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Distinguishing disorders of consciousness and related conditions

Distinguishing disorders of consciousness and related conditions
Condition Characteristic description Arousal Awareness Homeostatic functions* Movement Common location of brain injury
(Brain) death Irreversible, permanent cessation of brain functions (–) (–) Absent
  • Spinal reflexes only
 Entire brainstem
Coma Unarousable unawareness (–) (–) Impaired
  • Reflex posturing with extremities
  • Cranial nerve reflexes
 Ascending reticular activating system in upper brainstem tegmentum or bilateral hemispheres
Vegetative state/
unresponsive wakefulness syndrome		 Wakefulness without awareness (+) (–) Preserved
  • Spontaneous eye opening
  • Reflex posturing with extremities
  • Cranial nerve reflexes
 Variable brainstem or bilateral hemispheres
Cognitive motor dissociation Awake and aware, but unable to produce volitional movement or speechΔ (+) (+)Δ Preserved
  • Reflex posturing with extremities
  • Cranial nerve reflexes
  • Eye opening/gaze tracking may be present
 Bilateral thalamus, hemispheres
Locked-in syndrome Awake and aware, responds only by eye movement (+) (+) Preserved
  • Spontaneous eye movements, blinking
 Pontine base +/– tegmentum
Minimally conscious state Wakefulness with partial awareness (+) (+) Preserved
  • Variable spontaneous or responsive motor activity◊
 Variable brainstem or bilateral hemispheres
Akinetic mutism Absent/minimal volitional movement (+) (+) Preserved
  • Spontaneous eye movements
  • Postural tone/reflexes intact
 Cingulate gyrus, bilateral hemispheres
Catatonia Inability to move despite physical ability to do so (+) (+) Preserved
  • Posturing, stereotypies
  • Variable presence of agitation, echolalia, or behavioral mannerisms
 None (functional alterations in cortico-basal pathways may be seen in some patients)
Disorders of consciousness include several conditions that represent a continuum of brain injury. They are characterized by specific neurologic deficits and preserved neurologic functions and may be associated with a variety of cerebral conditions.

EEG: electroencephalogram; fMRI: functional magnetic resonance imaging; MCS: minimally conscious state.

* Includes sleep-wake cycles, temperature and blood pressure regulation, digestion, growth.

¶ Formerly also called "apallic syndrome" or "coma vigil."

Δ Awareness with preserved cognitive function can be identified by diagnostic testing including task-based EEG or fMRI of the brain.

◊ MCS is a heterogenous condition as some patients with severe impairments only localize painful stimuli (MCS minus) while other may follow some commands and use some verbal communication (MCS plus).

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