Joseph T Giacino1, Douglas I Katz2, Nicholas D Schiff3, John Whyte4, Eric J Ashman5, Stephen Ashwal6, Richard Barbano7, Flora M Hammond8, Steven Laureys9, Geoffrey S F Ling10, Risa Nakase-Richardson11, Ronald T Seel12, Stuart Yablon13, Thomas S D Getchius14, Gary S Gronseth15, Melissa J Armstrong16. 1. Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital and Harvard Medical School, Boston, MA; Department of Psychiatry, Massachusetts General Hospital, Boston, MA. 2. Department of Neurology, Boston University School of Medicine, Boston, MA; Braintree Rehabilitation Hospital, MA. 3. Department of Neurology and Neuroscience, Weill Cornell Medical College, New York, NY. 4. Moss Rehabilitation Research Institute, Elkins Park, PA. 5. Bronson Neuroscience Center, Bronson Methodist Hospital, Kalamazoo, MI. 6. Department of Pediatrics, Division of Child Neurology, Loma Linda University School of Medicine, CA. 7. Department of Neurology, University of Rochester Medical Center, NY. 8. Indiana University Department of Physical Medicine & Rehabilitation, University of Indiana School of Medicine, Indianapolis. 9. Coma Science Group-GIGA Research and Department of Neurology, Sart Tillman Liège University & University Hospital, Liège, Belgium. 10. Department of Neurology, Uniformed Services University of Health Sciences, Bethesda; Department of Neurology, Johns Hopkins University, Baltimore, MD. 11. James A. Haley Veterans' Hospital, US Department of Veterans Affairs, Tampa, FL. 12. Crawford Research Institute, Shepherd Center, Atlanta, GA; Center for Rehabilitation Science and Engineering, Department of Physical Medicine & Rehabilitation, Virginia Commonwealth University School of Medicine, Richmond. 13. Division of Physical Medicine & Rehabilitation, University of Mississippi School of Medicine, Jackson, MS; Brain Injury Program, Methodist Rehabilitation Center, Jackson, MS. 14. Heart Rhythm Society, Washington, DC. 15. Department of Neurology, University of Kansas Medical Center, Kansas City. 16. Department of Neurology, University of Florida College of Medicine, Gainesville.
Abstract
OBJECTIVE: To update the 1995 American Academy of Neurology (AAN) practice parameter on persistent vegetative state and the 2002 case definition on minimally conscious state (MCS) and provide care recommendations for patients with prolonged disorders of consciousness (DoC). METHODS: Recommendations were based on systematic review evidence, related evidence, care principles, and inferences using a modified Delphi consensus process according to the AAN 2011 process manual, as amended. RECOMMENDATIONS: Clinicians should identify and treat confounding conditions, optimize arousal, and perform serial standardized assessments to improve diagnostic accuracy in adults and children with prolonged DoC (Level B). Clinicians should counsel families that for adults, MCS (vs vegetative state [VS]/ unresponsive wakefulness syndrome [UWS]) and traumatic (vs nontraumatic) etiology are associated with more favorable outcomes (Level B). When prognosis is poor, long-term care must be discussed (Level A), acknowledging that prognosis is not universally poor (Level B). Structural MRI, SPECT, and the Coma Recovery Scale-Revised can assist prognostication in adults (Level B); no tests are shown to improve prognostic accuracy in children. Pain always should be assessed and treated (Level B) and evidence supporting treatment approaches discussed (Level B). Clinicians should prescribe amantadine (100-200 mg bid) for adults with traumatic VS/UWS or MCS (4-16 weeks post injury) to hasten functional recovery and reduce disability early in recovery (Level B). Family counseling concerning children should acknowledge that natural history of recovery, prognosis, and treatment are not established (Level B). Recent evidence indicates that the term chronic VS/UWS should replace permanent VS, with duration specified (Level B). Additional recommendations are included. Published by Elsevier Inc.
OBJECTIVE: To update the 1995 American Academy of Neurology (AAN) practice parameter on persistent vegetative state and the 2002 case definition on minimally conscious state (MCS) and provide care recommendations for patients with prolonged disorders of consciousness (DoC). METHODS: Recommendations were based on systematic review evidence, related evidence, care principles, and inferences using a modified Delphi consensus process according to the AAN 2011 process manual, as amended. RECOMMENDATIONS: Clinicians should identify and treat confounding conditions, optimize arousal, and perform serial standardized assessments to improve diagnostic accuracy in adults and children with prolonged DoC (Level B). Clinicians should counsel families that for adults, MCS (vs vegetative state [VS]/ unresponsive wakefulness syndrome [UWS]) and traumatic (vs nontraumatic) etiology are associated with more favorable outcomes (Level B). When prognosis is poor, long-term care must be discussed (Level A), acknowledging that prognosis is not universally poor (Level B). Structural MRI, SPECT, and the Coma Recovery Scale-Revised can assist prognostication in adults (Level B); no tests are shown to improve prognostic accuracy in children. Pain always should be assessed and treated (Level B) and evidence supporting treatment approaches discussed (Level B). Clinicians should prescribe amantadine (100-200 mg bid) for adults with traumatic VS/UWS or MCS (4-16 weeks post injury) to hasten functional recovery and reduce disability early in recovery (Level B). Family counseling concerning children should acknowledge that natural history of recovery, prognosis, and treatment are not established (Level B). Recent evidence indicates that the term chronic VS/UWS should replace permanent VS, with duration specified (Level B). Additional recommendations are included. Published by Elsevier Inc.
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