Proving cortical death after vascular coma: Evoked potentials, EEG and neuroimaging. Issue 6 (June 2018) - Gobert, Florent
Highlights: In vascular coma, a bilateral and multimodal abolition of cortical evoked potentials (EPs) does not exclude awakening. EEG reactivity may complete EPs in demonstrating cortical viability after sub-cortical lesions. The initial vascular lesion can induce a pseudo-anoxic coma with the same pattern and evolution. Abstract: Objectives: Several studies have shown that bilateral abolition of somatosensory evoked potentials after a nontraumatic coma has 100% specificity for nonawakening with ethical consequences for active care withdrawal. We propose to evaluate the prognostic value of bilateral abolished cortical components of SEPs in severe vascular coma. Methods: A total of 144 comatose patients after subarachnoid haemorrhage were evaluated by multimodal evoked potentials (EPs); 7 patients presented a bilateral abolition of somatosensory and auditory EPs. Their prognosis value was interpreted with respect to brainstem auditory EPs, EEG, and structural imaging. Results: One patient emerged from vegetative state during follow-up; 6 patients did not return to consciousness. The main neurophysiological difference was a cortical reactivity to pain preserved in the patient who returned to consciousness. This patient had focal sub-cortical lesions, which could explain the abolition of primary cortical components by a bilateral deafferentation of somatosensory and auditory pathways. Conclusions: This is the first report of a favourable outcome after a multimodal abolition of primary cortex EPs in vascular coma. For the 3 cases of vascular coma with preserved brainstem function, EEG reactivity and cortical EPs were abolished by a diffuse ischaemia close to cerebral anoxia. Significance: The complementarity of EPs, EEG, and imaging must be emphasised if therapeutic limitations are considered to avoid over-interpretation of the prognosis value of EPs.