Assessing the depth of language processing in patients with disorders of consciousness

The differential diagnosis of disorders of consciousness is challenging. The rate of misdiagnosis is approximately 40%, and new methods are required to complement bedside testing, particularly if the patient's capacity to show behavioral signs of awareness is diminished. At two major referral centers in Cambridge, United Kingdom, and Liege, Belgium, we performed a study involving 54 patients with disorders of consciousness. We used functional magnetic resonance imaging (MRI) to assess each patient's ability to generate willful, neuroanatomically specific, blood-oxygenation-level-dependent responses during two established mental-imagery tasks. A technique was then developed to determine whether such tasks could be used to communicate yes-or-no answers to simple questions. Of the 54 patients enrolled in the study, 5 were able to willfully modulate their brain activity. In three of these patients, additional bedside testing revealed some sign of awareness, but in the other two patients, no voluntary behavior could be detected by means of clinical assessment. One patient was able to use our technique to answer yes or no to questions during functional MRI; however, it remained impossible to establish any form of communication at the bedside. These results show that a small proportion of patients in a vegetative or minimally conscious state have brain activation reflecting some awareness and cognition. Careful clinical examination will result in reclassification of the state of consciousness in some of these patients. This technique may be useful in establishing basic communication with patients who appear to be unresponsive. 2010 Massachusetts Medical Society

Resting-state functional connectivity studies with fMRI showed that the brain is intrinsically organized into large-scale functional networks for which the hemodynamic signature is stable for about 10s. Spatial analyses of the topography of the spontaneous EEG also show discrete epochs of stable global brain states (so-called microstates), but they remain quasi-stationary for only about 100 ms. In order to test the relationship between the rapidly fluctuating EEG-defined microstates and the slowly oscillating fMRI-defined resting states, we recorded 64-channel EEG in the scanner while subjects were at rest with their eyes closed. Conventional EEG-microstate analysis determined the typical four EEG topographies that dominated across all subjects. The convolution of the time course of these maps with the hemodynamic response function allowed to fit a linear model to the fMRI BOLD responses and revealed four distinct distributed networks. These networks were spatially correlated with four of the resting-state networks (RSNs) that were found by the conventional fMRI group-level independent component analysis (ICA). These RSNs have previously been attributed to phonological processing, visual imagery, attention reorientation, and subjective interoceptive-autonomic processing. We found no EEG-correlate of the default mode network. Thus, the four typical microstates of the spontaneous EEG seem to represent the neurophysiological correlate of four of the RSNs and show that they are fluctuating much more rapidly than fMRI alone suggests. Copyright 2010 Elsevier Inc. All rights reserved.

At rest, the brain is traversed by spontaneous functional connectivity patterns. Two hypotheses have been proposed for their origins: they may reflect a continuous stream of ongoing cognitive processes as well as random fluctuations shaped by a fixed anatomical connectivity matrix. Here we show that both sources contribute to the shaping of resting-state networks, yet with distinct contributions during consciousness and anesthesia. We measured dynamical functional connectivity with functional MRI during the resting state in awake and anesthetized monkeys. Under anesthesia, the more frequent functional connectivity patterns inherit the structure of anatomical connectivity, exhibit fewer small-world properties, and lack negative correlations. Conversely, wakefulness is characterized by the sequential exploration of a richer repertoire of functional configurations, often dissimilar to anatomical structure, and comprising positive and negative correlations among brain regions. These results reconcile theories of consciousness with observations of long-range correlation in the anesthetized brain and show that a rich functional dynamics might constitute a signature of consciousness, with potential clinical implications for the detection of awareness in anesthesia and brain-lesioned patients.