title: Central thalamic deep brain stimulation to promote recovery from chronic posttraumatic minimally conscious state: challenges and opportunities.
abstract: BACKGROUND
  Central thalamic deep brain stimulation (CT-DBS) may have therapeutic potential to improve behavioral functioning in patients with severe traumatic brain injury (TBI), but its use remains experimental. Current research suggests that the central thalamus plays a critical role in modulating arousal during tasks requiring sustained attention, working memory, and motor function. The aim of the current article is to review the methodology used in the CT-DBS protocol developed by our group, outline the challenges we encountered and offer suggestions for future DBS trials in this population. RATIONAL FOR CT-DBS IN TBI:  CT-DBS may therefore be able to stimulate these functions by eliciting action potentials that excite thalamocortical and thalamostriatal pathways. Because patients in chronic minimally conscious state (MCS) have a very low probability of regaining functional independence, yet often have significant sparing of cortical connectivity, they may represent a particularly appropriate target group for CT-DBS. PIlOT STUDY RESULTS:  We have conducted a series of single-subject studies of CT-DBS in patients with chronic posttraumatic MCS, with 24-month follow-up. Outcomes were measured using the Coma Recovery Scale-Revised as well as a battery of secondary outcome measures to capture more granular changes. Findings from our index case suggest that CT-DBS can significantly increase functional communication, motor performance, feeding, and object naming in the DBS on state, with performance in some domains remaining above baseline even after DBS was turned off.
  
  
  CONCLUSIONS
  The use of CT-DBS in patients in MCS, however, presents challenges at almost every step, including during surgical planning, outcome measurement, and postoperative care. Additionally, given the difficulties of obtaining informed consent from patients in MCS and the experimental nature of the treatment, a robust, scientifically rooted ethical framework is resented for pursuing this line of work.
authors.affiliation: Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Boston, MA 02114, USA. jgiacino@partners.org
authors.forename: Joseph
authors.initials: J
authors.lastname: Giacino
authors.forename: Joseph J
authors.initials: JJ
authors.lastname: Fins
authors.forename: Andre
authors.initials: A
authors.lastname: Machado
authors.forename: Nicholas D
authors.initials: ND
authors.lastname: Schiff
mesh_terms: D001930:Brain Injuries / Q000150:complications / Q000628:therapy*; D001931:Brain Mapping; D002986:Clinical Trials as Topic / Q000941:ethics; D046690:Deep Brain Stimulation / Q000941:ethics / Q000295:instrumentation / Q000379:methods*; D004567:Electrodes, Implanted; D006801:Humans; D007258:Informed Consent; D016343:Monitoring, Intraoperative; D038361:Neuronavigation; D019635:Neurosurgical Procedures / Q000379:methods; D010347:Patient Care Planning; D018579:Patient Selection; D018458:Persistent Vegetative State / Q000209:etiology / Q000628:therapy*; D011182:Postoperative Care; D020127:Recovery of Function; D013788:Thalamus / Q000502:physiology*