Columbia University researchers have found the source of hidden consciousness in ‘comatose’ brain injury patients

The researchers have identified brain injuries that may underlie hidden consciousness, a puzzling phenomenon in which brain-injured patients are unable to respond to simple commands, making them appear unconscious despite having some level of awareness. 

Study leader Jan Claassen, MD, associate professor of neurology at Columbia University Vagelos College of Physicians and Surgeons and chief of critical care and hospitalist neurology at NewYork-Presbyterian/ Columbia University Irving Medical Center, said: “Our study suggests that patients with hidden consciousness can hear and comprehend verbal commands, but they cannot carry out those commands because of injuries in brain circuits that relay instructions from the brain to the muscles.”

The findings could help physicians more quickly identify brain-injured patients who might have hidden consciousness and better predict which patients are likely to recover with rehabilitation. 

Hidden consciousness, also known as cognitive motor dissociation (CMD), occurs in about 15% to 25% of patients with brain injuries stemming from head trauma, brain haemorrhage, or cardiac arrest.  

In previous research, Claassen and colleagues found that subtle brainwaves detectable with EEG are the strongest predictor of hidden consciousness and eventual recovery for unresponsive brain-injured patients.  

But the precise pathways in the brain that become disrupted in this condition were unknown.  



Patterns of brain injury


In the new study, the researchers used EEG to examine 107 brain injury patients.

The technique can determine when patients are trying, though unable, to respond to a command such as “keep opening and closing your right hand”.  

The analysis detected CMD in 21 of the patients.  

The researchers then analysed structural MRI scans from all of the patients.  

Co-lead author Qi Shen, PhD, associate research scientist in the Claassen lab and an expert in signal processing, machine learning, and biostatistics, said: “Using a technique we developed called bi-clustering analysis, we were able to identify patterns of brain injury that are shared among patients with CMD and contrast to those without CMD.”

The researchers found that all of the CMD patients had intact brain structures related to arousal and command comprehension, supporting the notion that these patients were hearing and understanding the commands but were unable to carry them out.  

Claasen said: “We saw that all of the CMD patients had deficits in brain regions responsible for integrating comprehended motor commands with motor output, preventing CMD patients from acting on verbal commands.”

The findings may allow researchers to better understand which brain injury patients have CMD, which will be useful for clinical trials that support recovery of consciousness. 

More research is required before these approaches can be applied to clinical practice.

But, Claasen added: “… our study shows that it may be possible to screen for hidden consciousness using widely available structural brain imaging, moving the detection of CMD one step closer to general clinical use. 

“Not every critical care unit may have resources and staff that is trained in using EEG to detect hidden consciousness, so MRI may offer a simple way to identify patients who require further screening and diagnosis.”

Image: MRI scans reveal brain injuries underlying hidden consciousness. Credit: Claassen lab, Columbia University Irving Medical Center. (CC BY-NC-ND).

Research Aether / Health Uncovered