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Predictive value of sensory and cognitive evoked potentials for awakening from coma

From the Departments of Clinical Neurophysiology (Dr. Fischer), Neurological Rehabilitation (Dr. Luauté), and Biostatistics (Dr. Adeleine), Hospices Civils de Lyon; Claude Bernard University EA1880 (Dr. Fischer), Lyon; and INSERM U280 (Dr. Morlet), Lyon, France.

Address correspondence and reprint requests to Dr. Catherine Fischer, Clinical Neurophysiology, Hopital Neurologique, 59 Boulevard Pinel, 69677 Bron Cedex, France; e-mail: catherine.fischer{at}chu-lyon.fr

Objectives: To determine the prognostic role of late auditory (N100) and cognitive evoked potentials (MMN) for awakening in a cohort of comatose patients categorized by etiology.

Methods: The authors prospectively studied a series of 346 comatose patients. Coma was caused by stroke (n = 125), trauma (n = 96), anoxia (n = 64), complications of neurosurgery (n = 54), and encephalitis (n = 7). Patients were followed for 12 months and classified as awake or unawake. Univariate and multivariate analyses were performed using regression logistic and Cox models.

Results: Pupillary light reflex, N100, middle-latency auditory evoked potentials, age, and etiology were the most discriminating factors for awakening. Statistical analysis showed that pupillary reflex was the strongest prognostic variable for awakening (estimated probability 79.7%). The estimated probability of awakening rose to 87% when N100 was present and to 89.9% when middle-latency evoked potentials (MLAEPs) were present. It was 13.7% when pupillary reflex was absent in anoxic patients. When MMN was present, 88.6% of patients awakened. No patient in whom MMN was present became permanently vegetative.

Conclusion: Pupillary reflex is the strongest prognostic variable, followed by N100 and MLAEPs allowing a reliable model for awakening. The presence of MMN is a predictor of awakening and precludes comatose patients from moving to a permanent vegetative state. Evaluation of primary sensory cortex and higher-order processes by middle-latency-, late, and cognitive evoked potentials should be performed in the prognosis for awakening in comatose patients.

Received January 26, 2004. Accepted in final form April 21, 2004.

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