Search Results (137)

We here delve into the intricate and evolving concepts of brain death and consciousness, particularly at the end of life. We examine the historical and technological advancements that have influenced our understanding of death, such as mechanical ventilation and resuscitation techniques. These developments have challenged traditional definitions of death, leading to the concept of brain death, defined as the irreversible loss of all brain functions, including the brainstem. We emphasize that consciousness exists on a continuum, ranging from full alertness to deep coma and complete cessation of brain activity. It explores various disorders of consciousness, including coma, vegetative state, minimally conscious state, and locked-in syndrome, each with distinct characteristics and levels of awareness. Neuroimaging techniques, such as EEG, fMRI, and DTI, are highlighted for their crucial role in diagnosing and understanding disorders of consciousness. These techniques help to detect covert consciousness, assess brain activity, and predict recovery potential. The phenomenon of the “wave of death,” which includes a paradoxical surge in brain activity at the point of death, is also discussed. We address the challenges in defining and understanding both death and consciousness, calling for biologically grounded, ethically defensible, and culturally sensitive definitions. We advocate for standardized neuroimaging protocols, longitudinal studies, and the integration of artificial intelligence to improve diagnosis and treatment. In conclusion, the document underscores the importance of an integrated, evidence-based approach to understanding the gray zones between life and death, recognizing that consciousness and death are dynamic processes with both biological and experiential dimensions. Full article

Pneumococcal meningoencephalitis is a severe infection associated with high morbidity and mortality. Although typically community-acquired, postoperative cases following elective ENT surgery are exceedingly rare. Antimicrobial resistance (AMR) among Streptococcus pneumoniae further complicates management, and missed opportunities for vaccination represent preventable risks. We report a case of a 41-year-old man with multiple comorbidities who developed fulminant S. pneumoniae meningitis 48 h after septoturbinoplasty. The clinical course was atypical, with altered consciousness but no classical meningeal signs, necessitating urgent intubation and intensive care admission. Cerebrospinal fluid cultures identified an MDR pneumococcal strain resistant to penicillin and macrolides but susceptible to vancomycin and meropenem. Empirical therapy with vancomycin and meropenem, combined with adjunctive corticosteroids and multidisciplinary ICU care, led to complete neurological recovery. This case highlights a rare but life-threatening postoperative complication and underscores two critical lessons. First, the growing challenge of multidrug-resistant pneumococcus requires timely recognition, aggressive empiric therapy, and access to effective agents. Second, the absence of pneumococcal vaccination in this high-risk surgical patient illustrates a preventable gap in care. Integrating vaccination screening into preoperative evaluations may reduce the risk of catastrophic postoperative CNS infections. Full article

Background: The Coma Recovery Scale–Revised (CRS-R) is the gold standard for diagnosing chronic disorders of consciousness (DoC); however, its clinical utility is limited by lengthy administration and the need for specialized training. The Simplified Evaluation of Disorders of Consciousness (SECONDs) provides a faster and more user-friendly alternative. Objective: This study aims to evaluate the validity and reliability of the Argentine adaptation of the SECONDs scale in adults with chronic DoC due to acquired brain injury. Methods: Twenty-nine patients were evaluated over two consecutive days by three blinded raters. On day one, rater A administered the SECONDs (A1) and rater B administered the CRS-R (B) to assess concurrent validity. On day two, rater A repeated the SECONDs (A2), and rater C performed an additional SECONDs assessment (C), permitting evaluation of intra-rater (A1 vs. A2) and inter-rater (A vs. C) reliability. Results: The SECONDs demonstrated excellent intra-rater (ICC = 0.98) and inter-rater (ICC = 0.86) reliability. Concurrent validity with the CRS-R was strong (r = 0.73, p < 0.001). Diagnostic agreement was high between A1 and B (κ = 0.75) and between both A1-A2 and A1-C (κ = 0.82). The median administration time was significantly shorter for the SECONDs (10 vs. 15 min; p < 0.001). Conclusion: The Argentine SECONDs is a valid, reliable, and efficient tool for the clinical assessment of DoC patients in rehabilitation settings. Full article

Background: Upright position recovery (i.e., verticalization) is crucial in the rehabilitation of severe acquired brain injury (sABI). VErticalization by tilt table equipped with robotic-assisted lower limbs cyclic Mobilization (VEM) may facilitate a safer adaptation to vertical posture, reducing orthostatic hypotension occurrence. This multicenter randomized controlled trial (RCT) aims at investigating efficacy, safety, and usability of VEM compared to Traditional Verticalization (TV) using a conventional tilt table in cognitive-motor rehabilitation of sABI patients; Methods: a total of 118 sABI patients with or emerged from prolonged Disorder of Consciousness (pDoC and eDoC) will be enrolled in six post-acute Neurorehabilitation Units and randomly allocated to VEM or TV arm (for each arm: total 25 sessions of 30 min daily treatment/5 days/week/5 weeks). Patients will undergo clinical–functional assessment, resting EEG recording and blood sampling, before, at the end of treatment, and after 1 month; Results: we will expect possible differences in safety and usability of verticalization between VEM and TV rehabilitative intervention and in their efficacy to improve clinical–functional findings and brain indices; Conclusions: this RCT will provide new insights for the intensive, tailored and safe neurorehabilitation intervention in patients with sABI. Full article

Acquired Brain Injury (ABI) is now widely regarded as a chronic condition but this change in conceptualization has not yet been realized in the way rehabilitation and care are offered and funded in the United States. Similarly, it is widely accepted that an optimized ABI system includes integration across the phases of care and recovery that considers the bio-psycho-socio-ecological (BPSE) dimensions beyond the injury itself. Despite the importance of BPSE factors informing care, typical post-injury care and management remain focused on acute presentation and the biological nature of the injury and there still exists relevant inter-country differences for disorders of consciousness (DoC) neurorehabilitation after severe ABI. This collaboration with Italian colleagues explores and compares the types and locations of rehabilitative services offered in a Post-Coma Unit of neurorehabilitation center in Italy (namely, Santa Lucia Foundation IRCCS in Rome) and in the United States following a “severe” ABI (sABI). This narrative seeks to describe the degree to which both systems utilize a BPSE informed approach to care. Full article

Background: Benzodiazepine poisoning is a frequent cause of emergency department (ED) visits, often related to suicide attempts. Flumazenil is the only specific antidote, but its continuous infusion protocol remains controversial because of its uncertain outcome benefits and increased risk of adverse events. This study aimed to evaluate the effect of continuous flumazenil infusion on the time to recovery of consciousness and secondary outcomes in patients with benzodiazepine poisoning stratified by hospitalization status. Methods: A retrospective cohort study was conducted at a tertiary hospital in Seoul, Korea, including adults treated for benzodiazepine poisoning in the ED between April 2019 and March 2024. The primary outcome being the time from arrival at the ED to regaining consciousness. Multivariate regression identified independent predictors of delayed recovery. Results: Among the 370 patients, 52.4% were hospitalized. Flumazenil infusion was administered in 46.8% of the patients, more often in hospitalized patients. In this group, flumazenil infusion significantly reduced the median time to regain consciousness (13.7 vs. 19.4 h, p = 0.006) but did not affect the overall hospital stay. In nonhospitalized patients, flumazenil infusion did not shorten the awakening time or prolong the ED stay. Adverse events, mainly agitation, were more frequent with flumazenil infusion. Conclusions: Continuous infusion of flumazenil accelerates the recovery of consciousness only in hospitalized patients who are severely affected by benzodiazepine poisoning but with increased adverse events and no reduction in hospital stay. Individualized patient selection and evidence-based protocols are needed for optimal and safe antidote use. Full article

Background: Dopamine (DA) is a critical neurotransmitter that regulates many physiological and behavioral processes. The central dopaminergic system plays a pivotal role in modulating general anesthesia (GA). DA release in the brain is mainly concentrated in the nucleus accumbens (NAc), prefrontal cortex, hypothalamus, and dorsal striatum. Several NAc neuron subtypes are essential for modulating states of consciousness during GA. However, whether NAc DA signal dynamics correlate with different states of consciousness under sevoflurane anesthesia remains to be elucidated. In this study, we measured the dynamic fluctuations of NAc DA levels throughout sevoflurane anesthesia to verify its role. Methods: An intensity-based genetically encoded DA indicator, dLight1.1, was employed to track DA release in the NAc. Fiber photometry combined with electroencephalogram/electromyogram recordings was employed to synchronously track NAc DA signal dynamics across different states of consciousness under sevoflurane anesthesia. Results: Under 2.5% sevoflurane exposure, DA release in the NAc significantly increased during the initial 100 s of sevoflurane induction, which was designated as sevo on-1 (mean ± standard error of the mean [SEM]; baseline vs. sevo on-1, p = 0.0261), and continued to decrease in the subsequent anesthesia maintenance phases (sevo on-1 vs. sevo on-4, p = 0.0070). Following the cessation of sevoflurane administration (with intervals denoted as sevooff), NAc DA gradually returned to baseline levels (sevo on-1 vs. sevo off-1, p = 0.0096; sevo on-1 vs. sevo off-3, p = 0.0490; sevo on-1 vs. sevo off-4, p = 0.0059; sevo on-4 vs. sevo off-4, p = 0.0340; sevo off-1 vs. sevo off-4, p = 0.0451). During the induction phase, NAc DA signal dynamics markedly increased during the pre-loss of consciousness (LOC) period (pre-anesthesia baseline vs. pre-LOC, p = 0.0329) and significantly declined after LOC (pre-LOC vs. post-LOC, p = 0.0094). For the emergence period, NAc DA release exhibited a noticeable increase during the initial period after recovery of consciousness (ROC) (anesthesia baseline vs. post-ROC, p = 0.0103; pre-ROC vs. post-ROC, p = 0.0086). Furthermore, the DA signals peaked rapidly upon the initiation of the burst wave and then gradually attenuated, indicating a positive correlation with the burst wave onset during burst suppression events. Conclusions: Our findings revealed that NAc DA neurotransmitter signal dynamics correlate with different states of consciousness throughout sevoflurane anesthesia. Full article

Background/Objectives: The Lowenstein Communication Scale (LCS) is a tool for the evaluation of communicative performance in patients with disorders of consciousness (DOC). This study investigated the reliability and validity of the LCS. Methods: We evaluated 23 inpatients with unresponsive wakefulness syndrome (UWS) and 18 in a minimally conscious state (MCS), at admission to a Consciousness Rehabilitation Department and one month later. The evaluations included assessments of LCS by two raters, and of the Coma Recovery Scale–Revised (CRS-R) by one rater. Results: Total inter-rater agreement in LCS task scoring was found in 58–100% of the patients. Cohen’s kappa values were >0.6 for most tasks. High correlations were found between the two raters on total scores and most subscales (r = 0.599–1.000, p < 0.001), and the differences between them were small. LCS subscales and total score intraclass correlations (ICC) were high. Internal consistency was acceptable (Cronbach’s α > 0.7) for most LCS subscales and total scores. Moderate to strong correlations were found between LCS and CRS-R scores (r = 0.554–0.949, p < 0.05), and the difference in responsiveness between LCS and CRS-R was non-significant. Conclusions: The findings indicate that the LCS is reliable and valid, making it a valuable clinical and research assessment tool for patients with DOC. Full article

Background/Objectives: Sports tourism, particularly international running events such as half marathons and marathons, has rapidly grown due to rising health consciousness and active lifestyles. Runners competing abroad face unique nutritional challenges that extend beyond physiological needs, including adaptation to local food cultures and psychosocial factors. This study aims to explore the nutritional difficulties encountered by international runners during competitions abroad, using participants of the Poznan Half Marathon 2025 as a case example. Methods: A qualitative research design was employed, involving semi-structured in-depth interviews with 12 international runners from the United Kingdom, Germany, and Ukraine. Participants had at least two years of experience competing internationally. Results: Four primary categories of nutritional challenges emerged: (1) quality and availability of food, (2) adaptation to local eating habits and physiological impacts, (3) hydration and access to appropriate fluids, and (4) logistical factors and the interactions between psychological stress, physical well-being, and nutritional choices. These factors influenced runners’ preparation, race-day performance, and recovery, highlighting the complexity of managing nutrition in unfamiliar environments. Conclusions: Nutritional challenges for international runners are multidimensional, requiring flexible and culturally sensitive nutritional strategies. Although these findings offer useful insights, they are based on a small, specific sample and should be generalized with caution. Further research is necessary to explore the broader applicability of the findings and their relevance to diverse athletic populations and contexts. Full article

Oral narratives play a crucial role in shaping the historical consciousness of Indigenous communities in Northeast India, where history writing is a relatively recent phenomenon. Among the Mizos, Nagas, Khasis, Kuki-Chins, and other Indigenous tribes of Northeast India, including the Bodos, the Garos, the Dimasas, or the Karbis of Assam, much of what is considered written history emerged during British colonial rule. Native historians later continued it in postcolonial India. However, written history, especially when based on fragmented colonial records, includes interpretive gaps. In such contexts, oral traditions provide complementary, and frequently, more authoritative frameworks rooted in cultural memory and collective transmission. Oral narratives, including ritual poetry, folk songs, myths, and folktales, serve as vital mediums for reconstructing the past. Scholars such as Jan Vansina view oral narratives as essential for understanding the histories of societies without written records, while Paul Thompson sees them as both a discovery and a recovery of cultural memory. Romila Thapar argues that narratives become indicative of perspectives and conditions in societies of the past, functioning as a palimpsest with multiple layers of meaning accruing over generations as they are recreated or reiterated over time. The folk narratives of the Mizos and Angami Nagas not only recount their origins and historical migrations, but also map significant geographical and cultural landmarks, such as Khezakheno and Lungterok in Nagaland, Rounglevaisuo in Manipur, and Chhinlung or Rih Dil on the Mizoram–Myanmar border. These narratives constitute a cultural understanding of the past, aligning with Greg Dening’s concept of “public knowledge of the past,” which is “culturally shared.” Additionally, as Linda Tuhiwai Smith posits, such stories, as embodiments of the past, and of socio-cultural practices of communities, create spaces of resistance and reappropriation of Indigenous identities even as they reiterate the marginalization of these communities. This paper deploys these ideas to examine how oral narratives can be used to decolonize grand narratives of history, enabling Indigenous peoples, such as the Mizos and the Angamis in North East India, to reaffirm their positionalities within the postcolonial nation. Full article

Neurophysiological techniques, particularly somatosensory evoked potentials (SEPs) and electroencephalography (EEG), are essential tools for the functional and prognostic evaluation of patients with prolonged disorders of consciousness (DoC) in intensive neurorehabilitation settings. This narrative review critically analyzes the most relevant evidence regarding the use of SEPs and EEG in the management of post-comatose patients, highlighting the strategic role of physiatrists in integrating these assessments into individualized rehabilitation plans. A systematic search was conducted across major international databases (PubMed, Embase, Scopus, Cinahl, and DiTA) until December 2024, selecting consensus documents, official guidelines (including the 2021 ERC/ESICM guidelines), systematic reviews, observational studies, and significant Italian neurophysiological contributions. The literature supports the strong prognostic value of the bilateral presence of the N20 component in SEPs, while its early bilateral absence, particularly in post-anoxic cases, is a robust predictor of poor neurological outcomes. EEG provides complementary information, with continuous, reactive, and symmetrical patterns associated with favorable outcomes, while pathological patterns, such as burst suppression or isoelectric activity, predict a worse prognosis. Combining SEP and EEG assessments significantly improves prognostic sensitivity and specificity, especially in sedated or metabolically compromised patients. Additionally, the use of direct muscle stimulation (DMS) and nerve conduction studies enables accurate differentiation between central and peripheral impairments, which is crucial for effective rehabilitation planning. Overall, SEPs and EEG should be systematically incorporated into the evaluation and follow-up of DoC patients, and the acquisition of neurophysiological competencies by physiatrists represents a strategic priority for modern, effective, and personalized neurorehabilitation. Full article

In patients undergoing living donor liver transplantation (LDLT) with immediate postoperative extubation in the operating room (OR), rapid recovery of consciousness and spontaneous ventilation are essential, requiring effective analgesia without compromising respiratory function. This study evaluated whether intraoperative nefopam administration improves early postoperative pain control and reduces opioid consumption in this physiologically distinct population. A retrospective cohort of 376 adult LDLT recipients who met the criteria for OR extubation was analyzed. After propensity score matching, 182 patients who received intraoperative nefopam were compared with 182 matched controls. Pain intensity was measured using the visual analog scale (VAS), and total fentanyl consumption and opioid-related complications were recorded over the first 24 h postoperatively. Nefopam administration was associated with significantly lower VAS scores during the first 12 h after surgery (p < 0.001) and reduced 24 h fentanyl consumption (53.2 ± 20.8 mL vs. 58.6 ± 27.5 mL, p = 0.035). No serious adverse effects related to nefopam were observed. The incidence of postoperative nausea and vomiting did not differ significantly between the groups. These findings indicate that nefopam offers effective early analgesia and an opioid-sparing effect in LDLT recipients undergoing OR extubation, suggesting its clinical utility as a component of multimodal analgesia in this high-risk group. Although the reduction in opioid use did not translate into a decreased incidence of opioid-related complications, the favorable safety profile and analgesic efficacy of nefopam support further investigation through prospective trials to define its role in enhanced recovery protocols for OR-extubated LDLT recipients. Full article

Background/Objectives: Disorder of consciousness (DoC) poses diagnostic challenges due to behavioral assessment limitations. This study evaluates the spectral exponent (SE)—a neurophysiological biomarker quantifying the decay slope of electroencephalography (EEG) aperiodic activity—as an objective tool for consciousness stratification and clinical behavior scores correlation. Methods: The study involved 15 DoC patients, nine conscious brain-injured controls (BI), and 23 healthy controls (HC). Resting-state 32-channel EEG data were analyzed to compute SE across broadband (1–40 Hz) and narrowband (1–20 Hz, 20–40 Hz). Statistical frameworks included Bonferroni-corrected Kruskal–Wallis H tests, Bayesian ANOVA, and correlation analyses with CRS-R behavioral scores. Results: Narrowband SE (1–20 Hz) showed superior diagnostic sensitivity, differentiating DoC from controls (HC vs. DoC: p < 0.0001; BI vs. DoC: p = 0.0006) and MCS from VS/UWS (p = 0.0014). SE correlated positively with CRS-R index (1–20 Hz: r = 0.590, p = 0.021) and visual subscale (1–20 Hz: r = 0.684, p = 0.005). High-frequency (20–40 Hz) SE exhibited inconsistent results. Longitudinal tracking in an individual revealed a reduction in SE negativity, a flattening of the 1/f slope, and behavioral recovery occurring in parallel. Conclusions: Narrowband SE (1–20 Hz) is a robust biomarker for consciousness quantification, overcoming behavioral assessment subjectivity. Its correlation with visual function highlights potential clinical utility. Future studies should validate SE in larger cohorts and integrate multimodal neuroimaging. Full article

Background: Disorders of Consciousness (DoC) following acute brain injuries, such as intracerebral hemorrhage, present significant clinical challenges in intensive care and rehabilitation settings. Early multidisciplinary interventions, including physiatric care, are critical in optimizing recovery trajectories. However, evidence regarding the timing and intensity of rehabilitation interventions remains limited. This case report highlights the role of physiatrists in managing a critically ill patient with a DoC in an Intensive Care Unit (ICU), focusing on early rehabilitation strategies and individualized care planning. Case presentation: A 63-year-old male with a history of hypertension and cardiac disease presented with a left hemispheric hemorrhage and quadriventricular intraventricular hemorrhage. The patient was admitted to the ICU in a comatose state (Glasgow Coma Scale [GCS] 5). Initial physiatric evaluation revealed a critical condition precluding immediate initiation of an Individual Rehabilitation Project (IRP). Over subsequent weeks, clinical improvements were observed, including an increased GCS and Coma Recovery Scale-Revised (CRS-R) score. A tailored IRP was implemented, emphasizing passive mobilization to prevent complications such as muscle atrophy, joint contractures, and pressure ulcers. The patient demonstrated gradual progress, transitioning to a Minimally Conscious State (MCS) and achieving improved joint mobility and reduced peripheral edema. Discussion and Conclusions: This case underscores the pivotal role of physiatrists in ICU settings, particularly for patients with DoC. Early physiatric interventions, even in critically ill patients, can prevent secondary complications and facilitate functional recovery. Close collaboration with ICU teams and infectious disease specialists ensured the safe implementation of rehabilitation strategies despite the patient’s severe condition. The observed clinical improvements highlight the potential benefits of early mobilization and individualized care plans, both in terms of survival (quoad vitam) and quality of life (quoad valetudinem). This report emphasizes the need for further research to refine rehabilitation practices for patients with DoC, bridging gaps between acute care and neurorehabilitation. Full article

Introduction: Traumatic brain injuries (TBIs) are conditions affecting brain function caused by blunt or penetrating forces to the head. Symptoms may include confusion, impaired consciousness, coma, seizures, and focal or sensory neurological motor injuries. Objective: This study evaluated sex hormone profiles and their predictive role in returning consciousness after severe traumatic brain injury. Materials and Methods: We included 120 patients with TBIs and collected comprehensive information about each patient, including the cause of the trauma, age, gender, Glasgow Coma Scale (GCS) score, Injury Severity Score (ISS), and neuroradiological imaging data. The ISS was used to assess the severity of the trauma. At the same time, the lowest GCS score was recorded either before sedation and intubation in the emergency room or by emergency medical services personnel. For female participants, samples were collected during the luteal phase of the menstrual cycle (days 18 to 23). Results: The mean age of male patients was 33.40 years, ranging from 23 to 45 years, while female patients had an average age of 34.25 years, ranging from 25 to 48 years. The primary cause of injury for both genders was motor vehicle accidents. In male patients, testosterone levels were significantly higher in those classified as responsive (RC) compared to those non-responsive (NRC), with levels of 2.56 ± 0.47 ng/mL versus 0.81 ± 0.41 ng/mL (p = 0.003). A cut-off point of 1.885 ng/mL for testosterone levels in males was established, achieving a sensitivity and specificity of 86.7% and 86.7%, respectively. In female patients, progesterone levels were elevated in those who regained consciousness, measuring 1.80 ± 0.31 ng/mL compared to 0.62 ± 0.31 ng/mL (p = 0.012). A cut-off point of 1.335 ng/mL for progesterone levels in females was determined, with a sensitivity and specificity of 93.3% and 86.7%, respectively. Conclusions: We can conclude that sex hormone levels in the acute phase of TBIs can vary between males and females. Notably, serum testosterone levels in males and progesterone levels in females with TBIs are significant prognostic factors for assessing the likelihood of regaining consciousness after such injuries. These findings underscore the importance of considering sex hormone profiles in TBI recovery prognosis. Full article