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Disruption of posteromedial large-scale neural communication predicts recovery from coma
Stein Silva1, Francesco de Pasquale2, Corine Vuillaume2
1From the Critical Care Unit (S.S., B.R.), Critical Care and Anaesthesiology Department (S.S., C.V., B.R., T.G., T.S., O.F.), and SAMU 31 (V.B.), University Teaching Hospital of Purpan, Place du Dr Baylac, F-31059 Toulouse Cedex 9; INSERM U825 (S.S., C.V., I.L., P.P.), CHU Purpan, Place du Dr Baylac, F-31059 Toulouse Cedex 9, France; Department of Radiology (F.d.P.), Santa Lucia Foundation, Rome; ITAB (F.d.P.), Department of Neuroscience Imaging and Clinical Science, G. D'Annunzio University, Chieti, Italy; and Leenaards Memory Center (J.-F.D.), Department of Clinical Neuroscience CHUV and University of Lausanne, Switzerland. silva.s@chu-toulouse.fr.
Objective:
We hypothesize that the major consciousness deficit observed in coma is due to the breakdown of long-range neuronal communication supported by precuneus and posterior cingulate cortex (PCC), and that prognosis depends on a specific connectivity pattern in these networks.
Methods:
We compared 27 prospectively recruited comatose patients who had severe brain injury (Glasgow Coma Scale score <8; 14 traumatic and 13 anoxic cases) with 14 age-matched healthy participants. Standardized clinical assessment and fMRI were performed on average 4 ± 2 days after withdrawal of sedation. Analysis of resting-state fMRI connectivity involved a hypothesis-driven, region of interest-based strategy. We assessed patient outcome after 3 months using the Coma Recovery Scale-Revised (CRS-R).
Results:
Patients who were comatose showed a significant disruption of functional connectivity of brain areas spontaneously synchronized with PCC, globally notwithstanding etiology. The functional connectivity strength between PCC and medial prefrontal cortex (mPFC) was significantly different between comatose patients who went on to recover and those who eventually scored an unfavorable outcome 3 months after brain injury (Kruskal-Wallis test, p < 0.001; linear regression between CRS-R and PCC-mPFC activity coupling at rest, Spearman ρ = 0.93, p < 0.003).
Conclusion:
In both etiology groups (traumatic and anoxic), changes in the connectivity of PCC-centered, spontaneously synchronized, large-scale networks account for the loss of external and internal self-centered awareness observed during coma. Sparing of functional connectivity between PCC and mPFC may predict patient outcome, and further studies are needed to substantiate this potential prognosis biomarker.
