Diagnosing Level of Consciousness: The Limits of the Glasgow Coma Scale Total Score

Bodien, Yelena; Barra, Alice; Temkin, Nancy; Barber, Jason; Foreman, Brandon; Robertson, Claudia; Vassar, Mary J.; Manley, Geoff; Giacino, Joseph T.; Edlow, Brian L.

doi:10.1016/j.apmr.2020.09.017

Cited by 16 publications

(19 citation statements)

References 30 publications

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“…Furthermore, most GCS total scores represent a wide range of potential DoC diagnoses, suggesting that the total score is not an adequate proxy for level of consciosuess. 61 The Full Outline of UnResponsiveness (FOUR) score was developed to address some of the limitations inherent to the GCS and replaces the GCS verbal subscale, which is often untestable due to intubation, with an assessment of respiratory patterns and brainstem reflexes. 62,63 A systematic review published in 2019 found that both the GCS and FOUR Score predicted inhospital mortality and 3-month outcome with similar accuracy, but that the brainstem and respiratory subscales of the FOUR had lower accuracy as compared to the visual and motor…”

Section: Accepted Manuscriptmentioning

confidence: 99%

Behavioral Assessment of Patients with Disorders of Consciousness

et al. 2022

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Section: Accepted Manuscriptmentioning

confidence: 99%

Behavioral Assessment of Patients with Disorders of Consciousness

et al. 2022

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“…Although a GCS ≤ 8 has been considered a hallmark feature of coma, several limitations of the GCS have been identified, notably incomplete assessment of intubated patients, lack of items that distinguish coma from other DoC, failure to address brainstem reflexes, and limited ability to differentiate prognosis among patients with the lowest GCS [18,22,23]. Indeed, it is possible to have a GCS ≤ 8 in patients who are able to follow verbal commands or are localizing to pain and would not otherwise be considered comatose by most practitioners (e.g., eyes 2, motor 5, verbal 1 or eyes 1, motor 6, verbal 1) [24]. Additionally, the eye opening component may be misleading in coma, particularly because 73% of survey responders acknowledged treating at least one patient with eyes open coma [20] per month.…”

Section: Discussionmentioning

confidence: 99%

The Curing Coma Campaign International Survey on Coma Epidemiology, Evaluation, and Therapy (COME TOGETHER)

et al. 2022

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Background Although coma is commonly encountered in critical care, worldwide variability exists in diagnosis and management practices. We aimed to assess variability in coma definitions, etiologies, treatment strategies, and attitudes toward prognosis. Methods As part of the Neurocritical Care Society Curing Coma Campaign, between September 2020 and January 2021, we conducted an anonymous, international, cross-sectional global survey of health care professionals caring for patients with coma and disorders of consciousness in the acute, subacute, or chronic setting. Survey responses were solicited by sequential emails distributed by international neuroscience societies and social media. Fleiss κ values were calculated to assess agreement among respondents. Results The survey was completed by 258 health care professionals from 41 countries. Respondents predominantly were physicians (n = 213, 83%), were from the United States (n = 141, 55%), and represented academic centers (n = 231, 90%). Among eight predefined items, respondents identified the following cardinal features, in various combinations, that must be present to define coma: absence of wakefulness (81%, κ = 0.764); Glasgow Coma Score (GCS) ≤ 8 (64%, κ = 0.588); failure to respond purposefully to visual, verbal, or tactile stimuli (60%, κ = 0.552); and inability to follow commands (58%, κ = 0.529). Reported etiologies of coma encountered included medically induced coma (24%), traumatic brain injury (24%), intracerebral hemorrhage (21%), and cardiac arrest/hypoxic-ischemic encephalopathy (11%). The most common clinical assessment tools used for coma included the GCS (94%) and neurological examination (78%). Sixty-six percent of respondents routinely performed sedation interruption, in the absence of contraindications, for clinical coma assessments in the intensive care unit. Advanced neurological assessment techniques in comatose patients included quantitative electroencephalography (EEG)/connectivity analysis (16%), functional magnetic resonance imaging (7%), single-photon emission computerized tomography (6%), positron emission tomography (4%), invasive EEG (4%), and cerebral microdialysis (4%). The most commonly used neurostimulants included amantadine (51%), modafinil (37%), and methylphenidate (28%). The leading determinants for prognostication included etiology of coma, neurological examination findings, and neuroimaging. Fewer than 20% of respondents reported routine follow-up of coma survivors after hospital discharge; however, 86% indicated interest in future research initiatives that include postdischarge outcomes at six (85%) and 12 months (65%). Conclusions There is wide heterogeneity among health care professionals regarding the clinical definition of coma and limited routine use of advanced coma assessment techniques in acute care settings. Coma management practices vary across sites, and mechanisms for coordinated and sustained follow-up after acute treatment are inconsistent. There is an urgent need for the development of evidence-based guidelines and a collaborative, coordinated approach to advance both the science and the practice of coma management globally.

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“…Both the GCS and CRS-R were included in analyses as they have complementary strengths ( i.e ., CRS-R has higher psychometric properties than the GCS; GCS is more widely-used and faster to administer than the CRS-R) (Bodien et al, 2021; Giacino et al, 2004; Teasdale et al, 2014).…”

Section: Methodsmentioning

confidence: 99%

“…If a patient’s neurological examination fluctuated, the first behavioral evidence of coma emergence and command-following were reported. The GCS Total was included as a primary dependent variable in this study given its widespread use clinically; however, its limitations (i.e., only moderate psychometric properties, administration process is not standardized) must be acknowledged (Bodien et al, 2021). The CRS-R, which has strong psychometric properties and a standardized administration process (Giacino et al, 2004; Teasdale et al, 2014), along with the CAP, were used in addition to the GCS to more precisely classify each patient’s LOC into the following categories: coma, vegetative state, minimally conscious state minus (MCS-; MCS without language function), MCS plus (MCS+; MCS with language function), and post-traumatic confusional state (PTCS).…”

Section: Methodsmentioning

confidence: 99%

Automated detection of axonal damage along white matter tracts in acute severe traumatic brain injury

Maffei

Gilmore

Snider

et al. 2022

Preprint

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New techniques for individualized assessment of white matter integrity are needed to detect traumatic axonal injury (TAI) and predict outcomes in critically ill patients with acute severe traumatic brain injury (TBI). Diffusion MRI tractography has the potential to quantify white matter microstructure in vivo and has been used to characterize tract-specific changes in TBI. However, tractography is not routinely used in the clinical setting to assess the extent of TAI, in part because focal lesions reduce the robustness of automated methods. In the present study, we propose an automated pipeline for individualized assessment of white matter damage in patients with acute severe TBI that is based on tractography reconstructions and multivariate analysis of along-tract diffusion metrics. We used the Mahalanobis distance to test for a deviation of diffusion metrics along 40 white matter tracts in 18 patients with acute severe TBI as compared to 33 healthy subjects. The automated pipeline successfully reconstructed white matter tracts in all patients with a successful FreeSurfer anatomical segmentation (17 of 18 patients), including 13 with focal lesions. In these 17 patients, a mean of 37.5 +/- 2.1 tracts were reconstructed without the need for manual intervention and a mean of 2.47 +/- 2.1 needed to be reinitialized upon visual inspection. The pipeline detected at least one injured tract in all patients (mean: 12.6, SD: 7.6). The number and neuroanatomic location of disrupted tracts varied across patients and levels of consciousness. The pre-motor, parietal, and temporal sections of the corpus callosum were the structures most frequently injured (in 10, 9, and 8 patients respectively), consistent with histological studies of TAI. Multivariate measures of TAI did not show a significant association with behavioral measures of consciousness, or subscales measuring basic language and motor function. In summary, we provide proof-of-principle evidence that an automated tractography pipeline can be used to detect and quantify TAI in patients with acute severe head trauma and could therefore assist in the clinical assessment of TAI.

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Diagnosing Level of Consciousness: The Limits of the Glasgow Coma Scale Total Score

Cited by 16 publications

References 30 publications

Behavioral Assessment of Patients with Disorders of Consciousness

Behavioral Assessment of Patients with Disorders of Consciousness

The Curing Coma Campaign International Survey on Coma Epidemiology, Evaluation, and Therapy (COME TOGETHER)

Automated detection of axonal damage along white matter tracts in acute severe traumatic brain injury

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