Clinical Implementation of Functional MRI and EEG to Detect Cognitive Motor Dissociation: Lessons Learned in an Acute Care Hospital

Cognitive motor dissociation (CMD) occurs when patients with disorders of consciousness (DoC) resulting from severe brain injury demonstrate the ability to follow commands on task-based functional MRI (fMRI) or EEG assessment despite demonstrating no behavioral evidence of language function on bedside assessment. Recognizing the diagnostic and prognostic value of identifying patients with CMD, evidence-based guidelines published in the United States and Europe now recommend that these assessments are conducted as part of clinical care in patients for whom the behavioral assessment is ambiguous. We describe our experience evaluating patients with DoC for CMD using task-based fMRI and EEG. Although our center, and others, have used these tests in a research capacity for more than a decade, implementing them for clinical use posed multiple challenges and opportunities for innovation. We now have an institutionally supported, standardized, and effective approach for conducting clinical assessments of CMD and present lessons learned in this process so that other centers can more easily implement these evaluations. Among the key lessons are the need to consider ethical implications of clinical assessment for CMD; garner support of peers and departmental leadership; establish local standardized protocols for patient selection, data acquisition, analysis, and interpretation; and develop systems of effective communication of test results to families and clinical teams. As consensus or independent validation of optimal methods to assess CMD have not yet been established, the approach described is intended to be flexible, allowing for iterative improvements as more evidence becomes available.