Consciousness and disorders of consciousness · 2 Consciousness Short history of coma Scientific...
Transcript of Consciousness and disorders of consciousness · 2 Consciousness Short history of coma Scientific...
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Consciousness and disorders of consciousness
Audrey Vanhaudenhuyse PhDComa Science GroupCyclotron Research Centre &University Hospital of LiègeBelgium
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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
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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
Consciousness | History | Scientific | Clinical | Conclusion
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Short history of coma
Anoebis
heart Maät
Consciousness | History | Scientific | Clinical | Conclusion
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Artificial respirator (1952)
The resuscitation greats. Bjørn IbsenResuscitation. 2003
Bjørn Ibsen - Copenhagen
Consciousness | History | Scientific | Clinical | Conclusion
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Coma dépassé (1959)
Consciousness | History | Scientific | Clinical | Conclusion
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Definition of brain deathHarvard Committee 1968
Wijdicks, NEJM 2001Bueri et al Mov Disord. 2000, 15:583-6
Consciousness | History | Scientific | Clinical | Conclusion
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Scientific interest
Consciousness | History | Scientific | Clinical | Conclusion
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Laureys et al, Lancet Neurology, 2004
disorders of consciousness | behavioural evaluation | electrophysiology | neuroimaging | methods, ethics & quality of life | perspectives
Consciousness ≠ whole brain
Consciousness | History | Scientific | Clinical | Conclusion
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disorders of consciousness | behavioural evaluation | electrophysiology | neuroimaging | methods, ethics & quality of life | perspectives
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
Consciousness | History | Scientific | Clinical | Conclusion
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Laureys et al, Lancet Neurology, 2004
disorders of consciousness | behavioural evaluation | electrophysiology | neuroimaging | methods, ethics & quality of life | perspectives
Precuneus ≈ hub in the network
Axonal re-growth in Terry Wallis
Voss et al, J Clin Invest, 2006
Consciousness | History | Scientific | Clinical | Conclusion
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Vogt and Laureys, Prog Brain Res, 2005Vogt, Vogt and Laureys, NeuroImage, 2006
disorders of consciousness | behavioural evaluation | electrophysiology | neuroimaging | methods, ethics & quality of life | perspectives
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
Consciousness | History | Scientific | Clinical | Conclusion
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UNCONSCIOUS CONSCIOUS
Dehaene et al, Trends in Cognitive Sciences 2006
Global workspace theoryConsciousness | History | Scientific | Clinical | Conclusion
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disorders of consciousness | behavioural evaluation | electrophysiology | neuroimaging | methods, ethics & quality of life | perspectives
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
Consciousness | History | Scientific | Clinical | Conclusion
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Clinical interest
Consciousness | History | Scientific | Clinical | Conclusion
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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
Consciousness | History | Scientific | Clinical | Conclusion
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Diagnosis
Consciousness | History | Scientific | Clinical | Conclusion
Laureys et al., Current Opinion in Neurology, 2005
disorders of consciousness | behavioural evaluation | electrophysiology | neuroimaging | methods, ethics & quality of life | perspectives
Assessing consciousness
COGNITIVE CAPACITY
MOTOR RESPONSIVENESS
coma
VS
MCS
severe disability
arousal
communication
moderate disability
goodrecovery
live independently
professional reinsertion
awareness
Consciousness | History | Scientific | Clinical | Conclusion
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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
Consciousness | History | Scientific | Clinical | Conclusion
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disorders of consciousness | behavioural evaluation | electrophysiology | neuroimaging | methods, ethics & quality of life | perspectives
Coma recovery scale
Schnakers et al Brain Injury 2008
Consciousness | History | Scientific | Clinical | Conclusion
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Eye tracking : use a mirror!
Vanhaudenhuyse et alJ Neurol Neurosurg Psychiatry 2008
n=52
Consciousness | History | Scientific | Clinical | Conclusion
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Owen, Coleman, Boly, Davis, Laureys & Pickard, Science, 2006
Signs of consciousness on fMRI
Consciousness | History | Scientific | Clinical | Conclusion
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≠ “automatic” brain response
Soddu et al, Prog Brain Res 2009
Consciousness | History | Scientific | Clinical | Conclusion
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disorders of consciousness | behavioural evaluation | electrophysiology | neuroimaging | methods, ethics & quality of life | perspectives
Monti & Vanhaudenhuyse, Coleman, Boly, Pickard, Tshibanda, Owen, LaureysNew England J Med 2010
Yes-No communication with fMRI
Consciousness | History | Scientific | Clinical | Conclusion
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Communication via fMRI
Sorger et al, Prog Brain Res 2009
Consciousness | History | Scientific | Clinical | Conclusion
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disorders of consciousness | behavioural evaluation | electrophysiology | neuroimaging | methods, ethics & quality of life | perspectives
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
Consciousness | History | Scientific | Clinical | Conclusion
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Conclusion
Consciousness | History | Scientific | Clinical | Conclusion
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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
Consciousness | History | Scientific | Clinical | Conclusion
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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