The repetition of behavioral assessments in diagnosis of disorders of consciousness

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Errors of diagnosis are reported to be frequent (up to 40%) in patients with disorders of consciousness (DOC).1 Patients in unresponsive wakefulness syndrome/vegetative state (UWS/VS6) are characterized by the presence of arousal without awareness (ie, only reflexive behaviors), whereas patients in minimally conscious state (MCS7) show inconsistent, but reproducible, purposeful behaviors. Patients in MCS are subcategorized into MCS– and MCS+, based on signs of language processing.8 Patients in MCS+ are able to show response to commands, whereas patients in MCS– only show lower level of conscious behaviors such as visual pursuit or object localization. When patients recover functional communication and/or functional object use, they have emerged from the MCS (EMCS7).
In this context, behavioral misdiagnosis can be attributed to a large number of factors, including motor or language impairments and vigilance fluctuations.9 Bedside evaluation is still considered the “gold standard” in clinical practice.10 Indeed, behavioral scales are often the only available tools in clinical centers to assess patients' level of consciousness. To date, the most sensitive and validated scale is the Coma Recovery Scale‐Revised (CRS‐R11).
Recent guidelines emphasize the importance of repeated or extended assessments to minimize misdiagnosis attributed to fluctuating levels of consciousness.9 However, to our knowledge, no study has investigated the number of examinations needed to increase diagnosis accuracy in patients with DOC.
The aims of our study were twofold: (1) to determine whether the diagnosis is influenced by the number of CRS‐R assessments and (2) to evaluate the number of CRS‐R examinations required to obtain a reliable and accurate diagnosis.
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