Diagnostic accuracy of the vegetative and minimally conscious state: Clinical consensus versus standardized neurobehavioral assessment

TLDR

Previous studies show up to 43 % of patients with disorders of consciousness are incorrectly diagnosed as vegetative state, yet recent investigations into the accuracy of this diagnosis are lacking. This study aimed to compare clinical consensus diagnoses of vegetative state and minimally conscious state with those derived from the standardized JFK Coma Recovery Scale‑Revised. We prospectively evaluated 103 patients with mixed etiologies, obtaining daily clinical consensus diagnoses from physicians and CRS‑R assessments from research staff, categorizing each patient as VS, MCS, or uncertain. Among patients clinically diagnosed as VS, 41 % were actually in MCS per CRS‑R, while 10 % of those clinically diagnosed as MCS had emerged from MCS; additionally, 89 % of uncertain cases were MCS, indicating that standardized neurobehavioral assessment is more sensitive and that misdiagnosis rates have not improved over the past 15 years.

Abstract

Abstract Background Previously published studies have reported that up to 43% of patients with disorders of consciousness are erroneously assigned a diagnosis of vegetative state (VS). However, no recent studies have investigated the accuracy of this grave clinical diagnosis. In this study, we compared consensus-based diagnoses of VS and MCS to those based on a well-established standardized neurobehavioral rating scale, the JFK Coma Recovery Scale-Revised (CRS-R). Methods We prospectively followed 103 patients (55 ± 19 years) with mixed etiologies and compared the clinical consensus diagnosis provided by the physician on the basis of the medical staff's daily observations to diagnoses derived from CRS-R assessments performed by research staff. All patients were assigned a diagnosis of 'VS', 'MCS' or 'uncertain diagnosis.' Results Of the 44 patients diagnosed with VS based on the clinical consensus of the medical team, 18 (41%) were found to be in MCS following standardized assessment with the CRS-R. In the 41 patients with a consensus diagnosis of MCS, 4 (10%) had emerged from MCS, according to the CRS-R. We also found that the majority of patients assigned an uncertain diagnosis by clinical consensus (89%) were in MCS based on CRS-R findings. Conclusion Despite the importance of diagnostic accuracy, the rate of misdiagnosis of VS has not substantially changed in the past 15 years. Standardized neurobehavioral assessment is a more sensitive means of establishing differential diagnosis in patients with disorders of consciousness when compared to diagnoses determined by clinical consensus.