PET in conjunction with resting-state functional MRI for the study of chronic disorders of consciousness

In Disorders of Consciousness, ¹⁸F-fluorodeoxyglucose PET (FDG-PET) is known to be effective in distinguishing vegetative state/unresponsive wakefulness syndrome from minimally conscious state, and when combined with MRI techniques, the risk of misdiagnosis decreases. However, FDG-PET studies on chronic patients with different etiologies (traumatic, vascular, and anoxic brain injury) are limited, and the association between metabolic activity and resting-state functional MRI (fMRI) networks remains unclear. This study combined FDG-PET with resting-state functional MRI and MRI to assess: i) the diagnostic accuracy of FDG-PET metabolism in different etiological groups of patients; ii) whether resting-state fMRI networks presence or absence was associated with higher versus lower FDG-PET metabolism. A group of 84 chronic patients underwent FDG-PET (47 vegetative state/unresponsive wakefulness syndrome, 31 minimally conscious state, and six emerged from a minimally conscious state), equally distributed in traumatic, vascular, and anoxic etiologies. Eight cases of covert cortical processing were identified. A subgroup of 68 patients also underwent resting-state fMRI. Standardized uptake values were calculated for these areas of interest: 10 resting-state fMRI networks, the precuneus, and a whole-brain mask. Patients in a vegetative state/unresponsive wakefulness syndrome exhibited a significant decrease in metabolism compared to patients in a minimally conscious state across all areas of interest. Patients with covert cortical processing showed intermediate metabolic levels between the two diagnostic categories. The anoxic group displayed a severe decrease in metabolism compared to patients with traumatic and vascular etiologies. The highest diagnostic accuracy among the areas of interest was reached in the precuneus and medial visual network (Area Under the Curve, AUC = 0.82-0.83). However, when anoxic patients were excluded, the diagnostic accuracy did not reach statistical significance, although the medial visual network and precuneus retained a trend of gradually increasing metabolism as clinical conditions improved. Identification of resting-state functional MRI networks was associated with increased metabolism in all networks at the group level, even excluding patients with severe structural damage. FDG-PET proves to be a technique capable of distinguishing vegetative state/unresponsive wakefulness syndrome from minimally conscious state even in chronic patients, although its diagnostic accuracy can be significantly affected by the etiology. There is a concordance between the metabolism level and the presence of resting-state fMRI networks.