Traumatic brain injury

A traumatic brain injury (TBI), also known as an intracranial injury, is an injury to the brain caused by an external force. TBI can be classified based on severity ranging from mild traumatic brain injury (mTBI/concussion) to severe traumatic brain injury. TBI can also be characterized based on mechanism (closed or penetrating head injury) or other features (e.g., occurring in a specific location or over a widespread area). Head injury is a broader category that may involve damage to other structures such as the scalp and skull. TBI can result in physical, cognitive, social, emotional and behavioral symptoms, and outcomes can range from complete recovery to permanent disability or death. Causes include falls, vehicle collisions and violence. Brain trauma occurs as a consequence of a sudden acceleration or deceleration within the cranium or by a complex combination of both movement and sudden impact. In addition to the damage caused at the moment of injury, a variety of events follo

Sympathetic activity and early mobilization in patients in intensive and intermediate care with severe brain injuries: a preliminary prospective randomized study

Dimitri Nestor Alice Van De Ville

Background: Patients who experience severe brain injuries are at risk of secondary brain damage, because of delayed vasospasm and edema. Traditionally, many of these patients are kept on prolonged bed rest in order to maintain adequate cerebral blood flow, especially in the case of subarachnoid hemorrhage. On the other hand, prolonged bed rest carries important morbidity. There may be a clinical benefit in early mobilization and our hypothesis is that early gradual mobilization is safe in these patients. The aim of this study was to observe and quantify the changes in sympathetic activity, mainly related to stress, and blood pressure in gradual postural changes by the verticalization robot (Erigo (R)) and after training by a lower body ergometer (MOTOmed-letto (R)), after prolonged bed rest of minimum 7 days. Methods: Thirty patients with severe neurological injuries were randomized into 3 groups with different protocols of mobilization: Standard, MOTOmed-letto (R) or Erigo (R) protocol. We measured plasma catecholamines, metanephrines and blood pressure before, during and after mobilization. Results: Blood pressure does not show any significant difference between the 3 groups. The analysis of the catecholamines suggests a significant increase in catecholamine production during Standard mobilization with physiotherapists and with MOTOmed-letto (R) and no changes with Erigo (R). Conclusions: This preliminary prospective randomized study shows that the mobilization of patients with severe brain injuries by means of Erigo (R) does not increase the production of catecholamines. It means that Erigo (R) is a well-tolerated method of mobilization and can be considered a safe system of early mobilization of these patients. Further studies are required to validate our conclusions.

BioMed Central2016

EEG paradigms as a supplemental tool to behavioral assessments of DOC

Jean-Paul Noel, Serafeim Perdikis, Andrea Serino

Introduction Diagnosis and prediction of recovery in the acute phase of disorders of consciousness (DOC) are critical for subsequent medical decisions. However, reliable assessment remains elusive due to the inability of current validated clinical scales to take into account motor and drive deficits. Recently, the Motor Behaviour Tool (MBT), a novel clinical scale, has been developed to address this caveat (1). In this context, neuroimaging and brain-computer interface (BCI) have also been proposed to improve the diagnosis and prognosis of these patients.(2). Objectives This pilot study aims to investigate the diagnostic and prognostic value of two electroencephalography (EEG)-based paradigms in patients with DOC, i.e., coma, Unresponsive Awareness Syndrome (UWS) or Minimally Conscious State (MCS). As a second step, we will employ them as evidence to further establish the added value of the MBT (i.e., assessment of minimal responses suggesting remaining conscious processing) combined with the Coma Recovery Scale-Revised (CRS-R), a standardized validated scale commonly used to assess consciousness in this population (3). Patients & Methods Acute DOC patients undergo CRS-R and MBT assessment prior to two EEG paradigms. Firstly, a motor attempt EEG-BCI coupled with Functional Electrical Stimulation (FES) is used (4). We hypothesize that replacing the need for overt movements with motor attempt can alleviate the tendency of CRS-R to underestimate the level of awareness in case of cognitive-motor dissociation (CMD) (5). In addition, a second EEG protocol presents patients with FES-tactile (T), auditory (A), and audio-tactile (AT) stimuli both in actionable and non-actionable space. EEG evoked potentials observed in the actionable space are expected to show a non-linear addition of sensory stimuli (i.e., A+T ≠ AT) indicating multisensory integration and the capacity of conscious processing (6). Results Pending elaborate analysis, preliminary findings show (Fig. 1) that BCI accuracy is significantly above chance only for a patient who was diagnosed as UWS by the CRS-R evaluation, but exhibited a motor behavior classified as CMD confirmed by the MBT tool, and not for one in real UWS (same diagnosis based on CRS-R and MBT), implying the presence of the hypothesized relation between motor EEG correlates and awareness (7). Average EEG evoked potentials of 8 patients during the second EEG paradigm highlight a difference between within (solid line) vs. outside (dashed line) the actionable space (Fig. 2), suggesting awareness-dependent modulation. Future analyses will explore correlations of such EEG descriptors with the clinical outcomes. Conclusion EEG correlates extracted from these EEG paradigms are promising tools for diagnosis of DOC and may supplement current clinical scales to help the validation of new tools like the MBT. References J. M. Pignat, E. Mauron, J. Jöhr, C. Gilart De Keranflec'h, D. Van De Ville, M. G. Preti, D. E. Meskaldji, V. Hörnberg, S. Laureys, B. Draganski, R. Frackowiak, K. Diserens, Outcome prediction of consciousness disorders in the acute stage based on a complementary motor behavioural tool, PLOS ONE 11(6), e0156882 (2016). A. M. Owen, M. R. Coleman, M. Boly, M. H. Davis, S. Laureys, J. D. Pickard, Detecting awareness in the vegetative state, Science, 313, 1402 (2006). J. T. Giacino, K. Kalmar, J. Whyte, The JFK Coma Recovery Scale-Revised: measurement characteristics and diagnostic utility, Arch. Phys. Med. Rehabil. 85(12), 2020-9 (2004). T. Corbet, R. Leeb, A. Biasiucci, S. Perdikis, J. del R. Millán et al. BCI-NMES therapy enhances effective connectivity in the damaged hemisphere in stroke patients. 6th International Brain-Computer Interface Meeting, Asilomar, California, USA (2016). N. D. Schiff, Cognitive motor dissociation following severe brain injuries, JAMA Neurol. 72(12), 1413–1415 (2015). J. P. Noel, C. Pfeiffer, O. Blanke, A. Serino, Full body peripersonal space as the space of the bodily self, Cognition 144, 49-57 (2015). A. M . Goldfine, J. D. Victor, M. M. Conte, J. C. Bardin, N. D. Schiff, Determination of awareness in patients with severe brain injury using EEG power spectral analysis, Clin. Neurophysiol. 122(11), 2157-68 (2011).

2017

EEG paradigms as a supplemental tool to behavioral assessments of DOC

Jean-Paul Noel, Serafeim Perdikis, Andrea Serino

2017

Sympathetic activity and early mobilization in patients in intensive and intermediate care with severe brain injuries: a preliminary prospective randomized study

Dimitri Nestor Alice Van De Ville

BioMed Central2016