Towards the routine use of brain imaging to aid the clinical diagnosis of disorders of consciousness
1 Impaired Consciousness Study Group, Wolfson Brain Imaging Centre, University of Cambridge, Cambridge, UK 2 MRC Cognition and Brain Sciences Unit, 15 Chaucer Road, Cambridge, UK 3 Department of Psychology, University College London, London, UK 4 Royal Hospital for Neurodisability, London, UK 5 Academic Neurosurgery Unit, University of Cambridge, Cambridge, UK
Correspondence to: Dr Martin Coleman, Impaired Consciousness Study Group, Wolfson Brain Imaging Centre, Addenbrookes Hospital, Cambridge CB2 0QQ, UK E-mail: mrc30{at}cam.ac.uk
Clinical audits have highlighted the many challenges and dilemmas faced by clinicians assessing persons with disorders of consciousness (vegetative state and minimally conscious state). The diagnostic decision-making process is highly subjective, dependent upon the skills of the examiner and invariably dictated by the patients’ ability to move or speak. Whilst a considerable amount has been learnt since Jennett and Plum coined the term ‘vegetative state’, the assessment process remains largely unchanged; conducted at the bedside, using behavioural assessment tools, which are susceptible to environmental and physiological factors. This has created a situation where the rate of misdiagnosis is unacceptably high (up to 43%). In order to address these problems, various functional brain imaging paradigms, which do not rely upon the patient's ability to move or speak, have been proposed as a source of additional information to inform the diagnostic decision making process. Although accumulated evidence from brain imaging, particularly functional magnetic resonance imaging (fMRI), has been encouraging, the empirical evidence is still based on relatively small numbers of patients. It remains unclear whether brain imaging is capable of informing the diagnosis beyond the behavioural assessment and whether brain imaging has any prognostic utility. In this study, we describe the functional brain imaging findings from a group of 41 patients with disorders of consciousness, who undertook a hierarchical speech processing task. We found, contrary to the clinical impression of a specialist team using behavioural assessment tools, that two patients referred to the study with a diagnosis of vegetative state did in fact demonstrate neural correlates of speech comprehension when assessed using functional brain imaging. These fMRI findings were found to have no association with the patient's behavioural presentation at the time of investigation and thus provided additional diagnostic information beyond the traditional clinical assessment. Notably, the utility of brain imaging was further underlined by the finding that the level of auditory processing revealed by functional brain imaging, correlated strongly (rs = 0.81, P < 0.001) with the patient's subsequent behavioural recovery, 6 months after the scan, suggesting that brain imaging may also provide valuable prognostic information. Although further evidence is required before consensus statements can be made regarding the use of brain imaging in clinical decision making for disorders of consciousness, the results from this study clearly highlight the potential of imaging to inform the diagnostic decision-making process for persons with disorders of consciousness.
Key Words: vegetative state; minimally conscious state; speech comprehension; brain imaging
Abbreviations: CRS, Coma Recovery Scale; FDR, False discovery rate; fMRI, functional magnetic resonance imaging; SPM, statistical parametric mapping
Received April 2, 2009. Revised May 14, 2009. Accepted May 29, 2009.