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Observational Study
. 2022 Aug;21(8):704-713.
doi: 10.1016/S1474-4422(22)00212-5.

Cognitive-motor dissociation and time to functional recovery in patients with acute brain injury in the USA: a prospective observational cohort study

Jennifer Egbebike  1 , Qi Shen  1 , Kevin Doyle  1 , Caroline A Der-Nigoghossian  2 , Lucy Panicker  2 , Ian Jerome Gonzales  2 , Lauren Grobois  1 , Jerina C Carmona  1 , Athina Vrosgou  1 , Arshneil Kaur  2 , Amelia Boehme  3 , Angela Velazquez  1 , Benjamin Rohaut  4 , David Roh  5 , Sachin Agarwal  5 , Soojin Park  5 , E Sander Connolly  6 , Jan Claassen  7
Affiliations
Observational Study

Cognitive-motor dissociation and time to functional recovery in patients with acute brain injury in the USA: a prospective observational cohort study

Jennifer Egbebike et al. Lancet Neurol. 2022 Aug.

Abstract

Background: Recovery trajectories of clinically unresponsive patients with acute brain injury are largely uncertain. Brain activation in the absence of a behavioural response to spoken motor commands can be detected by EEG, also known as cognitive-motor dissociation. We aimed to explore the role of cognitive-motor dissociation in predicting time to recovery in patients with acute brain injury.

Methods: In this observational cohort study, we prospectively studied two independent cohorts of clinically unresponsive patients (aged ≥18 years) with acute brain injury. Machine learning was applied to EEG recordings to diagnose cognitive-motor dissociation by detecting brain activation in response to verbal commands. Survival statistics and shift analyses were applied to the data to identify an association between cognitive-motor dissociation and time to and magnitude of recovery. The prediction accuracy of the model that was built using the derivation cohort was assessed using the validation cohort. Functional outcomes of all patients were assessed with the Glasgow Outcome Scale-Extended (GOS-E) at hospital discharge and at 3, 6, and 12 months after injury. Patients who underwent withdrawal of life-sustaining therapies were censored, and death was treated as a competing risk.

Findings: Between July 1, 2014, and Sept 30, 2021, we screened 598 patients with acute brain injury and included 193 (32%) patients, of whom 100 were in the derivation cohort and 93 were in the validation cohort. At 12 months, 28 (15%) of 193 unresponsive patients had a GOS-E score of 4 or above. Cognitive-motor dissociation was seen in 27 (14%) patients and was an independent predictor of shorter time to good recovery (hazard ratio 5·6 [95% CI 2·5-12·5]), as was underlying traumatic brain injury or subdural haematoma (4·4 [1·4-14·0]), a Glasgow Coma Scale score on admission of greater than or equal to 8 (2·2 [1·0-4·7]), and younger age (1·0 [1·0-1·1]). Among patients discharged home or to a rehabilitation setting, those diagnosed with cognitive-motor dissociation consistently had higher scores on GOS-E indicating better functional recovery compared with those without cognitive-motor dissociation, which was seen as early as 3 months after the injury (odds ratio 4·5 [95% CI 2·0-33·6]).

Interpretation: Recovery trajectories of clinically unresponsive patients diagnosed with cognitive-motor dissociation early after brain injury are distinctly different from those without cognitive-motor dissociation. A diagnosis of cognitive-motor dissociation could inform the counselling of families of clinically unresponsive patients, and it could help clinicians to identify patients who will benefit from rehabilitation.

Funding: US National Institutes of Health.

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Conflict of interest statement

Declaration of interests DR is supported by grant funding from the US National Institutes of Health (NIH; HL151901). SA is supported by grant funding from the NIH (HL153311). SP is supported by grant funding from the NIH (NS113055). JC is a minority shareholder at iCE Neurosystems and is supported by grant funding from the NIH (NS106014, NS112760), and the McDonnell Foundation. All other authors declare no competing interests.

Figures

Figure 1.
Figure 1.
Distribution of study population. CMD, cognitive motor dissociation
Figure 2.
Figure 2.
Recovery trajectory over the first year following acute brain injury Alluvial plots representing individual GOS-E development across follow-up time points in patients with acute brain injury. Top plot CMD patients (N=27) and bottom plot non-CMD patients (N=166). Green lines indicate patients that recovered to a GOS-E of 4 or above at any point in time by one year after the injury, grey lines indicate patients were alive by 12 months but did not improve to a GOS-E of 4 or above, and black boxes indicate those patients that were dead by the time of these respective follow-up time-points. GOS-E, Glasgow Outcome Scale-Extended.
Figure 3.
Figure 3.
Predictors of time to functional recovery Independent predictors of time to good functional recovery (defined as a GOS-E of 4 or above) based on a Cox proportional hazards regression model in the overall population. We included all variables associated with recovery from the univariate analysis (Supplemental Table 4) in the multivariable models.
Figure 4.
Figure 4.
Functional outcomes stratified by CMD diagnosis and discharge disposition. NS, not significant; * P<0.05; ** P<0.01; *** P<0.001
See this image and copyright information in PMC

Comment in

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