专注于微妙的迹象和运动行为推出没有响应从患者的意识

Model of Behavioral and Cognitive Evolution After Severe Brain Impairment The diagnostic spectrum and clinical evolution after severe brain impairment is represented on a 2-dimensional graph comparing the degree of cognitive content (x-axis) against the degree of behavioral response (y-axis). The red-yellow-green color gradient represents an approximation of the degree of recovery, with red being the worst and green the best. Both cognitive content and behavioral response are determined using the CRS-R in conjunction with the MBT-r, which we developed to expand the range of motor testing to detect subtle, purposeful movements (the so-called positive signs) and brainstem release signs (the so-called negative signs). Concerning the motor/behavioral response of patients with CMD, the functional ambulation category quantifies the degree of functional motor recovery. In cases of a total lack of motor response, AIEs may unveil CMD-defining covert cognition. For patients with a good behavioral response, confusion and neuropsychological assessment protocols distinguish between the different degrees of functional recovery. Patients with a severe brain impairment appear to fall mainly into 2 categories—true disorders of consciousness (spanning from VS/UWS to MCS+, red hues) and CMD/locked-in state (yellow-green hues)—with different underlying lesions (represented by the symbolic brain images), clinical manifestations (e.g., brainstem release signs), and prognosis (represented by the arrows along the recovery pathways). The circles/ellipses surrounding the different diagnoses (VS/UWS, MCS-, etc.) account for the fact that many patients never recover after a specific point in the recovery pathway. Widespread lesions across heteromodal cortical association areas and cortico-thalamic tracts cause the impairment in patients with true disorders of consciousness. Consequently, many of these patients may suffer chronically from a total (VS/UWS) or partial (MCS) lack of awareness. Posturing typically lasts after conscious emergence, causing characteristic clinical motor patterns usually not seen in patients with CMD. Patients with CMD, on the other hand, are characterized by a total (complete CMD, with covert cognition only detectable by AIEs) or near-total (clinical CMD with subtle, purposeful movements) lack of determined movements. Most patients with CMD do not develop brainstem release signs, except for complete locked-in state patients, who typically manifest decorticate/decerebrate posturing. We indicate the potential recovery pathways using symbolic arrows. AIE = advanced imaging and electrophysiology technique; CMD = cognitive motor dissociation; CRS-R = Coma Recovery Scale–Revised; MBT-r = Motor Behavior Tool–Revised; MCS = minimally conscious state (+ = plus and − = minus); VS/UWS = vegetative state/unresponsive wakefulness state. Created using the vector graphics editor Adobe Illustrator (Adobe Inc., San Jose, CA). Brain images were derived from the population-averaged tractography atlas by Yeh et al.²⁴