page
Copyright
Handbook of Clinical Neurology 3rd Series
Foreword
Preface
Contributors
Chapter 1 Definitions, diagnostic criteria, and clinical assessment scales in disorders of consciousness
Abstract
Introduction
Nomenclature, Nosology, and Diagnostic Criteria for Disorders of Consciousness
Coma
Unresponsive wakefulness state/vegetative state
Minimally conscious state
Emergence from minimally conscious state
Confusional state
Cognitive motor dissociation
Clinical Assessment Scales
Coma Recovery Scale–Revised
Coma Recovery Scale–Revised For Accelerated Standardized Testing
Simplified Evaluation of CONsciousness Disorders
Full Outline of UnResponsiveness Score
Western Neuro Sensory Stimulation Profile
Wessex Head Injury Matrix
Disorders of Consciousness Scale
Sensory Modality Assessment and Rehabilitation Technique
Revised Motor Behavior Tool
Individualized Quantitative Behavioral Assessment
The Curing Coma Campaign
Conclusion
References
Chapter 2 A historical review of consciousness and its disorders
Abstract
Definition of Consciousness
Concepts of Consciousness: Dualism vs Monism
Monism predominates
Further Contributions from Philosophy, Psychology, and Psychiatry
Basic and Medical Science Contributions to Consciousness
Disorders of Brain and Mental Functions
Delirium
Stupor and Coma
Wakefulness With Variable Responsiveness and/or Awareness
The Minimally Conscious State
The Unresponsive Wakefulness Syndrome/Persistent Vegetative State
Brain Death
Remaining Challenges
References
Further reading
Chapter 3 Neuroscience of coma
Abstract
Introduction
Part 1: The Arousal System
Brainstem
Hypothalamus and basal forebrain
White matter tracts
Part 2: Regulation of Arousal Through the Central Thalamus and Mesocircuit
The central thalamus
Intralaminar nuclei
The mesocircuit
Part 3: The Awareness System
Principles of the awareness system
Where is the awareness system?
How does awareness work?
Regulation of the awareness system
Part 4: Integrative Models of Consciousness
Conclusions
References
Chapter 4 A scientific approach to diagnosis of disorders of consciousness
Abstract
Introduction
Contemporary Taxonomy of DoC
Coma
Vegetative state/unresponsive wakefulness syndrome
Minimally conscious state
Emergence from minimally conscious state
Locked-in syndrome
Misdiagnosis and Misprognostication
Behavioral Assessment
Cognitive Motor Dissociation/Covert Consciousness
Neuroimaging Diagnosis of DoC
Stimulus-based fMRI
Resting-state fMRI
Electrophysiologic Diagnosis of DoC
Conventional EEG
Quantitative EEG
Consensus Guidelines and Practical Recommendations
Conclusion
References
Chapter 5 Cardiac arrest and disorders of consciousness
Abstract
Introduction
Consciousness and Disorders of Consciousness
Anatomy and Pathophysiology of Disorders of Consciousness
Pathophysiology of Disorders of Consciousness after Cardiac Arrest
Neurophysiologic Testing and Diagnostic Imaging
Hospital course and management
Neurologic Prognostication
Future Directions
References
Chapter 6 Traumatic brain injury and disorders of consciousness
Abstract
Introduction
Epidemiology and Definitions
Neurobiology of Traumatic DOC
Ascending reticular activating system
Mesocircuit model
Frontoparietal model
Recovery
Diagnostic Testing and Contributions to Prognostication
Clinical exam
Coma Recovery Scale—Revised
Neuroimaging
Structural imaging
Diffuse axonal injury
White matter injury and dysfunction
Functional MRI
Cognitive motor dissociation
Positron emission tomography
Electrophysiology
Electrophysiology in the acute phase and risk of seizure
Electrophysiology in the prolonged and chronic phases
ABCD model
Perturbational complexity index
Evoked potentials
Timeline for Recovery
Predicting Emergence of Consciousness
Prognostication in the acute phase
Prognostication in the prolonged and chronic phases
Clinical factors
Therapeutic Opportunities
Acute phase
Prolonged and chronic phases
Conclusions
References
Chapter 7 Advances in neuroimaging in disorders of consciousness
Abstract
Rationale
Neuroimaging Tools: Basics
CT, PET, and SPECT
MRI
Image Analysis
Diagnosis of DoC Patients Aided With Neuroimaging
CT, PET, and SPECT
MRI
Prognosis of DoC Patients Aided With Neuroimaging
CT, PET, and SPECT
MRI
Future Perspectives and Open Questions
Conclusion
References
Chapter 8 Electrophysiology in disorders of consciousness
Abstract
Introduction
Shortcomings of Purely Behavioral Assessments of Consciousness
Electroencephalography
Electrode placement and artifact
Conventional features
Resting EEG in DoC
Commonly encountered patterns
Seizures and interictal continuum in DoC
Prognostic patterns in DoC after cardiac arrest
Brain death ancillary testing
Sleep architecture
Quantitative EEG
Passive Stimulation
Evoked potentials
Event-related potentials
Transcranial magnetic stimulation—EEG
Active paradigms
Detection of cognitive-motor dissociation in acute DoC using EEG
Toward an Updated Taxonomy of DoC
Integration of Electrophysiology Studies in Clinical Practice
Challenges and Future Applications of EEG in DoC
References
Chapter 9 Evoked potentials in patients with disorders of consciousness
Abstract
Introduction
General Principles of Evoked Potentials
Evoked Potentials in Acute Disorders of Consciousness
Short-Latency SSEPs After Cardiac Arrest
Influence of filters, sedation, hypothermia, and timing of recordings on findings
Bilaterally Absent Short-Latency SSEP (N20) in Patients After CA
False-Positive Bilaterally Absent N20 After Cardiac Arrest
Short-Latency SSEP Amplitudes (N20-P25) and Outcome Prediction After Cardiac Arrest
Potential self-fulfilling prophecy
High-Frequency Oscillations in Short-Latency SSEPs
Short-Latency SSEPs and Outcome Prediction in Traumatic Brain Injury
Middle-Latency SSEP—N70
Short- and Middle-Latency AEP and Outcome Prediction in Acute DoC
VEP and Outcome Prediction in Patients After Cardiac Arrest
Long-Latency/Event-Related Potentials
Mismatch Negativity in Patients With DoC
P300/P3 (and Later ERPs) in Patients With DoC
Guideline Recommendations on ERPs in Patients With Chronic DoC
Conclusions
References
Chapter 10 Blood and cerebrospinal fluid biomarkers in disorders of consciousness
Abstract
Introduction
Neuronal Biomarkers
Neuron-specific enolase
Neurofilament light chain
Tau protein
Ubiquitin C-terminal hydrolase L1
α-II Spectrin
Glial Biomarkers
S100B
Glial fibrillary acidic protein
Inflammatory Biomarkers
Metabolic Biomarkers
Limitations and Recommendations for Future Biomarker Research
References
Chapter 11 Medical and surgical treatments in disorders of consciousness
Abstract
Introduction
Medical Treatment Strategies for Disorders of Consciousness
Dopaminergic drugs
Gamma-aminobutyric acid (GABA)-agonistic drugs
Surgical Treatment Strategies for Disorders of Consciousness
Deep brain stimulation
Vagal nerve stimulation
Conclusions and Future Directions
Conflicts of interest
References
Further reading
Chapter 12 Non-pharmacologic interventions in disorders of consciousness
Abstract
Management Strategies to Promote Recovery After Coma: Where We Stand
Introduction to disorders of consciousness and clinical management strategies
Pathophysiologic models for severe brain injuries and recovery
Brain stimulations therapies
From Research to Practice_ Challenges for Translation to Clinical Setting
Identify the optimal stimulation parameters and reveal their precise mechanisms of action
Develop patient-fitted interventions based on endotype and phenotype
Conclusions
Conflict of interest statement
References
Chapter 13 Emerging ethical issues in patients with disorders of consciousness: A clinical guide
Abstract
Historical Context
Ethical Issues in Diagnosis
Ethical Issues in Prognosis
The fallacy of the self-fulfilling prophecy
Barriers to communication with surrogates
Prognostic implications of identifying cognitive-motor dissociation
Principles of Surrogate Decision-Making
Shared decision-making
Optimal Medical Care
Refusal of Life-Sustaining Therapy
Neuropalliative Care
Human Rights and Systems of Care
Future Directions
References
Chapter 14 Neurologic prognostication in coma and disorders of consciousness
Abstract
Introduction
Coma and DoC
Definitions
Pathophysiology of DoC
Neurologic Prognostication in DoC After Severe Acute Brain Injury
Limitations of current prognostication practices
Comatose survivors of cardiac arrest
Prognostic markers in clinical practice
DoC in acute ischemic stroke
DoC in traumatic brain injury
DoC in intracerebral hemorrhage
DoC in aneurysmal subarachnoid hemorrhage
Other DoC
Future Perspectives
Conclusion
References
Chapter 15 The Curing Coma Campaign: A platform for advancing science and clinical care worldwide
Abstract
Introduction
Coma and Disorders of Consciousness: Where We Came From
Beyond Clinical Assessment
The Problem of Prognostication
Coma as a Disease Entity
A Blue Ocean for Neurocritical Care Research
What Is the Curing Coma Campaign?
Who Is the Curing Coma Campaign?
Curing Coma Campaign Work to Date
National Institutes of Health Symposia
Gap analyses in coma science
Ethics
Initial CCC research studies
World Coma Day
The Worldwide Challenge of Curing Coma
Scope
Customs
Resources
Defining Success for Curing Coma
Is this really a “moonshot”?
The science of consciousness
New treatments for coma and DoC
Making coma care available and accessible
Culture change in the care of patients with coma and DoC
Future Directions
References
Index

Peter W. Kaplan

Dr. Peter Kaplan is Professor of Neurology and serves as the Director of Epilepsy and EEG at Johns Hopkins Bayview Medical Center. He focuses on epilepsy, clinical neurophysiology and nonconvulsive status epilepticus. He has written extensively about these subjects as well as about eclampsia and neurologic disease in women. Dr. Peter Kaplan received his medical training from St. Bartholomews Medical School, University of London. He then obtained membership to the Royal College of Physicians in England. He completed his residency in neurology at Duke University Medical Center. He completed fellowships in epilepsy and clinical neurophysiology at the same institution.

Affiliations and expertise

Professor of Neurology, Johns Hopkins Bayview Medical Center, USA

Romergryko G. Geocadin

Dr. Romergryko G. Geocadin is a professor of neurology, neurosurgery, and anesthesiology-critical care medicine at the Johns Hopkins University School of Medicine in Baltimore, Maryland. He also currently serves as Co-Chair of the Johns Hopkins Clinician-Scientist Career Development Award Committee and is the Co-Founder/Co-Director of the Johns Hopkins Encephalitis Center. Dr. Geocadin completed his undergraduate education at the University of the Philippines-Diliman Campus, followed by his medical education at UERM School of Medicine in the Philippines, neurology residency at New York University, and neurocritical care clinical and research fellowship at Johns Hopkins University. He was founding Director of the Johns Hopkins Bayview Medical Center - Multidisciplinary Neurocritical Care Unit and past Chair of the Johns Hopkins Multidisciplinary Critical Care practice committee. Dr. Geocadin’s research, which focuses on translational studies on acute disorders of consciousness from animal models to clinical trials in brain injury after cardiac arrest resuscitation, is funded by the National Institutes of Health (NIH). He is one of the Principal Investigators for the ICECAP trial under the SIREN Network. Dr. Geocadin has led or contributed to the development of numerous practice guidelines, scientific statements, and reports from the American Academy of Neurology (AAN), American Heart Association, The Joint Commission, and the Institutes of Medicine on resuscitation and disorders of consciousness. Additionally. Dr. Geocadin was the Past President of the Neurocritical Care Society and the Vice President of the American Neurological Association from 2022 to 2024.

Affiliations and expertise

Johns Hopkins Bayview Medical Center, Department of Neurology, Baltimore, MD, USA

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