The misdiagnosis of prolonged disorders of consciousness by a clinical consensus compared with repeated coma-recovery scale-revised assessment

Abstract

Background Previous studies have shown that a single Coma-Recovery Scale-Revision (CRS-R) assessment can identify high rates of misdiagnosis by clinical consensus. The aim of this study was to investigate the proportion of misdiagnosis by clinical consensus compared to repeated behavior-scale assessments in patients with prolonged disorders of consciousness (DOC). Methods Patients with prolonged DOC during hospitalization were screened by clinicians, and the clinicians formed a clinical-consensus diagnosis. Trained professionals used the CRS-R to evaluate the consciousness levels of the enrolled patients repeatedly (≥5 times) within a week. Based on the repeated evaluation results, the enrolled patients with prolonged DOC were divided into unresponsive wakefulness syndrome (UWS), minimally conscious state (MCS), and emergence from MCS (EMCS). Finally, the relationship between the results of the CRS-R and the clinical consensus were analyzed. Results In this study, 137 patients with a clinical-consensus diagnosis of prolonged DOC were enrolled. It was found that 24.7% of patients with clinical UWS were actually in MCS after a single CRS-R behavior evaluation, while the repeated CRS-R evaluation results showed that the proportion of misdiagnosis of MCS was 38.2%. A total of 16.7% of EMCS patients were misdiagnosed with clinical MCS, and 1.1% of EMCS patients were misdiagnosed with clinical UWS. Conclusions The rate of the misdiagnosis by clinical consensus is still relatively high. Therefore, clinicians should be aware of the importance of the bedside CRS-R behavior assessment and should apply the CRS-R tool in daily procedures. Trial registration ClinicalTrials.gov ID: NCT04139239; Registered 24 October 2019 - Retrospectively registered.

Estimating the Minimal Number of Repeated Examinations for Random Responsiveness With the Coma Recovery Scale—Revised as an Example

“…Many studies have shown that the fluctuations of MCS often leads to missed diagnosis (the missed diagnosis rate may be higher than 35%) (Stender et al, 2014 , van Erp et al, 2015 ), and that such diagnostic errors can affect patient outcomes and treatment decisions (Demertzi et al, 2011 ). Especially when DOC patients were tested only once, even when using the most sensitive scale of the Coma Recovery Scale-Revised (CRS-R) (Giacino et al, 2004 ), a single assessment resulted in a 25% missed diagnosis (Wang et al, 2020 ). Therefore, recent guidelines have emphasized the importance of repeated assessments to increase the accuracy of clinical diagnosis (Giacino et al, 2018 ; Kondziella et al, 2020 ).…”

Therapeutic Use of Transcranial Direct Current Stimulation in the Rehabilitation of Prolonged Disorders of Consciousness

“…However, it is also true that these scales are not sensitive to covert changes in cognitive functioning or awareness ( 73 ). On the one hand, clinical scales mainly rely on motor outputs, which can be highly inconsistent and limited in PDOC, due to lesions in motor cortices ( 15 , 39 , 74 , 75 ). In addition, the presence of injury in language and visual cortices may also interfere with the patients' ability to understand the instructions and show appropriate responses ( 76 ).…”

Optical brain imaging and its application to neurofeedback

“…Given that patients with prolonged disorders of consciousness are often misdiagnosed ( Wang et al, 2020 ), beyond CLIS, there is critical need for robust non-invasive bed-side tools to evaluate level of consciousness and for re-establishing communication. Besides their immediate impact on self-determination and quality of life, such systems may also trigger neural recovery as it was shown for BCIs in restoration of movement and accelerate emergence from minimally conscious state (EMCS).…”