Clinical neurophysiology of prolonged disorders of consciousness: From

diagnostic stimulation to therapeutic neuromodulation

This study discussed the The identification of signs of awareness in

patients with prolonged disorders of consciousness (DoC) after severe brain
injury is a challenging task for clinicians. Differentiating on behavioural
examination the vegetative state (VS) from the minimally conscious state (MCS)
can lead to a high misdiagnosis rate. Advanced neuroimaging and
neurophysiological techniques can supplement clinical evaluation by providing
physiological evidence of brain activity. However, an open issue remains whether
these empirical results are directly or indirectly associated with covert
consciousness and limitations emerge for their diagnostic application at the
single-patient level. On the therapeutic side, the efficacy of both noninvasive and
invasive brain stimulation/modulation trials is matter of debate. The present
review provides an updated analysis of the diagnostic and prognostic impact that
the different neurophysiological techniques of stimulation [including short-latency
evoked potentials, long-latency event related potentials (ERPs), transcranial
magnetic stimulation (TMS), TMS-EEG co-registration] offer in prolonged DoC.
The results of the therapeutic stimulation techniques are also evaluated. It is
concluded that TMS-EEG emerges as the most promising tool for differentiating
VS from MCS whereas ERPs allow neurophysiologists to probe covert cognitive
capacities of each patient. Significant behavioural improvements in prolonged
DoC with brain stimulation techniques are still anecdotical and further treatment
options are awaited.
The clinical ‘‘hard problem” of detecting for certainty consciousness in
VS/UWS and MCS states has not been resolved yet, but neurosciences have
brought lately relevant contributions to identify the neural bases of arousal and
wakefulness and so to better focus the questions to be answered.
Electrophysiology, with the advent of new techniques, has provided both
diagnostic and prognostic clues, accessible at the bedside and therefore
complementing the behavioural assessment. It is therefore an important goal of
the research field to identify multiple approaches to detecting awareness that can
be combined to improve clinical practice.