Athena Demertzi. Coma Science Group Cyclotron Research Centre and Neurology Department University Hospital of Liège, BELGIUM

Transcription

1 Coma Recovery Scale Revised workshop op Vienna, 22/09/2009 Athena Demertzi Neuropsychologist, o og st, PhD Student t Coma Science Group Cyclotron Research Centre and Neurology Department University Hospital of Liège, BELGIUM

2 Attitudes Consciousness Clinical evaluation Coma Recovery Scale Questions Demertzi et al., ANYAS 2009

3 Definition Consciousness Clinical evaluation Coma Recovery Scale Questions Conscious Wakefulness Locked-in syndrome Drowsiness Light sleep Deep Sleep Minimally Conscious State General Anesthesia Coma Vegetative state Laureys, Trends in Cognitive Sciences, 2005

4 Clinical entities Permanent Minimally Conscious State? Laureys, Scientific American, 2007

5 Clinical evaluation The absence of proof isn t proof of absence Anonymous

6 Misdiagnosis of vegetative state n=103 post-comatose patients 45 clinical i l diagnosis i of vegetative ti state t 27 Coma Recovery Scale diagnosis 40% misdiagnosis 38% Schnakers et al Ann Neurol 06; BMC Neurology, % Childs et al Neurology 93 43% Andrews et al BMJ 96

7 Reflex versus voluntary

8 Anatomy of consciousness Laureys et al., Yearbook of Intensive Care Medicine, 2002

9 Visual pursuit p<.05 Vanhaudenhuyse et al., JNNP, 2008

10 Blinking to threat N=91 VS patients Positive predictive value (blink and recovery) : 30% Negative predictive value (no blink and no recovery) : 80% blinking is no sign of consciousness Vanhaudenhuyse et al., Neurology, 2008

11 Coma Recovery Scale -Revised

12 Introduction

13 Supplementary but important

14 Prerequisite Important: Keep your patient awake!

15 Auditory Function 8/8 3/4 2/4 2/4 Object-related command eye movement Look at the [object 1] Look at the [object 2] limb movement Take the [object 1] Take the [object 2] Non-object related command eye movement Look away from me Look up /down limb movement Touch my hand Move [object/ part of body] oral movement/ vocalization Open your mouth Say ah

16 Visual Function 3/4 3/4 2/8 2/4 2/4 Same as Score direction/ no contact needed/ no tactile cues! Any direction > 2 sec 2/4 > 2 sec

17 Motor Function Able to move Unable to move 4/4 2/2 3/4 2/4 1/4 1/4 2 objects- Show me how to use Automatic motor behaviors. If not Tennis ball- Take the ball PAIN

18 Oromotor Function 2 words Aural set/ Visual Set prompts, CVC form 1 1 e.g. tongue blade, yawning

19 Communication Scale 6/6 2/6

20 Arousal Scale x x x 3 failures to a verbal prompt Eyes open across examination Tactile, pressure, noxious stimulation 1

21 Brainstem reflexes COLD H 2 O HOT H 2 O COLD H 2 O

22 Contingent Behavior

23 Questions? " a (wo)man s brain is a mystery... y and even more so in this state."

24 Steven Laureys, MD PhD Audrey Vanhaudenhuyse Marie-Aurélie Bruno Olivia Gosseries Pierre Boveroux MD Muriel Kirsch MD Audrey Maudoux Victor Cologan Melanie Boly, MD PhD Andrea Soddu, PhD Quentin Noirhomme, PhD Ing Caroline Schnakers, PhD Didier Ledoux MD PhD Christophe Phillips, PhD Ing Pierre Maquet, MD PhD Adrian Owen, PhD (Cambridge) Nico Schiff MD, Joe Giacino PhD (NY) Louis Puybasset, MD (Paris) Haibo Di, PhD (Zhejiang & Bejing) Slides on website the patients & families