Prevalence, semiology and neuroimaging of movements in comatose adults at risk of death by neurologic criteria: a prospective cohort study

Abstract

Abstract Purpose In comatose patients at risk of death by neurologic criteria (DNC), spinal-mediated movements (SMM) and movements of unclear neuroanatomic origin (MUO) are occasionally challenging to discriminate from cerebral-mediated movements. Our objectives were to assess the respective prevalence and semiology of SMM and of MUO in this population and to estimate the associations between these movements with cerebral blood flow and perfusion. Methods In this prospective cohort study conducted in 15 intensive care units across Canada, we enrolled consecutive, brain-injured adults with an unconfounded Glasgow Coma Scale score of 3. Physicians conducted standardized DNC clinical evaluation, and participants underwent a brain CT-perfusion scan with CT-angiography reconstructions within a 2-h delay. We assessed the prevalence and semiology of SMM and MUO with descriptive statistics. We estimated the associations between SMM and MUO with cerebral blood flow and brain perfusion using generalized linear mixed models with a logit link function, age and sex as covariates, and random intercepts for study sites. Results We included 282 participants with a median [IQR] age of 60 [47—69] years. The respective prevalence of SMM and MUO were 27% (95% CI: 22—32%) and 12% (95% CI: 9—16%). SMM and MUO were not associated with the presence of cerebral blood flow on CT-angiography (aOR for SMM: 1.14, 95% CI: 0.63—2.05; aOR for MUO: 1.36, 95% CI: 0.61—3.01) or brain perfusion on CT-perfusion (aOR for SMM: 1.44, 95% CI: 0.77—2.68; aOR for MUO: 1.75, 95% CI: 0.77—3.97). Findings were similar in the subgroup of 204 patients fulfilling clinical criteria for DNC. Conclusions SMM and MUO are common among comatose patients at risk of DNC. Their prevalence is similar among alive comatose patients and patients fulfilling clinical criteria for DNC. These movements are not associated with cerebral blood flow on CT-angiography or brain perfusion on CT-perfusion. Trial registration: Registered on ClinicalTrials.gov: NCT03098511 on March 27, 2017. Graphical abstract