[How can we define the modalities and clinical levels of coma to wakefulness?]

The starting point of the French conference of consensus concerning arousal after coma was to answer the following question: "How can we define the ways of going from coma to arousal and their clinical levels?

A team of readers have picked up in the literature one hundred and fifty papers, out of which fifty six have been analysed.

From this analysis, three points emerged: The concepts of coma and arousal; The conditions of evolution from coma to arousal; Various groups of patients depending on their expressing arousal. One could not find any consensual model concerning the different ways of going from coma to arousal. The variability of the technics and the changing validity of all scores did not allow the conditions of arousal to reach a satisfactory level of proof. The Glasgow Coma Scale (GCS) is the recognised standard for severe wakefulness' impairment, but it is not sensitive enough while patients' arousing. The Glasgow Outcome Scale (GOS) takes into account the patients' situations far later and does not include situations such as Minimally Conscious States (MCS). That's why we face multiple scores, either ordinal, or categorial, all tending to evaluate the slow levels of arousal.

Clinical findings concerning arousal are to be completed by non-clinical data. This would be greatly helpful to define appropriate management concerning individualized groups of patients. At this stage, another challenge for clinicians is to make the difference between emerging wakefulness and growing conscious activity.