Consciousness and disorders of consciousness · 2 Consciousness Short history of coma Scientific interest Clinical interest Conlusion Terry Schiavo °1963, vegetative 1990, †2005

www.comascience.org

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Consciousness and disorders of consciousness

Audrey Vanhaudenhuyse PhDComa Science GroupCyclotron Research Centre &University Hospital of LiègeBelgium

www.comascience.org2

Consciousness

Short history of coma

Scientific interest

Clinical interest

Conlusion

Terry Schiavo °1963, vegetative 1990, † 2005

Overview

« Irreversible loss of the capacity for consciousness and social interaction equals death »- Robert Veatch, 1975

« Should organs from patients in permanent vegetative state be used for transplantation? »- Hoffenberg, Lancet 1997

Consciousness | History | Scientific | Clinical | Conclusion


Laureys, Trends in Cognitive Sciences, 2005

Reducing consciousness to 2D

Coma

General Anesthesia

Locked-in syndrome

Minimally Conscious State- more than reflex movements

- no communication

Vegetative state

Conscious Wakefulness

Drowsiness

St I-II Sleep

St III-IV Sleep

LucidDreaming

REM Sleep

= necessary but not sufficient

EpilepsySleepwalking


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Short history of coma

Anoebis

heart Maät



Artificial respirator (1952)

The resuscitation greats. Bjørn IbsenResuscitation. 2003

Bjørn Ibsen - Copenhagen



Coma dépassé (1959)



Definition of brain deathHarvard Committee 1968

Wijdicks, NEJM 2001Bueri et al Mov Disord. 2000, 15:583-6


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Scientific interest



Laureys et al, Lancet Neurology, 2004

disorders of consciousness | behavioural evaluation | electrophysiology | neuroimaging | methods, ethics & quality of life | perspectives

Consciousness ≠ whole brain




Laureys et al, Neuroimage 1999

Consciousness ≈ frontoparietal

areas that are systematically dysfunctional in the vegetative state

areas that recover metabolism after recovery from the vegetative state

Laureys et al, J Neurol Neurosurg Psychiatry, 1999



Laureys et al, Lancet Neurology, 2004


Precuneus ≈ hub in the network

Axonal re-growth in Terry Wallis

Voss et al, J Clin Invest, 2006



Vogt and Laureys, Prog Brain Res, 2005Vogt, Vogt and Laureys, NeuroImage, 2006


Precuneus ≈ hub in the network

ANESTHESIAActivity in PCC/precuneus

loss of command following

WAKE

DROWSY

SEDATION

ANESTHESIA

WAKE

SLEEPActivity in PCC/precuneus

WAKE STAGE 2 STAGE 3-4 REM SLEEPActivity in PCC/precuneus



UNCONSCIOUS CONSCIOUS

Dehaene et al, Trends in Cognitive Sciences 2006

Global workspace theoryConsciousness | History | Scientific | Clinical | Conclusion



Consciousness ≈ thalamo-cortical

Intralaminar nuclei “reconnections”in spontaneous recovery from

the vegetative state

Laureys et al, Lancet 2000 Schiff et al., Nature 2007

Intralaminar nuclei stimulationinduces “recovery” from

the minimally conscious state


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Clinical interest



Disorders of consciousness

Laureys, Scientific American 2007

PermanentMinimally Conscious

State

?

1994, Multi-Society Task Force on PVS>1 year (traumatic)>3 months (non-traumatic; anoxic)

1952, artificial respirator (Ibsen, Copenhagen)Redefinition of death based on neurological criteria

1966 Plum & Posner (NY)

1972Jennett (Glasgow) & Plum (NY)

2002, Aspen Workgroup


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Diagnosis


Laureys et al., Current Opinion in Neurology, 2005


Assessing consciousness

COGNITIVE CAPACITY

MOTOR RESPONSIVENESS

coma

VS

MCS

severe disability

arousal

communication

moderate disability

goodrecovery

live independently

professional reinsertion

awareness



Misdiagnosis of vegetative state

n=103 post-comatose patients

45 clinical consensus diagnosis ‘vegetative state’ 18 signs of awareness (Coma Recovery Scale)

�� 40% potential misdiagnoses

Schnakers et al, BMC Neurology 2009




Coma recovery scale

Schnakers et al Brain Injury 2008



Eye tracking : use a mirror!

Vanhaudenhuyse et alJ Neurol Neurosurg Psychiatry 2008

n=52



Owen, Coleman, Boly, Davis, Laureys & Pickard, Science, 2006

Signs of consciousness on fMRI



≠ “automatic” brain response

Soddu et al, Prog Brain Res 2009




Monti & Vanhaudenhuyse, Coleman, Boly, Pickard, Tshibanda, Owen, LaureysNew England J Med 2010

Yes-No communication with fMRI



Communication via fMRI

Sorger et al, Prog Brain Res 2009




EEG-based Brain Computer Interfaces

ms-200 50 300 550 800 1050 1300

-5

-10

-15

-20

-25

5

10

15

20

25

Pz (µV)

Count TARGET (own name)

Coma or total locked-in syndrome?

21-y old woman basilar artery thrombosis - day 49

Other names PASSIVE

Count TARGET (other name)

Own name PASSIVE

Schnakers et al, Neurology, 2008Schnakers et al, Neurocase, 2009


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Conclusion



Translational research

Tononi & Laureys, The Neurology of Consciousness, 2009Laureys & Boly, Nature Clinical Practice, 2008Owen, Schiff & Laureys, Prog Brain Res, 2009

EXTERNALAWARENESS

INTERNAL AWARENESS

Neural correlates of conscious awareness≈ emergent property of the collective behavior

of fronto-parietal neuronal ‘global workspace’≈ cortico-thalamo-cortical functional connectivity

Diagnostic use ≈ 40% signs of consciousness in vegetative state


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THANK YOUslides can be downloaded on websiteEU funded positions open

PhD candidates:Marie-Aurélie BrunoOlivia GosseriesAthena DemertziCamille ChatelleMarie ThonnardVictor CologanJean-Floris Tshibanda MDPierre Boveroux MDMuriel Kirsch MDAudrey Maudoux MDIsabelle Lutte MD

PhDs:Audrey VanhaudenhuyseMelanie Boly MDDidier Ledoux MD Caroline Schnakers Quentin Noirhomme EngineeringAndrea Soddu PhysicsBetina Sorger MaastrichtDorothée Lulé Tubingen

Visiting fellows: Natalia Lapitskaia, Remy Lehembre, Jonathan Orban, Francisco Gomez…

Collaborations:NY N Schiff, J Fins, J GiacinoCambridge A Owen et alMilano M Massimini et alWisconsin G Tononi et alTubingen & Wurzburg A KüblerParis L Puybasset et alHangzou China H DiSalzburg M SchabusLyon F PerrinWeizmann R Malach et alNaples M Papa

Consciousness | Neural correlates | Diagnosis | Prognosis | Treatment | Ethics | Conclusion

Documents

Consciousness and disorders of consciousness · 2 Consciousness Short history of coma Scientific interest Clinical interest Conlusion Terry Schiavo °1963, vegetative 1990, †2005