Deep brain stimulation in five patients with severe disorders of consciousness

Lemaire, Jean‐Jacques; Sontheimer, Anna; Pereira, Bruno; Coste, Jérôme; Rosenberg, Sarah; Sarret, Catherine; Coll, Guillaume; Gabrillargues, Jean; Jean, Betty; Gillart, Thierry; Coste, Aurélien; Roche, Basile; Kelly, A.; Pontier, Bénédicte; Feschet, Fabien

doi:10.1002/acn3.648

Cited by 49 publications

(37 citation statements)

References 44 publications

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“…Since 1968, a systematic review of the literature (through Medline, Embase, and web of Science) found that ten studies reporting 78 unique DoC patients who underwent DBS have been published ( Table 1 ) ( McLardy et al, 1968 ; Tsubokawa et al, 1990 ; Cohadon and Richer, 1993 ; Schiff et al, 2007 ; Yamamoto et al, 2010 ; Wojtecki et al, 2014 ; Adams et al, 2016 ; Magrassi et al, 2016 ; Chudy et al, 2018 ; Lemaire et al, 2018 ).…”

Section: Invasive Electric Stimulationmentioning

confidence: 99%

“…Multiple targets have been tested including the reticular formation ( McLardy et al, 1968 ; Tsubokawa et al, 1990 ; Yamamoto et al, 2010 ), the central nucleus of the thalamus ( McLardy et al, 1968 ; Tsubokawa et al, 1990 ; Cohadon and Richer, 1993 ; Schiff et al, 2007 ; Yamamoto et al, 2010 ; Wojtecki et al, 2014 ; Adams et al, 2016 ; Chudy et al, 2018 ), the anterior intralaminar nuclei and paralaminar areas ( Magrassi et al, 2016 ). In two studies, pallidal stimulation was associated to thalamic targets ( Hassler et al, 1969 ; Lemaire et al, 2018 ). The multiplicity of targets in the limited number of both VS/UWS and MCS patients makes it impossible to identify the superiority of a procedure among the others.…”

Section: Invasive Electric Stimulationmentioning

confidence: 99%

“…In the first situation, DBS will modulate a damaged cortex with altered capacity of long distance synchronization while, in the second, a modulation of the thalamus will have an effect on a preserved cortex. The most recent studies tend to take this into account by excluding anoxic causes ( Lemaire et al, 2018 ) or trying to identify the potential connectivity that the DBS may restore ( Schiff et al, 2007 ; Magrassi et al, 2016 ). Nonetheless, most of the studies mixed patients with similar clinical presentations but with a potentially great physio-pathological heterogenicity.…”

Section: Invasive Electric Stimulationmentioning

confidence: 99%

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Electromagnetic Brain Stimulation in Patients With Disorders of Consciousness

et al. 2019

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Severe brain injury is a common cause of coma. In some cases, despite vigilance improvement, disorders of consciousness (DoC) persist. Several states of impaired consciousness have been defined, according to whether the patient exhibits only reflexive behaviors as in the vegetative state/unresponsive wakefulness syndrome (VS/UWS) or purposeful behaviors distinct from reflexes as in the minimally conscious state (MCS). Recently, this clinical distinction has been enriched by electrophysiological and neuroimaging data resulting from a better understanding of the physiopathology of DoC. However, therapeutic options, especially pharmacological ones, remain very limited. In this context, electroceuticals, a new category of therapeutic agents which act by targeting the neural circuits with electromagnetic stimulations, started to develop in the field of DoC. We performed a systematic review of the studies evaluating therapeutics relying on the direct or indirect electro-magnetic stimulation of the brain in DoC patients. Current evidence seems to support the efficacy of deep brain stimulation (DBS) and non-invasive brain stimulation (NIBS) on consciousness in some of these patients. However, while the latter is non-invasive and well tolerated, the former is associated with potential major side effects. We propose that all chronic DoC patients should be given the possibility to benefit from NIBS, and that transcranial direct current stimulation (tDCS) should be preferred over repetitive transcranial magnetic stimulation (rTMS), based on the literature and its simple use. Surgical techniques less invasive than DBS, such as vagus nerve stimulation (VNS) might represent a good compromise between efficacy and invasiveness but still need to be further investigated.

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Section: Invasive Electric Stimulationmentioning

confidence: 99%

Section: Invasive Electric Stimulationmentioning

confidence: 99%

Section: Invasive Electric Stimulationmentioning

confidence: 99%

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Electromagnetic Brain Stimulation in Patients With Disorders of Consciousness

et al. 2019

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“…In this latter condition, practitioners can use the atlas like classical histological atlases from the proportional grid plates, and at the same time they can adjust or specify directly the targets from the MRI plates. Furthermore, the MDBA is of considerable value to study injured and deformed brains as indirect methods are unreliable due to the hampered landmarks in the injured brain (50). The MDBA also improves scientific knowledge of the deep brain structural aspect as revealed by current MRI.…”

Section: Discussionmentioning

confidence: 99%

MRI Atlas of the Human Deep Brain

Lemaire

Salles²,

Coll

et al. 2019

Front. Neurol.

Self Cite

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Mastering detailed anatomy of the human deep brain in clinical neurosciences is challenging. Although numerous pioneering works have gathered a large dataset of structural and topographic information, it is still difficult to transfer this knowledge into practice, even with advanced magnetic resonance imaging techniques. Thus, classical histological atlases continue to be used to identify structures for stereotactic targeting in functional neurosurgery. Physicians mainly use these atlases as a template co-registered with the patient's brain. However, it is possible to directly identify stereotactic targets on MRI scans, enabling personalized targeting. In order to help clinicians directly identify deep brain structures relevant to present and future medical applications, we built a volumetric MRI atlas of the deep brain (MDBA) on a large scale (infra millimetric). Twelve hypothalamic, 39 subthalamic, 36 telencephalic, and 32 thalamic structures were identified, contoured, and labeled. Nineteen coronal, 18 axial, and 15 sagittal MRI plates were created. Although primarily designed for direct labeling, the anatomic space was also subdivided in twelfths of AC-PC distance, leading to proportional scaling in the coronal, axial, and sagittal planes. This extensive work is now available to clinicians and neuroscientists, offering another representation of the human deep brain ([ https://hal.archives-ouvertes.fr/ ] [hal-02116633]). The atlas may also be used by computer scientists who are interested in deciphering the topography of this complex region.

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“…Encouraging results have been obtained on DoC patients with invasive electrical stimulation of the brain (16)(17)(18)(19) and recently, transcranial delivery of a low intensity electrical current over the scalp with tDCS (20)(21)(22). However, the efficacy of tDCS is debated (23)(24)(25), and its mechanisms have not been established yet.…”

Section: Main Text Introductionmentioning

confidence: 99%

Combined behavioral and electrophysiological evidence for a direct cortical effect of prefrontal tDCS on disorders of consciousness

Hermann¹,

Raimondo²,

Hirsch³

et al. 2019

Preprint

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Severe brain injuries can lead to long-lasting disorders of consciousness (DoC) such as vegetative state/unresponsive wakefulness syndrome (VS/UWS) or minimally conscious state (MCS). While behavioral assessment remains the gold standard to determine conscious state, EEG has proven to be a promising complementary tool to monitor the effect of new therapeutics. Encouraging results have been obtained with invasive electrical stimulation of the brain, and recent studies identified transcranial direct current stimulation (tDCS) as an effective approach in randomized controlled trials. This non-invasive and inexpensive tool may turn out to be the preferred treatment option. However, its mechanisms of action and physiological effects on brain activity remain unclear and debated. Here, we stimulated 60 DoC patients with the anode placed over left-dorsolateral prefrontal cortex in a prospective open-label study. Clinical behavioral assessment improved in twelve patients (20%) and none deteriorated. This behavioral response after tDCS coincided with an enhancement of putative EEG markers of consciousness: in comparison with non-responders, responders showed increases of power and long-range cortico-cortical functional connectivity in the theta-alpha band, and a larger and more sustained P300 suggesting improved conscious access to auditory novelty. The EEG changes correlated with electric fields strengths in prefrontal cortices, and no correlation was found on the scalp. Taken together, this prospective intervention in a large cohort of DoC patients strengthens the validity of the proposed EEG signatures of consciousness, and is suggestive of a direct causal effect of tDCS on consciousness.

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Deep brain stimulation in five patients with severe disorders of consciousness

Cited by 49 publications

References 44 publications

Electromagnetic Brain Stimulation in Patients With Disorders of Consciousness

Electromagnetic Brain Stimulation in Patients With Disorders of Consciousness

MRI Atlas of the Human Deep Brain

Combined behavioral and electrophysiological evidence for a direct cortical effect of prefrontal tDCS on disorders of consciousness

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