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Disorders of Consciousness Clinical Practice Guidelines

(2018)
American Academy of Neurology, American Congress of Rehabilitation Medicine, and
National Institute on Disability, Independent Living, and Rehabilitation Research

Reviewed and summarized by Medscape editors

September 14, 2018

Guidelines were released on August 8, 2018, by the American Academy of Neurology, American Congress of
Rehabilitation Medicine, and National Institute on Disability, Independent Living, and Rehabilitation Research.[1,2]

Use standard neurobehavioral assessment scales, such as those recommended by the American Congress of
Rehabilitation Medicine (ACRM), as opposed to bedside examination.

Conduct serial assessments, with reassessment dependent on individual circumstances; if ambiguity continues,
multimodal imaging and electrophysiologic evaluations should be used.

If clinical examination does not reveal evidence of consciousness but preserved conscious awareness is
suggested by neuroimaging or electrophysiologic testing, conduct frequent neurobehavioral reevaluations.

Avoid statements such as these patents have a universally poor prognosis when discussing prognosis with
caregivers during the first 28 days after injury.

Perform serial standardized behavioral evaluations to identify trends in recovery.

In patients with posttraumatic vegetative state (VS) or unresponsive wakefulness syndrome (UWS), after 2 to 3
months after injury, use the Disability Rating Scale; the presence of P300; or electroencephalography reactivity for
prognosis of 12-month recovery of consciousness.

At 6 to 8 weeks and 1 to 2 months after injury, perform MRI and single-photon emission computed tomography
(SPECT), respectively, for prognosis of recovery of consciousness and degree of disability or recovery at 12
months.

Coma Recovery Scale–Revised in nontraumatic, postanoxic VS/UWS and somatosensory evoked potentials can
assist in prognosis of recovery of consciousness at 24 months.

Patients with nontraumatic VS/UWS often recover consciousness after 3 months; and patients with traumatic
VS/UWS, after 12 months. At this point, the term "permanent VS" should not be used, and instead, "chronic
VS/UWS" should be used.

Explain to families that minimally conscious states (MCSs) that are diagnosed within 5 months of injury and are
caused by trauma are associated with more favorable outcomes, and VS/UWS and nontraumatic disorders of
consciousness (DoC) causes are associated with poorer outcomes. Prognosis, however, is not universally poor.

At the point of the chronic phase of VS/UWS (3 months after nontraumatic brain injury [TBI]; 12 months after TBI),
emphasize the likelihood of permanent severe disability and need for long-term assistive care.

If there are no medical contraindications, patients with traumatic VS/UWS or MCS at 4 to 16 weeks after injury
should receive amantadine at a dosage of 100 to 200 mg twice daily.

In children with prolonged DoC, clinicians should treat confounding conditions, increase arousal before diagnostic
assessments, use reliable standardized behavioral assessments, and conduct serial assessments.
Inform families that there are no established treatments for children with prolonged DoC.

References

1. Yasgur BS. New Guidelines for Minimally Conscious, Vegetative States Releases. Medscape Medical
News. WebMD Inc. August 9, 2018. https://www.medscape.com/viewarticle/900462

2. Giacino JT, Katz DI, Schiff ND, et al. Practice Guideline Update Recommendations Summary: Disorders of
Consciousness. Report of the Guideline Development, Dissemination, and Implementation Subcommittee of
the American Academy of Neurology; the American Congress of Rehabilitation Medicine; and the National
Institute on Disability, Independent Living, and Rehabilitation Research. Neurology. 2018 Aug 8.
http://n.neurology.org/content/neurology/early/2018/08/08/WNL.0000000000005926.full.pdf

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Any views expressed above are the author's own and do not necessarily reflect the views of WebMD or Medscape.

Cite this: Disorders of Consciousness Clinical Practice Guidelines (2018) - Medscape - Sep 14, 2018.