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One of the most delicate con rmations of the fact that the states of impaired consciousness are expressions of neurophysiologic changes in the cerebrum is the altered EEG Some change of brain waves occurs in all disturbances of consciousness except the milder degrees of confusion, in most cases of delirium tremens, and in catatonia These alterations usually consist of a disorganization of the EEG background pattern, including disappearance of alpha rhythm and replacement by random slow waves of low to moderate voltage in the initial stages of confusion; a more regular pattern of slow, two- to three-per-second waves of high voltage in stupor; slow low-voltage waves or intermittent suppression of organized electrical activity in the deep coma of hypoxia and ischemia; and ultimately a complete absence of electrical activity in brain death In some deeply comatose patients, the EEG may transiently show diffuse and variable (8- to 12-Hz) activity, which may be mistaken for physiologic alpha rhythm However, the former pattern (so-called alpha coma) is not limited to the posterior cerebral regions, is not monorhythmic like normal alpha activity, and displays no reactivity to sensory stimuli This alpha-like activity pattern may be associated with pontine or diffuse cortical lesions and has a poor prognosis (Iragui and McCutchen; page 29) A rarer EEG abnormality is spindle coma, in which sleep spindles dominate the record (page 341) The EEG accurately re ects the depth of certain metabolic comas, particularly those due to hepatic or renal failure In these conditions the slow waves become higher in amplitude as coma deepens, ultimately assuming a high-voltage rhythmic delta pattern and a triphasic con guration There is also a general correspondence between the intensity of stimuli required to elicit motor activity and the degree of slowing of the background rhythm Not all cerebral disorders that cause confusion, stupor, and coma have the same effects on the EEG In cases of intoxication with sedatives, exempli ed by barbiturates, fast activity initially replaces normal rhythms Coma in which myoclonus or twitching is a major clinical feature may show frequent sharp waves or a sharpness to the background slowing of the EEG The differences in EEG changes among metabolic derangements probably represent important biologic distinctions at the neuronal level that have not yet been elucidated (see also Chap 2).

Our current understanding of the anatomy and physiology of alertness comes largely from the elegant experiments of Bremer and of Magoun and Moruzzi in the 1930s and 1940s Observing cats in whom he had sectioned the brainstem between the pons and midbrain and at the level of the lower medulla, Bremer found that the rostral section caused a sleep-like state and synchronized EEG rhythms that were characteristic of sleep; animals with the lower section remained awake, with appropriate desynchronized EEG rhythms He interpreted this to mean, in large part correctly, that a constant stream of sensory stimuli, provided by trigeminal and other cranial sources, was required to maintain the awake state Several years later, Morrison and Dempsey demonstrated a system of nonspeci c projections from the thalamus to all cortical regions, independent of any speci c sensory nucleus A critical re nement of this concept resulted from the observation by Mor-

Finally we can change the Marker itself by adjustments made to the Circle and increase the size This can be seen in the following illustration

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