Skip to main content
Log in

Abstract

Purpose of Review

The purpose of this review is to update the reader on recent trends in disorders of consciousness (DOC) including pathophysiology, diagnosis, treatment, and prognosis.

Recent Findings

Non-behavioral assessments such as electroencephalography, functional magnetic resonance imaging, and positron emission tomography have resulted in improved understanding of the brain networks underlying consciousness. These non-behavioral assessments also provide valuable information on diagnosis and prognosis. Behavioral assessments of disorders of consciousness should be performed using a standardized assessment, performed serially. In addition to pharmacologic treatments, stimulation and energy modalities are being studied in DOC. Recent long-term studies of DOC have provided a more favorable long-term prognosis for functional recovery.

Summary

Non-behavioral assessments of disorders of consciousness, combined with behavioral assessments, will provide improved diagnostic and prognostic information, as promising energy and stimulation modalities are trialed. Patients with disorders of consciousness should be treated in centers with expertise in providing care to this unique patient population.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Fig. 1
Fig. 2

Similar content being viewed by others

References

Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. Plum FPJ, Posner J. The diagnosis of stupor and coma. 3rd ed. Philadelphia; 1982.

  2. Giacino JT, Katz DI, Schiff ND, Bodien YG. Brain injury medicine -principles and practice: assessment and rehabilitation management of individuals with disorders of consciousness. 3rd ed. New York, NY: Springer; 2022.

    Google Scholar 

  3. Giacino J, Whyte J. The vegetative and minimally conscious states: current knowledge and remaining questions. J Head Trauma Rehabil. 2005;20:30–50.

    Article  PubMed  Google Scholar 

  4. Giacino JT, Katz DI, Schiff ND, Whyte J, Ashman EJ, Ashwal S, et al. 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. 2018;91:450–60. https://doi.org/10.1212/WNL.0000000000005926.

    Article  PubMed  PubMed Central  Google Scholar 

  5. Laureys S, Celesia GG, Cohadon F, Lavrijsen J, León-Carrión J, Sannita WG, et al. Unresponsive wakefulness syndrome: a new name for the vegetative state or apallic syndrome. BMC Med. 2010;8:68. https://doi.org/10.1186/1741-7015-8-68.

    Article  PubMed  PubMed Central  Google Scholar 

  6. Giacino J, Ashwal S, Childs N, Cranford R, Jennett B, Katz D, et al. The minimally conscious state: definition and diagnostic criteria. Neurology. 2002;58:349–53.

    Article  PubMed  Google Scholar 

  7. Sherer M, Katz DI, Bodien YG, Arciniegas DB, Block C, Blum S, et al. Post-traumatic confusional state: a case definition and diagnostic criteria. Arch Phys Med Rehabil. 2020;101:2041–50. https://doi.org/10.1016/j.apmr.2020.06.021.

    Article  PubMed  Google Scholar 

  8. Edlow BL, Claassen J, Schiff ND, Greer DM. Recovery from disorders of consciousness: mechanisms, prognosis and emerging therapies. Nat Rev Neurol. 2021;17:135–56. https://doi.org/10.1038/s41582-020-00428-x.

    Article  PubMed  Google Scholar 

  9. Kondziella D, Menon DK, Helbok R, Naccache L, Othman MH, Rass V, et al. A precision medicine framework for classifying patients with disorders of consciousness: Advanced Classification of Consciousness Endotypes (ACCESS). Neurocrit Care. 2021;35:27–36. https://doi.org/10.1007/s12028-021-01246-9.

    Article  PubMed  Google Scholar 

  10. Adams JH, Graham DI, Jennett B. The neuropathology of the vegetative state after an acute brain insult. Brain. 2000;123(Pt 7):1327–38. https://doi.org/10.1093/brain/123.7.1327.

    Article  PubMed  Google Scholar 

  11. Vanhaudenhuyse A, Noirhomme Q, Tshibanda LJ-F, Bruno M-A, Boveroux P, Schnakers C, et al. Default network connectivity reflects the level of consciousness in non-communicative brain-damaged patients. Brain. 2010;133:161–71. https://doi.org/10.1093/brain/awp313.

    Article  PubMed  Google Scholar 

  12. Threlkeld ZD, Bodien YG, Rosenthal ES, Giacino JT, Nieto-Castanon A, Wu O, et al. Functional networks reemerge during recovery of consciousness after acute severe traumatic brain injury. Cortex. 2018;106:299–308. https://doi.org/10.1016/j.cortex.2018.05.004.

    Article  PubMed  PubMed Central  Google Scholar 

  13. Schiff ND. Recovery of consciousness after brain injury: a mesocircuit hypothesis. Trends Neurosci. 2010;33:1–9. https://doi.org/10.1016/j.tins.2009.11.002.

    Article  CAS  PubMed  Google Scholar 

  14. Fridman EA, Beattie BJ, Broft A, Laureys S, Schiff ND. Regional cerebral metabolic patterns demonstrate the role of anterior forebrain mesocircuit dysfunction in the severely injured brain. Proc Natl Acad Sci USA. 2014;111:6473–8. https://doi.org/10.1073/pnas.1320969111.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  15. Childs NL, Mercer WN, Childs HW. Accuracy of diagnosis of persistent vegetative state. Neurology. 1993;43:1465–7.

    Article  CAS  PubMed  Google Scholar 

  16. Andrews K, Murphy L, Munday R, Littlewood C. Misdiagnosis of the vegetative state: retrospective study in a rehabilitation unit. BMJ. 1996;313.

  17. Kondziella D, Bender A, Diserens K, van Erp W, Estraneo A, Formisano R, et al. European Academy of Neurology guideline on the diagnosis of coma and other disorders of consciousness. Eur J Neurol. 2020;27:741–56. https://doi.org/10.1111/ene.14151.

    Article  CAS  PubMed  Google Scholar 

  18. Wijdicks EFM, Bamlet WR, Maramattom BV, Manno EM, McClelland RL. Validation of a new coma scale: the FOUR score. Ann Neurol. 2005;58:585–93. https://doi.org/10.1002/ana.20611.

    Article  PubMed  Google Scholar 

  19. Foo CC, Loan JJM, Brennan PM. The relationship of the FOUR score to patient outcome: a systematic review. J Neurotrauma. 2019;36:2469–83. https://doi.org/10.1089/neu.2018.6243.

    Article  PubMed  PubMed Central  Google Scholar 

  20. Wannez S, Heine L, Thonnard M, Gosseries O, Laureys S. The repetition of behavioral assessments in diagnosis of disorders of consciousness. Ann Neurol. 2017;81:883–9. https://doi.org/10.1002/ana.24962.

    Article  PubMed  Google Scholar 

  21. Whyte J, Dipasquale MC, Vaccaro M. Assessment of command-following in minimally conscious brain injured patients. Arch Phys Med Rehabil. 1999;80:653–60.

    Article  CAS  PubMed  Google Scholar 

  22. Dipasquale MC, Whyte J. The use of quantitative data in treatment planning for minimally conscious patients. J Head Trauma Rehabil. 1996;11:9–17.

    Article  Google Scholar 

  23. Day KV, DiNapoli MV, Whyte J. Detecting early recovery of consciousness: a comparison of methods. Neuropsycholological Rehabil. 2018;28:1233–41.

    Article  Google Scholar 

  24. Skandsen T, Kvistad KA, Solheim O, Strand IH, Folvik M, Vik A. Prevalence and impact of diffuse axonal injury in patients with moderate and severe head injury: a cohort study of early magnetic resonance imaging findings and 1-year outcome. J Neurosurg. 2010;113:556–63.

    Article  PubMed  Google Scholar 

  25. Izzy S, Mazwi NL, Martinez S, Spencer CA, Klein JP, Parikh G, et al. Revisiting grade 3 diffuse axonal injury: not all brainstem microbleeds are prognostically equal. Neurocrit Care. 2017;27:199–207. https://doi.org/10.1007/s12028-017-0399-2.

    Article  PubMed  PubMed Central  Google Scholar 

  26. Lant ND, Gonzalez-Lara LE, Owen AM, Fernández-Espejo D. Relationship between the anterior forebrain mesocircuit and the default mode network in the structural bases of disorders of consciousness. Neuroimage Clin. 2016;10:27–35. https://doi.org/10.1016/j.nicl.2015.11.004.

    Article  PubMed  Google Scholar 

  27. Fernández-Espejo D, Soddu A, Cruse D, Palacios EM, Junque C, Vanhaudenhuyse A, et al. A role for the default mode network in the bases of disorders of consciousness. Ann Neurol. 2012;72:335–43. https://doi.org/10.1002/ana.23635.

    Article  PubMed  Google Scholar 

  28. Wu X, Zhang J, Cui Z, Tang W, Shao C, Hu J, et al. White matter deficits underlying the impaired consciousness level in patients with disorders of consciousness. Neurosci Bull. 2018;34:668–78. https://doi.org/10.1007/s12264-018-0253-3.

    Article  PubMed  PubMed Central  Google Scholar 

  29. Wang L, Yang Y, Chen S, Ge M, He J, Yang Z, et al. White matter integrity correlates with residual consciousness in patients with severe brain injury. Brain Imaging Behav. 2018;12:1669–77. https://doi.org/10.1007/s11682-018-9832-1.

    Article  PubMed  Google Scholar 

  30. Sanz LRD, Thibaut A, Edlow BL, Laureys S, Gosseries O. Update on neuroimaging in disorders of consciousness. Curr Opin Neurol. 2021;34:488–96. https://doi.org/10.1097/WCO.0000000000000951.

    Article  PubMed  PubMed Central  Google Scholar 

  31. Curley WH, Forgacs PB, Voss HU, Conte MM, Schiff ND. Characterization of EEG signals revealing covert cognition in the injured brain. Brain. 2018;141:1404–21. https://doi.org/10.1093/brain/awy070.

    Article  PubMed  PubMed Central  Google Scholar 

  32. •• Claassen J, Doyle K, Matory A, Couch C, Burger KM, Velazquez A, et al. Detection of brain activation in unresponsive patients with acute brain injury. N Engl J Med. 2019;380:2497–505. https://doi.org/10.1056/NEJMoa1812757. (This study demonstrated how standard EEG could be used in the intensive care setting to prognosticate short-term and long-term recovery, with implications on end of life decision making.)

    Article  PubMed  Google Scholar 

  33. Thibaut A, Panda R, Annen J, Sanz LRD, Naccache L, Martial C, et al. Preservation of brain activity in unresponsive patients identifies MCS Star. Ann Neurol. 2021;90:89–100. https://doi.org/10.1002/ana.26095.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  34. • Aubinet C, Cassol H, Gosseries O, Bahri MA, Larroque SK, Majerus S, et al. Brain metabolism but not gray matter volume underlies the presence of language function in the minimally conscious state (MCS): MCS+ versus MCS- neuroimaging differences. Neurorehabil Neural Repair. 2020;34:172–84. https://doi.org/10.1177/1545968319899914. (This study highlights how functional imaging can have a stronger correlation with level of consciousness than structural imaging.)

    Article  PubMed  Google Scholar 

  35. Owen AM, Coleman MR, Boly M, Davis MH, Laureys S, Pickard JD. Detecting awareness in the vegetative state. Science. 2006;313:1402. https://doi.org/10.1126/science.1130197.

    Article  CAS  PubMed  Google Scholar 

  36. Young MJ, Bodien YG, Giacino JT, Fins JJ, Truog RD, Hochberg LR, Edlow BL. The neuroethics of disorders of consciousness: a brief history of evolving ideas. Brain. 2021;144:3291–310. https://doi.org/10.1093/brain/awab290.

    Article  PubMed  PubMed Central  Google Scholar 

  37. Edlow BL, Chatelle C, Spencer CA, Chu CJ, Bodien YG, O’Connor KL, et al. Early detection of consciousness in patients with acute severe traumatic brain injury. Brain. 2017;140:2399–414. https://doi.org/10.1093/brain/awx176.

    Article  PubMed  PubMed Central  Google Scholar 

  38. Giacino J. Sensory stimulation: theoretical perspectives and the evidence for effectiveness. NeuroRehabilitation. 1996;6:69–78. https://doi.org/10.1016/1053-8135(95)00149-2.

    Article  CAS  PubMed  Google Scholar 

  39. Li J, Cheng Q, Liu F-K, Huang Z, Feng S-S. Sensory stimulation to improve arousal in comatose patients after traumatic brain injury: a systematic review of the literature. Neurol Sci. 2020;41:2367–76. https://doi.org/10.1007/s10072-020-04410-9.

    Article  PubMed  Google Scholar 

  40. Pape TL-B, Rosenow JM, Steiner M, Parrish T, Guernon A, Harton B, et al. Placebo-controlled trial of familiar auditory sensory training for acute severe traumatic brain injury: a preliminary report. Neurorehabil Neural Repair. 2015;29:537–47. https://doi.org/10.1177/1545968314554626.

    Article  PubMed  Google Scholar 

  41. Bender Pape TL, Livengood SL, Kletzel SL, Blabas B, Guernon A, Bhaumik DK, et al. Neural connectivity changes facilitated by familiar auditory sensory training in disordered consciousness: a TBI pilot study. Front Neurol. 2020;11:1027. https://doi.org/10.3389/fneur.2020.01027.

    Article  PubMed  PubMed Central  Google Scholar 

  42. Gao Y, Zhang Y, Li Z, Ma L, Yang J. Persistent vegetative state after severe cerebral hemorrhage treated with amantadine: a retrospective controlled study. Medicine (Baltimore). 2020;99:e21822. https://doi.org/10.1097/MD.0000000000021822. This retrospective trial adds to the body of literature supporting the use of amantadine as a psychostimulant medication to improve recovery from the level of consciousness, including the chronic phase of recovery.

    Article  CAS  PubMed  Google Scholar 

  43. Li X, Li C, Hu N, Wang T. Music interventions for disorders of consciousness: a systematic review and meta-analysis. J Neurosci Nurs. 2020;52:146–51. https://doi.org/10.1097/JNN.0000000000000511.

    Article  CAS  PubMed  Google Scholar 

  44. Giacino JT, Whyte J, Bagiella E, Kalmar K, Childs N, Khademi A, et al. Placebo-controlled trial of amantadine for severe traumatic brain injury. N Engl J Med. 2012;366:819–26.

    Article  CAS  PubMed  Google Scholar 

  45. Hintze TD, Small CE, Montgomery J, Reveles KR, Hafeez S, Barthol CA. Comparison of amantadine, modafinil, and standard of care in the acute treatment of disorders of consciousness after severe traumatic brain injury. Clin Neuropharmacol. 2022;45:1–6. https://doi.org/10.1097/WNF.0000000000000487.

    Article  CAS  PubMed  Google Scholar 

  46. Edlow BL, Sanz LRD, Polizzotto L, Pouratian N, Rolston JD, Snider SB, et al. Therapies to restore consciousness in patients with severe brain injuries: a gap analysis and future directions. Neurocrit Care. 2021;35:68–85. https://doi.org/10.1007/s12028-021-01227-y.

    Article  PubMed  PubMed Central  Google Scholar 

  47. Thibaut A, Schiff N, Giacino J, Laureys S, Gosseries O. Therapeutic interventions in patients with prolonged disorders of consciousness. Lancet Neurol. 2019;18:600–14. https://doi.org/10.1016/S1474-4422(19)30031-6.

    Article  PubMed  Google Scholar 

  48. Whyte J, Rajan R, Rosenbaum A, Katz D, Kalmar K, Seel R, et al. Zolpidem and restoration of consciousness. Am J Phys Med Rehabil. 2014;93:101–13. https://doi.org/10.1097/PHM.0000000000000069.

    Article  PubMed  Google Scholar 

  49. Zhang B, O’Brien K, Won W, Li S. A retrospective analysis on clinical practice-based approaches using zolpidem and lorazepam in disorders of consciousness. Brain Sci. 2021. https://doi.org/10.3390/brainsci11060726.

    Article  PubMed  PubMed Central  Google Scholar 

  50. Nardone R, Sebastianelli L, Brigo F, Golaszewski S, Trinka E, Pucks-Faes E, et al. Effects of intrathecal baclofen therapy in subjects with disorders of consciousness: a reappraisal. J Neural Transm (Vienna). 2020;127:1209–15. https://doi.org/10.1007/s00702-020-02233-8.

    Article  CAS  PubMed  Google Scholar 

  51. Halbmayer L-M, Kofler M, Hitzenberger G, Matzak H, Fava E, Genelin E, et al. On the recovery of disorders of consciousness under intrathecal baclofen administration for severe spasticity-an observational study. Brain Behav. 2022;12:e2566. https://doi.org/10.1002/brb3.2566.

    Article  PubMed  PubMed Central  Google Scholar 

  52. Kundu B, Brock AA, Englot DJ, Butson CR, Rolston JD. Deep brain stimulation for the treatment of disorders of consciousness and cognition in traumatic brain injury patients: a review. Neurosurg Focus. 2018;45:E14. https://doi.org/10.3171/2018.5.FOCUS18168.

    Article  PubMed  PubMed Central  Google Scholar 

  53. Bourdillon P, Hermann B, Sitt JD, Naccache L. Electromagnetic brain stimulation in patients with disorders of consciousness. Front Neurosci. 2019;13:223. https://doi.org/10.3389/fnins.2019.00223.

    Article  PubMed  PubMed Central  Google Scholar 

  54. Schiff ND, Giacino JT, Kalmar K, Victor JD, Baker K, Gerber M, et al. Behavioural improvements with thalamic stimulation after severe traumatic brain injury. Nature. 2007;448:600–3. https://doi.org/10.1038/nature06041.

    Article  CAS  PubMed  Google Scholar 

  55. Lemaire J-J, Sontheimer A, Pereira B, Coste J, Rosenberg S, Sarret C, et al. Deep brain stimulation in five patients with severe disorders of consciousness. Ann Clin Transl Neurol. 2018;5:1372–84. https://doi.org/10.1002/acn3.648.

    Article  PubMed  PubMed Central  Google Scholar 

  56. Zhang Y, Song W. Transcranial direct current stimulation in disorders of consciousness: a review. Int J Neurosci. 2018;128:255–61. https://doi.org/10.1080/00207454.2017.1381094.

    Article  PubMed  Google Scholar 

  57. Thibaut A, Bruno M-A, Ledoux D, Demerzi A, Laureys S. tDCS in patients with disorders of conscousness: sham-controlled randomized double-blind study. Neurology. 2014;82:1112–8.

    Article  PubMed  Google Scholar 

  58. Thibaut A, Wannez S, Donneau A-F, Chatelle C, Gosseries O, Bruno M-A, Laureys S. Controlled clinical trial of repeated prefrontal tDCS in patients with chronic minimally conscious state. Brain Inj. 2017;31:466–74. https://doi.org/10.1080/02699052.2016.1274776.

    Article  PubMed  Google Scholar 

  59. Huang W, Wannez S, Fregni F, Hu X, Jing S, Martens G, et al. Repeated stimulation of the posterior parietal cortex in patients in minimally conscious state: a sham-controlled randomized clinical trial. Brain Stimul. 2017;10:718–20. https://doi.org/10.1016/j.brs.2017.02.001.

    Article  PubMed  Google Scholar 

  60. Estraneo A, Pascarella A, Moretta P, Masotta O, Fiorenza S, Chirico G, et al. Repeated transcranial direct current stimulation in prolonged disorders of consciousness: a double-blind cross-over study. J Neurol Sci. 2017;375:464–70. https://doi.org/10.1016/j.jns.2017.02.036.

    Article  PubMed  Google Scholar 

  61. Martens G, Lejeune N, O’Brien AT, Fregni F, Martial C, Wannez S, et al. Randomized controlled trial of home-based 4-week tDCS in chronic minimally conscious state. Brain Stimul. 2018;11:982–90. https://doi.org/10.1016/j.brs.2018.04.021.

    Article  PubMed  Google Scholar 

  62. Zhang X, Liu B, Li Y, Duan G, Hou J, Wu D. Multi-target and multi-session transcranial direct current stimulation in patients with prolonged disorders of consciousness: a controlled study. Front Neurosci. 2021;15:641951. https://doi.org/10.3389/fnins.2021.641951.

    Article  PubMed  PubMed Central  Google Scholar 

  63. Cincotta M, Giovannelli F, Chiaramonti R, Bianco G, Godone M, Battista D, et al. No effects of 20 Hz-rTMS of the primary motor cortex in vegetative state: a randomised, sham-controlled study. Cortex. 2015;71:368–76. https://doi.org/10.1016/j.cortex.2015.07.027.

    Article  PubMed  Google Scholar 

  64. Liu P, Gao J, Pan S, Meng F, Pan G, Li J, Luo B. Effects of high-frequency repetitive transcranial magnetic stimulation on cerebral hemodynamics in patients with disorders of consciousness: a sham-controlled study. Eur Neurol. 2016;76:1–7. https://doi.org/10.1159/000447325.

    Article  PubMed  Google Scholar 

  65. Fan J, Zhong Y, Wang H, Aierken N, He R. Repetitive transcranial magnetic stimulation improves consciousness in some patients with disorders of consciousness. Clin Rehabil. 2022;36:916–25. https://doi.org/10.1177/02692155221089455.

    Article  PubMed  Google Scholar 

  66. Briand M-M, Gosseries O, Staumont B, Laureys S, Thibaut A. Transcutaneous auricular vagal nerve stimulation and disorders of consciousness: a hypothesis for mechanisms of action. Front Neurol. 2020;11:933. https://doi.org/10.3389/fneur.2020.00933.

    Article  PubMed  PubMed Central  Google Scholar 

  67. Noé E, Ferri J, Colomer C, Moliner B, O’Valle M, Ugart P, et al. Feasibility, safety and efficacy of transauricular vagus nerve stimulation in a cohort of patients with disorders of consciousness. Brain Stimul. 2020;13:427–9. https://doi.org/10.1016/j.brs.2019.12.005.

    Article  PubMed  Google Scholar 

  68. Hakon J, Moghiseh M, Poulsen I, Øland CML, Hansen CP, Sabers A. Transcutaneous vagus nerve stimulation in patients with severe traumatic brain injury: a feasibility trial. Neuromodulation. 2020;23:859–64. https://doi.org/10.1111/ner.13148.

    Article  PubMed  Google Scholar 

  69. Yu Y, Yang Y, Gan S, Guo S, Fang J, Wang S, et al. Cerebral hemodynamic correlates of transcutaneous auricular vagal nerve stimulation in consciousness restoration: an open-label pilot study. Front Neurol. 2021;12:684791. https://doi.org/10.3389/fneur.2021.684791.

    Article  PubMed  PubMed Central  Google Scholar 

  70. Monti MM, Schnakers C, Korb AS, Bystritsky A, Vespa PM. Non-invasive ultrasonic thalamic stimulation in disorders of consciousness after severe brain injury: a first-in-man report. Brain Stimul. 2016;9:940–1. https://doi.org/10.1016/j.brs.2016.07.008.

    Article  PubMed  Google Scholar 

  71. Cain JA, Spivak NM, Coetzee JP, Crone JS, Johnson MA, Lutkenhoff ES, et al. Ultrasonic thalamic stimulation in chronic disorders of consciousness. Brain Stimul. 2021;14:301–3. https://doi.org/10.1016/j.brs.2021.01.008.

    Article  PubMed  Google Scholar 

  72. Hemphill JC, White DB. Clinical nihilism in neuroemergencies. Emerg Med Clin North Am. 2009;27:27–37, vii-viii. https://doi.org/10.1016/j.emc.2008.08.009.

  73. Leblanc G, Boutin A, Shemilt M, Lauzier F, Moore L, Potvin V, et al. Incidence and impact of withdrawal of life-sustaining therapies in clinical trials of severe traumatic brain injury: a systematic review. Clin Trials. 2018;15:398–412. https://doi.org/10.1177/1740774518771233.

    Article  PubMed  Google Scholar 

  74. Elmer J, Torres C, Aufderheide T, Austin M, Callaway C, Golan E, Herren H, Jasti J, Kudenchuk P, Scales D, Stub D, Richardson D, Zive D. Association of early withdrawal of life-sustaining therapy for perceived neurological prognosis with mortality after cardiac arrest. Resuscitation. 2016;102:127–35.

    Article  PubMed  PubMed Central  Google Scholar 

  75. Brown EN, Lydic R, Schiff ND. General anesthesia, sleep, and coma. N Engl J Med. 2010;36:2638–50. https://doi.org/10.1046/j.0013-0427.2003.00027.x.

    Article  Google Scholar 

  76. Stender J, Mortensen KN, Thibaut A, Darkner S, Laureys S, Gjedde A, Kupers R. The minimal energetic requirement of sustained awareness after brain injury. Curr Biol. 2016;26:1494–9. https://doi.org/10.1016/j.cub.2016.04.024.

    Article  CAS  PubMed  Google Scholar 

  77. Snider SB, Bodien YG, Bianciardi M, Brown EN, Wu O, Edlow BL. Disruption of the ascending arousal network in acute traumatic disorders of consciousness. Neurology. 2019;93:e1281–7. https://doi.org/10.1212/WNL.0000000000008163.

    Article  PubMed  PubMed Central  Google Scholar 

  78. Steriade M. Arousal: revisiting the reticular activating system. Science. 1996;272:225–6. https://doi.org/10.1126/science.272.5259.225.

    Article  CAS  PubMed  Google Scholar 

  79. Berlingeri M, Magnani FG, Salvato G, Rosanova M, Bottini G. Neuroimaging studies on disorders of consciousness: a meta-analytic evaluation. J Clin Med. 2019. https://doi.org/10.3390/jcm8040516.

    Article  PubMed  PubMed Central  Google Scholar 

  80. Kotchoubey B, Pavlov YG. A systematic review and meta-analysis of the relationship between brain data and the outcome in disorders of consciousness. Front Neurol. 2018;9:315. https://doi.org/10.3389/fneur.2018.00315.

    Article  PubMed  PubMed Central  Google Scholar 

  81. Estraneo A, Fiorenza S, Magliacano A, Formisano R, Mattia D, Grippo A, et al. Multicenter prospective study on predictors of short-term outcome in disorders of consciousness. Neurology. 2020;95:e1488–99. https://doi.org/10.1212/WNL.0000000000010254.

    Article  PubMed  PubMed Central  Google Scholar 

  82. • Thibaut A, Bodien YG, Laureys S, Giacino JT. Minimally conscious state “plus”: diagnostic criteria and relation to functional recovery. J Neurol. 2020;267:1245–54. https://doi.org/10.1007/s00415-019-09628-y. (This study demonstrates the positive prognostic implications of patients in MCS+ on behavioral assessments.)

    Article  PubMed  Google Scholar 

  83. • Hammond FM, Giacino JT, Nakase Richardson R, Sherer M, Zafonte RD, Whyte J, et al. Disorders of consciousness due to traumatic brain injury: functional status ten years post-injury. J Neurotrauma. 2019;36:1136–46. https://doi.org/10.1089/neu.2018.5954. (This study demonstrates the potential for long-term functional recovery following DOC and the positive prognostic value of following commands within 28 days post injury.)

    Article  PubMed  Google Scholar 

  84. Kowalski RG, Hammond FM, Weintraub AH, Nakase-Richardson R, Zafonte RD, Whyte J, Giacino JT. Recovery of consciousness and functional outcome in moderate and severe traumatic brain injury. JAMA Neurol. 2021;78:548–57. https://doi.org/10.1001/jamaneurol.2021.0084.

    Article  PubMed  Google Scholar 

Download references

Author information

Authors and Affiliations

Authors

Corresponding author

Correspondence to Michael H. Marino.

Ethics declarations

Conflict of Interest

The authors declare no competing interests.

Human and Animal Rights and Informed Consent

This article does not contain any studies with human or animal subjects performed by any of the authors.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Supplementary Information

Below is the link to the electronic supplementary material.

Supplementary file1 (PDF 185 KB)

Supplementary file2 (PDF 762 KB)

Rights and permissions

Springer Nature or its licensor (e.g. a society or other partner) holds exclusive rights to this article under a publishing agreement with the author(s) or other rightsholder(s); author self-archiving of the accepted manuscript version of this article is solely governed by the terms of such publishing agreement and applicable law.

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Marino, M.H., Koffer, J. & Nalla, S. Update on Disorders of Consciousness. Curr Phys Med Rehabil Rep 11, 62–73 (2023). https://doi.org/10.1007/s40141-023-00384-9

Download citation

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s40141-023-00384-9

Keywords

Navigation