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Nat Rev Neurol. 2014 Feb;10(2):99-114. doi: 10.1038/nrneurol.2013.279. Epub 2014 Jan 28.

Disorders of consciousness after acquired brain injury: the state of the science.

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Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, 300 First Avenue, Charlestown, Boston, MA 02129, USA.
Division of Medical Ethics, Weill Cornell Medical College, 435 East 70th Street, Suite 4-J, New York, NY 10021, USA.
Coma Science Group, Cyclotron Research Centre and Neurology Department, University and University Hospital of Liège, Sart Tilman B30, 4000 Liège, Belgium.
Feil Family Brain and Mind Research Institute, Weill Cornell Medical College, 1300 York Avenue, New York, NY 10065, USA.


The concept of consciousness continues to defy definition and elude the grasp of philosophical and scientific efforts to formulate a testable construct that maps to human experience. Severe acquired brain injury results in the dissolution of consciousness, providing a natural model from which key insights about consciousness may be drawn. In the clinical setting, neurologists and neurorehabilitation specialists are called on to discern the level of consciousness in patients who are unable to communicate through word or gesture, and to project outcomes and recommend approaches to treatment. Standards of care are not available to guide clinical decision-making for this population, often leading to inconsistent, inaccurate and inappropriate care. In this Review, we describe the state of the science with regard to clinical management of patients with prolonged disorders of consciousness. We review consciousness-altering pathophysiological mechanisms, specific clinical syndromes, and novel diagnostic and prognostic applications of advanced neuroimaging and electrophysiological procedures. We conclude with a provocative discussion of bioethical and medicolegal issues that are unique to this population and have a profound impact on care, as well as raising questions of broad societal interest.

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