État végétatif et état de conscience minimale : Travaux ?· État végétatif et état de conscience…

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    tat vgtatif et tat de conscience minimale : Travaux de recherche rcents

    Steven LaureysComa Science GroupCentre de Recherches du Cyclotron & Service de NeurologieUniversit de Lige

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    disorders of consciousness | behavioural evaluation | electrophysiology | neuroimaging | methods, ethics & quality of life | perspectives

    Laureys, Owen and Schiff, Lancet Neurology, 2005

    Diffrents tats de conscience

    NORMALEV

    EIL

    CO

    NSC

    IEN

    CE

    DE

    LEN

    VIR

    ON

    NEM

    ENT

    COMA

    EVEI

    L

    CO

    NSC

    IEN

    CE

    DE

    LEN

    VIR

    ON

    NEM

    ENT

    ETATVEGETATIF

    EVEI

    L

    CO

    NSC

    IEN

    CE

    DE

    LEN

    VIR

    ON

    NEM

    ENT

    ETAT DECONSCIENCE

    MINIMAL

    EVEI

    L

    CO

    NSC

    IEN

    CE

    DE

    LEN

    VIR

    ON

    NEM

    ENT

    diagnosis | outcome | clinical | EEG | MRI | fMRI | pain | treatment | ethics

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    Comment faire le diagnostic ?

    n=103 post-comatose patients 45 clinical consensus diagnosis

    of vegetative state 18 Coma Recovery Scale diagnosis of MCS

    40% misdiagnosis38% Schnakers et al Ann Neurol37% Childs et al Neurology 9343% Andrews et al BMJ 96

    diagnosis | outcome | clinical | EEG | MRI | fMRI | pain | treatment | ethics

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    Comment valuer la poursuite visuelle ?

    Vanhaudenhuyse et al JNNP 2008

    n=52

    diagnosis | outcome | clinical | EEG | MRI | fMRI | pain | treatment | ethics

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    Projet fdral : Base de donnes 2007-08 (n=168)

    Le diagnostic annonc par le rfrant est erron dans 26% des cas (11% sans diagnostic)

    Erreur diagnostic au centre 13/137 (10%)

    patients avec:- fixation (6), poursuite visuelle (2), rponse la commande verbale (1), localisation de douleur (1), manipulation dobjet (1), communication non fonctionnelle intentionnelle (1) sont considrs comme tat vgtatif

    - communication fonctionnelle (1) considr comme tat de conscience minimale

    diagnosis | prognosis | treatment | pain | end of life | quality of life | conclusion

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    disorders of consciousness | behavioural evaluation | electrophysiology | neuroimaging | methods, ethics & quality of life | perspectives

    Coma recovery scalediagnosis | prognosis | treatment | pain | end of life | quality of life | conclusion

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    Projet fdral: Formation continue & DVD

    DEMO

    diagnosis | prognosis | treatment | pain | end of life | quality of life | conclusion

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    E-learning www.coma.ulg.ac.be/data/CRS-R

    DEMO

    diagnosis | prognosis | treatment | pain | end of life | quality of life | conclusion

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    site web protgdiagnosis | prognosis | treatment | pain | end of life | quality of life | conclusion

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    Pronostic

    Prediction is very difficult, especially about the futureNiels Bohr

    diagnosis | outcome | clinical | EEG | MRI | fMRI | pain | treatment | ethics

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    Evolution clinique aprs le coma

    Laureys, Scientific American, 2007

    PermanentMinimally Conscious

    State

    ?

    diagnosis | outcome | clinical | EEG | MRI | fMRI | pain | treatment | ethics

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    Etat vgtatif conscience minimale

    Belgian Federal project on VS and MCS

    0

    10

    20

    30

    40

    50

    60

    70

    80

    90

    100

    1 3 6 12

    Minimally conscious state (n=84)

    n=35

    %

    0

    10

    20

    30

    40

    50

    60

    70

    80

    90

    100

    1 3 6 12

    n=49

    %

    0

    10

    20

    30

    40

    50

    60

    70

    80

    90

    100

    1 3 6 12 EMERGENCE

    MCS

    Dead

    VS

    Vegetative state (n=116)

    Trau

    mat

    ic

    n=52

    %

    0

    10

    20

    30

    40

    50

    60

    70

    80

    90

    100

    1 3 6 12

    Non

    -tra

    umat

    ic

    n=64

    %

    diagnosis | outcome | clinical | EEG | MRI | fMRI | pain | treatment | ethics

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    NE PAS

    COCHER COMME CECI

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    QUESTIONS (rpondez par OUI ou NON)

    Age / Sexe (F-M) / Nationalit / Profession

    1. Lesprit et le cerveau sont deux entits spares

    2. Lesprit est une entit purement physique

    3. Une part spirituelle de nous-mme survit aprs la mort

    4. Chacun de nous a une me qui est spare de notre corps

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    POST-ANOXIC COMA

    MMN on auditory EPsN20 present

    exclude confounding factors including hypothermia, drugs, electrolyte disturbances

    brainstem reflexes(pupillary, cornea, oculocephalic, cough)

    apnea testing

    absent and GCS 3/15

    BRAIN DEATH

    positive

    GOODOUTCOMEFP 0%

    (95% IC NA)

    N20 absent

    POOROUTCOME

    FP 0.7% (95% IC 0-3.7%)

    or

    generalized suppression ( 33 g/l

    or

    FP 0% (95% IC 0-3%)

    D1-3: somatosensory EPs

    present

    negative

    Wijdicks et al, Neurology, 2006Boveroux et al, Reanimation, 2008

    ORGAN PROCUREMENT ORGANIZATION

    ORGAN PROCUREMENT ORGANIZATION

    (NHBD)

    confirmatory tests:isoelectrical EEG or

    transcranial Doppler orangiography or

    SPECT

    PHASE AIGU : LE COMA

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    Rflexe la menace visuelle

    91 patients post-coma patients 51% blinking to visual threat

    patients with blink recovery rate : 37% patients without blink recovery rate : 24%

    positive predictive value 30%negative predictive value 80%

    Vanhaudenhuyse et al Neurology 2008

    diagnosis | outcome | clinical | EEG | MRI | fMRI | pain | treatment | ethics

  • www.comascience.orgSchnakers et al, Brain Injury, 2008Schnakers et al, Neuropsychological Rehabilitation, 2005

    disorders of consciousness | behavioural evaluation | electrophysiology | neuroimaging | methods, ethics & quality of life | perspectives

    EEG : bispectral index

    Coma Recovery Score

    Bis

    pect

    rali

    ndex

    GOODOUTCOME

    BADOUTCOME

    diagnosis | outcome | clinical | EEG | MRI | fMRI | pain | treatment | ethics

  • www.comascience.orgSchnakers et al, Neurology, 2008; Neurocase 2009

    disorders of consciousness | behavioural evaluation | electrophysiology | neuroimaging | methods, ethics & quality of life | perspectives

    Potentiels voqus actifs

    ms-200 50 300 550 800 1050 1300

    -5-10-15-20-25

    510152025

    Pz (V)

    Count own name

    Complete locked-in syndrome

    Passive other nameCount other namePassive own name

    diagnosis | outcome | clinical | EEG | MRI | fMRI | pain | treatment | ethics

  • www.comascience.orgTollard et al, Crit Care Med 2009

    disorders of consciousness | behavioural evaluation | electrophysiology | neuroimaging | methods, ethics & quality of life | perspectives

    IRM-DTI & spectroscopiediagnosis | outcome | clinical | EEG | MRI | fMRI | pain | treatment | ethics

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    disorders of consciousness | behavioural evaluation | electrophysiology | neuroimaging | methods, ethics & quality of life | perspectives

    Resting state fMRI

    PCC

    Boly et al. Hum Brain Mapp, 2008 & Hum Brain Mapp in press

    Default intrinsic brain connectivity

    Boly et al. Ann N Y Acad Sci. 2008

    MFC

    Coma and Consciousness ConsortiumNY, Cambridge & Lige

    diagnosis | outcome | clinical | EEG | MRI | fMRI | pain | treatment | ethics

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    fMRI & PET activation studies6 fMRI studies (n=17) and 8 PET (n=32)n=48 patients (32 non-traumatic)

    62% absent or primary low level cortical activation (n=30) typical activation pattern (n=25; 52%; 8 traumatic) 84% (21/25) failed to recover (7 traumatic)

    no cortical activation (n=5; 10%; 1 traumatic) 100% (4/4) failed to recover (1 traumatic)

    38% high level activation (n=18) 7 traumatic 82% (9/11) recovered consciousness (6 traumatic)

    93% specificity 69% sensitivity

    Di et al, Clinical Medicine, 2008

    diagnosis | outcome | clinical | EEG | MRI | fMRI | pain | treatment | ethics

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    Activation to the patients namevegetative minimally conscious

    Di, Yu, Weng, Laureys et al, Neurology, 2007Di et al, Clinical Medicine, 2008

    ATYPICAL HIGH LEVELCORTICAL ACTIVATION

    diagnosis | outcome | clinical | EEG | MRI | fMRI | pain | treatment | ethics

  • www.comascience.orgOwen, Coleman, Boly, Davis, Laureys and Pickard, Science, 2006

    Active fMRI in vegetative state

    Boly et al, NeuroImage 2007

    diagnosis | outcome | clinical | EEG | MRI | fMRI | pain | treatment | ethics

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    Pensez-vous que5. Le patient en tat vgtatif ressent la douleur? 6. Le patient en tat de conscience minimale ressent la douleur?7. Le patient en locked-in syndrome ressent la douleur?

    tre en tat vgtatif chronique est pire que la mort8A. du point de vue du patient? 8B. du point de vue de la famille?

    tre en tat de conscience minimale chronique est pire qutre en tat vgtatif

    9A. du point de vue du patient? 9B. du point de vue de la famille?

    tre en locked-in syndrome est pire qutre en tat vgtatif ou en tat de conscience minimale