Coma: Detecting signs of consciousness in

severely brain injured patients

recovering from coma
C Schnakers
Coma Science Group, Cyclotron Research Centre
University of Liege, Lige, Belgium
J Giacino
JF !e"ical Center
#"ison, $J, US%
S Laureys
Coma Science Group, Cyclotron Research Centre
University of Liege, Lige, Belgium
&epartment of $eurology, C'U Sart (ilman
Lige, Belgium
Table of Contents
%rticle top
%)stract
&isor"ers of consciousness
&ifferential &iagnosis
Behavioral assessment
Conclusion
%ckno*le"gments
Figures an" (a)les
References
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Abstract
(he num)er of patients *ho survive severe acute )rain in+ury increase" "ramatically in
the last fe* years generating social, economical an" ethical challenges, $evertheless,
"etecting )ehavioral signs of consciousness is currently really "ifficult in patients *ith
limite" )ehavioral repertoires an" often complicate" )y inconsistent or easily e-hauste"
motor responses, %n error of "iagnosis can lea" to ina"e.uate care management /e,g,,
pain treatment0 an"1or inappropriate en"2of2life "ecision, 3n this revie*, *e *ill present
information a)out "iagnostic criteria, prognosis an" remnant )rain processing in the main
"isor"ers of consciousness, 4e *ill also "iscuss stan"ar"i5e" )ehavioral scales *hich
have )een "evelope" to facilitate the assessment of consciousness in patients recovering
from coma,
(he num)er of patients *ho survive severe acute )rain in+ury increase" "ramatically in
the last fe* years generating social, economical an" ethical challenges /Jennett, 67780,
#ven if a ma+ority of severely )rain in+ure" patients recover from coma *ithin the first
t*o *eeks after the insult, others *ill take more time an" go through "ifferent stages
)efore fully or partially recovering consciousness, &etecting )ehavioral signs of
consciousness is currently the main *ay to "istinguish conscious from unconscious
patients, (he "iagnosis of consciousness level is nevertheless really "ifficult to make in
patients *ith limite" )ehavioral repertoires an" often complicate" )y inconsistent or
easily e-hauste" motor responses, !is"iagnosis has conse.uently )een reporte" as )eing
really fre.uent /Chil"s et al,, 9::;< %n"re*s et al,, 9::=< Schnakers et al,, 677:0,
!oreover, an error of "iagnosis can lea" to ina"e.uate care management /e,g,, pain
treatment0 an"1or inappropriate en"2of2life "ecision, For these reasons, kno*ing
information a)out "iagnostic criteria, prognosis )ut also remnant )rain processing of each
"isor"er of consciousness can help in making the "iagnosis, Furthermore, stan"ar"i5e"
)ehavioral scales have )een "evelope" to facilitate the assessment of consciousness in
patients recovering from coma /!a+erus et al,, 6778< Gill2(*aithes, 677=0, 3n this paper,
*e *ill revie* the three ma+or "isor"ers of consciousness /i,e,, the coma, the vegetative
state an" the minimally conscious state0 encountere" in clinical practice an" *e *ill
"isentangle them from other states such as the locke"2in syn"rome an" )rain "eath /see
(a)le 90, 4e *ill then "iscuss )ehavioral assessment proce"ures "esigne" for their use at
the )e"si"e, focusing on those *hich are *ell vali"ate",
Disorders of consciousness
Coma
>lum an" >osner "efine" coma as a pathological state relate" to severe an" prolonge"
"ysfunction of vigilance an" consciousness />lum an" >osner, 9:==0, (his state results
from glo)al )rain "ysfunction /most often "ue to "iffuse a-onal in+ury follo*ing
traumatic )rain in+ury0, or from a lesion limite" to )rainstem structures involving the
reticular activating system, (he "istinguishing feature of coma is the continuous a)sence
of eye2opening /spontaneously or follo*ing stimulation0, (here is no evi"ence of visual
fi-ation or pursuit, even after manual eye2opening, $o voluntary motor )ehavior is
o)serve" an" )ehavioral responses are limite" to refle- activity only, #lectrical activity is
o)serve", al)eit characteri5e" )y slo* fre.uency )an"s /i,e,, mostly "elta an" theta
activity0 /?oung, 6777< Brenner, 67780, >ositon #mission (omography />#( scan0
stu"ies have also sho*n a @7 to 87 A re"uction of overall )rain meta)olism in traumatic
or hypo-ic coma /Laureys et al,, 677@0, (his state must last at least one hour to )e
"ifferentiate" from a transient "isor"er of consciousness /e,g,, syncope, confusion or
"elirium0, >rolonge" coma is rare, Usually, coma resolves *ithin 6 to @ *eeks, most
often evolving into BS or !CS /%ttia an" Cook, 9::C0, (ra"itional
electroencephalographic /##G0 measures have sho*n their efficacy in pre"icting
outcome after ano-ic or traumatic )rain "amage /?oung, 6777< Brenner, 67780, 'o*ever,
recent stu"ies have sho*n that somatosensory evoke" potentials /$670 an" mismatch
negativity /!!$0 have pre"ictive value superior to ##G, a )ilateral a)sence of the $67
or !!$ response in comatose patients )eing strongly associate" to a)sence of full
recovery /respectively, ::2977A of cases an" :92:;A of cases0 /%mantini et al,, 6778<
Fischer et al,, 677=0,
Vegetative state
(he term DvegetativeD suggests a preservation of autonomic functions /e,g,, car"io2
vascular, respiratory an" thermoregulation functions0 an" reemergence of the sleep2*ake
cycle /i,e,, perio"s of spontaneous eyes opening0, BS often results from trauma2in"uce"
)i2hemispheric in+ury involving the *hite matter or from )ilateral lesions in the thalamus
*ith sparing of the )rainstem, hypothalamus an" )asal ganglia /Giacino, 9::E0,
Behaviorally, there is no response to ver)al or"er an", although moaning may occur, there
is no intelligi)le speech /(he !ulti2Society (ask Force on >BS, 9::@0, 3nfre.uently,
)ehaviors such as inappropriate smiling, crying or grimacing, an" even ran"omly2
pro"uce" single *or"s have )een reporte" in patients "iagnose" *ith BS /4orking >arty
of the Royal College of >hysicians, 677;0, 4ith careful assessment, it is possi)le to
"emonstrate that these )ehaviors are not voluntary or goal2"irecte", Functional
neuroimaging stu"ies sho* a severe re"uction of )rain meta)olism in the fronto2temporo2
parietal net*ork *ith activation limite" to primary cortices after au"itory or no-ious
stimulation, suggesting the a)sence of integrate" )rain processing /Laureys an" Boly,
677E0, #sta)lishing a "efinitive prognosis is "ifficult, ho*ever, *hen this state lasts one
month or more, the patient is consi"ere" in DpersistentD BS, 4hen BS lasts more than ;
months /for non2traumatic etiologies0 or one year /for traumatic etiology0, the patient can
)e consi"ere" in DpermanentD BS /(he !ulti2Society (ask Force on >BS, 9::@0, 3n vie*
of lingering uncertainty a)out prognostic in"icators an" *ell2"ocumente" cases of late
recovery /Chil"s an" !ercer, 9::=0, the %merican Congress of Reha)ilitation !e"icine
/9::80 has recommen"e" that the term Dpermanent BSD )e a)an"one" in favor of
"ocumenting the cause of the BS /e,g,, traumatic )rain in+ury, stroke or ano-ia0 an" the
length of time post2onset as )oth carry prognostic information,
Minimally conscious state
(he minimally conscious state is characteri5e" )y the presence of inconsistent )ut
clearly2"iscerni)le )ehavioral signs of consciousness /Giacino et al,, 67760, Such signs
must )e repro"uci)le *ithin a given e-amination, although )ehavior may fluctuate across
e-aminations, 3n contrast to patients in BS *ho may "isplay ran"om episo"es of crying
or smiling, these )ehaviors are contingent upon appropriate environmental triggers in
!CS, #arly reemergence of visual pursuit appears to )e a )ehavioral marker of the
transition from BS to !CS /Giacino an" 4hyte, 67780, Functional neuroimaging stu"ies
have sho*n large regions of fronto2temporo2parietal activation after au"itory or no-ious
stimulation as *ell as intact connectivity )et*een primary an" associative cortices
suggesting greater preservation of "istri)ute" neural processing /Laureys an" Boly,
677E0, Regar"ing prognosis, the pro)a)ility of functional recovery at one year follo*ing
traumatic )rain in+ury is significantly more favora)le relative to BS /87A vs, ;A
attaining mo"erate "isa)ility0, Some patients in !CS progress slo*ly *hile others
remain in this con"ition permanently /Fins et al,, 677E0, 3t is also important to recogni5e
that, unlike BS, clearly2"efine" temporal parameters for recovery "o not e-ist /Lammi et
al,, 67780, an" there is *i"e heterogeneity in the "egree of functional recovery ultimately
attaine", Emergence from MCS occurs *hen the patient is a)le to relia)ly communicate
through ver)al or gestural yes2no responses, or is a)le to "emonstrate use of t*o or more
o)+ects /e,g,, hair)rush, cup0 in a functional manner /Giacino et al,, 67760,
Differential Diagnosis
Locked-in syndrome
(he locke"2in syn"rome /L3S0 is marke" )y tetraplegia an" anarthria in the setting of
near2normal to normal cognitive function /%merican Congress of Reha)ilitation
!e"icine, 9::80, (his state is cause" )y a lesion involving the ventral pons an", in =7A
of cases, is "ue to )asilar throm)osis, Because patients *ith L3S have spontaneous eyes
opening, )ut are una)le to speak or move the e-tremities, this state can easily )e confuse"
*ith BS, Fn average, the "iagnosis of L3S is not esta)lishe" until 6,8 months post2onset,
(here is evi"ence that family mem)ers ten" to "etect signs of consciousness /88A of
cases0 prior to me"ical staff /6;A of cases0 /Laureys et al,, 67780, Classic L3S consists of
complete paralysis of the oro)uccal musculature an" all four e-tremities, 'o*ever,
vertical eye movements, *hich allo* non2ver)al communication through "irectional
ga5e, are spare", >erceptual functions are also spare" as ascen"ing afferent a-ons remain
intact /%merican Congress of Reha)ilitation !e"icine, 9::80, Bauer has "escri)e"
multiple varieties of L3S, inclu"ing the incomplete form in *hich there is resi"ual motor
activity /fre.uently, finger or hea" movement0, an" total L3S, in *hich there is complete
immo)ility inclu"ing )oth hori5ontal an" vertical eye movements /Bauer et al,, 9:E:0,
Functional neuroimaging typically sho*s preserve" supra2tentorial areas *ith
hypometa)olism in the cere)ellum, a structure closely linke" to coor"inate" motor
activity0, 3nterestingly, significant hyperactivity has )een o)serve" )ilaterally in the
amyg"ala of acute L3S patients, likely reflecting an-iety generate" )y the ina)ility to
move or speak /stressing the importance of appropriate an-iety treatment soon after
"iagnosis0 /Laureys et al,, 67780, (he presence of a relatively normal an" reactive
electroencephalographic rhythm after a )rainstem lesion shoul" alert the physician, )ut
heterogeneity of ##G fin"ings suggests that this approach cannot per se "isentangle L3S
from "isor"ers of consciousness /Bassetti an" 'ess, 9::E0, &ata on life e-pectancy
suggest that some patients *ith L3S patients live t*elve or more years post2onset,
Surprisingly, L3S patients rate their .uality of life similarly to the healthy population
/Bruno et al,, 677:0, 3n the a)sence of other structural or functional )rain a)normalities
/Smart et al,, 677C0, patients *ith L3S are generally a)le to make in"epen"ent "ecisions
an" communicate their preferences /Schnakers et al,, 677C0,
rain deat!
Brain "eath is a con"ition in *hich there is Dirreversi)le unconsciousness *ith complete
loss of )rain functionD, 3t is marke" )y the presence of apnea an" the lack of any
)ehavioral response to the environment /!e"ical Consultants on the &iagnosis of &eath,
9:C90, Generally, an electroencephalogram "emonstrates electrocere)ral silence
reflecting the a)sence of electrical )rain activity, (ranscranial "oppler stu"ies reveal the
a)sence of cere)ral )loo" flo*, Finally, functional imaging, using cere)ral perfusion
tracers an" single photon emission tomography /S>#C(0, illustrate the Dempty skullD sign
in *hich the D*hole )rainD /Facco et al,, 9::C0 is inactive, %fter e-clu"ing )rain
"ysfunction "ue to "rug to-icity or hypothermia, a final "iagnosis can )e esta)lishe" after
= to 6@ hours,
e!avioral assessment
Consciousness
Behavioral o)servation constitutes the stan"ar" metho" for "etecting signs of
consciousness in severely )rain in+ure" patients, 3t is important, ho*ever, to make a
"istinction )et*een DarousalD an" DconsciousnessD, 3n"ee", a patient can )e arouse" )ut
sho* no signs of consciousness, as in BS, >reservation of arousal is therefore a necessary
)ut insufficient con"ition for consciousness /see Figure 90, !oreover, consciousness
shoul" not )e vie*e" as a "ichotomous phenomenon )ut rather as a continuum, 3t is
possi)le, for e-ample, for a patient in coma to rapi"ly evolve into BS, gra"ually transition
to !CS, an" su)se.uently lapse )ack into coma,
Misdiagnosis
&ifferentiating )et*een !CS an" BS can )e challenging, (he "etection of voluntary
)ehaviors is often "ifficult an" signs of consciousness can easily )e misse" "ue to
sensory an" motor "isa)ilities, tracheostomy, fluctuating arousal levels or am)iguous an"
rapi"ly e-hauste" responses /!a+erus et al,, 67780, >revious stu"ies have sho*n that ;E
to @; A of patients *ith "isor"ers of consciousness are erroneously "iagnose" *ith BS
/Chil"s et al,, 9::;< %n"re*s et al,, 9::=0, Since, other reports concerning the "iagnostic
criteria for BS an" !CS /Giacino et al,, 6776< 4orking >arty of the Royal College of
>hysicians, 677;0 have suggeste" lo*er mis"iagnosis estimates /Jennett, 67780, % more
recent stu"y, ho*ever has again reporte" a mis"iagnosis rate of @9A, consistent *ith the
earlier evi"ence /Schnakers et al,, 677:0, !is"iagnosis among patients *ith "isor"ers of
consciousness has hence not su)stantially change", %n accurate "iagnosis is nevertheless
crucial not only for "aily management /particularly, pain treatment0 an" en"2of2life
"ecisions, )ut also has prognostic implications as patients in !CS have more favora)le
functional outcomes as compare" to those in BS, Schnakers an" co*orkers /677:0
suggest that the systematic use of a sensitive stan"ar"i5e" neuro)ehavioral assessment
scale may help "ecrease "iagnostic error an" limit "iagnostic uncertainty,
e!avioral scales
$umerous )ehavioral rating scales have )een "evelope" an" vali"ate" to assess level of
consciousness an" esta)lish "iagnosis /!a+erus et al,, 67780, 3n this section, *e )riefly
revie* instruments commonly use" in the acute an" reha)ilitation settings,
(he Glasgow Coma Scale /GCS0 remains the most *i"ely use" scale in trauma an" acute
care settings, (he GCS *as the first vali"ate" rating scale "evelope" to monitor level of
consciousness in the intensive care unit /(eas"ale an" Jennett, 9:E@0, (his scale is
relatively )rief an" can easily )e incorporate" into routine clinical care, 3t inclu"es three
su)scales that a""ress arousal level, motor function an" ver)al a)ilities, Su)scales scores
are a""e" an" yiel" a total score ranging from ; to 98, &espite its *i"esprea" use, the
GCS has )een critici5e" for varia)le inter2rater agreement an" pro)lems "eriving scores
in patients *ith ocular trauma, tracheostomy or ventilatory support /!c$ett, 677E0,
(he Full Outline of UnResponsiveness scale /FFUR0 *as recently "evelope" to replace
the Glasgo* Coma Scale to assess severely )rain2in+ure" patients in intensive care
/4i+"icks, 677=< 4i+"icks et al,, 67780, (he scale is comprise" of four su)scales
assessing motor an" ocular responses, )rainstem refle-es an" )reathing, (he total score
ranges from 7 to 9=, Unlike the GCS, the FFUR "oes not assess ver)al functions to
accommo"ate the high num)er of intu)ate" patients in intensive care, % score of 7 on the
FFUR assumes the a)sence of )rainstem refle-es an" )reathing an", therefore, helps to
"iagnose )rain "eath, (he scale also monitors recovery of autonomic functions an" tracks
emergence from BS, (he FFUR is specifically "esigne" to "etect patients *ith locke"2in
syn"rome as it uses oculomotor comman"s that e-ploit vertical eye movements an" eye
)links, )oth of *hich are preserve" in L3S,
(he Wessex Head n!ur" Matrix /4'3!0 /Shiel et al,, 67770 *as "evelope" to capture
changes in patients in BS through emergence from post2traumatic amnesia, (his tool is
particularly sensitive to "etecting changes in patients in !CS not capture" )y tra"itional
scales such as the GCS /!a+erus an" Ban "er Lin"en, 67770, Shiel an" colla)orators
longitu"inally follo*e" :E severely )rain in+ure" patients recovering from coma to create
the 4'3!, 4'3! items *ere or"ere" accor"ing to the se.uence of recovery o)serve" in
these patients, (he =62item 4'3!Gs si- sections assess arousal level an" concentration,
visual consciousness /i,e,, visual pursuit0, communication, cognition /i,e,, memory an"
spatiotemporal orientation0 an" social )ehaviors, (he 4'3! score represents the rank of
the most comple- )ehavior o)serve",
(he Sensor" Modalit" #ssessment and Re$a%ilitation &ec$ni'ue /S!%R(0 /Gill2
(h*aites, 9::E0 *as "evelope" to i"entify signs of consciousness o)serve" "uring
Dsensory stimulations programsD inten"e" to support cere)ral plasticity an" improve level
of consciousness /4oo", 9::90, (he S!%R( assesses C mo"alities inclu"ing visual,
au"itory, tactile, olfactory an" gustatory sensation, motor functions, communication an"
arousal level, (he S!%R( is a hierarchical scale consisting of 8 response levels /Ga)sence
of responseG H Level 9< Grefle- responseG H Level 6< G *ith"ra*al responseG H Level ;<
Glocali5ation responseG H Level @< G"iscriminative responseG H Level 80, (he S!%R( has
previously )een sho*n to have very goo" vali"ity an" relia)ility in a population of =7
patients "iagnose" as )eing in a vegetative state or in a minimally conscious state /Gill2
(h*aites an" !un"ay, 677@0,
(he JF Coma Recover" Scale *as originally "evelope" )y investigators from the JF
Johnson Reha)ilitation 3nstitute in 9::9 /Giacino et al,, 9::90, (he scale *as revise" an"
repu)lishe" in 677@ as the JF Coma Recovery Scale2Revise" /CRS2R0 /Giacino et al,,
677@0, (he purpose of the CRS2R is to assist *ith "ifferential "iagnosis, prognostic
assessment an" treatment planning in patients *ith "isor"ers of consciousness, (he scale
consists of 6; items that comprise si- su)scales a""ressing au"itory, visual, motor,
oromotor, communication an" arousal functions /see (a)le 60, CRS2R su)scales are
comprise" of hierarchically2arrange" items associate" *ith )rain stem, su)cortical an"
cortical processes, (he lo*est item on each su)scale represents refle-ive activity *hile
the highest items represent cognitively2me"iate" )ehaviors, Scoring is stan"ar"i5e" an"
)ase" on the presence or a)sence of operationally2"efine" )ehavioral responses to
specific sensory stimuli, >sychometric stu"ies in"icate that the CRS2R meets minimal
stan"ar"s for measurement an" evaluation tools "esigne" for use in inter"isciplinary
me"ical reha)ilitation, %"e.uate interrater an" test2retest relia)ility have )een esta)lishe"
in"icating that the CRS2R can )e a"ministere" relia)ly )y traine" e-aminers an"
pro"uces reasona)ly sta)le scores over repeate" assessments, Bali"ity analyses support
use of the scale as an in"e- of neuro)ehavioral function an" have sho*n that the CRS2R
is capa)le of "iscriminating patients in !CS from those in BS *hich is of critical
importance in esta)lishing prognosis an" formulating treatment interventions /Schnakers
et al,, 677=< Schnakers et al,, 677C< Banhau"enhuyse et al,, 677C0, Spanish, >ortuguese,
3talian, German, French, &utch, $or*egian an" &anish translations of the CRS2R are
availa)le,
Conclusion
>atients *ith severe "isor"ers of consciousness present significant "iagnostic, prognostic
an" every"ay management pro)lems, Recovery of consciousness is usually very gra"ual,
sometimes marke" )y emergence of clear )ehavioral milestones, )ut more often )y su)tle
improvements, (here are fre.uent fluctuations in )oth arousal an" a*areness, an"
sometimes, there are set)acks, Su)tle signs of consciousness have to )e recogni5e" early
to avoi" mis"iagnosis, Be"si"e assessment of resi"ual cognitive functions is often
"ifficult "ue to insufficient arousal level, motor impairment, fluctuating responses,
se"ation or other confoun"ing factors, no*le"ge of me"ically2accepte" "iagnostic
criteria an" reliance on vali"ate" )ehavioral assessment scales are crucial for esta)lishing
accurate "iagnosis, prognostic an" management "ecisions /inclu"ing en"2of2life0,
Ackno"ledgments
Fur *ork is supporte" in part )y the $ational 3nstitute on &isa)ility an" Reha)ilitation
Research /%*ar" '9;;%7E77;70, the Belgian $ational Fun"s for Scientific Research
/F$RS0, #uropean Commission, James !c&onnell Foun"ation, !in" Science
Foun"ation, French Speaking Community Concerte" Research %ction, 3nternational
Rotary Foun"ation, Fon"ation !e"icale Reine #lisa)eth, an" University of Liege,
#igures and Tables
Table $: Diagnostic criteria for brain deat!% coma% vegetative and
minimally conscious states and locked-in syndrome
Consciousness
level
Diagnostic criteria &eference's(
rain deat!
$o arousal1eye2opening
$o )ehavioral signs of a*areness
%pnea
Loss of )rain functions /)rainstem
refle-es0
!e"ical Consultants on the
&iagnosis of &eath, 9:C9
Coma
$o arousal1eye2opening
$o )ehavioral signs of a*areness
3mpaire" spontaneous )reathing
3mpaire" )rainstem refle-es
$o vocali5ations I 9 hour
>lum J >osner, 9:==
Vegetative state
%rousal1stpontaneous or stimulus2
in"uce" eye opening
$o )ehavioral signs of a*areness
>reserve" spontaneous )reathing
>reserve" )rainstem refle-es
$o purposeful )ehaviors
$o language pro"uction of
comprehension
>reservation /partial or complete0 of
hypothalamic an" )rain stem
autonomic functions
I 9 monthK persistent vegetative
Compati)leK grimaces to pain,
locali5ation to soun"s
%typical )ut compati)leK visual
fi-ation, response to threat,
inappropriate single *or"s
(he !ulti2Society
(ask Force on >BS,
9::@
4orking >arty of
the Royal College
of >hysicians, 677;
Minimally
conscious state
%rousal1spontaneous eye2opening
Fluctuating )ut repro"uci)le
)ehavioral signs of a*areness
Giacino et al,, 6776
Response to ver)al or"er
#nvironmentally2contingent smiling
or crying
F)+ect locali5ation an"
manipulation
Sustaine" visual fi-ation an" pursuit
Ber)ali5ations
3ntentional )ut unrelia)le
communication
#mergence from !CSK functional
communication, functional o)+ect
use
Locked-in
syndrome
%rousal1spontaneous eye2opening
>reserve" cognitive functions
Communication vis eye ga5e
%narthria
(etraplegia
%merican Congress of
Reha)ilitation !e"icine,
9::8
#igure $
Behavioral o)servation assesses t*o "imensions of consciousnessK arousal an"
a*areness, 3n )rain "eath an" coma, )oth "imensions are a)sent, 3n the vegetative state,
arousal level is relatively preserve" in the a)sence of signs of a*areness, 3n the
minimally conscious state, )oth "imensions are present although )ehavioral signs often
fluctuate, 3n the locke"2in syn"rome, )oth "imensions are fully preserve" "espite
complete loss of speech an" motor functions,
Table) : C&*-& &esponse +rofile
Auditory #unction *cale
@ 2 Consistent !ovement to Comman" L
; 2 Repro"uci)le !ovement to Comman" L
6 2 Locali5ation to Soun"
9 2 %u"itory Startle
7 H $one
Visual #unction *cale
8 H F)+ect Recognition L
@ H F)+ect Locali5ationK Reaching L
; 2 >ursuit #ye !ovements L
6 H Fi-ation L
9 H Bisual Startle
7 H $one
Motor #unction *cale
= 2 Functional F)+ect Use
t
8 2 %utomatic !otor Response L
@ H F)+ect !anipulation L
; 2 Locali5ation to $o-ious Stimulation L
6 2 Fle-ion 4ith"ra*al
9 2 %)normal >osturing
7 2 $one1Flacci"
,romotor-Verbal #unction *cale
; 2 3ntelligi)le Ber)ali5ation L
6 2 Bocali5ation1Fral !ovement
9 2 Fral Refle-ive !ovement
7 H $one
Communication *cale
6 2 FunctionalK %ccurate
t
9 2 $on2FunctionalK 3ntentional L
7 H $one
Arousal *cale
; 2 %ttention L
6 2 #ye Fpening *1o Stimulation
9 2 #ye Fpening *ith Stimulation
7 2 Unarousa)le
L &enotes !CS
t
&enotes emergence from !CS
&eferences
%n"re*s , !urphy L, !un"ay R, Little*oo" C, 9::=, !is"iagnosis of the vegetative
stateK retrospective stu"y in a reha)ilitation unit, B!J ;9;/E7@C0K9;2=,
%mantini %, Grippo %, Fossi S, Cesaretti C, >iccioli %, >eris %, et al, 6778, >re"iction of
Ga*akeningG an" outcome in prolonge" acute coma from severe traumatic )rain in+uryK
evi"ence for vali"ity of short latency S#>s, Clinical $europhysiology 99=/90K66:26;8,
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kno*le"ge an" remaining .uestions, Journal of 'ea" (rauma Reha)ilitation 67/90K;7287,
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state, Brain 3n+ury 99/970K E6;HE;@,
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patient, Brain 3n+ury 67K9;6929;6C,
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&ead t!is article in ot!er formats and languages
>&F
Cite t!is article
Schnakers C, Giacino J, Laureys S, 6796, ComaK &etecting signs of consciousness in
severely )rain in+ure" patients recovering from coma, 3nK J' Stone, ! Blouin, e"itors,
3nternational #ncyclope"ia of Reha)ilitation, %vaila)le onlineK
httpK11cirrie,)uffalo,e"u1encyclope"ia1en1article19;;1
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ComaK !en"eteksi tan"a2tan"a kesa"aran "i otak parah luka pasien pulih "ari koma
C Schnakers
Coma Science Group, Cyclotron >usat >enelitian
Universitas Liege, Lige, Belgia
J Giacino
JF !e"ical Center
#"ison, $J, US%
S Laureys
Coma Science Group, Cyclotron >usat >enelitian
Universitas Liege, Lige, Belgia
&epartemen $eurologi, C'U Sart (ilman
Lige, Belgia
&aftar 3si
L >asal atas
L %)strak
L Gangguan kesa"aran
L &iagnosis
L >erilaku penilaian
L esimpulan
Ucapan (erima asih L
L Gam)ar "an (a)el
L Referensi
L Baca artikel ini "alam format lain "an )ahasa
L Cite artikel ini
L 'ak Cipta
L Cari
Baca versi, pen"ek kurang teknis "ari artikel ini
%)strak
Jumlah pasien yang )ertahan hi"up ce"era otak akut meningkat secara "ramatis "alam
)e)erapa tahun terakhir menghasilkan tantangan sosial, ekonomi "an etika, $amun
"emikian, men"eteksi tan"a2tan"a perilaku kesa"aran saat ini )enar2)enar sulit pa"a
pasien "engan repertoar perilaku ter)atas "an sering "ipersulit oleh respon motorik ti"ak
konsisten atau mu"ah lelah, Se)uah kesalahan "iagnosis "apat menye)a)kan mana+emen
pera*atan yang ti"ak mema"ai /misalnya, pengo)atan nyeri0 "an 1 atau ti"ak en"2of2
kehi"upan keputusan, &alam ulasan ini, kami akan menya+ikan informasi tentang kriteria
"iagnostik, prognosis "an sisa pengolahan otak "alam gangguan kesa"aran utama, ami
+uga akan mem)ahas skala perilaku stan"ar yang telah "ikem)angkan untuk
memu"ahkan penilaian kesa"aran pa"a pasien pulih "ari koma,
Jumlah pasien yang )ertahan hi"up ce"era otak akut meningkat secara "ramatis "alam
)e)erapa tahun terakhir menghasilkan tantangan sosial, ekonomi "an etika /Jennett,
67780, Bahkan +ika se)agian )esar pasien luka parah otak pulih "ari koma "alam "ua
minggu pertama setelah penghinaan, orang lain akan mengam)il le)ih )anyak *aktu "an
pergi melalui )er)agai tahap se)elum sepenuhnya atau se)agian pulih kesa"arannya,
!en"eteksi tan"a2tan"a perilaku kesa"aran saat ini cara utama untuk mem)e"akan sa"ar
"ari pasien ti"ak sa"ar, &iagnosis tingkat kesa"aran a"alah tetap )enar2)enar sulit untuk
mem)uat pa"a pasien "engan repertoar perilaku ter)atas "an sering "ipersulit oleh respon
motorik ti"ak konsisten atau mu"ah lelah, !is"iagnosis karena itu telah "ilaporkan
se)agai sangat sering /Chil"s et al, 9::;<, %n"re*s et al, 9::=<,, Schnakers et al, 677:0,
Selain itu, kesalahan "iagnosis "apat menye)a)kan mana+emen pera*atan yang ti"ak
mema"ai /misalnya, pengo)atan nyeri0 "an 1 atau ti"ak en"2of2kehi"upan keputusan,
Untuk alasan ini, informasi yang mengetahui tentang kriteria "iagnostik, prognosis tetapi
+uga sisa2sisa pengolahan otak "ari setiap gangguan kesa"aran "apat mem)antu "alam
mem)uat "iagnosis, Selain itu, skala perilaku stan"ar telah "ikem)angkan untuk
memu"ahkan penilaian kesa"aran pa"a pasien pulih "ari koma /!a+erus et al, 6778<,
Gill2(*aithes, 677=0, &alam tulisan ini, kita akan menin+au tiga gangguan utama
kesa"aran /yaitu, koma, kon"isi vegetatif "an negara kesa"aran minimal0 "itemui "alam
praktek klinis "an kami akan mengurai mereka "ari negara2negara lain seperti sin"rom
terkunci2in "an kematian otak /lihat (a)el 90, ami kemu"ian akan mem)ahas prose"ur
penilaian perilaku yang "irancang untuk penggunaan "i samping tempat ti"ur, "engan
fokus pa"a orang2orang yang )aik "ivali"asi,
Gangguan kesa"aran
oma
>lum "an >osner "i"efinisikan koma se)agai kea"aan patologis yang )erhu)ungan
"engan "isfungsi parah "an )erkepan+angan ke*aspa"aan "an kesa"aran />lum "an
>osner, 9:==0, 'asil negara ini "ari "isfungsi otak glo)al /paling sering karena untuk
mere"akan ce"era aksonal setelah ce"era otak traumatis0, atau "ari lesi ter)atas pa"a
struktur otak yang meli)atkan reticular mengaktifkan sistem, Fitur yang mem)e"akan
koma a"alah ti"ak a"anya terus mem)uka mata /spontan atau setelah rangsangan0, (i"ak
a"a )ukti fiksasi visual atau menge+ar, )ahkan setelah pengguna mem)uka mata, (i"ak
a"a perilaku motorik "iamati "an respon perilaku ter)atas pa"a aktivitas refleks sa+a,
%ktivitas listrik yang "iamati, meskipun "itan"ai "engan pita frekuensi lam)at /yaitu,
se)agian )esar "elta "an aktivitas theta0 /?oung, 6777< Brenner, 67780, >ositon #mission
(omography />#( scan0 penelitian +uga menun+ukkan penurunan @7 sampai 87A "ari
meta)olisme otak secara keseluruhan "alam kon"isi koma traumatis atau hipoksia
/Laureys et al,, 677@0, $egara ini harus )erlangsung seti"aknya satu +am untuk "i)e"akan
"ari gangguan sementara kesa"aran /misalnya, sinkop, ke)ingungan atau "elirium0,
oma )erkepan+angan +arang, Biasanya, koma memutuskan "alam *aktu 6 sampai @
minggu, paling sering )erkem)ang men+a"i BS atau !CS /%ttia "an Cook, 9::C0,
(ra"isional elektroensefalografik /##G0 langkah2langkah telah menun+ukkan
ke)erhasilan mereka "alam mempre"iksi hasil setelah kerusakan otak ano-ic atau
traumatis /?oung, 6777< Brenner, 67780, $amun, stu"i ter)aru menun+ukkan )ah*a
potensi mem)angkitkan somatosensori /$670 "an negatif mismatch /!!$0 memiliki
nilai pre"iktif unggul ##G, ti"ak a"anya )ilateral "ari respon $67 atau !!$ pa"a
pasien koma yang sangat terkait "engan ti"ak a"anya pemulihan penuh /masing2masing,
:: 2977A "ari kasus "an :92:;A kasus0 /%mantini et al, 6778<,, Fischer et al, 677=0,
Begetative state
3stilah DvegetatifD menun+ukkan pelestarian fungsi otonom /misalnya, car"io2vascular,
pernapasan "an fungsi termoregulasi0 "an ke)angkitan kem)ali "ari siklus ti"ur2)angun
/yaitu, perio"e pem)ukaan mata spontan0, BS sering ter+a"i karena trauma yang
"ise)a)kan ce"era )i2)elahan otak yang meli)atkan materi putih atau "ari lesi )ilateral "i
thalamus "engan hemat "ari ganglia otak, hipotalamus "an )asal /Giacino, 9::E0,
>erilaku, ti"ak a"a respon terha"ap perintah lisan "an, meskipun mengerang mungkin
ter+a"i, ti"ak a"a pi"ato "imengerti /!ulti2Society (ask Force on >BS, 9::@0, Jarang,
perilaku seperti patut tersenyum, menangis atau meringis, "an )ahkan acak2"ipro"uksi
kata2kata tunggal telah "ilaporkan pa"a pasien yang "i"iagnosis "engan BS />artai
Beker+a "ari Royal College of >hysicians, 677;0, &engan penilaian hati2hati, a"alah
mungkin untuk menun+ukkan )ah*a perilaku ini ti"ak sukarela atau tu+uan2"iarahkan,
Stu"i neuroimaging fungsional menun+ukkan penurunan )erat meta)olisme otak "alam
+aringan fronto2temporo2parietal "engan aktivasi ter)atas pa"a korteks pen"engaran
primer setelah atau rangsangan )er)ahaya, menun+ukkan ti"ak a"anya pengolahan otak
terpa"u /Laureys "an Boly, 677E0, !em)angun prognosis "efinitif sulit, namun, ketika
negara ini )erlangsung satu )ulan atau le)ih, pasien "ianggap "i BS DgigihD, etika BS
)erlangsung le)ih "ari ; )ulan /untuk non2traumatik etiologi0 atau satu tahun /untuk
etiologi trauma0, pasien "apat "ipertim)angkan "alam DpermanenD BS /!ulti2Society
(ask Force on >BS, 9::@0, &alam pan"angan keti"akpastian )erlama2lama tentang
in"ikator prognostik "an ter"okumentasi "engan )aik kasus2kasus pemulihan akhir
/Chil"s "an !ercer, 9::=0, ongres %merika Reha)ilitasi !e"icine /9::80 telah
merekomen"asikan )ah*a DBS tetapD harus "itinggalkan "emi men"okumentasikan
penye)a)nya "ari pan+ang /misalnya, ce"era otak traumatis, stroke atau ano-ia0 BS "an
*aktu pasca2onset )aik se)agai informasi carry prognostik,
!inimal sa"ar negara
$egara kesa"aran minimal "itan"ai "engan a"anya tan"a2tan"a perilaku ti"ak konsisten
tetapi +elas2"ilihat kesa"aran /Giacino et al,, 67760, (an"a2tan"a terse)ut harus
"irepro"uksi "alam u+ian yang "i)erikan, meskipun perilaku "apat )erfluktuasi "i seluruh
pemeriksaan, Ber)e"a "engan pasien "i BS yang mungkin menampilkan episo"e acak
menangis atau tersenyum, perilaku ini )ergantung pa"a lingkungan pemicu yang tepat
"alam !CS, %*al ke)angkitan kem)ali menge+ar visual yang tampaknya men+a"i
penan"a perilaku transisi "ari BS untuk !CS /Giacino "an 4hyte, 67780, Stu"i
neuroimaging fungsional telah menun+ukkan "aerah )esar fronto2temporo2parietal
aktivasi setelah stimulasi pen"engaran "an )eracun serta konektivitas utuh antara korteks
primer "an asosiatif menun+ukkan pelestarian yang le)ih )esar "ari proses syaraf
ter"istri)usi /Laureys "an Boly, 677E0, !engenai prognosis, kemungkinan pemulihan
fungsional pa"a satu ce"era otak traumatis tahun )erikutnya relatif signifikan le)ih
menguntungkan BS /87A vs ;A mencapai cacat se"ang0, Be)erapa pasien se"ang
)erlangsung !CS perlahan sementara yang lain tetap "alam kon"isi ini secara permanen
/sirip et al,, 677E0, 'al ini +uga penting untuk menya"ari )ah*a, ti"ak seperti BS, +elas2
"i"efinisikan parameter temporal untuk pemulihan ti"ak a"a /Lammi et al,, 67780, "an
a"a heterogenitas yang luas "i tingkat pemulihan fungsional pa"a akhirnya tercapai,
!unculnya "ari !CS ter+a"i ketika pasien mampu an"al )erkomunikasi melalui lisan
atau gestural ya2ti"ak respon, atau mampu menun+ukkan penggunaan "ua atau le)ih
o)yek /misalnya, sikat ram)ut, cangkir0 secara fungsional /Giacino et al,, 6776 0,
&ifferential &iagnosis
Locke"2in syn"rome
(he terkunci2"alam sin"rom /L3S0 "itan"ai "engan tetraplegia "an anarthria "alam
pengaturan men"ekati normal "engan fungsi kognitif normal /ongres %merika
Reha)ilitasi e"okteran, 9::80, on"isi ini "ise)a)kan oleh lesi yang meli)atkan pons
ventral "an, "alam =7A kasus, a"alah karena trom)osis )asilar, arena pasien "engan
L3S telah mem)uka mata spontan, tetapi ti"ak "apat )er)icara atau )ergerak ekstremitas,
kea"aan ini "apat "engan mu"ah )ingung "engan BS, Rata2rata, "iagnosis L3S ti"ak
"i"irikan sampai 6,8 )ulan pasca2onset, %"a )ukti )ah*a anggota keluarga cen"erung
untuk men"eteksi tan"a2tan"a kesa"aran /88A kasus0 se)elum staf me"is /6;A kasus0
/Laureys et al, 6778,0, lasik L3S ter"iri "ari kelumpuhan lengkap "ari otot2otot
oro)uccal "an keempat ekstremitas, $amun, gerakan mata vertikal, yang memungkinkan
komunikasi non2ver)al melalui tatapan arah, terhin"ar, Fungsi persepsi +uga terhin"ar
se)agai ascen"ing akson aferen tetap utuh /ongres %merika Reha)ilitasi e"okteran,
9::80, Bauer telah "i+elaskan )e)erapa varietas "ari L3S, termasuk )entuk lengkap "i
"alamnya a"a aktivitas motorik resi"ual /sering, +ari atau gerakan kepala0, "an L3S total,
"i mana a"a imo)ilitas lengkap termasuk gerakan mata horisontal "an vertikal /Bauer et
al, , 9:E:0, $euroimaging fungsional )iasanya menun+ukkan "ia*etkan supra2tentorial
"aerah "engan hipometa)olisme "i otak kecil, struktur )erhu)ungan erat "engan aktivitas
motorik "ikoor"inasikan0, !enariknya, hiperaktif signifikan telah "iamati )ilateral "alam
amig"ala pasien L3S akut, kemungkinan mencerminkan kecemasan yang "ihasilkan oleh
keti"akmampuan untuk )ergerak atau )er)icara /menekankan pentingnya pengo)atan
kecemasan yang tepat segera setelah "iagnosis0 /Laureys et al,, 67780, eha"iran irama
elektroensefalografik relatif normal "an reaktif setelah lesi )atang otak harus
mengingatkan "okter, tetapi heterogenitas temuan ##G menun+ukkan )ah*a pen"ekatan
ini ti"ak "apat per se menguraikan L3S "ari gangguan kesa"aran /Bassetti "an 'ess,
9::E0, &ata harapan hi"up menun+ukkan )ah*a )e)erapa pasien "engan pasien L3S
tinggal "ua )elas tahun atau le)ih pasca2onset, %nehnya, pasien L3S tingkat kualitas
hi"up mereka mirip "engan populasi yang sehat /Bruno et al,, 677:0, &engan ti"ak
a"anya kelainan otak lainnya struktural atau fungsional /Smart et al,, 677C0, pasien
"engan L3S umumnya mampu mem)uat keputusan yang in"epen"en "an )erkomunikasi
preferensi mereka /Schnakers et al,, 677C0,
Ftak kematian
ematian otak a"alah suatu kon"isi "i mana a"a Dketi"aksa"aran ireversi)el "engan
hilangnya lengkap fungsi otakD, 'al ini "itan"ai "engan a"anya apnea "an ti"ak a"anya
respon perilaku terha"ap lingkungan /onsultan !e"is pa"a &iagnosis of &eath, 9:C90,
Umumnya, electroencephalogram menun+ukkan keheningan electrocere)ral
mencerminkan ti"ak a"anya aktivitas otak listrik, (ranskranial "oppler stu"i
mengungkapkan a"anya aliran "arah otak, %khirnya, pencitraan fungsional,
menggunakan pelacak perfusi otak "an tomografi emisi foton tunggal /S>#C(0,
menggam)arkan Dtengkorak kosongD tan"a "i mana Dseluruh otakD /Facco et al,, 9::C0
ti"ak aktif, Setelah ti"ak termasuk "isfungsi otak aki)at keracunan o)at atau hipotermia,
"iagnosis akhir "apat "i)entuk setelah = sampai 6@ +am,
>erilaku penilaian
esa"aran
>engamatan perilaku merupakan meto"e stan"ar untuk men"eteksi tan"a2tan"a kesa"aran
pa"a pasien luka )erat otak, 'al ini penting, namun, untuk mem)uat per)e"aan antara
DgairahD "an Dkesa"aranD, !emang, pasien "apat terangsang tapi ti"ak menun+ukkan
tan"a2tan"a kesa"aran, seperti "alam BS, >elestarian gairah karena itu merupakan
kon"isi yang "iperlukan tetapi ti"ak cukup untuk kesa"aran /lihat Gam)ar 90, Selain itu,
kesa"aran ti"ak harus "ilihat se)agai fenomena "ikotomis melainkan se)agai se)uah
kontinum, 'al ini "imungkinkan, misalnya, untuk pasien yang koma "engan cepat
)erkem)ang men+a"i BS, secara )ertahap transisi ke !CS, "an kemu"ian ter+erumus
kem)ali ke "alam koma,
!is"iagnosis
!em)e"akan antara !CS "an BS "apat menantang, &eteksi perilaku sukarela seringkali
sulit "an tan"a2tan"a kesa"aran "engan mu"ah "apat ter+a*a) karena cacat sensorik "an
motorik, trakeostomi, tingkat gairah )erfluktuasi atau tanggapan kelelahan am)igu "an
cepat /!a+erus et al,, 67780, >enelitian se)elumnya telah menun+ukkan )ah*a ;E hingga
@;A "ari pasien "engan gangguan kesa"aran yang keliru "i"iagnosis "engan BS /Chil"s
et al, 9::;<,, %n"re*s et al, 9::=0, arena, laporan2laporan lain mengenai kriteria
"iagnostik untuk BS "an !CS /Giacino et al, 6776<, >artai Beker+a "ari Royal College of
>hysicians, 677;0 telah menyarankan le)ih ren"ah perkiraan mis"iagnosis /Jennett,
67780, Se)uah stu"i yang le)ih )aru, namun telah kem)ali melaporkan tingkat
mis"iagnosis "ari @9A, sesuai "engan )ukti2)ukti se)elumnya /Schnakers et al,, 677:0,
!is"iagnosis antara pasien "engan gangguan kesa"aran telah maka ti"ak su)stansial
)eru)ah, &iagnosis yang akurat a"alah tetap penting ti"ak hanya untuk mana+emen
sehari2hari /khususnya, pengo)atan nyeri0 "an akhir2of2hi"up keputusan, tetapi +uga
memiliki implikasi prognostik se)agai pasien "i !CS memiliki hasil fungsional le)ih
menguntungkan "i)an"ingkan "engan yang a"a "i BS, Schnakers "an rekan ker+a /677:0
menun+ukkan )ah*a penggunaan sistematis skala penilaian sensitif stan"ar
neuro)ehavioral "apat mem)antu mengurangi kesalahan "iagnostik "an mem)atasi
keti"akpastian "iagnostik,
>erilaku skala
Banyak skala penilaian perilaku telah "ikem)angkan "an "ivali"asi untuk menilai tingkat
kesa"aran "an mem)angun "iagnosis /!a+erus et al,, 67780, >a"a )agian ini, kita
menin+au secara singkat instrumen yang )iasa "igunakan "alam pengaturan akut "an
reha)ilitasi,
(he Glasgo* Coma Scale /GCS0 tetap men+a"i skala yang paling )anyak "igunakan
"alam trauma "an pengaturan pera*atan akut, GCS a"alah "ivali"asi pertama >eringkat
skala "ikem)angkan untuk memantau tingkat kesa"aran "i unit pera*atan intensif
/(eas"ale "an Jennett, 9:E@0, Skala ini relatif singkat "an mu"ah "apat "imasukkan ke
"alam pera*atan klinis rutin, 3ni mencakup tiga su)scales )ah*a alamat gairah tingkat,
fungsi motorik "an kemampuan ver)al, Skor su)skala "itam)ahkan "an menghasilkan
skor total )erkisar antara ; sampai 98, !eskipun "igunakan secara luas, GCS telah
"ikritik karena varia)el antar2rater kesepakatan "an masalah )erasal skor pa"a pasien
"engan trauma okular, trakeostomi atau "ukungan ventilasi /!c$ett, 677E0,
(he Futline >enuh unresponsiveness skala /#!>%(0 )aru2)aru ini "ikem)angkan untuk
menggantikan Glasgo* Coma Scale untuk menilai )erat otak2luka pasien "alam
pera*atan intensif /4i+"icks, 677=<, 4i+"icks et al, 67780, Skala ini ter"iri "ari empat
su)2skala menilai respon motor "an okular, refleks )atang otak "an pernapasan, (otal
skor )erkisar "ari 7 hingga 9=, Ber)e"a "engan GCS, #!>%( ti"ak menilai fungsi ver)al
untuk mengakomo"asi tingginya +umlah pasien "iintu)asi "alam pera*atan intensif,
Se)uah skor 7 pa"a #!>%( mengasumsikan ti"ak a"anya refleks )atang otak "an
pernapasan "an, karena itu, mem)antu untuk men"iagnosa kematian otak, Skala +uga
memantau pemulihan fungsi otonom "an munculnya lagu "ari BS, (he #!>%(
"irancang khusus untuk men"eteksi pasien "engan sin"rom terkunci2in karena
menggunakan perintah oculomotor yang mengeksploitasi gerakan mata vertikal "an
)erke"ip mata, yang ke"uanya "ia*etkan "alam L3S,
epala 4esse- Ce"era !atri- /kehen"ak0 /Shiel et al,, 67770 "ikem)angkan untuk
menangkap peru)ahan pa"a pasien "i BS melalui munculnya "ari pasca2trauma amnesia,
%lat ini sangat sensitif untuk men"eteksi peru)ahan pa"a pasien "i !CS ti"ak "itangkap
oleh skala tra"isional seperti GCS /!a+erus "an Ban "er Lin"en, 67770, Shiel "an
kola)orator longitu"inal "iikuti :E pasien terluka parah otak pulih "ari koma untuk
mem)uat olahan, 3tem kehen"ak "iperintahkan sesuai "engan urutan pemulihan "iamati
pa"a pasien ini, #nam kehen"ak2=6 item )agian menilai tingkat gairah "an konsentrasi,
kesa"aran visual /misalnya, menge+ar visual0, komunikasi, kognisi /misalnya, memori
"an orientasi spatiotemporal0 "an perilaku sosial, Skor kehen"ak merupakan pangkat "ari
perilaku yang paling kompleks "iamati,
%ssessment !o"alitas Sensory "an Reha)ilitasi (eknik /S!%R(0 /Gill2(h*aites, 9::E0
"ikem)angkan untuk mengi"entifikasi tan"a2tan"a kesa"aran "iamati selama Dprogram
rangsangan sensorikD "imaksu"kan untuk men"ukung plastisitas otak "an meningkatkan
tingkat kesa"aran /4oo", 9::90, (he S!%R( menilai C mo"alitas termasuk visual,
pen"engaran, sensasi taktil, penciuman, "an gustatory, fungsi motorik, komunikasi "an
tingkat gairah, S!%R( a"alah skala hirarki yang ter"iri "ari 8 tingkat respon /Gti"ak
a"anya responG 2 Level 9< Grespon refleksG 2 Level 6, Grespon penarikanG 2 Level ;< Grespon
lokalisasiG 2 Level @, Grespon "iskriminatifG 2 (ingkat 80, (he S!%R( se)elumnya telah
ter)ukti memiliki vali"itas yang sangat )aik "an kehan"alan "alam populasi =7 pasien
yang "i"iagnosis se)agai "alam kea"aan vegetatif atau "alam kea"aan kesa"aran minimal
/Gill2(h*aites "an !un"ay, 677@0,
(he JF Coma Scale >emulihan pa"a a*alnya "ikem)angkan oleh peneliti "ari JF
Johnson Reha)ilitation 3nstitute pa"a tahun 9::9 /Giacino et al,, 9::90, Skala ini "irevisi
"an "iter)itkan ulang pa"a tahun 677@ se)agai JF Coma >emulihan Skala2Revisi /CRS2
R0 /Giacino et al,, 677@0, (u+uan "ari CRS2R a"alah untuk mem)antu "iagnosis
"iferensial, penilaian prognosis "an perencanaan pengo)atan pa"a pasien "engan
gangguan kesa"aran, Skala ini ter"iri "ari 6; item yang ter"iri "ari enam su)2skala
menangani pen"engaran, visual, motorik, oromotor, komunikasi "an fungsi gairah /lihat
(a)el 60, CRS2R su)skala ter"iri "ari item2hierarkis "iatur terkait "engan )atang otak,
su)kortikal "an proses kortikal, 3tem teren"ah pa"a setiap su)skala merupakan kegiatan
refleksif se"angkan item tertinggi me*akili perilaku kognitif2"ime"iasi, Scoring a"alah
stan"ar "an )er)asis pa"a a"a atau ti"ak a"anya respon perilaku secara operasional
"i"efinisikan terha"ap rangsangan sensorik tertentu, Stu"i psikometrik menun+ukkan
)ah*a CRS2R memenuhi stan"ar minimal untuk pengukuran "an alat evaluasi yang
"irancang untuk "igunakan "alam reha)ilitasi me"is inter"isipliner, 3nterrater yang
mema"ai "an u+i2tes ulang relia)ilitas telah "i)entuk menun+ukkan )ah*a CRS2R "apat
"i)erikan an"al oleh pemeriksa terlatih "an menghasilkan skor yang cukup sta)il selama
penilaian "iulang, %nalisis Bali"itas men"ukung penggunaan skala se)agai in"eks fungsi
neuro)ehavioral "an telah menun+ukkan )ah*a CRS2R mampu mem)e"akan pasien
"alam !CS "ari orang2orang "i BS yang sangat penting "alam mem)angun prognosis
"an merumuskan intervensi pengo)atan /Schnakers et al,, 677=< Schnakers et al, 677C<,
Banhau"enhuyse et al, 677C0,, Spanyol, >ortugis, 3talia, ter+emahan Jerman, >erancis,
Belan"a, $or*egia "an &enmark "ari CRS2R yang terse"ia,
esimpulan
>asien "engan gangguan yang parah kesa"aran ha"ir signifikan "iagnostik, prognostik
"an masalah mana+emen sehari2hari, >emulihan kesa"aran )iasanya sangat )ertahap,
ka"ang2ka"ang "itan"ai "engan munculnya tonggak perilaku yang +elas, tetapi le)ih
sering "engan per)aikan halus, %"a fluktuasi sering "i ke"ua gairah "an kesa"aran, "an
ka"ang2ka"ang, a"a kemun"uran, (an"a2tan"a halus kesa"aran harus "iakui le)ih a*al
untuk menghin"ari mis"iagnosis, Be"si"e penilaian fungsi kognitif sisa seringkali sulit
karena tingkat gairah cukup, gangguan motorik, respon )erfluktuasi, se"asi atau faktor2
faktor lainnya, >engetahuan me"is yang "iterima kriteria "iagnostik "an ketergantungan
pa"a "ivali"asi skala penilaian perilaku sangat penting untuk mem)angun keputusan
yang akurat "iagnosis, prognosis "an mana+emen /termasuk akhir2hi"up20,
Ucapan (erima asih
>eker+aan kami "i"ukung se)agian oleh $ational 3nstitute on >enelitian Cacat "an
Reha)ilitasi />enghargaan '9;;%7E77;70, &ana $asional Belgia untuk Riset 3lmiah
/F$RS0, omisi #ropa, James !c&onnell Foun"ation, >ikiran Science Foun"ation,
>erancis %ksi omunitas >enelitian Ber)icara terpa"u, 3nternasional Rotary Foun"ation,
Fon"ation !e"icale Reine #lisa)eth, "an Universitas Liege,
Gam)ar "an (a)el
(a)el 9K riteria &iagnostik untuk kematian otak, koma, vegetatif "an negara minimal
sa"ar "an terkunci2"alam sin"rom
esa"aran &iagnostik tingkat kriteria Referensi /s0
Ftak kematian
L (i"ak a"a gairah 1 mem)uka mata
L (i"ak a"a tan"a2tan"a perilaku kesa"aran
L %pnea
L ehilangan fungsi otak /)rainstem refleks0
onsultan !e"is pa"a &iagnosis of &eath, 9:C9
oma
L (i"ak a"a gairah 1 mem)uka mata
L (i"ak a"a tan"a2tan"a perilaku kesa"aran
L Gangguan pernapasan spontan
L Refleks )atang otak Gangguan
L (i"ak a"a vokalisasiI 9 +am
>lum J >osner, 9:==
Begetative state
L Gairah 1 stpontaneous atau stimulus2in"uce" mem)uka mata
L (i"ak a"a tan"a2tan"a perilaku kesa"aran
L &ia*etkan spontan pernapasan
L Refleks )atang otak &ia*etkan
L (i"ak a"a tu+uan perilaku
L (i"ak a"a pro"uksi )ahasa pemahaman
L >elestarian /se)agian atau lengkap0 "ari hipotalamus "an otak )atang fungsi otonom
LI 9 )ulanK vegetatif persisten
L ompati)elK meringis terha"ap nyeri, lokalisasi terha"ap suara
L %typical namun kompati)elK visual fiksasi, menanggapi ancaman, kata2kata tunggal
ti"ak pantas
L !ulti2Society (ask Force on >BS, 9::@
L Beker+a >artai Royal College of >hysicians, 677;
!inimal sa"ar negara
L Gairah 1 spontan mem)uka mata
L >erilaku tan"a Fluktuasi tapi "irepro"uksi kesa"aran
L Respon untuk memesan lisan
L Lingkungan2kontingen tersenyum atau menangis
L F)yek lokalisasi "an manipulasi
L Fiksasi visual yang )erkelan+utan "an menge+ar
L Ber)ali5ations
L &isenga+a tetapi ti"ak "apat "ian"alkan komunikasi
L !unculnya "ari !CSK komunikasi fungsional, penggunaan o)+ek fungsional
Giacino et al, 6776,
Locke"2in syn"rome
L Gairah 1 spontan mem)uka mata
L &ia*etkan fungsi kognitif
L omunikasi tatapan mata vis
L %narthria
L (etraplegia
ongres %merika Reha)ilitasi e"okteran, 9::8
Gam)ar 9
>engamatan perilaku menilai "ua "imensi kesa"aranK gairah "an kesa"aran, &alam
kematian otak "an koma, ke"ua "imensi yang a)sen, &alam kea"aan vegetatif, tingkat
gairah relatif "ia*etkan "engan ti"ak a"anya tan"a2tan"a kesa"aran, &alam kea"aan
kesa"aran minimal, ke"ua "imensi ha"ir meskipun tan"a2tan"a perilaku sering
)erfluktuasi, &alam sin"rom terkunci2"alam, ke"ua "imensi sepenuhnya "ia*etkan
meskipun hilangnya lengkap )er)icara "an fungsi motorik,
Gam)ar 9
(a)le6K CRS2R Response >rofile
%u"itory Fungsi Skala
@ 2 Gerakan onsisten ke Comman" L
; 2 Gerakan "irepro"uksi ke Comman" L
6 2 Lokalisasi untuk Suara
9 2 %u"itory agetkan
7 2 (i"ak a"a
Bisual Fungsi Skala
8 2 L >engakuan F)yek
@ 2 F)yek LokalisasiK L !encapai
; 2 >ursuit #ye !ovements L
6 2 Fiksasi L
9 2 Bisual agetkan
7 2 (i"ak a"a
Fungsi motorik Skala
= 2 Fungsional F)yek Gunakan t
8 2 !otor L Respon Ftomatis
@ 2 F)yek L !anipulasi
; 2 Lokalisasi ke L Stimulasi $o-ious
6 2 Fleksi >enarikan
9 2 sikap %)normal
7 2 (i"ak a"a 1 Flacci"
Fromotor 1 Ber)al Fungsi Skala
; 2 L Ber)alisasi "imengerti
6 2 Fokalisasi Gerakan 1 Fral
9 2 Gerakan refleksif Fral
7 2 (i"ak a"a
omunikasi Skala
6 2 FungsionalK %kurat t
9 2 $on2FungsionalK L &isenga+a
7 2 (i"ak a"a
Gairah Skala
; 2 >erhatian L
6 2 #ye Fpening * 1 o Stimulasi
9 2 #ye Fpening "engan Stimulasi
7 2 Unarousa)le
L !erupakan !CS
t !enun+ukkan munculnya "ari !CS
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Gke)angkitanG "an hasil "alam koma )erkepan+angan akut "ari ce"era otak traumatik yang
parahK )ukti kea)sahan S#> latency pen"ek, Clinical $eurofisiologi 99= /90 K66:26;8,
ongres %merika Reha)ilitasi e"okteran, 9::8, Rekomen"asi untuk penggunaan
nomenklatur yang )ersangkutan seragam untuk pasien "engan peru)ahan )erat
kesa"aran, %rchives of e"okteran Fisik "an Reha)ilitasi E=K678267:,
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/;0 K@:E2899,
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of $eurology 669 /60 KEE2:9,
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Bruno !%, Schnakers C, &amas, >ellas F, Lutte 3, J Bernheim, !a+erus S, !oonen G,
Gol"man S, Laureys S, 677:, &ikunci23n Syn"rome pa"a %nakK Laporan "ari Lima
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@:K;7:,
Chil"s $L, !ercer 4$, Chil"s '4, 9::;, %kurasi "iagnosis kon"isi vegetatif,
$eurologi @; /C0 K9@=82=E,
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vegetatif, $e* #nglan" Journal of !e"icine ;;@ /90 K6@268,
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"an Reha)ilitasi E6 /990 KC:E2:79,
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onsultan !e"is pa"a &iagnosis of &eath, 9:C9, >e"oman untuk penentuan kematian,
Laporan konsultan me"is pa"a "iagnosis kematian kepa"a omisi >resi"en untuk Stu"i
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