A brain-computer interface may give unresponsive ICU patients a voice

by Columbia University Irving Medical Center

edited by Sadie Harley, reviewed by Robert Egan

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Unresponsive ICU patients in a new Columbia study were able to raise and lower the frequency of a beeping tone with their minds, via noninvasive EEG electrodes that recorded and translated their brain waves.

The study, published in the journal Brain, opens the door to noninvasive brain-computer interfaces that could allow seemingly comatose patients with hidden consciousness to communicate with doctors and family members.

"Research in the past decade by us and others has shown that many patients with acute brain injury who appear to be in a coma actually have some level of preserved consciousness, even though they are unable to speak or move their hands or eyes to communicate," says Jan Claassen, M.D., a professor of neurology at Columbia University Vagelos College of Physicians and Surgeons, who led the study.

"Our brain-computer interface is only a first step, but it shows that, in principle, we could hopefully in the future give some of these patients a voice."

Hidden consciousness is common

Claassen, who is also the medical director of the neurocritical care unit at NewYork-Presbyterian/Columbia University Irving Medical Center, has been one of the pioneers in recognizing hidden consciousness in brain-injured patients who are in a coma-like state and unable to respond to questions or directives from physicians or their families.

In 2019, his team used standard EEG technology and AI to analyze the brain waves of unresponsive, brain-injured patients and detected signs of hidden consciousness in 15% of the patients. The number shocked the critical care field, which had only documented the phenomenon in a few cases before then.

Though these patients did not respond to commands from their physicians—to blink, make a fist or wriggle their toes—analysis of the EEG recordings showed that the patients tried to comply but were unable to move their muscles. Claassen's team later found evidence that this dissociation between cognitive and motor functions is caused by a communication breakdown between the brain regions responsible for higher-order cognition and regions that control muscle movement.

In Claassen's studies, patients with cognitive motor dissociation, or CMD, are more likely to regain consciousness and recover a significant amount of day-to-day functioning. Though CMD identification techniques are still not available outside of research studies, they may help physicians in the future identify patients with the best odds of recovery.

"We've shown that detecting hidden consciousness has enormous promise to guide patient care," Claassen says.

Communicating with unresponsive patients

If unresponsive patients have hidden consciousness, it may be possible to develop technology that will allow them to communicate fundamental needs or to make their wishes known.

In recent years, scientists have developed brain-computer interface technology to help patients with paralysis due to spinal cord injuries control a mobility device. The technique has also been shown to facilitate communication with patients who have neurodegenerative diseases that affect movement and speech, such as amyotrophic lateral sclerosis (ALS).

Such technologies involve implanting a computer chip on the surface of the brain to translate a patient's thoughts into command signals.

But for an unresponsive, hospitalized patient with severe, acute brain injury, this approach is not ideal.

Instead, Claassen's team attached EEG wires to the heads of patients—a routine part of monitoring brain-injured patients—and trained the patients to control the computer using these EEG waves.

With this system, the researchers designed a simple challenge for patients: a beeping tone is played through the patient's headphones, and a recorded voice asks the patient to adjust the frequency of the beeps by trying to open and close their hands.

As the patient tries to perform the task, electrical impulses from the brain are relayed to a bedside computer, which analyzes the signals in real time. The voice encourages patients when they change the beep frequency and congratulates them when they meet the target.

In the study, Claassen's team tested the system with 41 clinically unresponsive patients with acute brain injury a few days after they were hospitalized.

Following a brief training period, about one in three patients were able to control the beeping tones using their thoughts alone, including all patients with CMD that was detected through a separate exam. Surprisingly, these patients were able to control the beeping within a few days of severe brain injury.

Though a previous study has shown that fMRI can be used to obtain answers to simple yes-or-no questions from a single unresponsive patient, fMRI is not practical for routine use.

"That's why our system is a major advancement," Claassen says. "EEG is used in clinical practice every day in the ICU. The only sophisticated part is the computer program we wrote, which analyzes the data in real time and modulates the feedback to the patient."

Next steps

Study participants and their family members said that having a brain-computer interface for their loved one was helpful and offered advice about ways to improve the technology, including adding personalized features, such as the voice of a loved one, culturally relevant details and functions to detect pain, hunger and awareness.

"Our goal is to refine the system so that patients can tell their doctors and loved ones how they are feeling—if they are in pain or hungry, for instance—with more direct communication."

"Patients with hidden consciousness or cognitive motor dissociation are unable to show any expression or communicate in any way," Claassen says. "I think that's where our work can be fundamentally transformative."

Publication details

Clinically unresponsive patients with acute brain injury activate a brain-computer interface, Brain (2026). DOI: 10.1093/brain/awag210

Journal information: Brain

Clinical categories

NeurologyCritical care medicine Provided by Columbia University Irving Medical Center Who's behind this story?

Sadie Harley

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