The misdiagnosis of prolonged disorders of consciousness by a clinical consensus compared with repeated coma-recovery scale-revised assessment

Abstract

Background: Previous studies have shown that a single Coma-Recovery Scale-Revision (CRS-R) assessment can identify high rates of misdiagnosis by clinical consensus. The aim of this study was to investigate the proportion of misdiagnosis by clinical consensus compared to repeated behavior-scale assessments in patients with prolonged disorders of consciousness (DOC).

Methods: Patients with prolonged DOC during hospitalization were screened by clinicians, and the clinicians formed a clinical-consensus diagnosis. Trained professionals used the CRS-R to evaluate the consciousness levels of the enrolled patients repeatedly (≥5 times) within a week. Based on the repeated evaluation results, the enrolled patients with prolonged DOC were divided into unresponsive wakefulness syndrome (UWS), minimally conscious state (MCS), and emergence from MCS (EMCS). Finally, the relationship between the results of the CRS-R and the clinical consensus were analyzed.

Results: In this study, 137 patients with a clinical-consensus diagnosis of prolonged DOC were enrolled. It was found that 24.7% of patients with clinical UWS were actually in MCS after a single CRS-R behavior evaluation, while the repeated CRS-R evaluation results showed that the proportion of misdiagnosis of MCS was 38.2%. A total of 16.7% of EMCS patients were misdiagnosed with clinical MCS, and 1.1% of EMCS patients were misdiagnosed with clinical UWS.

Conclusions: The rate of the misdiagnosis by clinical consensus is still relatively high. Therefore, clinicians should be aware of the importance of the bedside CRS-R behavior assessment and should apply the CRS-R tool in daily procedures.

Trial registration: ClinicalTrials.gov ID: NCT04139239 ; Registered 24 October 2019 - Retrospectively registered.

Keywords: Coma-recovery scale-revised; Disorders of consciousness; Minimally conscious state; Misdiagnosis; Unresponsive wakefulness syndrome.

Fig. 1

Flowchart of participants through the study. Of the 137 patients with prolonged DOC enrolled, 48 were diagnosed by clinical consensus as MCS and 89 as UWS. After a single CRS-R evaluation, 62 were diagnosed with MCS, 8 with EMCS, and 67 with UWS. After repeated CRS-R evaluations, 73 were diagnosed with MCS, 9 with EMCS, and 55 with UWS. DOC = disorders of consciousness; UWS = unresponsive wakefulness syndrome; MCS = minimally conscious state; EMCS = emergence from minimally conscious state; n = numbers

Fig. 2

The number of CRS-R subscales representing signs of consciousness when diagnosed with MCS or EMCS after a single CRS-R assessment and after repeated CRS-R assessments. a. In these terms, Auditory = 3–4 OR Visual = 2–5 OR Motor = 3–5 OR Oromotor/Verbal = 3 OR Communication = 1, indicating that the patient has signs of consciousness and is diagnosed as MCS. Of the patients with a clinical consensus diagnosis of UWS, 22 were diagnosed with MCS after a single CRS-R assessment. After repeated CRS-R assessments, 34 patients were diagnosed with MCS. b. In these terms, Motor = 6 OR Communication = 2, indicating that the patient has signs of full consciousness and is diagnosed as EMCS. Of the patients with a clinical consensus diagnosis of MCS and UWS, 8 were diagnosed with EMCS after a single CRS-R assessment. After repeated CRS-R assessments, 9 patients were diagnosed with EMCS. CRS-R = Coma Recovery Scale-Revised; MCS = minimally conscious state; EMCS = emergence from minimally conscious state