Mindsight: Diagnostics in Disorders of Consciousness

Table 1

Coma Recovery Scale revised.

	Description	Scored when
Auditory function
(4) Consistent movement to command^#	Object-related eye or limb movement or; movement with nonobject-related commands.	On all 4 trials on 2 different commands.
(3) Reproducible movement to command^#	Object-related eye or limbs movement or; movement with nonobject related commands.	3/4 trials on any one of the object or nonobject related commands.
(2) Localization to sound	Auditory stimulation (e.g., voice or noise) from the right and the left side for 5 s. Repeat the procedure 2 times on each side.	3/4 trials on any one of the object or nonobject related commands.
(1) Auditory startle	Auditory stimulation directly above the; patient’s head and out of view (4 trials).	Eyelid flutter or blink following the stimulus on at least 2 trials.
(0) None	Observed response to above method.	No response to any of the above.
Visual function scale
(5) Object recognition*	Object-related eye or limb movement commands.	3/4 clearly discernible responses.
(4) Object localization: reaching*	The patient is asked to touch an object with his/her arm or leg, 4 trials (2 left, 2 right presentations).	Movement must occur in the correct direction on 3/4 trials.
(3) Pursuit eye movements*	Move mirror to the right, left, upper, and lower directions. 2 trials in every direction (manually open eyes if necessary).	Eyes must follow the mirror for 45 degrees without loss of fixation on 2 occasions in any direction.
(2) fixation^∧	Present a brightly colored object in front of the patient’s face and then rapidly move to upper, lower, right, and left visual fields for a total of 4 trials (manually open eyes if necessary).	Eyes change from initial fixation point and then fixate on the new target location for more than 2 s. At least 2 fixations.
(1) Visual startle	Quickly move a finger to 1 inch in front of the patient’s eye, while avoiding contact with the eyelashes or inadvertent production of a breeze (manually open eyes if necessary). 4 trials per eye.	Blink promptly following presentation of visual threat on at least 2 trials with either eye.
(0) None	Observe response to above method.	No response to any of the above.
Motor function scale
(6) Functional object use^+	Place one object (comb) in the patient’s hand and instruct the patient to ‘‘show me how to use it.’’ Repeat the same instruction with a second object. 2 trials for each object.	Movements executed are compatible with specific function for both objects on all 4 trials.
	Observe for spontaneous automatic motor behaviors (nose scratching, grasping bedrail) during the examination.	At least 2 episodes of automatic motor; behaviour are observed within the; examination.
(5) Automatic motor response*	or; present a familiar gesture (e.g., wave) and ask the patient to ‘‘show me how to wave’’ 2 times and ‘‘I’m going to wave again. Do not move at all. Just hold still’’ 2 times (alternate each command)	Patient performs the gesture on trials; ‘‘just hold still.’’
	or; place a spoon in front of the patient’s mouth without making contact and ask the patient to ‘‘show me how to use the spoon’’ 2 times and ‘‘I’m going to show you a spoon. Do not move at all. Just hold still’’ 2 times.	Patient performs the gesture on trials; ‘‘just hold still.’’
(4) Object manipulation*	Place a ball on the dorsal surface of the patient’s hands and roll the ball across the index finger and thumb without touching the surface of the hand or fingers. Instruct the patient to ‘‘Take the ball.’’ 4 trials.	3/4 trials, the wrist must rotate and the; fingers should extend as the object is moved along the dorsal surface of the hand; the object must be grasped and held for a minimum of 5 s.
(3) Localization to noxious stimulation*	Apply deep pressure to nail beds of extremities for a minimum of 5 s. 2 trials on each side for a total of 4 trials.	The nonstimulated limb must locate and make contact with the stimulated body part at the point of stimulation on at least 2/4 trials.
(2) Flexion withdrawal	Apply deep pressure to nail beds of each extremity. 1 trial per extremity.	Isolated flexion withdrawal of at least 1 limb.
(1) Abnormal posturing	Observe response to above method.	Slow, stereotyped flexion or extension of the extremities immediately after the stimulation.
(0) None/flaccid	Observe response to above method.	No response to any of the above.
Oromotor/verbal function scale
(3) Intelligible verbalization^#	Ask the patient to answer autobiographical or object naming questions.	Each verbalization must consist of at least 1 consonant-vowel-consonant triad, and 2 different words must be documented, and words produced by writing or alphabet board are acceptable.
(2) Vocalization/oral movement	Nonreflexive oral movements, spontaneous vocalizations or vocalizations that occur during administration of vocalization commands.	At least 1 episode of spontaneous nonreflexive oral movement and/or vocalization (yawning is scored as reflexive oral movement).
(1) Oral reflexive movement	Present tongue blade between patient’s lips and/or teeth.	Clamping of jaws, tongue pumping, or chewing movement.
(0) None	Observe response to above method.	No response to any of the above.
Communication scale
(2) Functional: accurate^+	Ask 6 visual or auditory related questions (‘‘Am I touching my ear?’’, ‘‘Am I clapping my hand?”).	Clearly discernible and accurate yes/no responses on all 6 of the visual or auditory related questions.
(1) Nonfunctional: intentional^#	Observe response to above method	Clearly discernible and accurate yes/no responses on at least 2/6 of the visual or auditory related questions.
(0) None	Observe response to above method	No discernible verbal or nonverbal communication.
Arousal scale
(3) Attention	Consistency of behavioral responses; following verbal or gestural prompts.	No more than 3 occasions across the length of the evaluation in which the patient fails to respond to a verbal prompt.
(2) Eye-opening w/o stimulation	Observe status of the eyelids across length of assessment.	Eyes remain open across the length of the examination without the need for any stimulation.
(1) Eye-opening with stimulation	See above.	Tactile, pressure, or noxious stimulation; must be applied at least once during the examination in order for the patient to sustain eye opening.
(0) Unarousable	See above.	No eye opening.

^*denotes MCS−.
^#denotes MCS+.
⁺denotes emergence from MCS.
^∧denotes an MCS except for anoxic etiology.