Consciousness as a multidimensional phenomenon: implications for the assessment of disorders of consciousness

Disorders of consciousness (DoCs) pose a significant clinical and ethical challenge because they allow for complex forms of conscious experience in patients where intentional behaviour and communication are highly limited or non-existent. There is a pressing need for brain-based assessments that can precisely and accurately characterize the conscious state of individual DoC patients. There has been an ongoing research effort to develop neural measures of consciousness. However, these measures are challenging to validate not only due to our lack of ground truth about consciousness in many DoC patients but also because there is an open ontological question about consciousness. There is a growing, well-supported view that consciousness is a multidimensional phenomenon that cannot be fully described in terms of the theoretical construct of hierarchical, easily ordered conscious levels. The multidimensional view of consciousness challenges the utility of levels-based neural measures in the context of DoC assessment. To examine how these measures may map onto consciousness as a multidimensional phenomenon, this article will investigate a range of studies where they have been applied in states other than DoC and where more is known about conscious experience. This comparative evidence suggests that measures of conscious level are more sensitive to some dimensions of consciousness than others and cannot be assumed to provide a straightforward hierarchical characterization of conscious states. Elevated levels of brain complexity, for example, are associated with conscious states characterized by a high degree of sensory richness and minimal attentional constraints, but are suboptimal for goal-directed behaviour and external responsiveness. Overall, this comparative analysis indicates that there are currently limitations to the use of these measures as tools to evaluate consciousness as a multidimensional phenomenon and that the relationship between these neural signatures and phenomenology requires closer scrutiny.

Efficacy of peritoneal dialysis on encephalopathic patient with Citrullinemia type I

Citrullinemia type I (CTLN1) clinical spectrum includes an acute neonatal form ("classic" form) and a milder late-onset form (“non-classic" form). Infants with classic form appear normal at birth. Shortly thereafter, they experienced hyperammonemia and develops symptoms. Without prompt intervention, rapid neurological deterioration with seizures, spasticity, loss of consciousness and even death can occur. Continuous venovenous hemofiltration should be started in neonates and children with ammonia levels > 500 µmol/L or even at lower levels if there has been an inadequate response to medical management after 4 hours. Alternatively, but only in centers that lack ability or expertise to perform extracorporeal therapy, peritoneal dialysis can be utilized. The hallmarks of dialysis is rapid lowering of plasma ammonia concentration to avoid neurotoxicity and irreversible brain damage. Objectives To evaluate the effect of peritoneal dialysis on plasma ammonia levels and the clinical outcome in an encephalopathic Egyptian patient with CTLN1. Patient and Methods A 2.5 year old male patient with a classical form of CTLN1was recruited. The first presenting symptom of the patient was poor suckling and disturbed conscious level at the age of 5 day. He was admitted to neonatal intensive-care unit (NICU) with hyperammonemic encephalopathy and abnormal pattern of breathing. He developed apneic attack and underwent mechanical ventilation. The diagnosis of CTLN1 was established with elevated plasma ammonia concentration (350 µmol/L) and plasma citrulline concentration (2570 µmol/L). The patient was managed with peritoneal dialysis for 4 days, together with protein restriction, sodium benzoate, arginine therapy and high caloric intake. Results Plasma ammonia level was decreased with improvement of general condition and conscious level after dialysis. Upon discharge from NICU, the patient was referred to our Genetic clinic and no history of further hospital admission since then. Mild developmental delay mainly cognitive was noted during his regular clinic follow up. Conclusion CTLN1 can present with hyperammonemic encephalopathy which could be lethal if not promptly managed. Peritoneal dialysis proved to be an effective therapy of reducing plasma ammonia rapidly and improving outcome of the patient.

Partial Clipping Occlusion Including Rupture Point Is an Effective Strategy for Ruptured Giant Fusiform Basilar Artery Aneurysm: A Technical Case Report

Treatment of fusiform basilar artery aneurysms is still challenging today. The authors present a case of a patient with a ruptured giant fusiform basilar artery aneurysm successfully treated by clipping occlusion of the rupture point. A 62-year-old man suddenly fell into a coma due to subarachnoid hemorrhage (SAH) with a ruptured giant fusiform basilar artery aneurysm with a bleb on the right shoulder. We considered treating the lesion with stent-assisted coil embolization because of the aneurysm's shape, but we had to give up because stents were off-label in the acute phase SAH in our country. Instead, we successfully performed clipping surgery to partially occlude the aneurysm, including the rupture point via the anterior transpetrosal approach. His postoperative course was uneventful, without rerupture of the aneurysm, and his conscious level tended to improve. The postoperative imaging studies showed no complications and disappearance of the rupture point of the aneurysm. Although direct surgery for the giant fusiform basilar artery aneurysms is one of the challenging operations, it is an essential and highly effective treatment as a last resort for complex aneurysms if other treatments are not available.

Fluctuations in Neural Complexity During Wakefulness Relate To Conscious Level and Cognition

There has been considerable recent progress in measuring conscious level using neural complexity measures. For instance, such measures can reliably distinguish healthy awake from asleep subjects and vegetative state patients. However, this line of research has never explored the dynamics of conscious level during normal wakefulness. Being able to capture meaningful differences in conscious level during wakefulness may provide a vital new insight into the nature of consciousness, by demonstrating what biological, behavioural and cognitive factors relate to such differences. Here we take advantage of a large MEG and fMRI dataset of healthy adults, to examine within-subject conscious level fluctuations during resting state and tasks, by using a range of complexity measures. We first establish the validity of this approach in both neuroimaging domains by relating neural complexity measures to pre-existing techniques for capturing transitions of consciousness from full wakefulness into drowsiness and the earliest stages of sleep, finding decreased complexity as participants become increasingly drowsy. We further demonstrate that neural complexity measures in both MEG and fMRI change both within and between tasks, and relate to performance on an executive task, with higher complexity associated with better performance and faster reaction times. This approach provides a powerful new route to further explore the cognitive and neural underpinnings of consciousness.

Cerebral lipiodol embolisation

Cerebral lipiodol embolisation is a rare but serious complication of lymphangiography. A man in his seventies had undergone lymphangiography for a refractory chyle leak following oesophagectomy. The day after lymphangiography, his conscious level dropped with bilaterally miotic pupils, increased muscle tone and double incontinence. CT scan of the head showed patchy high density throughout basal ganglia, cortex and cerebellum but no infarct, in keeping with lipiodol embolisation. He was managed initially in intensive care and subsequently underwent thoracoscopy with clipping and suturing of the left thoracic duct, and later a talc pleurodesis. At 3 months, he had some cognitive limitations and was walking with a stick.

Unmet need of essential treatments for critical illness in Malawi

Background Critical illness is common throughout the world and has been the focus of a dramatic increase in attention during the COVID-19 pandemic. Severely deranged vital signs such as hypoxia, hypotension and low conscious level can identify critical illness. These vital signs are simple to check and treatments that aim to correct derangements are established, basic and low-cost. The aim of the study was to estimate the unmet need of such essential treatments for severely deranged vital signs in all adults admitted to hospitals in Malawi. Methods We conducted a point prevalence cross-sectional study of adult hospitalized patients in Malawi. All in-patients aged ≥18 on single days Queen Elizabeth Central Hospital (QECH) and Chiradzulu District Hospital (CDH) were screened. Patients with hypoxia (oxygen saturation <90%), hypotension (systolic blood pressure <90mmHg) and reduced conscious level (Glasgow Coma Scale <9) were included in the study. The a-priori defined essential treatments were oxygen therapy for hypoxia, intravenous fluid for hypotension and an action to protect the airway for reduced consciousness (placing the patient in the lateral position, insertion of an oro-pharyngeal airway or endo-tracheal tube or manual airway protection). Results Of the 1135 hospital in-patients screened, 45 (4.0%) had hypoxia, 103 (9.1%) had hypotension, and 17 (1.5%) had a reduced conscious level. Of those with hypoxia, 40 were not receiving oxygen (88.9%). Of those with hypotension, 94 were not receiving intravenous fluids (91.3%). Of those with a reduced conscious level, nine were not receiving an action to protect the airway (53.0%). Conclusion There was a large unmet need of essential treatments for critical illness in two hospitals in Malawi.

Investigating racing thoughts via ocular temporal windows: deficits in the control of automatic perceptual processes

Background Racing thoughts have been found in several states of bipolar disorder (BD), but also in healthy populations with subclinical mood alterations. The evaluation of racing thoughts relies on subjective reports, and objective measures are sparse. The current study aims at finding an objective neuropsychological equivalent of racing thoughts in a mixed group of BD patients and healthy controls by using a bistable perception paradigm. Method Eighty-three included participants formed three groups based on participants' levels of racing thoughts reported via the Racing and Crowded Thoughts Questionnaire. Participants reported reversals in their perception during viewing of the bistable Necker cube either spontaneously, while asked to focus on one interpretation of the cube, or while asked to accelerate perceptual reversals. The dynamics of perceptual alternations were studied both at a conscious level (with manual temporal windows reflecting perceptual reversals) and at a more automatic level (with ocular temporal windows derived from ocular fixations). Results The rate of windows was less modulated by attentional conditions in participants with racing thoughts, and most clearly so for ocular windows. The rate of ocular windows was especially high when participants with racing thoughts were asked to focus on one interpretation of the Necker cube and when they received these instructions for the first time. Conclusions Our results indicate that in subjects with racing thoughts automatic perceptual processes escape cognitive control mechanisms. Racing thoughts may involve not only conscious thought mechanisms but also more automatic processes.

Cerebral air embolism after indwelling pleural catheter insertion in a chronic hydropneumothorax secondary to epithelioid mesothelioma

A 75-year-old man with a history of epithelioid mesothelioma and a right-sided indwelling pleural catheter (IPC) presented with a history of a purulent fluid drainage via the IPC. The pleural fluid cultured Klebsiella oxytoca and Enterococcus faecalis. He was treated with a course of oral fluoroquinolone followed by uneventful IPC replacement. One and half hours postprocedure, the patient had a witnessed drop in conscious level accompanied by seizure like activity. Acute stroke was suspected and a CT head was performed. CT head revealed multiple serpiginous pockets of air along the cerebral fissure, with features that were highly suggestive of cerebral air embolism and multiple wedge-shaped areas of infarction involving the cerebral hemispheres. Further imaging revealed satisfactory position of the replaced IPC. The patient was admitted to the intensive care unit for high flow oxygen therapy and head down ventilation. However, his condition deteriorated and he died later.

A Jungian Analysis of the Chinese Kitchen God Image

This article studies the impact of Kitchen God beliefs and worship on Chinese mentality and behavior, both consciously and unconsciously. At the conscious level, the evolution of the Kitchen God beliefs has gone through four stages; Nature God, Animal God, Half-animal/Half human God, and finally Human God. The evolution of the Kitchen God in China displays the features of a couple, aging and secularization. The experience of “returning to the sacred origin” can be obtained through Kitchen God worship by burning an old paper image of the Kitchen God and pasting of a new one of him beside the kitchen stove year after year during the Kitchen God festival. The secret to continuity of life lies in repetition. The image of the Kitchen God as an important graphic symbol is formed by a constellation of images; good pot and evil pot, two dragons playing with a bead, rooster and dog, the psychological archetypes as yin and yang, unity of opposites, transformation and integration. This ritual serves as a bridge between Chinese people and their “ancestors,” “the other realm” (nirvana), and “the Self.” On an unconscious level, the psychological significance of Kitchen God beliefs is analyzed through “the family hexagram.” The collective unconscious for the Chinese can be revealed by a continuous pattern of concentric circles structure, that is, “heaven and earth—the Kitchen God—ancestors—parents—offspring.” Through a clinical case using Sandplay Therapy, this article will show that Kitchen God imagery unconsciously shows the constellation of “family.” Family is the place of belonging and home for Chinese people, helping the client return to his inner source and gain strength through acceptance and transformation. The implication of Kitchen God beliefs for today’s Chinese society is to return to the most primitive “Tao,” which presents a possible cure for many kinds of psychological problems we are facing. It suggests that researchers pay attention to the psychological phenomenon of clients’ using the Kitchen God image to express their cultural feelings toward family in psychological practice.