Remnant cognitive functioning in DOC Dr Schnakers C.

Remnant cognitive functioning in DOCDr Schnakers C.

Disorders of consciousness COMA MINIMALLYCONSCIOUSSTATE VEGETATIVESTATE NORMALCONSCIOUSNESS AROUSAL AWARENESS AROUSAL AROUSAL AROUSAL AWARENESS AWARENESS AWARENESS www.comascience.org Laureys et al, Lancet Neurol, 2004

Misdiagnosis n=103 post-comatose patients 44 had clinical consensus diagnosis of “vegetative state” 18 (41%) were actually conscious www.comascience.org Schnakers et al, BMC Neurol, 2009

VS-MCS outcome Vegetative state (n=116) Minimally conscious state (n=84) % % 100 100 90 90 80 80 70 70 60 60 Traumatic 50 50 40 40 30 30 n=52 n=35 20 20 10 10 0 0 EMERGENCE 1 3 6 12 1 3 6 12 % % MCS 100 100 Dead 90 90 VS 80 80 70 70 Non-traumatic 60 60 50 50 40 40 30 30 n=64 n=49 20 20 10 10 0 0 1 3 6 12 1 3 6 12 www.comascience.org Bruno et al, Belgian federal project on VS

Family needs (n=89) Inv Social Med Emot Care Sup Info Sup Satisfaction Dissatisfaction * * * Providing information may reduce stress and increase coping abilities (Friedemann-Sanchez et al., 2008). A poor adjustment to medical information can lead to hostility to the medical staff, which can lead to burnout. (Tzidkiahu et al., 1994; Sahraian et al., 2008) www.comascience.org Schnakers et al., in prep

End-of-life decisions in VS Eluana Englaro °1970, vegetative 1992, † 2009 IT Tony Blant, °1970, vegetative 1989, † 1993 UK Terry Schiavo °1963, vegetative 1990, † 2005 US When the diagnosis of a permanent VS is considered definite, it should be discussed with the relatives, [….] who should then be given the time to consider the implications, including the possibility of withdrawing artificial means of administering nutrition and hydration. (The Royal College of Physicians, 2003)

Consciousness Consciousness of the environment Self consciousness AROUSAL AWARENESS Baars, 1998 Shallice, 1988 • *Perception • *Cognition • Working memory • Attention (e.g., sustained, selective) www.comascience.org Laureys et al, Lancet Neurol, 2004

Nociceptive Perception Controls Vegetative patients 58 mm 34 mm 20 mm 6 mm -4 mm www.comascience.org Laureys et al, Neuroimage, 2002

Functional Connectivity disorders of consciousness | behavioural evaluation | electrophysiology | neuroimaging | methods, ethics & quality of life | perspectives (n=15) Primary somatosensory cortex SI Centred blood flow in posterior parietal cortex Centred blood flow in primary somatosensory cortex www.comascience.org Laureys et al, Neuroimage, 2002

GCS Glasgow Coma Scale Teasdale and Jennet, Lancet, 1974

CRS-R www.comascience.org Giacino et al, Arch Phys Med Rehabil, 2004

Sensitivity MCS diagnosis * Number of patients 45 36 32 24 Behavioural scales N=77 www.comascience.org Schnakers et al, Ann Neurol, 2006; Schnakers et al, Brain Inj, 2008

WHIM Cognitive recovery vigilance (eyes opening) attention (visual pursuit) language comprehension (command following) executive functioning (inhibite distractor) semantic memory (object recognition) praxia (imitation) non-functional communication (yes/no) writing orientation in time/space episodic memory Shiel et al, Clin Rehabil, 2000; Majerus et al, Neuropsychol Rehab, 2000

Motor - Cognition professional reinsertion live independently good recovery moderate disability severe disability Communication ? MINIMALLYCONSCIOUS MOTOR RESPONSIVENESS Awareness ? = non-reflex movements or command following VEGETATIVE arousal = eye opening coma COGNITIVE CAPACITY Laureys et al., Current Opinion in Neurology, 2005

MCS+ > MCS- MINIMALLY CONSCIOUS STATE + intelligible verbalizations non functional communication command following MINIMALLY CONSCIOUS STATE - appropriate smiling/crying localization to noxious stimulation fixation/visual pursuit disorders of consciousness | clinical evaluation | electrophysiology | neuroimaging | ethics & quality of life | conclusion www.comascience.org Majerus et al., PBR, 2008; Bruno et al., submitted

Active ERP Paradigm Listened target Counted target Non target Counting own name (n=4) Controls LIS total Counting unfamiliar name www.comascience.org Schnakers et al, Neurocase, 2008

Active ERP Paradigm www.comascience.org Schnakers et al, Neurol, 2008

Language processing Coleman et al., Brain, 2009

Misdiagnosis: fMRI vs. Behav 14/16 - Vigilance? - Compliance? 7/22 5/16 2/22 Coleman et al., Brain, 2009

Multi-component www.comascience.org Giacino et al, Arch Phys Med Rehabil, 2004

Neuropsychological testing? • 10 patients LIS chroniques • réponses oculaires Schnakers et al, J Neurol, 2008

In the future

www.comascience.org S. Laureys MD PhD M.Boly MD D.Ledoux MD C.Schnakers PhD A.Vanhaudenhuyse PhD M.A.Bruno PhD O.Gosseries PhD V.Cologan PhD P.Boveroux MD A.Demertzi PhD the patients & families C.Phillips PhD Ing Q.Noirhomme PhD Ing P.Maquet MD PhD L.Puybasset MD (France) F.Perrin PhD (France) F.Pellas MD (France) A.Owen PhD (UK) J.Giacino PhD (USA) N.Schiff MD (USA) H.Di PhD (Chine)

Own name CONTROLS (n=5) (n=4) MINIMALLY CONSCIOUS STATE (n=6) VEGETATIVE STATE (n=5) www.comascience.org Perrin, Schnakers et al, Arch Neurol, 2005

Predictor of outcome? ATYPICAL ‘HIGH LEVEL’ CORTICAL ACTIVATION vegetative state ACTIVATIONTO THE OWNNAME PUBLISHED DATA (n=48 patients) 6 fMRI (n=17) & 8 PET studies (n=32) “low level” or absent activation • low level activation 84% no recovery • no cortical activation 100% no recovery “high level” activation • 82% recovery (93% specificity 69% sensitivity) Di et al, Neurology, 2007 Di et al, Clinical Medicine, 2008

Remnant cognitive functioning in DOC Dr Schnakers C.