Which behaviours are first to emerge during recovery of consciousness after severe brain injury?

Martens, Géraldine; Bodien, Yelena; Sheau, Kristen; Christoforou, Andrea; Giacino, Joseph T.

doi:10.1016/j.rehab.2019.10.004

Cited by 28 publications

(18 citation statements)

References 42 publications

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“…The etiology of agitated behaviors in critically ill patients following sTBI is multifactorial (26), Pain and infection, for example, cause systemic catecholamine dysregulation and psychomotor disturbance. In comatose patients emerging from disorders of consciousness, being able to regain awareness to immediate surrounding is a sign of arousal (27). As patients undergo further neurological recovery, they develop the ability to interfere with medical treatment to minimize discomfort.…”

Section: Discussionmentioning

confidence: 99%

“…As patients undergo further neurological recovery, they develop the ability to interfere with medical treatment to minimize discomfort. The reemergence of these goal-directed behaviors, clinically present as severe agitation, strongly suggests the recovery of consciousness (27). In the sTBI population, continuous sedation is administered due to the need for mechanical ventilation, and clinical improvement prompts discontinuation of these interventions.…”

Section: Discussionmentioning

confidence: 99%

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Agitation Following Severe Traumatic Brain Injury Is a Clinical Sign of Recovery of Consciousness

et al. 2021

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Objective: Severe traumatic brain injury (sTBI) often results in disorders of consciousness. Patients emerging from coma frequently exhibit aberrant behaviors such as agitation. These non-purposeful combative behaviors can interfere with medical care. Interestingly, agitation is associated with arousal and is often among the first signs of neurological recovery. A better understanding of these behaviors may shed light on the mechanisms driving the return of consciousness in sTBI patients. This study aims to investigate the association between posttraumatic agitation and the recovery of consciousness.Methods: A retrospective chart review was conducted in 530 adult patients (29.1% female) admitted to Stony Brook University Hospital between January 2011 and December 2019 with a diagnosis of sTBI and Glasgow Coma Scale (GCS) ≤8. Agitation was defined as a Richmond Agitation Sedation Scale (RASS) > +1, or any documentation of equivalently combative and violent behaviors in daily clinical notes. The ability to follow verbal commands was used to define the recovery of consciousness and was assessed daily.Results: Of 530 total sTBI patients, 308 (58.1%) survived. Agitation was present in 169 of all patients and 162 (52.6%) of surviving patients. A total of 273 patients followed commands, and 159 of them developed agitation. Forty patients developed agitation on hospital arrival whereas 119 developed agitation later during their hospital course. Presence of in-hospital agitation positively correlated with command-following (r = 0.315, p < 0.001). The time to develop agitation and time to follow commands showed positive correlation (r = 0.485, p < 0.001). These two events occurred within 3 days in 54 (44.6%) patients, within 7 days in 81 (67.8%) patients, and within 14 days in 96 (80.2%) patients. In 71 (59.7%) patients, agitation developed before command-following; in 36 (30.2%) patients, agitation developed after command-following; in 12 (10.1%) patients, agitation developed on the same day as command-following.Conclusion: Posttraumatic agitation in comatose patients following sTBI is temporally associated with the recovery of consciousness. This behavior indicates the potential for recovery of higher neurological functioning. Further studies are required to identify neural correlates of posttraumatic agitation and recovery of consciousness after sTBI.

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Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Agitation Following Severe Traumatic Brain Injury Is a Clinical Sign of Recovery of Consciousness

et al. 2021

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“…In several studies, there is an inverse correlation between the probability of recovering from a DoC and the duration after the injury [5,6,8]; however, some recovery has been observed in patients years after the initial injury [3,9]. The integrity and function of various neural structures and their relationship to consciousness are crucial for predicting outcomes and treating patients [10,11].…”

Section: Traumatic Brain Injury and Consciousnessmentioning

confidence: 99%

“…Unlike coma and VS/UWS, the minimally conscious state (MCS) often includes impaired awareness and attention, as well as inconsistent responses that are consciously driven [9]. The first clinical signs to occur are generally visual pursuit and command following [11]. This category is further subdivided into without language (MCS-), or with language including command-following, intelligible verbalization, and/or intentional communication (MCS+) [4,[28][29][30].…”

Section: Disorders Of Consciousnessmentioning

confidence: 99%

Treating Traumatic Brain Injuries with Electroceuticals: Implications for the Neuroanatomy of Consciousness

et al. 2021

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According to the Centers for Disease Control and Prevention (CDC), traumatic brain injury (TBI) is the leading cause of loss of consciousness, long-term disability, and death in children and young adults (age 1 to 44). Currently, there are no United States Food and Drug Administration (FDA) approved pharmacological treatments for post-TBI regeneration and recovery, particularly related to permanent disability and level of consciousness. In some cases, long-term disorders of consciousness (DoC) exist, including the vegetative state/unresponsive wakefulness syndrome (VS/UWS) characterized by the exhibition of reflexive behaviors only or a minimally conscious state (MCS) with few purposeful movements and reflexive behaviors. Electroceuticals, including non-invasive brain stimulation (NIBS), vagus nerve stimulation (VNS), and deep brain stimulation (DBS) have proved efficacious in some patients with TBI and DoC. In this review, we examine how electroceuticals have improved our understanding of the neuroanatomy of consciousness. However, the level of improvements in general arousal or basic bodily and visual pursuit that constitute clinically meaningful recovery on the Coma Recovery Scale-Revised (CRS-R) remain undefined. Nevertheless, these advancements demonstrate the importance of the vagal nerve, thalamus, reticular activating system, and cortico-striatal-thalamic-cortical loop in the process of consciousness recovery.

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“…[20][21][22] The GCS was not designed, however, to differentiate these DoC states and lacks assessment of items such as visual pursuit and fixation that are crucial for detecting consciousness. 23,24 In fact, the GCS has been estimated to have a false negative rate of 38% for detection of consciousness. 24 It follows that, in some patients, neither GCS total scores nor subscale scores may characterize injury severity accurately.…”

Section: Introductionmentioning

confidence: 99%

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

Bodien

Barra²,

Temkin³

et al. 2020

Archives of Physical Medicine and Rehabilitation

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Which behaviours are first to emerge during recovery of consciousness after severe brain injury?

Cited by 28 publications

References 42 publications

Agitation Following Severe Traumatic Brain Injury Is a Clinical Sign of Recovery of Consciousness

Agitation Following Severe Traumatic Brain Injury Is a Clinical Sign of Recovery of Consciousness

Treating Traumatic Brain Injuries with Electroceuticals: Implications for the Neuroanatomy of Consciousness

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

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