DOC联盟交流会（6）：脑损伤后意识障碍的临床决策

文章转载自-天坛意识障碍诊疗病房

今天为大家带来的是复旦大学附属华山医院神经外科毛颖/吴雪海团队在《Neuroscience Bulletin》期刊在线发表了题为“Clinical Decision on Disorders of Consciousness After Acquired Brain Injury: Stepping Forward”的综述文章。

目前，随着临床意识障碍（DOC）评估体系的日益完善（结合有价值的行为评估工具、先进的神经影像和脑电技术），临床上可以采用256EEG在床旁获得相对较高的个体化苏醒预测准确率（87%）。尽管多种干预促醒手段（药物治疗、神经调控等）的临床研究已被开展，然而仅有金刚烷胺和经颅直流电刺激（tDCS）获得了II级临床证据。先进的脑机接口技术、外科促醒技术将将为DOC的促醒治疗提供新的契机。为了提高临床DOC诊断的准确性、实现临床管理优化，本文呈现了一项经验性的脑损伤后DOC管理流程。

参考文献（上下滑动阅读）

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[2] Giacino JT, Fins JJ, Laureys S, Schiff ND: Disorders of consciousness after acquired brain injury: the state of the science. Nat Rev Neurol 2014, 10(2):99-114.

[3] Wu H, Qi Z, Wu X, Zhang J, Wu C, Huang Z, Zang D, Fogel S, Tanabe S, Hudetz AG et al: Anterior precuneus related to the recovery of consciousness. Neuroimage Clin 2022, 33:102951.

[4] Zhang H, Dai R, Qin P, Tang W, Hu J, Weng X, Wu X, Mao Y, Wu X, Northoff G: Posterior cingulate cross-hemispheric functional connectivity predicts the level of consciousness in traumatic brain injury. Sci Rep 2017, 7(1):387.

[5] Song M, Zhang Y, Cui Y, Yang Y, Jiang T: Brain Network Studies in Chronic Disorders of Consciousness: Advances and Perspectives. Neurosci Bull 2018, 34(4):592-604.

[6] Qin P, Wu X, Huang Z, Duncan NW, Tang W, Wolff A, Hu J, Gao L, Jin Y, Wu X et al: How are different neural networks related to consciousness? Ann Neurol 2015, 78(4):594-605.

[7] Spindler LRB, Luppi AI, Adapa RM, Craig MM, Coppola P, Peattie ARD, Manktelow AE, Finoia P, Sahakian BJ, Williams GB et al: Dopaminergic brainstem disconnection is common to pharmacological and pathological consciousness perturbation. Proc Natl Acad Sci U S A 2021, 118(30).

[8] Qin P, Wu X, Wu C, Wu H, Zhang J, Huang Z, Weng X, Zang D, Qi Z, Tang W et al: Higher-order sensorimotor circuit of the brain's global network supports human consciousness. Neuroimage 2021, 231:117850.

[9] Practice guideline update recommendations summary: Disorders of consciousness: Report of the Guideline Development, Dissemination, and Implementation Subcommittee of the American Academy of Neurology; the American Congress of Rehabilitation Medicine; and the National Institute on Disability, Independent Living, and Rehabilitation Research. Neurology 2019, 93(3):135.

[10] Kondziella D, Bender A, Diserens K, van Erp W, Estraneo A, Formisano R, Laureys S, Naccache L, Ozturk S, Rohaut B et al: European Academy of Neurology guideline on the diagnosis of coma and other disorders of consciousness. Eur J Neurol 2020, 27(5):741-756.

[11] Annen J, Filippini MM, Bonin E, Cassol H, Aubinet C, Carriere M, Gosseries O, Thibaut A, Barra A, Wolff A et al: Diagnostic accuracy of the CRS-R index in patients with disorders of consciousness. Brain Inj 2019, 33(11):1409-1412

[12] Giacino JT, Fins JJ, Laureys S, Schiff ND: Disorders of consciousness after acquired brain injury: the state of the science. Nat Rev Neurol 2014, 10(2):99-114.

[13] Wu H, Qi Z, Wu X, Zhang J, Wu C, Huang Z, Zang D, Fogel S, Tanabe S, Hudetz AG et al: Anterior precuneus related to the recovery of consciousness. Neuroimage Clin 2022, 33:102951.

[14] Zhang H, Dai R, Qin P, Tang W, Hu J, Weng X, Wu X, Mao Y, Wu X, Northoff G: Posterior cingulate cross-hemispheric functional connectivity predicts the level of consciousness in traumatic brain injury. Sci Rep 2017, 7(1):387.

[15] Song M, Zhang Y, Cui Y, Yang Y, Jiang T: Brain Network Studies in Chronic Disorders of Consciousness: Advances and Perspectives. Neurosci Bull 2018, 34(4):592-604.

[16] Qin P, Wu X, Huang Z, Duncan NW, Tang W, Wolff A, Hu J, Gao L, Jin Y, Wu X et al: How are different neural networks related to consciousness? Ann Neurol 2015, 78(4):594-605.

[17] Spindler LRB, Luppi AI, Adapa RM, Craig MM, Coppola P, Peattie ARD, Manktelow AE, Finoia P, Sahakian BJ, Williams GB et al: Dopaminergic brainstem disconnection is common to pharmacological and pathological consciousness perturbation. Proc Natl Acad Sci U S A 2021, 118(30).

[18] Qin P, Wu X, Wu C, Wu H, Zhang J, Huang Z, Weng X, Zang D, Qi Z, Tang W et al: Higher-order sensorimotor circuit of the brain's global network supports human consciousness. Neuroimage 2021, 231:117850.

[19] Practice guideline update recommendations summary: Disorders of consciousness: Report of the Guideline Development, Dissemination, and Implementation Subcommittee of the American Academy of Neurology; the American Congress of Rehabilitation Medicine; and the National Institute on Disability, Independent Living, and Rehabilitation Research. Neurology 2019, 93(3):135.

[20] Kondziella D, Bender A, Diserens K, van Erp W, Estraneo A, Formisano R, Laureys S, Naccache L, Ozturk S, Rohaut B et al: European Academy of Neurology guideline on the diagnosis of coma and other disorders of consciousness. Eur J Neurol 2020, 27(5):741-756.

[21] Annen J, Filippini MM, Bonin E, Cassol H, Aubinet C, Carriere M, Gosseries O, Thibaut A, Barra A, Wolff A et al: Diagnostic accuracy of the CRS-R index in patients with disorders of consciousness. Brain Inj 2019, 33(11):1409-1412

[22] Giacino JT, Fins JJ, Laureys S, Schiff ND: Disorders of consciousness after acquired brain injury: the state of the science. Nat Rev Neurol 2014, 10(2):99-114.

[23] Wu H, Qi Z, Wu X, Zhang J, Wu C, Huang Z, Zang D, Fogel S, Tanabe S, Hudetz AG et al: Anterior precuneus related to the recovery of consciousness. Neuroimage Clin 2022, 33:102951.

[24] Zhang H, Dai R, Qin P, Tang W, Hu J, Weng X, Wu X, Mao Y, Wu X, Northoff G: Posterior cingulate cross-hemispheric functional connectivity predicts the level of consciousness in traumatic brain injury. Sci Rep 2017, 7(1):387.

[25] Song M, Zhang Y, Cui Y, Yang Y, Jiang T: Brain Network Studies in Chronic Disorders of Consciousness: Advances and Perspectives. Neurosci Bull 2018, 34(4):592-604.

[26] Qin P, Wu X, Huang Z, Duncan NW, Tang W, Wolff A, Hu J, Gao L, Jin Y, Wu X et al: How are different neural networks related to consciousness? Ann Neurol 2015, 78(4):594-605.

[27] Spindler LRB, Luppi AI, Adapa RM, Craig MM, Coppola P, Peattie ARD, Manktelow AE, Finoia P, Sahakian BJ, Williams GB et al: Dopaminergic brainstem disconnection is common to pharmacological and pathological consciousness perturbation. Proc Natl Acad Sci U S A 2021, 118(30).

[28] Qin P, Wu X, Wu C, Wu H, Zhang J, Huang Z, Weng X, Zang D, Qi Z, Tang W et al: Higher-order sensorimotor circuit of the brain's global network supports human consciousness. Neuroimage 2021, 231:117850.

[29] Practice guideline update recommendations summary: Disorders of consciousness: Report of the Guideline Development, Dissemination, and Implementation Subcommittee of the American Academy of Neurology; the American Congress of Rehabilitation Medicine; and the National Institute on Disability, Independent Living, and Rehabilitation Research. Neurology 2019, 93(3):135.

吴雪海教授对此工作的点评

DOC患者的意识恢复可以在ABI后的任何时间发生，涉及急性到亚急性以及慢性恢复的过程。神经影像和电生理正在迅速增加我们对意识机制的了解，并为DOC的客观评估提供了新的机会。目前，对于意识恢复至关重要的意识网络、神经环路机制尚未完全阐明。我们在临床的DOC评估中，应当将行为学、神经成像和电生理数据应整合到多模式的评估方法中，单一工具不足以解释DOC患者意识表征的差异性质。现有的催醒疗法不可能对所有的DOC患者都有效，应当有针对性的对每个DOC患者的催醒治疗潜力进行个体化评估。在不远的将来，不仅会出现更准确DOC苏醒的预测，还会出现更为精准的意识评估工具。

何江弘教授对此工作的点评

近年来，对于慢性意识障碍的评估与诊断，疾病本质特征、发生机制的理解都有了极大的推进，而对于DOC的理解、诊断、预后及理念仍存在差异和争论。

尽管功能影像学的成组研究结果已显示其对pDOC患者的诊断和预后评估有显著作用，但在个体水平上还没有明确的标准，不能以简单结果进行武断判断，尚不能作为正式临床结论报告。被动或主动fMRI范式可补充床边无遵嘱患者的行为评估；因为干扰因素更多，仍需对结果谨慎解读。对于电生理检测，因为不同时间点意识水平的波动和患者脑损伤的差异性，需要一系列不同空间脑区及多种层级模态的电生理及诱发电位检测，多次采集，来综合评判患者的意识水平和预后。

本工作将意识障碍的诊断和预后判断做了系统性的总结和分析，对于诊断和预后技术做了系统性的梳理，对于意识障碍诊断和预后判断技术方法的进一步探索，发挥了重要意义。

（杨艺编辑整理)

(yangyi_md@bjtth.org）

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