The role of early electroclinical assessment in improving the evaluation of patients with disorders of consciousness.

We all share the need to optimise the evaluation of patients with disorders of consciousness (DOC), given the high rate of misdiagnosis of vegetative state based on clinical examination. We believe that one way to do this is to optimise assessment from the early stages, in order to reduce discontinuity between the hospital and rehabilitation phases. While clinical observation remains the "gold standard" for the diagnostic assessment of patients with DOC, neurophysiological investigations (electroencephalography, short latency evoked potentials and event-related potentials) could help to further understanding of the pathophysiology underlying the state of unresponsiveness, differentiate coma from other apparently similar conditions (i.e., locked-in and locked-in-like syndromes), and potentially integrate prognostic evaluation with monitoring of the evolution of the clinical state. Moreover, these techniques have the considerable advantage of being available at the bedside. Discontinuity between the hospital and rehabilitation phases is rightly considered to be one of the critical points in the assessment of patients with DOC. In our view, a continuum of expert neurological assessment that begins with monitoring of the acute phase (focusing on evolution of primary brain damage and secondary complications) and follows through to the patient's discharge from the intensive care unit (focusing on the pathophysiology of brain damage and prognostication based on clinical, neuroimaging and neurophysiological tests) could help to: i) optimise the rehabilitation programme according to the expectations of recovery; ii) provide a basis for comparison with subsequent periodic re-evaluations; iii) ensure uniformity of assessment regardless of the heterogeneity of care facilities; and iv) characterise a subset of patients who, showing discrepancies between neurophysiological tests and clinical status, are more likely to undergo unexpected recovery.