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Resistance to eye opening in patients with disorders of consciousness

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Resistance to eye opening (REO) is a commonly encountered phenomenon in clinical practice. We aim to investigate whether REO is a sign of consciousness or a reflex in severely brain-injured patients.


We recorded REO in chronic patients with disorders of consciousness during a multimodal diagnostic assessment. REO evaluations were performed daily in each patient and clinical diagnosis of unresponsive wakefulness syndrome (UWS), minimally conscious state with (MCS+) or without (MCS−) preserved language processing was made using the Coma Recovery Scale-Revised (CRS-R).


Out of 150 consecutive patients, 79 patients fit inclusion criteria. REO was seen in 19 patients (24.1%). At the group level, there was a significant relationship between the presence of REO and the level of consciousness. We also observed a difference in the repeatability of REO between patients in UWS, MCS− and MCS+. Out of 23 patients in UWS, six showed REO, in whom five showed atypical brain patterns activation.


Our findings suggest a voluntary basis for REO and stress the need for multiple serial assessments of REO in these patients, especially since most patients show fluctuating levels of consciousness.

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The study was supported by the University and University Hospital of Liège, the Belgian National Funds for Scientific Research (FRS-FNRS), Human Brain Project (EU-H2020-fetflagship-hbp-sga1-ga720270), Luminous project (EU-H2020-fetopen-ga686764), the French Speaking Community Concerted Research Action (ARC-06/11-340), the James McDonnell Foundation, Mind Science Foundation, IAP research network P7/06 of the Belgian Government (Belgian Science Policy), the European Commission, the Public Utility Foundation ‘Université Européenne du Travail’, “Fondazione Europea di Ricerca Biomedica”, and the BIAL Foundation. OB is a research fellow, AT, VCV and OG are post-doctoral fellows, and SL is research director at FRS-FNRS. The authors thank Prof. Pierre Maquet from the Neurology department, University Hospital of Liège, as well as the whole Neurology staff, patients and their families.

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Authors and Affiliations



The authors have contributed to conception and design of the study (HJvO, SL, OG), acquisition and analysis of data (HJvO, AT, AV, LH, VCV, SW, OB, OG), writing of the manuscript (HJvO, OG), creation of the figures (HJvO, OG) and critical revision of the manuscript for intellectual content (AT, AV, LH, VCV, SW, OB, SL).

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Correspondence to Olivia Gosseries.

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The authors declare that they have no conflict of interest.

Ethical standards

The study was approved by the Ethics Committee of the Medical School of the University of Liège and written consents were obtained from the legal representative of each patient.

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van Ommen, H.J., Thibaut, A., Vanhaudenhuyse, A. et al. Resistance to eye opening in patients with disorders of consciousness. J Neurol 265, 1376–1380 (2018).

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