AAN: new guidelines for minimally conscious and vegetative states

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Takeaway

  • American Academy of Neurology (AAN) has updated 1995 practice guideline on persistent vegetative state (VS) and 2002 case definition of minimally conscious state (MCS) and provided recommendations for managing prolonged disorders of consciousness (DoC) (≥28 days).

Why this matters

Key results

  • 18 recommendations.
  • Key recommendations among them are:
    • Identify and treat confounding conditions, optimize arousal, and perform serial standardized assessments to improve diagnostic accuracy in patients with prolonged DoC.
    • Counsel families that for adults, MCS (vs VS/UWS) and traumatic (vs nontraumatic) etiology have better outcomes.
    • When prognosis is poor, discuss long-term care and acknowledge prognostic uncertainty.
    • Use structural MRI, SPECT, and the Coma Recovery Scale–Revised to aid prognostication in adults; no tests are helpful in children.
    • Assess and treat pain; discuss supporting evidence.
    • Prescribe amantadine (Symmetrel, others) for adults with traumatic VS/UWS or MCS to speed functional recovery and reduce early disability.
    • Acknowledge that natural history of recovery, prognosis, and treatment in children are not established.

Expert comments

  • Accompanying essay: “If its recommendations are heeded, the Guideline will be viewed as a historic work that helped transform the care of patients with DoC and deepened society’s appreciation of the ethical mandate to work towards this laudable goal.”

Study design

  • Guideline Development, Dissemination, and Implementation Subcommittee of the AAN; American Congress of Rehabilitation Medicine; National Institute on Disability, Independent Living, and Rehabilitation Research.
  • Sources: systematic review, related data, care principles, inferences.
  • Modified Delphi consensus process was used.
  • Funding: collaborating groups.