A roundtable discussion at the ISICEM Congress in Brussels on disorders of consciousness (DoC) focused on enhancing understanding, diagnosis, and prognosis for patients in ICUs.
The main takeaway is that disorders of consciousness represent a continuum, and diagnoses should not be limited to binary terms like "coma" or "awake." These states can involve complex cognitive-motor dissociation, where patients maintain cognitive function but show no motor response. The importance of improving early diagnosis and prognosis was highlighted, with a focus on avoiding errors, as families often feel misinformed about their loved ones' conditions.
The traditional Glasgow Coma Scale is insufficient for detecting subtle signs of consciousness. Advances in imaging, like functional MRI and electrophysiology, have shown that some patients, though unresponsive at the bedside, can exhibit cognitive responses when assessed with these technologies. Cognitive motor dissociation has become increasingly recognised, but there are still gaps in our understanding and tools for detecting this condition. More standardised assessments are needed to improve accuracy and avoid misdiagnosis. Clinicians are encouraged to identify treatable causes of DoC, maximise arousal prior to behavioral assessments, and avoid confounders like sedation.
Currently, there are no definitive treatments for enhancing recovery from acute DoC. While some pharmacological and neuromodulatory interventions are under development, evidence remains insufficient. However, optimising medical management to prevent complications and initiating early rehabilitation in the ICU has shown promise for improving outcomes. Family involvement in early rehabilitation is encouraged when safe. There's also a call for consensus on clinical guidelines for ICU interventions.
Outcomes for patients with DoC vary widely, from full recovery to prolonged vegetative states or death. Early withdrawal of life-sustaining treatment is common, but it can confound studies and decisions, as patients might still have the potential for recovery. Accurate prognostication is challenging due to the lack of standardised methods. Clinicians are advised to practice humility, avoid hasty prognostic decisions, and communicate the uncertainty of outcomes to families. Shared decision-making is essential, and ongoing evaluation of prognosis throughout the ICU stay is critical.
The roundtable emphasised the need for collaboration across disciplines to improve understanding of DoC. Key future goals include developing common data elements, identifying pathophysiological mechanisms, and enhancing clinical trial designs. Advancements in AI and precision medicine hold promise for better patient outcomes. It's crucial to remain updated on this rapidly evolving field, refine clinical exams, and continue to support families with clear and empathetic communication.
In conclusion, improving diagnosis, treatment, and prognosis for patients with DoC will require continued research, better assessment tools, and greater collaboration between clinicians and researchers. The importance of shared decision-making and the need to be cautious in prognostication were key takeaways from the discussions.
Source: ISICEM 2025 Roundtable Conference
Image Credit: ISICEM 2025
