title: Disconnection of the ascending arousal system in traumatic coma.
abstract: Traumatic coma is associated with disruption of axonal pathways throughout the brain, but the specific pathways involved in humans are incompletely understood. In this study, we used high angular resolution diffusion imaging to map the connectivity of axonal pathways that mediate the 2 critical components of consciousness-arousal and awareness-in the postmortem brain of a 62-year-old woman with acute traumatic coma and in 2 control brains. High angular resolution diffusion imaging tractography guided tissue sampling in the neuropathologic analysis. High angular resolution diffusion imaging tractography demonstrated complete disruption of white matter pathways connecting brainstem arousal nuclei to the basal forebrain and thalamic intralaminar and reticular nuclei. In contrast, hemispheric arousal pathways connecting the thalamus and basal forebrain to the cerebral cortex were only partially disrupted, as were the cortical "awareness pathways." Neuropathologic examination, which used β-amyloid precursor protein and fractin immunomarkers, revealed axonal injury in the white matter of the brainstem and cerebral hemispheres that corresponded to sites of high angular resolution diffusion imaging tract disruption. Axonal injury was also present within the gray matter of the hypothalamus, thalamus, basal forebrain, and cerebral cortex. We propose that traumatic coma may be a subcortical disconnection syndrome related to the disconnection of specific brainstem arousal nuclei from the thalamus and basal forebrain.
authors: Department of Neurology, Brigham and Women's Hospital, Harvard Medical School, Boston, USA. bedlow@partners.org
authors: Brian L
authors: BL
authors: Edlow
authors: Robin L
authors: RL
authors: Haynes
authors: Emi
authors: E
authors: Takahashi
authors: Joshua P
authors: JP
authors: Klein
authors: Peter
authors: P
authors: Cummings
authors: Thomas
authors: T
authors: Benner
authors: David M
authors: DM
authors: Greer
authors: Steven M
authors: SM
authors: Greenberg
authors: Ona
authors: O
authors: Wu
authors: Hannah C
authors: HC
authors: Kinney
authors: Rebecca D
authors: RD
authors: Folkerth
mesh_terms: D001143:Arousal / Q000502:physiology; D001933:Brain Stem / Q000473:pathology* / Q000502:physiology; D020207:Coma, Post-Head Injury / Q000175:diagnosis* / Q000503:physiopathology*; D056324:Diffusion Tensor Imaging / Q000379:methods; D017809:Fatal Outcome; D005260:Female; D006801:Humans; D008875:Middle Aged; D009434:Neural Pathways / Q000473:pathology
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