Évaluation de la conscience aux soins intensifs

Évaluation de la conscience
aux soins intensifs
Steven Laureys
Coma Science Group
Service de Neurologie &
Centre de Recherches du Cyclotron
Université de Liège
www.comascience.org
disorders of consciousness | clinical evaluation | electrophysiology | neuroimaging | ethics & quality of life | conclusion
Overview
Disorders of consciousness
Behavioural evaluation
Electrophysiology
Neuroimaging
Ethics & quality of life
Terry Schiavo °1963, vegetative 1990, † 2005
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disorders of consciousness | clinical evaluation | electrophysiology | neuroimaging | ethics & quality of life | conclusion
A brief history of coma
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Bjørn Ibsen
(1952)
Rigshospitalet Copenhagen
The resuscitation greats. Bjørn Ibsen
Resuscitation. 2003
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Pius XII
(1957)
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Coma dépassé
(1959)
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Jean Morelle & Guy Alexandre
The first organ transplant from a brain-dead donor
Neurology, 2005;64;1938-1942
(1963)
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Christiaan Barnard
Louis Washkansky
(1967)
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Ad Hoc Committee Harvard
(1968)
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disorders of consciousness | clinical evaluation | electrophysiology | neuroimaging | ethics & quality of life | conclusion
Disorders of consciousness
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QUESTIONS
(répondez par OUI ou NON)
Age / Sexe (F-M) / Nationalité / Profession
1.
L’esprit et le cerveau
sont deux entités séparées
2.
L’esprit est une entité purement physique
3.
Une part spirituelle de nous-même
survit après la mort
4.
Chacun de nous a une âme
qui est séparée de notre corps
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disorders of consciousness | clinical evaluation | electrophysiology | neuroimaging | ethics & quality of life | conclusion
Mind brain beliefs
Zeman 2005 in The Boundaries of Consciousness
(Ed) Laureys
www.comascience.org
disorders
of consciousness
| clinicalevaluation
evaluation
| electrophysiology
| neuroimaging
| ethics
& quality
of of
lifelife
| conclusion
disorders
of consciousness
| behavioural
| electrophysiology
| neuroimaging
| methods,
ethics
& quality
| perspectives
Consciousness: arousal & awareness
Laureys, Owen and Schiff, Lancet Neurology, 2005
AWARENESS
LOCKED-IN
SYNDROME
AROUSAL
MINIMALLY
CONSCIOUS
STATE
AWARENESS
AWARENESS
AROUSAL
AWARENESS
VEGETATIVE
STATE
AROUSAL
COMA
AROUSAL
AWARENESS
AROUSAL
NORMAL
CONSCIOUSNESS
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disorders of consciousness | clinical evaluation | electrophysiology | neuroimaging | ethics & quality of life | conclusion
Clinical evaluation
The absence of proof isn’t proof of the absence
Anonymous
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Brain death criteria
Wijdicks, NEJM 2001
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Motor activity in brain death
Lazarus' sign in brain death
Bueri et al Mov Disord. 2000, 15:583-6
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disorders
of consciousness
| clinicalevaluation
evaluation
| electrophysiology
| neuroimaging
| ethics
& quality
of of
lifelife
| conclusion
disorders
of consciousness
| behavioural
| electrophysiology
| neuroimaging
| methods,
ethics
& quality
| perspectives
MOTOR RESPONSIVENESS
Reflex versus voluntary
professional
reinsertion
live
independently
severe
disability
MCS
moderate
disability
good
recovery
communication
voluntary behavior
VS
eye opening
coma
COGNITIVE CAPACITY
Laureys et al., Current Opinion in Neurology, 2005
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disorders
of consciousness
| clinicalevaluation
evaluation
| electrophysiology
| neuroimaging
| ethics
& quality
of of
lifelife
| conclusion
disorders
of consciousness
| behavioural
| electrophysiology
| neuroimaging
| methods,
ethics
& quality
| perspectives
Glasgow Coma Scale
Teasdale & Jennett, Lancet, 1974
E - eye opening
C. Not assessable
AROUSAL
4. Spontaneous
y
3. To speech
HELLO
PAIN
2. To pain
&
PAIN
1. None
&
Laureys et al., Yearbook of Intensive Care Medicine, 2002
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disorders
of consciousness
| clinicalevaluation
evaluation
| electrophysiology
| neuroimaging
| ethics
& quality
of of
lifelife
| conclusion
disorders
of consciousness
| behavioural
| electrophysiology
| neuroimaging
| methods,
ethics
& quality
| perspectives
Glasgow Coma Scale
Teasdale & Jennett, Lancet, 1974
V - verbal response
T. Not assessable
5. Oriented conversation
A.C. Cident
ICU Liège,
March 2002
AWARENESS
WHERE AM I ?
4. Confused speech
STUPID !!!
3. Inappropriate words
2. Incomprehensible sounds
1. None
Laureys et al., Yearbook of Intensive Care Medicine, 2002
10… OFF !?
GROAN
…
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disorders
of consciousness
| clinicalevaluation
evaluation
| electrophysiology
| neuroimaging
| ethics
& quality
of of
lifelife
| conclusion
disorders
of consciousness
| behavioural
| electrophysiology
| neuroimaging
| methods,
ethics
& quality
| perspectives
Glasgow Coma Scale
Teasdale & Jennett, Lancet, 1974
M - motor response
y
AWARENESS
CLOSE
YOUR EYES
6. Obeys simple commands
PAIN
5. Localizes pain
1
4. Withdraws (normal flexion)
PAIN
3. Stereotyped flexion
PAIN
2. Stereotyped extension
PAIN
1. None
PAIN
Laureys et al., Yearbook of Intensive Care Medicine, 2002
www.comascience.org
disorders
of consciousness
| clinicalevaluation
evaluation
| electrophysiology
| neuroimaging
| ethics
& quality
of of
lifelife
| conclusion
disorders
of consciousness
| behavioural
| electrophysiology
| neuroimaging
| methods,
ethics
& quality
| perspectives
FOUR
Wijdicks et al, 2005
www.comascience.org
disorders
of consciousness
| clinicalevaluation
evaluation
| electrophysiology
| neuroimaging
| ethics
& quality
of of
lifelife
| conclusion
disorders
of consciousness
| behavioural
| electrophysiology
| neuroimaging
| methods,
ethics
& quality
| perspectives
FOUR
Wijdicks et al, 2005
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Blink and you live
Laureys et al., Progress in Brain Research, 2005
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disorders of consciousness | clinical evaluation | electrophysiology | neuroimaging | ethics & quality of life | conclusion
Pensez-vous que
5. Le patient en état végétatif ressent la douleur?
6. Le patient en état de conscience minimale ressent la douleur?
7. Le patient en locked-in syndrome ressent la douleur?
Être en état végétatif chronique est pire que la mort
8A. du point de vue du patient?
8B. du point de vue de la famille?
Être en état de conscience minimale chronique est pire qu’être
en état végétatif
9A. du point de vue du patient?
9B. du point de vue de la famille?
Être en locked-in syndrome est pire qu’être
en état végétatif ou en état de conscience minimale
10A. du point de vue du patient?
10B. du point de vue de la famille?
www.comascience.org
disorders
of consciousness
| clinicalevaluation
evaluation
| electrophysiology
| neuroimaging
| ethics
& quality
of of
lifelife
| conclusion
disorders
of consciousness
| behavioural
| electrophysiology
| neuroimaging
| methods,
ethics
& quality
| perspectives
Coma recovery scale
www.comascience.org
disorders of consciousness | clinical evaluation | electrophysiology | neuroimaging | ethics & quality of life | conclusion
Fear for misdiagnosis
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Andreas Vesalius
(1514-1564)
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Fear of being buried alive
1896, Karnice-Karnicki, chamberlain of the tsar of Russia
(1896)
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Death and the media
(1980)
Transplants - Are the donors really dead ?
www.comascience.org
disorders of consciousness | clinical evaluation | electrophysiology | neuroimaging | ethics & quality of life | conclusion
Misdiagnosis of brain death
Over last 50 years
no single recovery recorded
if properly declared
brain death
(apnea test!)
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disorders of consciousness | clinical evaluation | electrophysiology | neuroimaging | ethics & quality of life | conclusion
Misdiagnosis of vegetative state
n=103 post-comatose patients
45 clinical consensus diagnosis
of “vegetative state”
27 Coma Recovery Scale diagnosis
(Coma Recuperatie Schaal)
ª
40% misdiagnosis
38% Schnakers et al Ann Neurol ´06 Schnakers et al, submitted
37% Childs et al Neurology ´93
43% Andrews et al BMJ ´96
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disorders of consciousness | clinical evaluation | electrophysiology | neuroimaging | ethics & quality of life | conclusion
How to assess eye tracking ?
n=52
Vanhaudenhuyse et al, JNNP 2008
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disorders of consciousness | clinical evaluation | electrophysiology | neuroimaging | ethics & quality of life | conclusion
Blinking to threat
n=91 VS patients
46 (51%) blinking to visual threat
17 (37%) recovered to MCS
11/45 without blink recovered MCS (24%)
ª
blinking is no sign of consciousness
Schnakers, Giacino et al, submitted
www.comascience.org
disorders of consciousness | clinical evaluation | electrophysiology | neuroimaging | ethics & quality of life | conclusion
Electrophysiology
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disorders
of consciousness
| clinicalevaluation
evaluation
| electrophysiology
| neuroimaging
| ethics
& quality
of of
lifelife
| conclusion
disorders
of consciousness
| behavioural
| electrophysiology
| neuroimaging
| methods,
ethics
& quality
| perspectives
time-frequency balanced spectral entropy
EEG entropy
Gosseries et al, in preparation
75% sensitivity
75% specificity
CONTROL
(n=15)
MCS
(n=15)
VS
(n=15)
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disorders
of consciousness
| clinicalevaluation
evaluation
| electrophysiology
| neuroimaging
| ethics
& quality
of of
lifelife
| conclusion
disorders
of consciousness
| behavioural
| electrophysiology
| neuroimaging
| methods,
ethics
& quality
| perspectives
Cognitive evoked potentials
minimally conscious state
µV
-10.0
OTHER NAMES
-7.5
-5.0
OWN NAME
N1
-2.5
0.0
100
200
300
400
500
600
700
800
900
1000 1100
1200 1300 1400 1500 ms
2.5
5.0
7.5
10.0
Laureys, Perrin et al., Neurology, 2004
Perrin et al, Archives in Neurology, 2006
P3
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disorders of consciousness | clinical evaluation | neuroimaging | ethics & quality of life | future | conclusion
Functional neuroimaging
The map is not the territory
Alfred Korzybski (1879-1950)
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disorders of consciousness | clinical evaluation | neuroimaging | ethics & quality of life | future | conclusion
c resting metabolism
d activation studies
z
passive
z
active
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disorders
of consciousness
| clinicalevaluation
evaluation
| electrophysiology
| neuroimaging
| ethics
& quality
of of
lifelife
| conclusion
disorders
of consciousness
| behavioural
| electrophysiology
| neuroimaging
| methods,
ethics
& quality
| perspectives
Resting metabolism
Laureys, Owen & Schiff, Lancet Neurology, 2004
(sleep data from Pierre Maquet; anesthesia data from Mike Alkire)
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disorders
of consciousness
| clinicalevaluation
evaluation
| electrophysiology
| neuroimaging
| ethics
& quality
of of
lifelife
| conclusion
disorders
of consciousness
| behavioural
| electrophysiology
| neuroimaging
| methods,
ethics
& quality
| perspectives
“Awareness network”
n=60
Laureys et al, NeuroImage 1999
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disorders
of consciousness
| clinicalevaluation
evaluation
| electrophysiology
| neuroimaging
| ethics
& quality
of of
lifelife
| conclusion
disorders
of consciousness
| behavioural
| electrophysiology
| neuroimaging
| methods,
ethics
& quality
| perspectives
“miracle” recovery from MCS
Terry Wallis wakes from
19-year MCS
Voss, … Schiff, Journal of Clinical Investigation, 2006
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disorders
of consciousness
| clinicalevaluation
evaluation
| electrophysiology
| neuroimaging
| ethics
& quality
of of
lifelife
| conclusion
disorders
of consciousness
| behavioural
| electrophysiology
| neuroimaging
| methods,
ethics
& quality
| perspectives
Thalamo-cortical modulation
Laureys et al., Lancet, 2000
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disorders
of consciousness
| clinicalevaluation
evaluation
| electrophysiology
| neuroimaging
| ethics
& quality
of of
lifelife
| conclusion
disorders
of consciousness
| behavioural
| electrophysiology
| neuroimaging
| methods,
ethics
& quality
| perspectives
Thalamic stimulation
Schiff et al., Nature, 2007
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disorders of consciousness | clinical evaluation | electrophysiology | neuroimaging | ethics & quality of life | conclusion
Amantadine in MCS
amantadine
Schnakers et al, JNNP 2008
amantadine
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disorders of consciousness | clinical evaluation | electrophysiology | neuroimaging | ethics & quality of life | conclusion
Neuroimaging
c resting brain function
d brain activation studies
passive paradigms
z active paradigms
z
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disorders of consciousness | clinical evaluation | electrophysiology | neuroimaging | ethics & quality of life | conclusion
Pensez-vous que
11. on peut arrêter le traitement (nutrition et hydratation) chez le patient en état
végétatif chronique ?
12. on peut arrêter le traitement chez
le patient en état de conscience minimale chronique ?
13. on peut arrêter le traitement chez
le patients locked-in chronique?
Souhaiteriez-vous de continuer à vivre si vous étiez :
14. en état végétatif chronique
15. en état de conscience minimale chronique
16. en locked-in syndrome chronique
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disorders
of consciousness
| clinicalevaluation
evaluation
| electrophysiology
| neuroimaging
| ethics
& quality
of of
lifelife
| conclusion
disorders
of consciousness
| behavioural
| electrophysiology
| neuroimaging
| methods,
ethics
& quality
| perspectives
Do they feel pain ?
NO RESPONSE
AWAKENING
GRIMACING
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disorders
of consciousness
| clinical
evaluation
| neuroimaging
| ethics| &
qualityethics
of life& |quality
future
conclusion
disorders
of consciousness
| behavioural
evaluation
| electrophysiology
| neuroimaging
methods,
of |life
| perspectives
Vegetative is not apallic
Painful stimulation
Low level
disconnected
cortical activation
Laureys et al., Neuroimage, 2002
Laureys, Nature Reviews Neuroscience, 2006
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Hable con Ella
"…a (wo)men’s brain is a mystery...
and even more so in this state."
Pedro Almodóvar
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disorders of consciousness | clinical evaluation | electrophysiology | neuroimaging | ethics & quality of life | conclusion
Emotional processing
Laureys et al., Neurology, 2004
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disorders of consciousness | clinical evaluation | electrophysiology | neuroimaging | ethics & quality of life | conclusion
Neuroimaging
c resting brain function
d brain activation studies
passive paradigms
z active paradigms
z
www.comascience.org
disorders
of consciousness
| clinicalevaluation
evaluation
| electrophysiology
| neuroimaging
| ethics
& quality
of of
lifelife
| conclusion
disorders
of consciousness
| behavioural
| electrophysiology
| neuroimaging
| methods,
ethics
& quality
| perspectives
Active fMRI paradigms
Boly et al, NeuroImage 2007
Owen, Coleman, Boly, Davis, Laureys and Pickard, Science, 2006
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disorders of consciousness | clinical evaluation | electrophysiology | neuroimaging | ethics & quality of life | conclusion
fMRI precedes the clinic
vegetative
Di et al, Neurology, 2007
minimally conscious
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disorders of consciousness | clinical evaluation | electrophysiology | neuroimaging | ethics & quality of life | conclusion
Ethics &
quality of life
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disorders
of consciousness
| clinicalevaluation
evaluation
| electrophysiology
| neuroimaging
| ethics
& quality
of of
lifelife
| conclusion
disorders
of consciousness
| behavioural
| electrophysiology
| neuroimaging
| methods,
ethics
& quality
| perspectives
Locked-in syndrome (LIS)
Laureys et al., Progress in Brain Research, 2005
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disorders
of consciousness
| clinicalevaluation
evaluation
| electrophysiology
| neuroimaging
| ethics
& quality
of of
lifelife
| conclusion
disorders
of consciousness
| behavioural
| electrophysiology
| neuroimaging
| methods,
ethics
& quality
| perspectives
Quality of life in LIS
QUESTION 17.
Anamnestic Comparative Self Assessment (Bernheim et al)
XX
X Locked-in patients n=70
X Matched healthy controls n=70
QUESTION 18.
Êtes-vous croyant : Non-Oui (quelle religion / pratiquant ?)
Bruno, Pellas… Laureys, in preparation
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disorders of consciousness | clinical evaluation | electrophysiology | neuroimaging | ethics & quality of life | conclusion
Conclusions
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disorders of consciousness | clinical evaluation | electrophysiology | neuroimaging | ethics & quality of life | conclusion
Conclusions
• Diagnosis
• misdiagnosis of VS (40%)
• behavioral evaluation (CRS-R)
• need for objective markers of consciousness
• Vegetative state
• disconnection syndrome with impaired
fronto-parietal neuronal “workspace”
• Minimally conscious state
• preserved emotional & pain perception
• Locked-in syndrome
• right to communicate, right to die, right to live
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disorders of consciousness | clinical evaluation | electrophysiology | neuroimaging | ethics & quality of life | conclusion
www.comascience.org
thanks to
also thanks to
Melanie Boly MD
Didier Ledoux MD
Caroline Schnakers
Audrey Vanhaudenhuyse
Marie-Aurélie Bruno
Olivia Gosseries
Victor Cologan
Pierre Boveroux MD
Athena Demertzi
Gustave Moonen MD PhD
Christophe Phillips PhD Ing
Quentin Noirhomme PhD Ing
Pierre Maquet MD PhD
the patients & families
Frédéric Pellas MD (Nîmes)
Adrian Owen PhD (Cambridge)
Louis Puybasset MD (Paris)
Fabien Perrin PhD (Lyon)
Haibo Di PhD (Zhejiang)
Joe Giacino PhD, Nico Schiff MD (NY)
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