Center for Neurotechnology and Neurorecovery, Department of Neurology, Massachusetts General Hospital and Harvard Medical School, Boston, MA.
Athinoula A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital, Charlestown, MA.
Crit Care Med. 2024 Sep 1;52(9):1414-1426. doi: 10.1097/CCM.0000000000006372. Epub 2024 Aug 15.
For critically ill patients with acute severe brain injuries, consciousness may reemerge before behavioral responsiveness. The phenomenon of covert consciousness (i.e., cognitive motor dissociation) may be detected by advanced neurotechnologies such as task-based functional MRI (fMRI) and electroencephalography (EEG) in patients who appear unresponsive on the bedside behavioral examination. In this narrative review, we summarize the state-of-the-science in ICU detection of covert consciousness. Further, we consider the prognostic and therapeutic implications of diagnosing covert consciousness in the ICU, as well as its potential to inform discussions about continuation of life-sustaining therapy for patients with severe brain injuries.
We reviewed salient medical literature regarding covert consciousness.
We included clinical studies investigating the diagnostic performance characteristics and prognostic utility of advanced neurotechnologies such as task-based fMRI and EEG. We focus on clinical guidelines, professional society scientific statements, and neuroethical analyses pertaining to the implementation of advanced neurotechnologies in the ICU to detect covert consciousness.
We extracted study results, guideline recommendations, and society scientific statement recommendations regarding the diagnostic, prognostic, and therapeutic relevance of covert consciousness to the clinical care of ICU patients with severe brain injuries.
Emerging evidence indicates that covert consciousness is present in approximately 15-20% of ICU patients who appear unresponsive on behavioral examination. Covert consciousness may be detected in patients with traumatic and nontraumatic brain injuries, including patients whose behavioral examination suggests a comatose state. The presence of covert consciousness in the ICU may predict the pace and extent of long-term functional recovery. Professional society guidelines now recommend assessment of covert consciousness using task-based fMRI and EEG. However, the clinical criteria for patient selection for such investigations are uncertain and global access to advanced neurotechnologies is limited.
对于急性严重脑损伤的危重症患者，意识可能在行为反应之前重新出现。在床边行为检查中表现无反应的患者中，通过任务型功能磁共振成像（fMRI）和脑电图（EEG）等先进神经技术可能会检测到隐匿意识（即认知运动分离）现象。在本叙述性综述中，我们总结了 ICU 中隐匿意识检测的最新技术。此外，我们还考虑了在 ICU 中诊断隐匿意识的预后和治疗意义，以及它在为严重脑损伤患者继续维持生命治疗的讨论中提供信息的潜力。
我们回顾了有关隐匿意识的重要医学文献。
我们纳入了研究先进神经技术（如任务型 fMRI 和 EEG）的诊断性能特征和预后效用的临床研究。我们重点关注与在 ICU 中实施先进神经技术以检测隐匿意识相关的临床指南、专业学会科学声明和神经伦理分析。
我们提取了有关隐匿意识对 ICU 严重脑损伤患者临床护理的诊断、预后和治疗相关性的研究结果、指南建议和学会科学声明建议。
新出现的证据表明，约 15-20%在床边行为检查中表现无反应的 ICU 患者存在隐匿意识。隐匿意识可能存在于创伤性和非创伤性脑损伤患者中，包括行为检查提示昏迷状态的患者。ICU 中隐匿意识的存在可能预测长期功能恢复的速度和程度。专业学会指南现在建议使用任务型 fMRI 和 EEG 评估隐匿意识。然而，用于此类研究的患者选择的临床标准尚不确定，并且全球获得先进神经技术的机会有限。
