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[Disorders of consciousness as an initial symptom of intestinal invagination].

Two infants with intussusception were presented with lethargy and vomiting. Initially, the classical abdominal manifestations of the disease were missing. In order to avoid a delay of the correct treatment, intussusception should be considered in infants with altered consciousness and ultrasonography of the abdomen should be included in the diagnostic work up.

Consciousness Disorders↗

Disorders of consciousness: differential diagnosis and neuropathologic features.

Disorders of consciousness present intriguing challenges to the neurologist and neurorehabilitation specialist. Assessment is constrained by the lack of reliable methods of assessing consciousness, and there are no treatment interventions known to influence the course of recovery from these conditions. In addition, the relationship between the clinical features associated with these disorders and their corresponding pathophysiologic substrate is also unclear. Our understanding of disorders of consciousness has not kept pace with the advances in neurosurgical management that have decreased mortality following severe injury. There is still considerable confusion regarding differential diagnosis and prognostication concerning states of severely altered consciousness. The purpose of this article is to discuss the content and neural basis of consciousness and to review the terminology most often used to describe altered states of consciousness. The neurobehavioral criteria for differentiating among specific syndromes associated with severe alterations in consciousness are presented. Representative case studies are utilized to illustrate the characteristic clinical profiles of coma, vegetative state, persistent and permanent vegetative state, minimally conscious state, akinetic mutism, and locked-in syndrome. Areas of ambiguity and controversy are emphasized and future directions for research are suggested.

Akinetic Mutism↗

Chronic disorders of consciousness.

The vegetative state and the minimally conscious state are disorders of consciousness that can be acute and reversible or chronic and irreversible. Diffuse lesions of the thalami, cortical neurons, or the white-matter tracts that connect them cause the vegetative state, which is wakefulness without awareness. Functional imaging with PET and functional MRI shows activation of primary cortical areas with stimulation, but not of secondary areas or distributed neural networks that would indicate awareness. Vegetative state has a poor prognosis for recovery of awareness when present for more than a year in traumatic cases and for 3 months in non-traumatic cases. Patients in minimally conscious state are poorly responsive to stimuli, but show intermittent awareness behaviours. Indeed, findings of preliminary functional imaging studies suggest that some patients could have substantially intact awareness. The outcomes of minimally conscious state are variable. Stimulation treatments have been disappointing in vegetative state but occasionally improve minimally conscious state. Treatment decisions for patients in vegetative state or minimally conscious state should follow established ethical and legal principles and accepted practice guidelines of professional medical specialty societies.

Awareness↗

[Partial disorders of consciousness in epilepsy].

A group of 50 patients with partial disorders of consciousness in epilepsy was distinguished as a result of observation of 500 epileptic patients. Partial disorders of consciousness were observed in periods before, after and between the fits. Their durations were in the range from several minutes to several days.

Adolescent↗

Multimodal neuroimaging approaches to disorders of consciousness.

Advances in neuroimaging techniques hold significant promise for improving understanding of disorders of consciousness arising from severe brain injuries. We review neuroimaging studies of the vegetative state (VS) and minimally conscious state (MCS), and findings in an unusual case of late emergence from MCS. Multimodal neuroimaging studies using positron emission tomography techniques, functional magnetic resonance imaging, and quantitative electroencephalography and magnetoencephalography quantify variations of residual cerebral activity across these patient populations. The results suggest models to distinguish the pathophysiologic basis of VS and MCS. Less clear are potential brain mechanisms underlying late recovery of communication in rare MCS patients. Diffusion tensor magnetic resonance imaging studies and recent experimental findings suggest that structural remodeling of the brain following severe injury may play a role in late functional recoveries. More generally, relatively long time courses of recovery following severe brain injury emphasize the need to develop markers for identifying patients who may harbor potential for further meaningful recovery. Introduction of neuroimaging into the clinical evaluation process will require developing frameworks for longitudinal assessments of cerebral function. Although limited in number, available studies already provide important insights into underlying brain mechanisms that may help guide development of such assessment strategies.

Arousal↗

A measure of neurobehavioral functioning after coma. Part I: Theory, reliability, and validity of Disorders of Consciousness Scale.

This is longitudinal validation study describes the psychometric properties of the Disorders of Consciousness Scale (DOCS). This is Part I of a two-part series. Part II illustrates and describes the clinical and scientific implementation of the DOCS measure. The study was conducted at one intensive care unit, two acute rehabilitation hospitals, and one long-term acute chronic care hospital. Participants were unconscious after severe brain injury (BI). We conducted interrater reliability analyses using ratings from interdisciplinary pairs. Results indicated a higher-than-expected level of agreement and no significant difference between any pairs ( chi-square = 8(5df), p = 0.15) (df = degrees of freedom). Examinations of ratings by discipline groups indicated that the DOCS is impacted minimally by discipline. Validity analyses demonstrate that 23 of 34 test stimuli remain stable over time with no floor or ceiling effect. DOCS measures obtained within 94 days of injury predicted recovery of consciousness up to 1 year after injury (c-indices of 0.70 and 0.86). Positive (0.71) and negative (0.68) predictive values indicate that the DOCS predicts recovery and lack of recovery. Twenty-three of the DOCS test stimuli produce a reliable, valid, and stable measure of neurobehavioral recovery after severe BI that predicts recovery and lack of recovery of consciousness 1 year after injury.

Adult↗

Disorders of consciousness: anatomical and physiological mechanisms.

The anatomical and physiological mechanisms of consciousness are reviewed, focussing on the wakefulness mechanisms, which are one aspect, albeit an indispensable one, of consciousness. In trying to understand disorders of consciousness, it must be remembered that wake physiology is linked to sleep physiology and a brief summary of the phenomenology and regulation of the wake sleep cycle is therefore presented. Wakefulness is produced and maintained by a complex neural network composed of at least ten groups of neurones, which spread out from the medulla oblongata to the telencephalic structures. Some of these elements (reticular formation and diffuse thalamic nuclei) contribute to the arousal and general activation of the brain, while others (aminergic and peptidergic neurones) contribute to the quality of wakefulness, as well as to general activation. Disorders of wakefulness may be due to dysfunction of one or several elements of the wake network or sleep disorders, as well as to sleep deprivation.

Animals↗

Altered states of consciousness in disorders of daytime sleepiness.

Patients with daytime sleepiness present altered states of consciousness. The occurrence of these states impairs their professional, social and familial activities and may threaten life itself. The automatic behavior syndrome is characterized by continuation of mechanical activity and complete amnesia. Episodes lasting from a few seconds to several hours are correlated with repetitive micro-sleep periods. During cataplectic attacks, patients may have a meshing of reality with hallucinatory dream contents. Sleep-induced apnea may lead to abnormal movement and abnormal ambulation during sleep as well as hallucinations in the early morning. These altered states of consciousness must be considered as diagnostic indexes in differentiating epileptic syndromes from syndromes of daytime sleepiness.

Adult↗