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Francisco Chacón-Lozsán: Coma Is Not a Diagnosis – Final Pathway Of Brain Arousal And Awareness Failure
Francisco Chacón-Lozsán/LinkedIn
Jun 2, 2026, 19:27

Francisco Chacón-Lozsán: Coma Is Not a Diagnosis – Final Pathway Of Brain Arousal And Awareness Failure

Francisco Chacón-Lozsán, Fellow at World Extreme Medicine, Member of European Society of Intensive Care Medicine (ESICM) and American College of Cardiology, shared a post on LinkedIn about recent article by Stein Silva et al., published in Intensive Care Medicine, adding:

“Coma is not a diagnosis…

It is the final common pathway of multiple catastrophic failures across the brain’s arousal and awareness networks.

And in the ICU, minutes matter.

This 2026 narrative review in Intensive Care Medicine proposes something many clinicians desperately need:

A truly structured, physiology driven, stepwise diagnostic strategy for coma of unknown origin.What makes this paper particularly valuable is that it moves beyond the classic ‘CT with labs and LP’ reflex approach.

Instead, it reframes coma through modern network neuroscience.

The authors emphasize that nearly all causes of coma ultimately converge on disruption of:

  • the ascending reticular activating system (ARAS)
  • thalamocortical connectivity
  • frontoparietal networks responsible for awareness and arousal

This matters clinically.

Because bedside examination can still localize dysfunction surprisingly well.

The review highlights how:

  • pupils
  • gaze deviation
  • respiratory pattern
  • posture
  • brainstem reflexes

can rapidly differentiate:

  • metabolic/toxic coma
  • diencephalic dysfunction
  • pontine lesions
  • medullary injury
  • hemispheric structural lesions

One of the strongest messages of the paper:

Repeated reassessment is mandatory.

Not optional.

The authors recommend reassessment every 15–30 minutes initially, then every 2–4 hours once stable.

Coma is dynamic. A single neurological exam is never enough.

Another excellent point: normal CT does not exclude severe pathology.

MRI remains substantially superior for:

  • posterior fossa lesions
  • PRES
  • diffuse axonal injury
  • encephalitis
  • venous thrombosis
  • subtle ischemia

The EEG section is especially important for intensivists.

The paper reinforces that:

  • up to 18% of mixed ICU coma populations may have nonconvulsive seizures
  • continuous EEG is often required
  • thalamocortical disconnection can potentially be inferred from EEG spectral patterns

The proposed ABCD EEG framework is fascinating: progressive slowing and suppression may reflect increasing thalamocortical disconnection.

Potentially allowing bedside neurophysiological stratification of coma severity.

Perhaps the most important conceptual shift in this review:

Moving from phenotypes to endotypes.

Not merely asking: ‘What syndrome is this?’

But instead: ‘What network is failing?’ ‘What mechanism is suppressing consciousness?’ ‘What dysfunction is reversible?’

That transition may fundamentally change neurocritical care in the next decade.

Reference 

Silva S et al. Stepwise clinical and diagnostic strategy for coma of unknown origin. Intensive Care Medicine. 2026.”

Title: Stepwise clinical and diagnostic strategy for coma of unknown origin

Authors: Stein Silva, Miriam Treggiari, Giuseppe Citerio, Robert David Stevens, Marzia De Lucia, Virginia Newcombe, Aurore Thibaut, Nicolas Weiss, Romain Sonneville

Francisco Chacón-Lozsán

Other posts featuring Francisco Chacón-Lozsán on Hemostasis Today.

ARAS ascending reticular activating system Aurore Thibaut Blood coma diencephalic dysfunction Francisco Chacón-Lozsán Giuseppe Citerio Health Hematology Hemostasis News Hemostasis Today ICU Intensive Care Medicine Marzia De Lucia Medicine Miriam Treggiari Neuroscience Nicolas Weiss Robert David Stevens Romain Sonneville Stein Silva Virginia Newcombe
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