Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital and Harvard Medical School, Boston, MA; Department of Psychiatry, Massachusetts General Hospital, Boston, MA.
Department of Neurology, Boston University School of Medicine, Boston, MA; Braintree Rehabilitation Hospital, MA.
Arch Phys Med Rehabil. 2018 Sep;99(9):1710-1719. doi: 10.1016/j.apmr.2018.07.002. Epub 2018 Aug 8.
To update the 1995 American Academy of Neurology (AAN) practice parameter on persistent vegetative state and the 2002 case definition for the minimally conscious state (MCS) by reviewing the literature on the diagnosis, natural history, prognosis, and treatment of disorders of consciousness lasting at least 28 days.
Articles were classified per the AAN evidence-based classification system. Evidence synthesis occurred through a modified Grading of Recommendations Assessment, Development and Evaluation process. Recommendations were based on evidence, related evidence, care principles, and inferences according to the AAN 2011 process manual, as amended.
No diagnostic assessment procedure had moderate or strong evidence for use. It is possible that a positive EMG response to command, EEG reactivity to sensory stimuli, laser-evoked potentials, and the Perturbational Complexity Index can distinguish MCS from vegetative state/unresponsive wakefulness syndrome (VS/UWS). The natural history of recovery from prolonged VS/UWS is better in traumatic than nontraumatic cases. MCS is generally associated with a better prognosis than VS (conclusions of low to moderate confidence in adult populations), and traumatic injury is generally associated with a better prognosis than nontraumatic injury (conclusions of low to moderate confidence in adult and pediatric populations). Findings concerning other prognostic features are stratified by etiology of injury (traumatic vs nontraumatic) and diagnosis (VS/UWS vs MCS) with low to moderate degrees of confidence. Therapeutic evidence is sparse. Amantadine probably hastens functional recovery in patients with MCS or VS/UWS secondary to severe traumatic brain injury over 4 weeks of treatment. Recommendations are presented separately.
通过回顾至少持续 28 天的意识障碍的诊断、自然史、预后和治疗的文献，更新 1995 年美国神经病学学会 (AAN) 关于持续性植物状态的实践参数和 2002 年最小意识状态 (MCS) 的病例定义。
根据 AAN 基于证据的分类系统对文章进行分类。通过修改后的推荐评估、制定和评估分级过程进行证据综合。根据 AAN 2011 年流程手册（经修订），建议基于证据、相关证据、护理原则和推断，以及 AAN 证据分级系统。
没有诊断评估程序具有中等或强证据支持使用。命令性肌电图反应、感觉刺激的脑电图反应、激光诱发电位和扰动复杂性指数可能能够区分 MCS 与植物状态/无反应性觉醒综合征 (VS/UWS)。创伤性 VS/UWS 患者从长时间 VS/UWS 中恢复的自然史要好于非创伤性病例。MCS 一般与 VS 相比预后更好（成人人群的置信度为低到中等），创伤性损伤一般与非创伤性损伤相比预后更好（成人和儿科人群的置信度为低到中等）。关于其他预后特征的发现根据损伤的病因（创伤性与非创伤性）和诊断（VS/UWS 与 MCS）进行分层，置信度为低到中等。治疗证据稀少。金刚烷胺可能会加速严重创伤性脑损伤后 4 周内 MCS 或 VS/UWS 患者的功能恢复。建议分别列出。
