Precision Medicine for Traumatic Coma
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INVITED COMMENTARY
Precision Medicine for Traumatic Coma Yousef Hannawi1 and Robert D. Stevens2* © 2020 Springer Science+Business Media, LLC, part of Springer Nature and Neurocritical Care Society
Trauma is a leading cause of severe neurological injury and the primary etiology in many patients with disorders of consciousness (DOC) [1]. Neurological recovery following traumatic coma is a multidimensional process that involves the reemergence of wakefulness, awareness, sensorimotor function, higher-order cognitive domains, and the progressive restoration of functional independence [2]. When recovery of consciousness fails or is delayed, patients can present with severely impaired phenotypes such as the unresponsive wakefulness or minimally conscious states [2]. The lack of accurate prognostic models to predict the trajectory of recovery following severe traumatic brain injury (TBI) is widely recognized as a major unmet need in intensive care medicine. Additionally, in spite of decades of translational and clinical research, there are no therapeutic interventions that can effectively change the natural history of traumatic coma recovery. In the face of uncertainty, family members and medical teams may elect to withdraw or maintain lifesustaining therapies on the basis of false assumptions and self-fulfilling prophecies [3, 4]. Advances in image acquisition, brain mapping and network science have emerged as major opportunities to not only gain insights on the biological mechanisms of TBI, but also to increase the accuracy of recovery prediction and, perhaps most importantly, to identify targets for therapy [5]. Two innovations have been particularly impactful. Diffusion tensor imaging (DTI) has provided a window on the precise anatomical distribution and prognostic importance of traumatic white matter damage [6]. Resting state functional MRI (rs-fMRI) has shown that *Correspondence: [email protected] 2 Division of Neuroscience Critical Care, Departments of Anesthesiology and Critical Care Medicine, Neurology, Neurosurgery, and Radiology, Johns Hopkins University School of Medicine, 600N. Wolfe St, Phipps 455, Baltimore, MD 21287, USA Full list of author information is available at the end of the article
This article refers to the original article: https://doi.org/10.1007/s1202 8-020-01062-7.
the architecture of topographically distinct large-scale networks is massively disrupted after severe brain injury [7]. Additionally, recent work has found that connectivity strength within and between resting-state networks is predictive of long-term functional outcome following severe neurological insults such as anoxic brain injury [8]. These findings support MRI-derived structural and functional connectivity indices as versatile biomarkers in unresponsive patients. In this issue of Neurocritical Care, Edlow et al. [9] propose a clinical trial platform for comatose patients who are in the ICU following severe TBI. Their overarching aim is to identify specific brain connectivity signatures that would guide interventions to
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