Annals of Clinical and Experimental NeurologyAnnals of Clinical and Experimental NeurologyАнналы клинической и экспериментальной неврологии2075-54732409-2533Eco-Vector63010.54101/ACEN.2021.3.6ReviewsОбзорыReview ArticleCognitive motor dissociation in patients with chronic disorders of consciousness: a literature reviewФеномен когнитивно-моторного разобщения среди пациентов с хроническими нарушениями сознания: литературный обзорhttps://orcid.org/0000-0002-4043-743XBelkinVladimir A.БелкинВладимир Андреевич
Russian Federation

neurologist, Intensive care unit

врач-невролог, отделение реанимации и интенсивной терапии

vbelkin@neuro-ural.ruhttps://orcid.org/0000-0002-3014-4350IlinaKseniya A.ИльинаКсения Александровна
Russian Federation

neurologist, Department of anesthesiology and intensive care

врач-невролог отд. анестезиологии-реанимации

vbelkin@neuro-ural.ruhttps://orcid.org/0000-0001-8576-9983RyabinkinaYulia V.РябинкинаЮлия Валерьевна
Russian Federation

D. Sci. (Med.), Head, Department of anesthesiology and intensive care

д.м.н., зав. отд. анестезиологии-реанимации с палатами реанимации и интенсивной терапии

vbelkin@neuro-ural.ruClinical Institute of the BrainООО «Клиника Института мозга»Research Center of NeurologyФГБНУ «Научный центр неврологии»04102021153546118032020Copyright ©; 2021, Belkin V.A., Ilina K.A., Ryabinkina Y.V.Copyright ©; 2021, Белкин В.А., Ильина К.А., Рябинкина Ю.В.2021Belkin V.A., Ilina K.A., Ryabinkina Y.V.Белкин В.А., Ильина К.А., Рябинкина Ю.В.https://creativecommons.org/licenses/by/4.0https://annaly-nevrologii.com/pathID/article/view/630

Chronic disorders of consciousness include several conditions that differ significantly in both clinical and neurophysiological features. As medical technology continues to develop, the differential diagnosis of disorders of consciousness extends beyond purely clinical work. Nevertheless, all types of consciousness disorders are united by varying degrees of dissociation between wakefulness, cognitive and motor activity. The external similarity and minimal differences in clinical symptoms in unresponsive patients may hide different morphofunctional variants of this condition. In particular, use of electroencephalography and functional magnetic re- sonance imaging techniques allows us to detect covert consciousness in some clinically unresponsive patients. Based on various estimates, this phenomenon occurs in 5–15% of all cases. A special instance of covert consciousness is cognitive motor dissociation (CMD), defined as activation of cortical motor centers, recorded using neurophysiological techniques, in response to a corresponding instruction to perform a movement without its visible performance. Some researchers believe that detection of CMD indicates a more favourable prognosis for the subsequent restoration of consciousness, rather than its absence. The aim of this review is to examine CMD and its potential significance for outcomes in patients with chronic disorders of consciousness.

К хроническим нарушениям сознания относится ряд состояний, значительно различающихся как по клинической, так и по нейрофизиологической картине. С развитием медицинских технологий дифференциальная диагностика нарушений сознания выходит за рамки чисто клинической работы. Тем не менее все виды нарушений сознания объединяет выраженная в разной степени диссоциация между бодрствованием, познавательной и двигательной активностью. За внешним сходством и минимальным разнообразием клинических проявлений у ареактивных пациентов могут скрываться различные морфофункциональные варианты такого состояния. В частности, применение методик, основанных на электроэнцефалографии и функциональной магнитно-резонансной томографии, позволяет выявлять наличие скрытого сознания у некоторых клинически ареактивных пациентов. По разным оценкам, частота такого явления составляет 5–15%. Частным случаем скрытого сознания является когнитивно-моторное разобщение (КМР), определяемое как зафиксированная при помощи нейрофизиологических методик активация моторных центров коры в ответ на соответствую- щую инструкцию осуществить движение без видимой его реализации. Ряд исследователей предполагают, что выявление КМР указывает на более благоприятный прогноз для последующего восстановления сознания, нежели его отсутствие. Цель данного обзора — рассмотреть феномен КМР и его потенциальное значение для исходов у пациентов с хроническим нарушением сознания.

chronic disorders of consciousnessvegetative stateunresponsive wakefulness syndromecognitive motor dissociationхронические нарушения сознаниявегетативное состояниесиндром ареактивного бодрствованиякогнитивно-моторное разобщениеZasler N.D. Terminology in evolution: caveats, conundrums and controversies. NeuroRehabilitation. 2004;19(4):285–892. DOI: 10.3233/NRE-2004-19404. PMID: 15671582.Gosseries O., Zasler N.D., Laureys S. Recent advances in disorders of consciousness: focus on the diagnosis. Brain Inj. 2014;28(9):1141–1150. DOI: 10.3109/02699052.2014.920522. PMID: 25099018.Zasler N.D., Aloisi M., Contrada M., Formisano R. Disorders of consciousness terminology: history, evolution and future directions. Brain Inj. 2019;33(13-14):1684–1689. DOI: 10.1080/02699052.2019.1656821. PMID: 31498704.Giacino J.T., Ashwal S., Childs N. et al. The minimally conscious state: definition and diagnostic criteria. Neurology. 2002;12(58):349–353. DOI: 10.1212/WNL.58.3.349. PMID: 11839831.Fins J.J., Bernat J.L. Ethical, palliative, and policy considerations in disorders of consciousness. Neurology. 2018;91(10):471–475. DOI: 10.1212/WNL.0000000000005927. PMID: 30089621.Gosseries O., Bruno M.A., Chatelle C. et al. Disorders of consciousness: what’s in a name? NeuroRehabilitation. 2011;28(1):3–14. DOI: 10.3233/NRE-2011-0625. PMID: 21335671.Bruno M.A., Vanhaudenhuyse A., Thibaut A. et al. From unresponsive wakefulness to minimally conscious PLUS and functional locked-in syndromes: recent advances in our understanding of disorders of consciousness. J Neurol. 2011;258:1373–1384. DOI: 10.1007/s00415-011-6114-x. PMID: 2167419.Belkin V.A. Review of the American Congress of Rehabilitation Medicine (ACRM) clinical recommendations for the diagnosis and treatment of patients with chronic im-pairment of consciousness. Farmateka. 2019;26(3):14–19. DOI: 10.18565/pharmateca.2019.3.14-19. (In Russ.)Белкин В.А. Обзор клинических рекомендаций Американского конгресса реабилитационной медицины (ACRM) по диагностике и лечению пациентов с хроническим нарушением сознания. Фарматека. 2019;26(3):14–19. DOI: 10.18565/pharmateca.2019.3.14–19.Schnakers C., Perrin F., Schabus M. et al. Detecting consciousness in a total locked-in syndrome: an active event-related paradigm. Neurocase. 2009;15(4):271–277. DOI: 10.1080/13554790902724904. PMID: 19241281.Bardin J.C., Fins J.J., Katz D.I. et al. Dissociations between behavioral and functional magnetic resonance imaging-based evaluations of cognitive function after brain in-jury. Brain. 2011;134(Pt 3):769–782. DOI: 10.1093/brain/awr005. PMID: 21354974.Bardin J.C., Fins J.J., Katz D.I. et al. Dissociations between behavioral and functional magnetic resonance imaging-based evaluations of cognitive function after brain injury. Brain. 2011;134(Pt 3):769–782. DOI: 10.1093/brain/awr005. PMID: 21354974.Naci L., Sinai L., Owen A.M. Detecting and interpreting conscious experiences in behaviorally non-responsive patients. Neuroimage. 2015;145(Pt B):304–313. DOI: 10.1016/j.neuroimage.2015.11.059. PMID: 26679327.Rohaut B., Eliseyev A., Claassen J. Uncovering consciousness in unresponsive ICU patients: technical, medical and ethical considerations. Crit Care. 2019;23(1):78. DOI: 10.1186/s13054-019-2370-4. PMID: 30850022.Owen A.M., Coleman M.R., Boly M. et al. Detecting awareness in the vege-tative state. Science. 2006;313:1402–1402. DOI: 10.1126/science.1130197. PMID: 18591475.Fernández-Espejo D., Owen A.M. Detecting awareness after severe brain injury. Nat Rev Neurosci. 2013;14(11):801–809. DOI: 10.1038/nrn3608. PMID: 24088810.Fernández-Espejo D., Rossit S., Owen A.M. A thalamocortical mechanism for the absence of overt motor behavior in covertly aware patients. JAMA Neurol. 2015;72(12):1442–1450. DOI: 10.1001/jamaneurol.2015.2614. PMID: 26501399.Parent A., Hazrati L.N. Functional anatomy of the basal ganglia. I. The cortico-basal ganglia-thalamo-cortical loop. Brain Res Brain Res Rev. 1995;20(1):91–127. DOI: 10.1016/0165-0173(94)00007-C. PMID: 7711769.Schiff N.D. Cognitive motor dissociation following severe brain injuries. JAMA Neurol. DOI: 10.1001/jamaneurol.2015.2899. PMID: 26502348.Laureys S., Schiff N.D. Coma and consciousness: paradigms (re)framed by neuroimaging. Neuroimage. 2012;61(2):478–491. DOI: 10.1016/j.neuroimage.2011.12.041. PMID: 22227888.Fins J.J. Rights come to mind: brain injury, ethics, and the struggle for consciousness. New York: Cambridge University Press; 2015. DOI: 10.1017/CBO9781139051279.Monti M.M., Vanhaudenhuyse A., Coleman M.R. et al. Willful modulation of brain activity in disorders of consciousness. N Engl J Med. 2010b;362(7):579–589. DOI: 10.1056/NEJMoa0905370. PMID: 20130250.Forgacs P.B., Conte M.M., Fridman E.A. et al. Preservation of electroence-phalographic organization in patients with impaired consciousness and imaging-based evidence of command-following. Ann Neurol. 2014;76(6):869–879. DOI: 10.1002/ana.24283. PMID: 25270034.Kondziella D., Friberg C.K., Frokjaer V.G. et al. Preserved consciousness in vegetative and minimal conscious states: systematic review and meta-analysis. J Neurol Neuro-surg Psychiary. 2016;87(5):485–492. DOI: 10.1136/ jnnp-2015-310958. PMID: 26139551.Kondziella D., Friberg C.K., Frokjaer V.G. et al. Preserved consciousness in vegetative and minimal conscious states: systematic review and meta-analysis. J Neurol Neurosurg Psychiary. 2016;87(5):485–492. DOI: 10.1136/ jnnp-2015-310958. PMID: 26139551.Edlow B., Fins J.J. Assessment of covert consciousness in the intensive care unit: clinical and ethical considerations. J Head Trauma Rehabil. 2018;33(6):424–434. DOI: 10.1097/HTR.0000000000000448. PMID: 30395042.Iazeva E.G., Legostaeva L.A., Zimin A.A. et al. A Russian validation study of the Coma Recovery Scale-Revised (CRS-R). Brain Inj. 2019;33(2):218–225. DOI: 10.1080/02699052.2018.1539248. PMID: 30388893.Claassen J., Doyle K., Matory A. et al. Detection of brain activation in unresponsive patients with acute brain injury. N Engl J Med. 2019; 380(26):2497–2505. DOI: 10.1056/NEJMoa1812757. PMID: 31242361.Curley W.H., Forgacs P.B., Voss H.U. et al. Characterization of EEG signals revealing covert cognition in the injured brain. Brain. 2018;141(5):1404–1421. DOI: 10.1093/brain/awy070. PMID: 29562312.Cruse D., Chennu S., Chatelle C. et al. Bedside detection of awareness in the vegetative state: a cohort study. Lancet. 2011;378(9809):2088–2094. DOI: 10.1016/S0140-6736(11)61224-5. PMID: 22078855.Giacino J.T., Edlow B. Covert consciousness in the intensive care unit. Trends Neurosci. 2019;42(12):844–847. DOI: 10.1016/j.tins.2019.08.011. PMID: 3151497.Jöhr J., Halimi F., Pasquier J. et al. Recovery in cognitive motor dissociation after severe brain injury: a cohort study. PLoS One. 2020;15(2):e0228474. DOI: 10.1371/journal.pone.0228474. PMID: 32023323.Skibsted A.P., Amiri M., Fisher P.M. et al. Consciousness in Neurocritical Care Cohort Study using fMRI and EEG (CONNECT-ME): protocol for a longitudinal prospective study and a tertiary clinical care service. Front Neurol. 2018;9:1012. DOI: 10.3389/fneur.2018.01012. PMID: 30542319.Reitsma J.B., Rutjes A.W., Khan K.S. et al. A review of solutions for diagnostic accuracy studies with an imperfect or missing reference standard. J Clin Epidemiol. 2009;62(8):797–806. DOI: 10.1016/j.jclinepi.2009.02.005. PMID: 19447581.Van Erp W.S., Lavrijsen J.C., van de Laar F.A. et al. The vegetative state/unresponsive wakefulness syndrome: a systematic review of prevalence studies. Eur J Neurol. 2014;21:1361– 1368. DOI: 10.1111/ene.12483. PMID: 25039901.Schnakers C., Vanhaudenhuyse A., Giacino J. et al. Diagnostic accuracy of the vegetative and minimally conscious state: clinical consensus versus standar-dized neurobe-havioral assessment. BMC Neurol. 2009;9:35 DOI: 10.1186/1471-2377-9-35. PMID: 19622138.Schnakers C., Vanhaudenhuyse A., Giacino J. et al. Diagnostic accuracy of the vegetative and minimally conscious state: clinical consensus versus standar-dized neurobehavioral assessment. BMC Neurol. 2009;9:35 DOI: 10.1186/1471-2377-9-35. PMID: 19622138.Brefel-Courbon C., Payoux P., Ory F. et al. Clinical and imaging evidence of zolpidem effect in hypoxic encephalopathy. Ann Neurol. 2007;62:102–105. DOI: 10.1002/ana.21110. PMID: 17357126.Thengone D.J., Voss H.U., Fridman E.A., Schiff N.D. Local changes in network structure contribute to late communication recovery after severe brain injury. Sci Trans Med. 2016;8(368):368re5. DOI: 10.1126/scitranslmed.aaf6113. PMID: 27928029.