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See detailFunctional connectivity in the default network during resting state is preserved in a vegetative but not in a brain dead patient.
Boly, Mélanie ULg; Tshibanda, Luaba ULg; Vanhaudenhuyse, Audrey ULg et al

in Human Brain Mapping (2009), 30(8), 2393-400

Recent studies on spontaneous fluctuations in the functional MRI blood oxygen level-dependent (BOLD) signal in awake healthy subjects showed the presence of coherent fluctuations among functionally ... [more ▼]

Recent studies on spontaneous fluctuations in the functional MRI blood oxygen level-dependent (BOLD) signal in awake healthy subjects showed the presence of coherent fluctuations among functionally defined neuroanatomical networks. However, the functional significance of these spontaneous BOLD fluctuations remains poorly understood. By means of 3 T functional MRI, we demonstrate absent cortico-thalamic BOLD functional connectivity (i.e. between posterior cingulate/precuneal cortex and medial thalamus), but preserved cortico-cortical connectivity within the default network in a case of vegetative state (VS) studied 2.5 years following cardio-respiratory arrest, as documented by extensive behavioral and paraclinical assessments. In the VS patient, as in age-matched controls, anticorrelations could also be observed between posterior cingulate/precuneus and a previously identified task-positive cortical network. Both correlations and anticorrelations were significantly reduced in VS as compared to controls. A similar approach in a brain dead patient did not show any such long-distance functional connectivity. We conclude that some slow coherent BOLD fluctuations previously identified in healthy awake human brain can be found in alive but unaware patients, and are thus unlikely to be uniquely due to ongoing modifications of conscious thoughts. Future studies are needed to give a full characterization of default network connectivity in the VS patients population. [less ▲]

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See detailDifferent beliefs about pain perception in the vegetative and minimally conscious states: a European survey of medical and paramedical professionals.
Demertzi, Athina ULg; Schnakers, Caroline ULg; Ledoux, Didier ULg et al

in Progress in Brain Research (2009), 177

Pain management in severely brain-damaged patients constitutes a clinical and ethical stake. At the bedside, assessing the presence of pain and suffering is challenging due to both patients' physical ... [more ▼]

Pain management in severely brain-damaged patients constitutes a clinical and ethical stake. At the bedside, assessing the presence of pain and suffering is challenging due to both patients' physical condition and inherent limitations of clinical assessment. Neuroimaging studies support the existence of distinct cerebral responses to noxious stimulation in brain death, vegetative state, and minimally conscious state. We here provide results from a European survey on 2059 medical and paramedical professionals' beliefs on possible pain perception in patients with disorders of consciousness. To the question "Do you think that patients in a vegetative state can feel pain?," 68% of the interviewed paramedical caregivers (n=538) and 56% of medical doctors (n=1166) answered "yes" (no data on exact profession in 17% of total sample). Logistic regression analysis showed that paramedical professionals, religious caregivers, and older caregivers reported more often that vegetative patients may experience pain. Following professional background, religion was the highest predictor of caregivers' opinion: 64% of religious (n=1009; 850 Christians) versus 52% of nonreligious respondents (n=830) answered positively (missing data on religion in 11% of total sample). To the question "Do you think that patients in a minimally conscious state can feel pain?" nearly all interviewed caregivers answered "yes" (96% of the medical doctors and 97% of the paramedical caregivers). Women and religious caregivers reported more often that minimally conscious patients may experience pain. These results are discussed in terms of existing definitions of pain and suffering, the remaining uncertainty on the clinical assessment of pain as a subjective first-person experience and recent functional neuroimaging findings on nociceptive processing in disorders of consciousness. In our view, more research is needed to increase our understanding of residual sensation in vegetative and minimally conscious patients and to propose evidence-based medical guidelines for the management of possible pain perception and suffering in these vulnerable patient populations. [less ▲]

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See detailDiagnostic accuracy of the vegetative and minimally conscious state: clinical consensus versus standardized neurobehavioral assessment.
Schnakers, Caroline ULg; Vanhaudenhuyse, Audrey ULg; Giacino, Joseph et al

in BMC Neurology (2009), 9

BACKGROUND: Previously published studies have reported that up to 43% of patients with disorders of consciousness are erroneously assigned a diagnosis of vegetative state (VS). However, no recent studies ... [more ▼]

BACKGROUND: Previously published studies have reported that up to 43% of patients with disorders of consciousness are erroneously assigned a diagnosis of vegetative state (VS). However, no recent studies have investigated the accuracy of this grave clinical diagnosis. In this study, we compared consensus-based diagnoses of VS and MCS to those based on a well-established standardized neurobehavioral rating scale, the JFK Coma Recovery Scale-Revised (CRS-R). METHODS: We prospectively followed 103 patients (55 +/- 19 years) with mixed etiologies and compared the clinical consensus diagnosis provided by the physician on the basis of the medical staff's daily observations to diagnoses derived from CRS-R assessments performed by research staff. All patients were assigned a diagnosis of 'VS', 'MCS' or 'uncertain diagnosis.' RESULTS: Of the 44 patients diagnosed with VS based on the clinical consensus of the medical team, 18 (41%) were found to be in MCS following standardized assessment with the CRS-R. In the 41 patients with a consensus diagnosis of MCS, 4 (10%) had emerged from MCS, according to the CRS-R. We also found that the majority of patients assigned an uncertain diagnosis by clinical consensus (89%) were in MCS based on CRS-R findings. CONCLUSION: Despite the importance of diagnostic accuracy, the rate of misdiagnosis of VS has not substantially changed in the past 15 years. Standardized neurobehavioral assessment is a more sensitive means of establishing differential diagnosis in patients with disorders of consciousness when compared to diagnoses determined by clinical consensus. [less ▲]

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See detailBehavioral Assessment in Patients with Disorders of Consciousness: Gold Standard or Fool’s Gold?
Schnakers, Caroline ULg; Giacino, Joseph; Rodriguez-Moreno et al

in Progress in Brain Research (2009), 177

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See detailAssessment of visual pursuit in post-comatose states: use a mirror
Vanhaudenhuyse, Audrey ULg; Schnakers, Caroline ULg; Brédart, Serge ULg et al

in Journal of Neurology, Neurosurgery & Psychiatry (2008), 79(2),

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See detailSleep modulates the neural substrates of both spatial and contextual memory consolidation
Rauchs, G; Orban, P; Schmidt, Christina ULg et al

in PLoS ONE (2008), 3(8), 2949

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See detailLe Locked-In Syndrome : la conscience emmurée
Bruno, Marie-Aurélie ULg; Pellas, F.; Schnakers, Caroline ULg et al

in Revue Neurologique (2008), 164

The Locked-In syndrome(LIS) is defined by: (i) the presence of sustained eye opening (bilateral ptosis should be ruled out as a complicating factor);(ii) preserved awareness; (iii) aphonia or hypophonia ... [more ▼]

The Locked-In syndrome(LIS) is defined by: (i) the presence of sustained eye opening (bilateral ptosis should be ruled out as a complicating factor);(ii) preserved awareness; (iii) aphonia or hypophonia; (iv) quadriplegia or quadriparesis; and (v) a primary mode of communication that uses vertical or lateral eye movement or blinking. Acute ventral pontine lesions are its most common cause. Following such brainstem lesions patients may remain comatose for sometime and then gradually awaken, remaining paralyzed and voiceless, superficially resembling the vegetative state. Background. – It has been shown that more than half of the time physicians fail to recognize early signs of awareness in LIS. Given appropriate medical care,life expectancy may be several decades but the chances of good motor recovery remain small. Eye-controlled computer technology now allows LIS patients to communicate and control their environment. Recent studies show that most LIS patients self-report meaningful quality of life and the demand for euthanasia is infrequent. Conclusion. – Patients suffering from LIS should not be denied the right to die – and to die with dignity –but also they should not be denied the right to live–and to live with dignity and the best possible pain and symptom management and revalidation. [less ▲]

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See detailConsciousness and cerebral baseline activity fluctuations
Boly, Mélanie ULg; Phillips, Christophe ULg; Balteau, Evelyne ULg et al

in Human Brain Mapping (2008), 29

The origin of within-subject variability in perceptual experiments is poorly understood. We here review evidence that baseline brain activity in the areas involved in sensory perception predict subsequent ... [more ▼]

The origin of within-subject variability in perceptual experiments is poorly understood. We here review evidence that baseline brain activity in the areas involved in sensory perception predict subsequent variations in sensory awareness. We place these findings in light of recent findings on the architecture of spontaneous BOLD fluctuations in the awake human brain, and discuss the possible origins of the observed baseline brain activity fluctuations. [less ▲]

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See detailExperiences de mort imminente: phenomenes paranormaux ou neurologiques?
Thonnard, Marie ULg; Schnakers, Caroline ULg; Boly, Mélanie ULg et al

in Revue Médicale de Liège (2008), 63(5-6), 438-44

Seeing a bright light at the end of a tunnel or having a sense of being out of the physical body are phenomena that some patients report after having been close to death. Some spiritual and psychological ... [more ▼]

Seeing a bright light at the end of a tunnel or having a sense of being out of the physical body are phenomena that some patients report after having been close to death. Some spiritual and psychological theories have been developed in order to explain these near-death-experiences. Clinical studies have aimed to determine their frequency and to assess their precipitating factors. Recent neuroimaging studies, however, have shown the involvement of the temporo-parietal cortex in the generation of out-of-body experiences and are offering a physiological, neurological account for the phenomenon, rebuffing dualistic, non-physical explanations. [less ▲]

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See detailIs there anybody in there? Detecting awareness in disorders of consciousness.
Demertzi, Athena; Vanhaudenhuyse, Audrey ULg; Bruno, Marie-Aurelie et al

in Expert Review of Neurotherapeutics (2008), 8(11), 1719-30

The bedside detection of awareness in disorders of consciousness (DOC) caused by acquired brain injury is not an easy task. For this reason, differential diagnosis using neuroimaging and ... [more ▼]

The bedside detection of awareness in disorders of consciousness (DOC) caused by acquired brain injury is not an easy task. For this reason, differential diagnosis using neuroimaging and electrophysiological tools in search for objective markers of consciousness is being employed. However, such tools cannot be considered as diagnostic per se, but as assistants to the clinical evaluation, which, at present, remains the gold standard. Regarding therapeutic management in DOC, no evidence-based recommendations can be made in favor of a specific treatment. The present review summarizes clinical and paraclinical studies that have been conducted with neuroimaging and electrophysiological techniques in search of residual awareness in DOC. We discuss the medical, scientific and ethical implications that derive from these studies and we argue that, in the future, the role of neuroimaging and electrophysiology will be important not only for the diagnosis and prognosis of DOC but also in establishing communication with these challenging patients. [less ▲]

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See detailA twitch of consciousness: defining the boundaries of vegetative and minimally conscious states.
Noirhomme, Quentin ULg; Schnakers, Caroline ULg; Laureys, Steven ULg

in Journal of Neurology, Neurosurgery & Psychiatry (2008), 79(7), 741-2

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See detailLocked-in: don't judge a book by its cover.
Bruno, Marie-Aurélie ULg; Bernheim, J. L.; Schnakers, Caroline ULg et al

in Journal of Neurology, Neurosurgery & Psychiatry (2008), 79(1), 2

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See detailVoluntary brain processing in disorders of consciousness
Schnakers, Caroline ULg; Perrin, F.; Schabus, M. et al

in Neurology (2008), 71(20), 1614-1620

Background: Disentangling the vegetative state from the minimally conscious state is often difficult when relying only on behavioral observation. In this study, we explored a new active evoked related ... [more ▼]

Background: Disentangling the vegetative state from the minimally conscious state is often difficult when relying only on behavioral observation. In this study, we explored a new active evoked related potentials paradigm as an alternative method for the detection of voluntary brain activity. Methods: The participants were 22 right-handed patients (10 traumatic) diagnosed as being in a vegetative state (VS) (n 8) or in a minimally conscious state (MCS) (n 14). They were presented sequences of names containing the patient’s own name or other names, in both passive and active conditions. In the active condition, the patients were instructed to count her or his own name or to count another target name. Results: Like controls, MCS patients presented a larger P3 to the patient’s own name, in the passive and in the active conditions. Moreover, the P3 to target stimuli was higher in the active than in the passive condition, suggesting voluntary compliance to task instructions like controls. These responses were even observed in patients with low behavioral responses (e.g., visual fixationand pursuit). In contrast, no P3 differences between passive and active conditions were observed for VS patients. Conclusions: The present results suggest that active evoked-related potentials paradigms may permit detection of voluntary brain function in patients with severe brain damage who present with a disorder of consciousness, even when the patient may present with very limited to questionablyany signs of awareness. [less ▲]

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See detailBewusstseinsstörungen - Diagnose und Prognose
Laureys, Steven ULg; FAYMONVILLE, Marie-Elisabeth ULg; BOLY, Mélanie ULg et al

in Junginger, T. (Ed.) Grenzsituationen der Intensivmedizin-Entscheidungsgrundlagen (2008)

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See detailRevelations from the unconscious: studying residual brain function in coma and related states.
Laureys, Steven ULg; Boly, Mélanie ULg; Schnakers, Caroline ULg et al

in Bulletin et Mémoires de l'Académie Royale de Médecine de Belgique (2008), 163(7-9), 381-8388-90

The purpose of our research is to contribute to a better understanding of the residual brain function of patients who survive an acute brain damage but remain in a coma, vegetative state, minimally ... [more ▼]

The purpose of our research is to contribute to a better understanding of the residual brain function of patients who survive an acute brain damage but remain in a coma, vegetative state, minimally conscious state or locked-in syndrome. The diagnosis, prognosis, therapy and medical management of these patients remain difficult. These studies are also of interest scientifically, as they help to elucidate the neural correlates of human consciousness. We here review our studies on bedside behavioral evaluation scales, electrophysiology and functional neuroimaging in these disorders of consciousness and conclude by discussing methodological and ethical issues and current concepts of the standards for care and quality of life in these challenging conditions. [less ▲]

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See detailHypnose et perception de la douleur
Vanhaudenhuyse, Audrey ULg; Boveroux, Pierre ULg; Boly, Mélanie ULg et al

in Revue Médicale de Liège (2008), 63(5-6), 424-8

Improvement in functional neuroimaging allows researchers to disentangle the brain mechanisms involved in the pain modulation encountered during hypnosis. It has been shown that the anterior cingulate and ... [more ▼]

Improvement in functional neuroimaging allows researchers to disentangle the brain mechanisms involved in the pain modulation encountered during hypnosis. It has been shown that the anterior cingulate and prefrontal cortices are important in the modulation of incoming sensory and noxious input. Moreover, clinical studies in certain types of surgery (eg thyroidectomy, mastectomy and plastic surgery) have demonstrated that hypnosis may avoid general anesthesia. [less ▲]

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See detailMesurer la douleur chez le patient non communicant.
Chatelle, Camille ULg; Vanhaudenhuyse, Audrey ULg; Mergam, Anne-Nora ULg et al

in Revue Médicale de Liège (2008), 63(5-6), 429-37

Pain is a subjective experience. Its assessment is based on the subject's direct verbal report. This method of assessment is, however, impossible in patients who cannot communicate their feelings. In this ... [more ▼]

Pain is a subjective experience. Its assessment is based on the subject's direct verbal report. This method of assessment is, however, impossible in patients who cannot communicate their feelings. In this context, indirect measurements such as behavioral observations or physiological measurements are needed. To facilitate the assessment of pain in non-communicative patients, numerous standardized behavioral scales have been developed. The aim of this review is to discuss the main validated pain scales employed in end-stage dementia, newborn and preverbal children, and severely brain damaged patients with a disorder of consciousness such as coma, the vegetative state or the minimally conscious state. [less ▲]

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See detailMeasuring the effect of amantadine in chronic anoxic minimally conscious state.
Schnakers, Caroline ULg; Hustinx, Roland ULg; Vandewalle, Gilles ULg et al

in Journal of Neurology, Neurosurgery & Psychiatry (2008), 79(2), 225-7

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