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Guideline on the Diagnosis of Coma Infographic European Academy of Neurology Guideline on the diagnosis of coma and other disorders of consciousness REVIEW OF EVIDENCE IN THE CURRENT LITERATURE Filtered by “Englisch language”, humans”, “after January 1, 2002 Identifi cation Identifi Identifi cation Identifi Clinical topics Neuroimaging EEG by university librarian by university librarian 26525 1649 779 PubMed search supervised Screening Screening PubMed PubMed PubMed citations citations citations Eligibility Eligibility 99 citations 82 citations 52 citations 16 original 44 original 30 original Inclusion Inclusion publications publications publications Excluding reviews, commentaries, publications without single suject level data, publications with n ≤3; including missing publications identifi ed manually from reference lists Evidence to support diagnostic decisions DoC must be diff erentiated from in coma and other DoC (28 days after conditions mimicking unresponsiveness brain injury) is limited but in which consciousness is intact DoC includes patients in coma, vegetative Recommendations followed the Grading state/unresponsive wakefulness syndrome of Recommendations Assessment, (VS/UWS), and minimally conscious Development and Evaluation (GRADE) state (MCS) system 16 experts from 10 countries reviewed the scientifi c evidence RECOMMENDATIONS FOR DIAGNOSIS For frequent evaluations, use the FOUR score to assess level of consciousness instead of the Glasgow Coma Scale (GCS) For regular monitoring of signs of Perform a comprehensive neurological discomfort, use Nociception Coma examination Scale-Revised (NCS-R) Passively open the eyes to diagnose visual pursuit to rule out cortical blindness, damage to the optic nervous structures and central or peripheral oculomotor palsies Probe for voluntary eye movements using a mirror Resting state fl uorodeoxyglucose (FDG) Other stimuli (pictures of patient’s or PET may be considered as part of relatives’ faces or personal objects) may multimodal patient assessment also be used As part of multimodal assessment, use resting state fMRI and active fMRI Use salient stimuli and/or familiar activities examination to diagnose signs of covert consciousness Use visual analysis of clinical standard EEG Repeat clinical assessments in the subacute to help rule out non-convulsive status and chronic setting, using the Coma epilepticus Recovery Scale-Revised (CRS-R) to classify the level of consciousness Use sleep EEG, quantitative analysis of high-density EEG, TMS-EEG, and cognitive Obtain clinical standard EEG, searching evoked potentials to help diff erentiate for rapid eye movement sleep and slow between VS/UWS and MCS wave sleep Consider PET and functional MRI to complement behavioral assessment CONCLUSIONS Evidence to support classifi cation of coma Serial assessments may increase the and prolonged DoC is limited diagnostic yield and reveal signs of consciousness in fMRI/PET and EEG Low-cost and easy-to-implement bedside paradigms in patients who initially lack measures can have immediate clinical such signs impact Clinical rating scales (CRS-R and the FOUR) High-density EEG, PET and fMRI are and careful inspection of voluntary eye logistically challenging and require movements, EEG-based techniques and signifi cant technological and computational functional neuroimaging (fMRI, PET) should expertise but enable refi ned patient be integrated into a composite diagnoses evaluation standard Multimodal assessment and neuroimaging Patients should be diagnosed with the is necessary to avoid misdiagnosis highest level of consciousness as revealed by any of the three approaches (clinical, EEG, neuroimaging) Read the Guideline in full in the European Journal of Neurology at http://bit.ly/ComaDoCGL.
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