Researchers from the Brain Institute and the Pitié-Salpêtrière Hospital, coordinated by Lionel Naccache (Sorbonne University / AP-HP), Jacobo Sitt (Inserm) and Benjamin Rohaut (Sorbonne University / AP-HP) have shown that an approach ” multimodal » makes it possible to achieve better prognoses for patients admitted to intensive care because of a “ disorder of consciousness »[1]. This type of approach combines clinical, electrophysiological, behavioral, and neuroimaging indicators. They published their work in the journal Nature Medicine [2].
Reduce uncertainties
In order to evaluate the cognitive recovery abilities of patients suffering from a disorder of consciousness, a neurological prognosis is “ usually » obtained from several indicators, including the examination of “ standard measurements of brain anatomy » (CT and MRI) and its functioning (electroencephalogram). Gold, ” even with this information in hand, there often remains some uncertainty in the prognosis, which can impact medical decision-making », Underlines the neurologist-resuscitator Benjamin Rohaut, first author of the study. And these patients are often very fragile and exposed to numerous complications, which each time raises the question of the intensity of care », he points out.
Furthermore, ” doctors sometimes observe a dissociation between the patient’s behavior and their brain activity “. So ” some patients in a vegetative state seem to understand what is said to them, but are unable to communicate it to caregivers » (cf. Minimal consciousness: new results to evaluate brain activity and improve it).
An approach that does not “guarantee bias-free decision-making”
To characterize the clinical benefit of a “multi-modal” approach[3]doctors have “ monitored and evaluated » 349 intensive care patients between 2009 and 2021. After each “ multi-modal assessment “, they formulated a prognosis that could be ” Good “, ” uncertain ” Or ” unfavorable » [4]. None of the patients who received a notice “ unfavorable » had regained consciousness a year later. In contrast, patients with a “ Good ” prognosis ” presented a much more favorable evolution of their cognitive abilities ” than the others.
Scientists further observed that increasing the number of indicators made it possible to increase the accuracy of diagnosis and, as a result, “ the team’s confidence in its own assessments “.
These works come “ empirically validate the recent recommendations of the European and American academies of neurology », says Jacobo Sitt. However, this approach does not “ does not guarantee bias-free decision-making » (cf. Emmanuel Hirsch: The Vincent Lambert affair, “an ethical and political failure from which we should learn some lessons”). Access to evaluation tools, “ which are expensive and require specific expertise ”, is also a problem for its implementation.
[1] DoC in English for Disorder of consciousness. They include comas, “vegetative” states, or “vegetative” states. minimal consciousness »
[2] Rohaut, B., Calligaris, C., Hermann, B. et al. Multimodal assessment improves neuroprognosis performance in clinically unresponsive critical-care patients with brain injury. Nat Med (2024). https://doi.org/10.1038/s41591-024-03019-1
[3] It combines PET scan, multivariate EEG analysis algorithms, functional MRI, potential » cognitive (electrical responses to sensory stimulation), and other tools.
[4] Respectively 22%, 45.5% and 32.5% of cases
Source: Inserm, CP (05/30/2024)
