Jacobson Samuel D, Kansara Vedant, Assuras Stephanie, Shen Qi, Kruger Lucie, Carmona Jerina, Song You Lim, Cespedes Lizbeth, Yazdi Mariam, Velazquez Angela, Gonzales Ian, Egawa Satoshi, Connolly E Sander, Ghoshal Shivani, Roh David, Agarwal Sachin, Park Soojin, Claassen Jan
Department of Neurology, Neurological Institute, Columbia University Medical Center, NewYork-Presbyterian Hospital, 177 Fort Washington Avenue, MHB 8 Center, Room 300, New York, NY, 10032, USA.
NewYork-Presbyterian Hospital, New York, NY, USA.
Neurocrit Care. 2025 Apr;42(2):587-594. doi: 10.1007/s12028-024-02086-z. Epub 2024 Aug 13.
Brain activation to motor commands is seen in 15% of clinically unresponsive patients with acute brain injury. This state called cognitive motor dissociation (CMD) is detectable by electroencephalogram (EEG) or functional magnetic resonance imaging, predicts long-term recovery, and is recommended by recent guidelines to support prognostication. However, false negative CMD results are a particular concern, and occult aphasia in clinically unresponsive patients may be a major factor. This study aimed to quantify the impact of aphasia on CMD testing.
We prospectively studied 61 intensive care unit patients admitted with acute primary intracerebral hemorrhage (ICH) who had behavioral evidence of command following or were able to mimic motor commands. All patients underwent an EEG-based motor command paradigm used to detect CMD and comprehensive aphasia assessments. Logistic regression was used to identify predictors of brain activation, including aphasia types and associations with recovery of independence (Glasgow Outcome Scale-Extended score ≥ 4).
Of 61 patients, 50 completed aphasia and the EEG-based motor command paradigm. A total of 72% (n = 36) were diagnosed with aphasia. Patients with impaired comprehension (i.e., receptive or global aphasia) were less likely to show brain activation than those with intact comprehension (odds ratio [OR] 0.23 [95% confidence interval 0.05-0.89], p = 0.04). Brain activation was independently associated with Glasgow Outcome Scale-Extended ≥ 4 by 12 months (OR 2.4 [95% confidence interval 1.2-5.0], p = 0.01) accounting for the Functional Outcome in Patients with Primary ICH score (OR1.3 [95% confidence interval 1.0-1.8], p = 0.01).
Brain activation to motor commands is four times less likely for patients with primary ICH with impaired comprehension. False negative results due to occult receptive aphasia need to be considered when interpreting CMD testing. Early detection of brain activation may help predict long-term recovery in conscious patients with ICH.
在15%临床上无反应的急性脑损伤患者中可观察到大脑对运动指令的激活。这种状态称为认知运动分离（CMD），可通过脑电图（EEG）或功能磁共振成像检测到，可预测长期恢复情况，并且近期指南推荐其用于辅助预后评估。然而，CMD结果假阴性是一个特别值得关注的问题，临床上无反应患者中隐匿性失语可能是一个主要因素。本研究旨在量化失语对CMD检测的影响。
我们前瞻性地研究了61例因急性原发性脑出血（ICH）入住重症监护病房的患者，这些患者有执行指令的行为证据或能够模仿运动指令。所有患者均接受了基于EEG的运动指令范式以检测CMD，并进行了全面的失语评估。采用逻辑回归来确定大脑激活的预测因素，包括失语类型以及与独立恢复（格拉斯哥扩展预后量表评分≥4）的相关性。
61例患者中，50例完成了失语评估和基于EEG的运动指令范式检测。共有72%（n = 36）的患者被诊断为失语。与理解能力正常的患者相比，理解能力受损（即感觉性失语或完全性失语）的患者大脑激活的可能性更小（比值比[OR] 0.23 [95%置信区间0.05 - 0.89]，p = 0.04）。到12个月时，大脑激活与格拉斯哥扩展预后量表≥4独立相关（OR 2.4 [95%置信区间1.2 - 5.0]，p = 0.01），这一结果在考虑原发性ICH患者功能预后评分后仍然成立（OR1.3 [95%置信区间1.0 - 1.8]，p = 0.01）。
对于理解能力受损的原发性ICH患者，大脑对运动指令的激活可能性降低四倍。在解释CMD检测结果时，需要考虑隐匿性感觉性失语导致的假阴性结果。早期检测大脑激活可能有助于预测ICH清醒患者的长期恢复情况。
