Neurological disorders remain the leading cause of global disability-adjusted life years (DALYs).¹ The burden of acute neurological diseases is even higher in low- and middle-income countries (LMICs) and is expected to continue rising in the future.² Coma and disorder of consciousness are common manifestations or sequelae of a variety of neurological disorders. Thus, coma is a commonly encountered entity among a highly heterogenous group of patients. The outcomes of these patients vary significantly, ranging from complete recovery or partial recovery to long-term states of unconsciousness.³

NCS has launched the Curing Coma Campaign (CCC) with the aim of improving the outcome of patients with coma and disorder of consciousness. This overarching “Blue Ocean” strategy is a much needed and highly ambitious project, which has a global vision and aims to embrace  health care workers from different backgrounds who are involved in the management of patients with coma and disorders of consciousness. Three major pillars were identified to attain the goals of the project, including endotyping of patients with coma and disorders of consciousness, biomarkers, and proof of concept studies. Subsequent proceedings have identified specific research priorities and existing gaps. However, LMICs have several unique limitations that can potentially complicate the implementation and expansion of CCC, such that LMIC perspectives are imperative to consider to ensure CCC’s global success.⁴

There is wide variability on the definition and understanding of coma, with differences in treatment strategies and prognostication of comatose patients. This was evidenced by NCS’s recently conducted multinational COME TOGETHER survey involving 41 nations and 258 health care professionals.⁵ There is also significant variability in the delivery of neurocritical care globally, and the international PRINCE study was conducted to explore this variability.⁶ Such international epidemiological studies are important early steps on the CCC roadmap. Unfortunately, LMICs remain largely under-represented in these studies. To ensure that such studies are truly globally representative, more LMICs need to be proactive and get involved in future surveys. In conjunction, NCS should strive to recruit more LMICs through regional chapter leads and by identifying regional champions.

Because patients with coma are highly heterogenous, endotyping and identifying sub-groups of patients is highly desirable. The majority of recent clinical trials have yielded neutral results, much of which is likely explained by their use of a one-size-fits all approach while enrolling a highly heterogenous patient population.⁷ In patients with coma, incorporating biomarkers and other precision-based medicine approaches could potentially help identify subgroups of patients with a higher likelihood of recovery.⁸ Though the application of advanced endotyping tools like functional MRI and task-based EEG seems promising, such technologies are largely unavailable in LMICs, thereby limiting their applicability.⁴ Instead, most clinicians typically base their prognostication on the etiology of a patient’s coma along with their neurological examination findings and neuroimaging. Only a small minority of clinicians have also incorporated tools like functional MRI, EEG, and laboratory biomarkers.⁵ Future research should explore how currently available and utilized modalities can be better implemented for endotyping. For example, preliminary studies have revealed that simple bedside evaluations like the FOUR score, ocular tracking, and spontaneous eye blinking can have prognostic significance in patients with coma.

Figure 1. Barriers for management of patients with coma in LMICs.

Figure 2. Proposed measures to enhance success of CCC in LMICs.

The management of patients with coma in LMICs is complicated by multiple factors (Fig. 1). Health insurance policies are either primitive or non-existent in many regions, and as a result, the cost of health care is often borne by patients and their families. There is also a lack of public awareness about coma, while health care workers are predisposed to prevailing attitudes of nihilism and self-fulfilling prophecy that are further confounded by an often protracted clinical course and an absence of reliable prognostic tools. Post-acute care is an additional issue, as rehabilitation centers and long-term care centers are not well developed in many places. Finally, because of the limited resources available in most LMICs, most government authorities and public health policy makers tend to consolidate their resources into preventive measures like vaccination against common infectious diseases.

Considering the complexity of managing patients with coma in LMICs, focusing on acute treatments is not enough—effective preventive measures to minimize the burden of diseases that lead to coma should also be prioritized (Fig. 2). For CCC to be successfully implemented in LMICs, we need detailed epidemiological data and further research on optimal utilization strategies for the resources and expertise that are available. There is a critical need for reliable prognostic tools that are locally implementable in order to divert limited resources to comatose patients with a higher likelihood of recovery. Cost-effectiveness analyses should also be performed to help convince policy makers to allocate more resources for these patients. More well-designed clinical and translational research is ultimately needed to minimize these gaps in evidence and practice.