Program

P033

Poster

Cerebral diffusion tensor imaging, awakening, consciousness recovery prognosis in comatose patients and physical and rehabilitation medicine: a case report

Mr Basile WITTWERa, Dr Alice FRASERb, Dr Loïc LE CHAPELAINb, Dr Nathalie KHALILb, Dr Sophie PLANELc, Dr Jean-Marie BEISb, Prof Jean PAYSANTb

a CHU NANCY, Service de Neurologie, b IRR Nancy CMPR Lay-Saint-Christophe, c CHU NANCY, Service de Neuroradiologie

Introduction:

Evolution of comatose patients can be made either towards a persistent vegetative state (or unresponsive wakefulness syndrome - UWS), minimally conscious state or a recovery of self and environment awareness. Investigations remain insufficient to estimate the prognosis and optimize the orientation and long-term follow-up of these patients in physical and rehabilitation medicine (PRM). Multimodal magnetic resonance imaging (MRI), are being evaluated for the diagnosis and prognosis of altered consciousness states (1,2). Diffusion tensor imaging (DTI) could predict the mid-term evolution within a 95% specificity.

Case report

A 29-years-old woman gives birth by vaginal delivery (pre-eclampsia) with the onset of a HELLP syndrome. At 4 A.M., comatose state (GCS: 3/5). TDM showed a parenchymal pontine and midbrain hematoma. No sign of awakening. The brain MRI (M3) showed atrophy (pons, midbrain, and middle cerebellar peduncles). DTI sequence with tractography shows a complete interruption of the left corticospinal tract as well as a rarefaction of inferior cerebellar peduncle fibers. The patient occasionally opens her eyes, without eye-tracking or other awakening sign (M10). The question then arises of the orientation of this patient in a persistent vegetative states unit and the future taking care by PRM team.

Discussion

DTI MRI with measure of anisotropy fraction could be a promising tool in order to predict the prognosis of altered conscious states and optimize the orientation and long-term follow-up of these patients in PRM.

References

1. Galanaud, D. et al. Assessment of white matter injury and outcome in severe brain trauma: a prospective multicenter cohort. Anesthesiology 117, 1300-1310 (2012).

2. Huisman, T. A. G. M. et al. Diffusion tensor imaging as potential biomarker of white matter injury in diffuse axonal injury. AJNR Am J Neuroradiol 25, 370-376 (2004).

3. Irimia, A. et al. Neuroimaging of structural pathology and connectomics in traumatic brain injury: Toward personalized outcome prediction. Neuroimage Clin 1, 1-17 (2012).

4. Luyt, C.-E. et al. Diffusion tensor imaging to predict long-term outcome after cardiac arrest: a bicentric pilot study. Anesthesiology 117, 1311-1321 (2012)

Keywords : Coma ; awakening ; MRI ; diffusion tension imaging