Disorders of consciousness after acquired brain injury: the state of the science

Disorders of consciousness (DOC) present clinical challenges of diagnosis and treatment, but also provide unique opportunities for fundamental scientific research into the nature of human consciousness. Giacino et al. review recent advances in the neurobiology, diagnosis and treatment of DOC, including the use of novel neuroimaging and electrophysiological assessments. They also discuss the medicolegal and ethical issues surrounding these advances that will influence the medical care of patients with DOC. The concept of consciousness continues to defy definition and elude the grasp of philosophical and scientific efforts to formulate a testable construct that maps to human experience. Severe acquired brain injury results in the dissolution of consciousness, providing a natural model from which key insights about consciousness may be drawn. In the clinical setting, neurologists and neurorehabilitation specialists are called on to discern the level of consciousness in patients who are unable to communicate through word or gesture, and to project outcomes and recommend approaches to treatment. Standards of care are not available to guide clinical decision-making for this population, often leading to inconsistent, inaccurate and inappropriate care. In this Review, we describe the state of the science with regard to clinical management of patients with prolonged disorders of consciousness. We review consciousness-altering pathophysiological mechanisms, specific clinical syndromes, and novel diagnostic and prognostic applications of advanced neuroimaging and electrophysiological procedures. We conclude with a provocative discussion of bioethical and medicolegal issues that are unique to this population and have a profound impact on care, as well as raising questions of broad societal interest.