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Emerging Treatment for Patients with Disorders of Consciousness: The Field of Neuromodulation

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Coma and Disorders of Consciousness

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Abstract

In this chapter, we review the major neurostimulation techniques being tested for intervention in patients with a disorder of consciousness (DOC). These include deep brain stimulation (DBS), spinal cord stimulation (SCS), vagus nerve stimulation (VNS), median nerve stimulation (MNS), transcranial electrical stimulation (tES), transcranial magnetic stimulation (TMS), and transcranial focus ultrasound stimulation (tFUS). We begin by summarizing the two main neuroscientific frameworks for understanding the relationship between brain dysfunction and loss and recovery of consciousness after injury, namely, the Mesocircuit Hypothesis and the ascending reticular activating system (ARAS). We then describe how each of these frameworks has motivated distinct pools of clinical research, with each supporting the selection of different targets and neurostimulatory techniques. The chapter then reviews, for each technique, the mechanisms of action, the rationale for its application in DOC, and the evidence to date. Finally, we conclude with a comparison of the techniques discussed as well as an overview of the current limitations of the field and opportunities for future directions.

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Notes

  1. 1.

    Magrassi et al. [93] evaluated 40 DOC patients, 29 VS/UWS, and 11 MCS and reported that 87% of the assessed cohort failed to meet basic criteria for DBS implantation.

  2. 2.

    The auricular branch of the vagus nerve is the only afferent branch of the nerve on the body’s surface, and it innervates the external acoustic meatus, inner tragus, and skin around the cymba concha. taVNS devices thus deliver electrical impulses to these parts of the external ear [206].

  3. 3.

    rTMS does, however, seem compatible with intracranial electrodes.

Abbreviations

ABR:

Auditory brainstem response

ACC:

Anterior cingulate cortex

AEP:

Auditory-evoked potential

ARAS:

Ascending reticular activating system

ASL:

Arterial spin labeling

BAEP:

Brainstem auditory-evoked potential

C/NC:

Coma/Near Coma

CBF:

Cerebral blood flow

CBV :

Cerebral blood volume

CGI-I:

Clinical Global Impression—Improvement

CRS-R:

Coma Recovery Scale-Revised

CT:

Controlled trial

DB:

Double blind

DBS:

Deep brain stimulation

DLPFC:

Dorsolateral prefrontal cortex

DMN:

Default mode network

DOC:

Disorder(s) of consciousness

DOCS:

Disorders of Consciousness Scale

ECG:

Electrocardiogram

EEG:

Electroencephalography

fMRI:

Functional magnetic resonance imaging

fNIRS:

Functional Near-Infrared Spectroscopy

FOUR:

The Full Outline of UnResponsiveness

GCS:

Glasgow Coma Scale

GOS:

Glasgow Outcome Scale

HBO:

Hyperbaric oxygen therapy

HC :

Healthy controls

IS:

Institutional scale

M1:

Primary motor cortex

MCS:

Minimally conscious state

MEG:

Magnetoencephalography

MEP:

Motor-evoked potential

MN:

Median nerve

MNS:

Median nerve stimulation

MPFC:

Medial prefrontal cortex

MRI:

Magnetic resonance imaging

Obs:

Observational

OL:

Open label

PCC:

Posterior cingulate cortex

PET:

Positron emission tomography

PFC:

Prefrontal cortex

RCT:

Randomized controlled trial

RDR:

Rappaport Disability Rating Scale

RF:

Reticular formation

rTMS:

Repetitive transcranial magnetic stimulation

SB:

Single blind

SCS:

Spinal cord stimulation

SEP:

Somatosensory-evoked potential

SPECT:

Single-photon emission computed tomography

taVNS:

Transcutaneous nerve stimulation

TBI:

Traumatic brain injury

TCD:

Transcranial Doppler Ultrasound

tES:

Transcranial electric stimulation

tFUS:

Transcranial focused ultrasound stimulation

TMS:

Transcranial magnetic stimulation

tSCS:

Transcutaneous spinal cord stimulation

TSI :

Time since injury

VNS:

Vagus nerve stimulation

VS/UWS:

Vegetative state/unresponsive wakefulness syndrome

WNSSP:

Western Neuro Sensory Stimulation Profile

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Authors and Affiliations

  1. Department of Psychology, University of California, Los Angeles (UCLA), Los Angeles, CA, USA

    Amber R. Hopkins & Martin M. Monti

  2. Coma Science Group, GIGA Consciousness, University of Liège, Liège, Belgium

    Marie M. Vitello & Aurore Thibaut

  3. Centre du Cerveau2, University Hospital of Liège, Liège, Belgium

    Marie M. Vitello & Aurore Thibaut

  4. Brain Injury Research Center (BIRC), Department of Neurosurgery, University of California, Los Angeles (UCLA), Los Angeles, CA, USA

    Martin M. Monti

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  1. Amber R. Hopkins
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Correspondence to Amber R. Hopkins .

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  1. Research Institute, Casa Colina Hospital and Centers for Healthcare, Pomona, CA, USA

    Caroline Schnakers

  2. Coma Science Group GIGA-Consciousness, University of Liège, Liège, Belgium

    Steven Laureys

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Hopkins, A.R., Vitello, M.M., Thibaut, A., Monti, M.M. (2023). Emerging Treatment for Patients with Disorders of Consciousness: The Field of Neuromodulation. In: Schnakers, C., Laureys, S. (eds) Coma and Disorders of Consciousness. Springer, Cham. https://doi.org/10.1007/978-3-031-50563-8_8

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