Estado vegetativo-alfa persistente

Oliveira-Souza, R.; Gusmão, D. L.; Figueiredo, W. M.; López, J. R. R. A.; Mello, J. S.; Ribeiro, S. A.; Alvarenga, H.

doi:10.1590/S0004-282X1989000200014

Resumos

Após revisão sumária dos conceitos de «coma» e «coma-alfa», relatamos o caso de uma paciente com doença de Pick provável que, nos estágios terminais da doença, permaneceu várias semanas em estado vegetativo com EEG de vigília normal e reativo à fotoestimulação. Enfatizamos (a) algumas das implicações do aspecto dos olhos nesses pacintes, (b) a importância de distinguir a atividade alfa do ritmo alfa verdadeiro e (c) sugerimos que a categoria «coma-alfa» inclua apenas aqueles com afecções do tegmento da junção pontomesencefálica, de qualquer natureza, reservando a designação «estado vegetativo-alfa» persistente para os que se encontrem em estado vegetativo e exibam EEG em virgília idêntico ao normal.

After briefly reviewing the concepts of «coma» and «alpha-coma», we report the case of a patient with presumable Pick's disease who spent several weeks in a vegetative state with a normal and reactive EEG in the alpha range in the later stages of her illness. We (a) emphasize some implications of the appearence of the eyes in such patients, b) stress the importance of distinguishing alpha activity from true alpha rhythm and (c) suggest the category «alpha-coma» should include only those individuals bearing evidence of disorders of the junctional tegmentum of the pons and midbrain. In a complementary way, we propose that patients in a persistent vegetative state displaying normal EEG should be separately classified as persistent «alpha-vegetative state».

Estado vegetativo-alfa persistente

Persistent alpha-vegetative state

R. Oliveira-Souza^I; D. L. Gusmão^II; W. M. Figueiredo^III; J. R. R. A. López^IV; J. S. Mello^V; S. A. Ribeiro^I; H. Alvarenga^I

^IServiço de Neurologia, Hospital Universitário Gaffrée e Guinle, UNI-RIO, Rio de Janeiro (HUGG)

^IIEx-Residente de Neurologia, Santa Casa de Misericórdia, Rio de Janeiro

^IIIServiço de Clínica Médica III, HUGG

^IVHospital Dr Philippe Pinel, DINSAM-MS, Rio de Janeiro (HPP)

^VServiço de Epilepsia e Eletrencefalografia, HPP

RESUMO

Após revisão sumária dos conceitos de «coma» e «coma-alfa», relatamos o caso de uma paciente com doença de Pick provável que, nos estágios terminais da doença, permaneceu várias semanas em estado vegetativo com EEG de vigília normal e reativo à fotoestimulação. Enfatizamos (a) algumas das implicações do aspecto dos olhos nesses pacintes, (b) a importância de distinguir a atividade alfa do ritmo alfa verdadeiro e (c) sugerimos que a categoria «coma-alfa» inclua apenas aqueles com afecções do tegmento da junção pontomesencefálica, de qualquer natureza, reservando a designação «estado vegetativo-alfa» persistente para os que se encontrem em estado vegetativo e exibam EEG em virgília idêntico ao normal.

SUMMARY

After briefly reviewing the concepts of «coma» and «alpha-coma», we report the case of a patient with presumable Pick's disease who spent several weeks in a vegetative state with a normal and reactive EEG in the alpha range in the later stages of her illness. We (a) emphasize some implications of the appearence of the eyes in such patients, b) stress the importance of distinguishing alpha activity from true alpha rhythm and (c) suggest the category «alpha-coma» should include only those individuals bearing evidence of disorders of the junctional tegmentum of the pons and midbrain. In a complementary way, we propose that patients in a persistent vegetative state displaying normal EEG should be separately classified as persistent «alpha-vegetative state».

Texto completo disponível apenas em PDF.

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Agradecimentos - Estamos em débito para com os Drs.: Hamilton Clemente, que gentilmente realizou o exame do LCR; Rogério Paysano Marrocos (Hospital Dr. P. Pinel), pelo auxílio na condução do caso; Sergio Luis Schmitt (Instituto de Biofísica, UFRJ), pelas críticas e sugestões ao manuscrito; Felício Jahara (Santa Casia de Misericórdia, RJ), pelo exame tomográfico. Sem eles, este trabalho não teria, sido realizado.

Rua General Belford 226 - 20961 Rio de Janeiro RJ - Brasil.

1. Austin EJ, Bhagat A, Dodrill CD, Wilkus RJ - EEG rhythms of alpha frequency in a patient with hyperosmolar diabetic coma followed by partial recovery. Electroenceph Clin Neurophysiol 57: 61P, 1984.
2. Austin EJ, Wilkus RJ, Longstreth WT - Etiology and prognosis of alpha-coma. Neurology 38: 773, 1988.
3. Autret A. Carrier H, Tommasi M, Jouvet M, Schott B - Étude physiopathologique et neuropathologique d'un syndrome de décortication cérébrale. Rev Neurol 131: 491, 1975.
4. Batini C, Moruzzi G, Palestini M, Rossi GF, Zanchetti A - Persistent patterns of wakefulness in the pretrigeminal midpontine preparation. Science 128: 30, 1958.
5. Boonstra S, Notermans SLH - The EEG in 17 cases of lesions of the brain-stem, established post-mortem. Electroenceph Clin Neurophysiol 23: 496, 1967.
6. Brain R - The physiological basis of consciousness: a critical review. Brain 81: 426, 1958.
7. Bricolo A, Gentilomo A, Rosadini G, Rossi GF - Long-lasting post-traumatic unconsciousness. Acta Neurol Scand 44: 512, 1968.
8. Brierley JB, Adams JH, Graham DI, Simpson JA - Neocortical death after cardiac arrest: a clinical, neurophysiological, and neuropathological report of two cases. Lancet 2: 560, 1971.
9. Cairns H, Oldfield RC, Pennybacker JB, Whitteridge D - Akinetic mutism with an epidermoid cyst of the 3rd. ventricle. Brain 64: 273, 1941.
10. Carrol WM, Mastaglia FL - «Locked-in coma» in postinfective polyneuropathy. Arch Neurol 36: 46, 1979.
11. Carrol WM, Mastaglia FL - Alpha and beta coma in drug intoxication uncomplicated by cerebral hypoxia. Electroenceph Clin Neurophysiol 46: 95, 1979.
12. Chase TN, Moretti L, Prensky AL - Clinical and electroencephalographic manifestations of vascular lesions of the pons. Neurology 18: 357, 1968.
13. Chatrian GE, White LE, Shaw CM - EEG pattern resembling wakefulness in unresponsive decerebrate state following traumatic brain-stem infarct. Electroenceph Clin Neurophysiol 16: 285, 1964.
14. Chokroverty S - «Alpha-like» rhythms in electroencephalograms in coma after cardiac arrest. Neurology 25: 655, 1975.
15. Collins AT, Chatrian GE - EEG rhythm of alpha frequency in a 22-month-old child. Neurology 30: 1316, 1980.
16. Constantinidis J, Krassoievitch M, Tissot M - Corrélations entre les perturbations électroencéphalographiques et les lésions anatomo-histologiques dans les démences. Encéphale 58: 19, 1969.
17. Cummings JL, Duchen LW - Kluvers-Bucy syndrome in Pick disease: clinical and pathologic correlations. Neurology 31: 1415, 1981.
18. Damasio AR, van Hoesen GW - Emotional disturbances associated with focal lesions of the limbic frontal lobe. In Heilman KM, Satz P (eds): Neuropsychology of Human Emotion. Guilford, New York, 1983, pg 85.
19. Dehaene I - Bilateral thalamo-subthalamic infarction. Acta Neurol Belg 82: 253, 1981.
20. Delay J, Brion S, Escourolle R - L'opposition anatomo-clinique des maladies de Pick et d'Alzheimer: étude de 38 cas. Presse Méd 65: 1495, 1957.
21. Delay J, Brion S, Escourolle R - L'opposition anatomo-clinique des maladies de Pick et d'Alzheimer: valeur diagnostique des examens complémentaires. Presse Méd 65:1515, 1957.
22. Delay J, Brion S, Escourolle R - Les lésions des noyaus gris et du tronc cérébral dans la maladie de Pick. Encéphale 49:463, 1960.
23. Delay J, Neveu P, Lerique P - Sur quelques résultats concordants de la pneumo-encéphalographie et de l'électro-encéphalographie dans le diagnostic des atrophies cérébrales. Rev Neurol 76: 263, 1944.
24. Deleu D, de Keyser J - Flunitrazepam intoxication simulating a structural brainstem lesion. J Neurol Neurosurg Psychiat 50: 236, 1987.
25. Dick JPR, Gledhill RF, Sheehy MP - Loss of consciousness in migraine: clinical and EEG findings during an attack. Ann Neurol 19: 514, 1986.
26. Dougherty JH, Rawlison DG, Levy DE, Plum F - Hypoxic-ischemic brain injury and the vegetative state: clinical and neuropathology correlation. Neurology 31: 991, 1981.
27. Façon E, Steriade M, Wertheim N - Hypersomnie prolongée engendrée par des lésions bilatérales du système activateur médial: le syndrome thrombotique de la bifurcation du tronc basilaire. Rev Neurol 98: 117, 1958.
28. Ferguson JM, Bennett DR: Sleep in a patient with a pontine infarction. Electroenceph Clin Neurophysiol 36: 210, 1974.
29. Flügel KA - Alphakoma, Pseudoalpha-Koma und Alpha-Pseudokoma: Zur Differentialdiagnose des sogenannten Alphakomas. Fortschr Neurol Psychiat 50: 371, 1982.
30. Fox JH, Penn R, Clasen R - Pathological diagnosis in clinically typical Alzheimer's disease. N Eng J Med 313: 1419, 1985.
31. Fung PC, Tucker RP - Alpha rhythm and alpha-like activity in coma. Clin Electroenceph 15:167, 1984.
32. Gordon EB, Sim M - The EEG in presenile dementia. J Neurol Neurosurg Psychiat 30: 285, 1967.
33. Grigg MM, Kelly MA, Celesia GG, Ghobrial MW, Ross ER - Electroencephalographic activity after brain death. Arch Neurol 44:948, 1987.
34. Grindal AB, Suter C - «Alpha-pattern coma» in high voltage electrical injury. Electroenceph Clin Neurophysiol 38: 521, 1975.
35. Grindal AB, Suter C, Martinez AJ - Alpha pattern coma: 24 cases with 9 survivors. Ann Neurol 1: 371, 1977.
36. Groen JJ, Endtz LJ - Hereditary Pick's disease: second examination of a large family and discussion of other hereditary cases with particular reference to electroencephalography and computerized tomography. Brain 105: 443, 1982.
37. Guiloff RJ, Cobb WA - Diagnosis of coma. Lancet 2: 1351, 1977.
38. Gurvitch AM, Zarzhetsky Yu V, Trush VD, Zonov VM - Experimental data on the nature of postressucitaLon alpha frequency activity. Electroenceph Clin Neurophysiol 58: 426, 1984.
39. Guterman B, Sebastian P, Sodha N - Recovery from alpha-coma after lorazepam overdose. Clin Electroenceph 12: 205, 1981.
40. Hansotia PL - Persistent vegetative state: review and report of electrodiagnostic studies in eight cases. Arch Neurol 42: 1048, 1985.
41. Hari R, Sulkava R, Haltia M - Brainstem auditory evoked responses and alpha-pattern coma. Ann Neurol 11: 187, 1982.
42. Higashi K, Hatano M, Abiko S. Ihara K, Katayama S, Wakuta Y, Okamura T, Yamashita T - Five-year follow-up study of patients with persistent vegetative state. J Neurol Neurosurg Psychiat 44: 552, 1881.
43. Homan RW, Jones MG - Alpha-pattern coma in a 2-month-old child. Ann Neurol 9: 611, 1981.
44. Hughes JR, Cayaffa J, Leestma J, Mizuna Y - Alternating «waking» and «sleep» EEG patterns in a deep comatose patient. Clin Electroenceph 3: 86, 1972.
45. Ingvar DH - Cerebral blood flow and metacolism in complete apalic syndromes, in states of severe dementia and in akinetic muism. Acta Neurol Scand 49: 233, 1973.
46. Ingvar DH, Brun A - Das komplette apaluscne Syndrom. Arch Psychiat Nervenkr 215: 219, 1972.
47. ingvar DH, Brun A, Hagberg B, Gustafson L - Reg.onal blood flow in the dominant hemisphere in connrmed cases of Alzheimer's disease, Pick's disease, and multi-infanct dementia: relationship to clinical symptomatology and neuropathological findings, in Katzman R, Terry RD, Bick KL (eds): Alzheimer's Disease: Senile Dementia and Related Disorders. Raven, New York, 1978, pg 203.
48. Iragui VJ, McCutchen CB - Physiologic and prognostic significance of «alpha-coma». J Neurol Neurosurg Psychiat 46: 632, 1983.
49. Jasper HH, Andrews HL - Electroencephalography: III. Normal differentiation of occipital and precentral regions in man. Arch Neurol Psychiat 39: 96, 1938.
50. Jasper HH, van Buren HL - Interrelationship between cortex and subcortical structures; clinical and electroencephalographic studies. Electroenceph Clin Neurophysiol suppl 4:168, 1953.
51. Jennett B, Plum F - Persistent vegetative state: a syndrome in search of a name. Lancet 1: 734, 1972.
52. Jóhannesson G, Brun A, Gustafson I, Ingvar DH - EEG in presenile dementia related to cerebral blood flow and autopsy findings. Acta Neurol Scand 56: 89, 1977.
53. Jouvet M, Michel F, Courjon J - Sur un stade d'activité électrique cérébrale, rapide au cours du sommeil physiologique. C R Soc Biol (Paris) 153: 1024, 1959.
54. Kaada BR, Karkmark W, Stokke O - Deep coma associated with desynchronization in EEG. Electroenceph Clin Neurophysiol 13: 785, 1961.
55. Katzman K - Alzheimer's disease. N Eng J Med 314: 964, 1986.
56. Keane JR, Zaias B, Itabashi HH - Levator-sparing oculomotor nerve palsy caused by a solitary midbrain metastasis. Arch Neurol 41: 210, 1984.
57. Kretschmer E - Das apallische Syndrom. Z ges Neurol Psychiat 169:576, 1940.
58. Kuroiwa Y, Furukawa T - EEG prognostication in drug-related alpha-coma. Arch Neurol 38: 200, 1981.
59. Kuroiwa Y, Furukawa T, Inaki K - Recovery from drug-induced alpha-coma. Neurology 31: 1359, 1981.
60. Lee SI - Coexistence of triphasic waves and alpha-coma pattern. Electroenceph Clin Neurophysiol 51:108, 1981.
61. Lersch DR, Kaplan AM - Alpha-pattern coma in childhood and adolescence. Arch Neurol 41: 68, 1984.
62. Letemendia F, Pampiglione, G - Clinical and electroencephalographic observations in Alzheimer's disease. J Neurol Neurosurg Psychiat 21: 167, 1958.
63. Lindsley DB, Bowden JW, Magoun HW - Effects upon the EEG of acute injury to the brain stem activating system. Electroenceph Clin Neurophysiol 1: 475, 1949.
64. Loeb C - Electroencephalographic changes during the state of coma. Electroenceph Clin Neurophysiol 10: 589, 1958.
65. Loeb C, Poggio GF - Electroencephalogram in a case with ponto-mesencephalic hemorrhage. Electroenceph Clin Neurophysiol 5: 295, 1953.
66. Loeb C, Rosadini G, Poggio GF - Electroencephalograms during coma: normal and borderline records in 5 patients. Neurology 9: 610-18 (1959).
67. Lundervold A - EEG in patients in coma due to localized brain lesions. Handbook Electroenceph Clin Neurophysiol 12: 37, 1975.
68. Lundervold A, Hauge T, Loken AC - Unusual EEG in unconscious patient with brain stem atrophy. Electroenceph Clin Neurophys ol 8: 665, 1956.
69. Marshall DW - Recovery from drug-induced coma. Neurology 34: 406, 1984.
70. Masson C, Mear JY, Masson M, Cambier J - «Ictus hypersomnique» symptomatique d'une hémorragie thalamique postérieure. Presse Méd 16: 79, 1987.
71. McGeachie R, Fleming J, Sharer L, Hyman RA - Diagnosis of Pick's disease by computed tomography. J Comput Assist Tomogr 3: 113, 1979.
72. McKahn G, Drachman D, Folstein M, Katzman R, Price D, Stadlan EM -Clinical diagnosis of Alzheimer's disease: report of the NINCDS-ADRDA Work Group under the auspices of the Department of Health and Human Services Task Force on Alzheimer's disease. Neurology 34: 939, 1984.
73. Meienberg O, Mumenthaler M, Karbowski K - Quadriparesis and nuclear oculomotor palsy with total bilateral ptosis mimicking coma: a mesencephalic «locked-in syndrome»: Arch Neurol 36: 708, 1979.
74. Mingazzini G - On aphasia due to atrophy of the cerebral convolutions. Brain 36: 493, 1914.
75. Moruzzi G, Magoun HW - Brain stem reticular formation and activation of the EEG. Electroenceph Clin Neurophysiol 1: 455, 1949.
76. Muñoz-Garcia D, Ludwin SK - Classic and generalized variants of Pick's disease: a clinicopathological, ultrastructural, and immunocytochemical comparative study. Ann Neurol 16: 467, 1984.
77. Neary D, Snowden JS, Bowden DM, Sims NR, Mann DMA, Benton JS, Northen B, Yates PO, Davison AN - Neuropsychological syndromes in presenile dementia due to cerebral atrophy. J Neurol Neurosurg Psychiat 49: 163, 1986.
78. Neary D, Snowden JS, Northen B, Goulding P - Dementia of frontal lobe type. J Neurol Neurosurg Psychiat 51: 353, 1988.
79. Neumann MA - Pick's disease. J Neuropath Exp Neurol 8: 255, 1949.
80. Neumann MA, Cohn R - Reticular formation and coma in man. Trans Am Neurol Ass 89: 235, 1964.
81. Neundörfer B, Meyer-Wahl D, Meyer JG: Alpha-EEG und Bewustlosigkeit: ein kasuistischer Beitrag zur lokaldiagnostischen Bedeutung des _a-EEG beim bewustlosen Patienten. Z EEG-EMG 5: 106, 1974.
82. Nyström S - A case of decortication following a severe head injury. Acta Neurol Scand 35: 101, 1960.
83. Obeso JA, Iragui MI, Marti-Masso JF, Maravi E, Teijeira JM, Carrera N, Teijeira N - Neurophysiological assessment of alpha pattern coma. J Neurol Neurosurg Psychiat 43: 63, 1980.
84. Obrador S, Reinoso-Suarez F, Carbonell J, Cordoba A, Martinez-Moreno E, Navarro V, Oliva H, Oliveros JC - Comatose state, maintained during eight years following a vascular ponto-mesencephalic lesion. Electroenceph Clin Neurophysiol 38: 21, 1975.
85. Obrist WD - Electroencephalography in aging and dementia. In Katzman R, Terry RD, Bick KL (eds): Alzheimer's Disease: Senile Dementia and Related Disorders. Raven, New York, 1978, pg 227.
86. Pilleri G - The Klüver-Bucy syndrome in man: a clinico-anatomical contribution to the function of the medial temporal lobe structures. Psychiat Neurol (Basel) 152: 65, 1966.
87. Plum F, Posner J - The Diagnosis of Stupor and Coma. Ed 3. Dairs, Philadelphia, 1980.
88. Pulst SM, Lombroso CT - External ophtalmoplegia, alpha and spindle coma in imipramine overdose: case report and review of the literature. Ann Neurol 14: 587, 1983.
89. Radermecker J - Severe acute necrosis of the pons with long survival: electro-clinical symptoms and absence of cerebral lesions. Electroenceph Clin Neurophysiol 23: 281, 1967.
90. Rae-Grant A, Blume W, Lau C, Hachinski VC, Fisman M, Merskey H - The electroencephalogram in Alzheimer-type dementia. Arch Neurol 44: 50, 1987.
91. Roger J, Roger A, Gastaut H - Electro-clinical correlations in 30 cases of vascular syndromes of the brain and brain stem. Electroenceph Clin Neurophysiol 16: 164, 1954.
92. Rosadini G, Gentilomo A - Sleep EEG patterns during the apallic syndrome. Electroenceph Clin Neurophysiol 25: 87, 1968.
93. Routtemberg A - The two-arousal hypothesis: reticular formation and limbic system. Psychol Rev 75:51, 1954.
94. Segarra J - Cerebral vascular disease and behavior: I. The syndrome of the mesencephalic artery (basilar artery bifurcation). Arch Neurol 22:408, 1970.
95. Sheridan PH, Sato S, Foster N, Bruno G, Cox C, Fedio P, Chase TN - Relation of EEG alpha background to parietal lobe function in Alzheimer's disease as measured by positron emission tomography and psychometry. Neurology 38:747, 1988.
96. Sieben G, de Reuck J, Vander Eeecken H - Thrombosis of the mesencephalic artery: a clinico-pathologic study of two cases and its correlation with the arterial vascularization. Acta Neurol Belg 77:151, 1977.
97. Silverman D - Retrospective study of EEG in coma. Electroenceph Clin Neurophysiol 15:486, 1963.
98. Stigsby B, Johannesson G, Ingvar DH - Regional EEG analysis and reg.onal cerebral blood flow in Alzheimer's and Pick's disease. In Katzman R, Terry RD, Bick KL (eds): Alzheimer's Disease: Senile Dementia and Related Disorders. Raven, New York, 1978.
99. Sulkava R, Haltia M, Pateau A, Wikstrom J, Palo J - Accuracy of clinical diagnosis in primary degenerative dementia: correlation with ncuropathological findings. J Neurol Neurosurg Psychiat 46:9, 1983.
100. Swain JM - Electroencephalographic abnormalities in presenile atrophy. Neurology 9:722, 1959.
101. Tavy DLJ, van Woerkom TCAM, Bots GTAM, Endtz LJ - Persistence of the blink reflex to sudden illumination in a comatose patient. Arch Neurol 41:323, 1984.
102. Thompson GN, Nielsen JM - Area essential to consciousness: cerebral localization of consciousness as established by neuropathological studies. J Am Med Ass 137:285, 1948.
103. Tomassen W, Kamphuisen HAC: Alpha coma. J Neurol Sci 76:1, 1986.
104. Turazzi S, Bricolo A - Acute pontine syndromes following head injury. Lancet 2:62, 1977.
105. Vignaendra V, Wilkus RJ, Copass MK, Chatrian GE - Electroencephalographic rhythms of alpha frequency in comatose patients after cardiopulmonary arrest. Neurology 24:582, 1974.
106. Walshe TM, Leonard C - Persistent vegetative state: extension of the syndrome to include chronic disorders. Arch Neurol 42:1045, 1985.
107. Walter WG, Griffiths GM, Nevin S - The electro-encephalogram in a case of pathological sleep due to hypothalamic tumor. Br Med J 1:107, 1939.
108. Wechsler AF, Verity A, Rosenschein S - Pick's disease: a clinical, computed tomographic, and histologic study with Golgi impregnation observations. Arch Neurol 39:287, 1982.
109. Westmoreland B, Klass D, Sharbrough FW, Reagan TJ - Alpha coma: electroencephalographic, clinical, pathological and etiologic correlations. Arch Neurol 32:713, 1975.
110. Wilkus RJ, Harvey F, Ojeman LM, Lettich E - Electroencephalogram and sensory evoked potentials: findings in an unresponsive patient with pontine infarct. Arch Neurol 24:538, 1971.
111. Wisniewski HM, Coblents JM, Terry RD - Pick's disease: a clinical and ultrastructural study. Arch Neurol 26:97, 1972

Datas de Publicação

Publicação nesta coleção
07 Jun 2011
Data do Fascículo
Jun 1989

This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.

[1] 1. Austin EJ, Bhagat A, Dodrill CD, Wilkus RJ - EEG rhythms of alpha frequency in a patient with hyperosmolar diabetic coma followed by partial recovery. Electroenceph Clin Neurophysiol 57: 61P, 1984.

[2] 2. Austin EJ, Wilkus RJ, Longstreth WT - Etiology and prognosis of alpha-coma. Neurology 38: 773, 1988.

[3] 3. Autret A. Carrier H, Tommasi M, Jouvet M, Schott B - Étude physiopathologique et neuropathologique d'un syndrome de décortication cérébrale. Rev Neurol 131: 491, 1975.

[4] 4. Batini C, Moruzzi G, Palestini M, Rossi GF, Zanchetti A - Persistent patterns of wakefulness in the pretrigeminal midpontine preparation. Science 128: 30, 1958.

[5] 5. Boonstra S, Notermans SLH - The EEG in 17 cases of lesions of the brain-stem, established post-mortem. Electroenceph Clin Neurophysiol 23: 496, 1967.

[6] 6. Brain R - The physiological basis of consciousness: a critical review. Brain 81: 426, 1958.

[7] 7. Bricolo A, Gentilomo A, Rosadini G, Rossi GF - Long-lasting post-traumatic unconsciousness. Acta Neurol Scand 44: 512, 1968.

[8] 8. Brierley JB, Adams JH, Graham DI, Simpson JA - Neocortical death after cardiac arrest: a clinical, neurophysiological, and neuropathological report of two cases. Lancet 2: 560, 1971.

[9] 9. Cairns H, Oldfield RC, Pennybacker JB, Whitteridge D - Akinetic mutism with an epidermoid cyst of the 3rd. ventricle. Brain 64: 273, 1941.

[10] 10. Carrol WM, Mastaglia FL - «Locked-in coma» in postinfective polyneuropathy. Arch Neurol 36: 46, 1979.

[11] 11. Carrol WM, Mastaglia FL - Alpha and beta coma in drug intoxication uncomplicated by cerebral hypoxia. Electroenceph Clin Neurophysiol 46: 95, 1979.

[12] 12. Chase TN, Moretti L, Prensky AL - Clinical and electroencephalographic manifestations of vascular lesions of the pons. Neurology 18: 357, 1968.

[13] 13. Chatrian GE, White LE, Shaw CM - EEG pattern resembling wakefulness in unresponsive decerebrate state following traumatic brain-stem infarct. Electroenceph Clin Neurophysiol 16: 285, 1964.

[14] 14. Chokroverty S - «Alpha-like» rhythms in electroencephalograms in coma after cardiac arrest. Neurology 25: 655, 1975.

[15] 15. Collins AT, Chatrian GE - EEG rhythm of alpha frequency in a 22-month-old child. Neurology 30: 1316, 1980.

[16] 16. Constantinidis J, Krassoievitch M, Tissot M - Corrélations entre les perturbations électroencéphalographiques et les lésions anatomo-histologiques dans les démences. Encéphale 58: 19, 1969.

[17] 17. Cummings JL, Duchen LW - Kluvers-Bucy syndrome in Pick disease: clinical and pathologic correlations. Neurology 31: 1415, 1981.

[18] 18. Damasio AR, van Hoesen GW - Emotional disturbances associated with focal lesions of the limbic frontal lobe. In Heilman KM, Satz P (eds): Neuropsychology of Human Emotion. Guilford, New York, 1983, pg 85.

[19] 19. Dehaene I - Bilateral thalamo-subthalamic infarction. Acta Neurol Belg 82: 253, 1981.

[20] 20. Delay J, Brion S, Escourolle R - L'opposition anatomo-clinique des maladies de Pick et d'Alzheimer: étude de 38 cas. Presse Méd 65: 1495, 1957.

[21] 21. Delay J, Brion S, Escourolle R - L'opposition anatomo-clinique des maladies de Pick et d'Alzheimer: valeur diagnostique des examens complémentaires. Presse Méd 65:1515, 1957.

[22] 22. Delay J, Brion S, Escourolle R - Les lésions des noyaus gris et du tronc cérébral dans la maladie de Pick. Encéphale 49:463, 1960.

[23] 23. Delay J, Neveu P, Lerique P - Sur quelques résultats concordants de la pneumo-encéphalographie et de l'électro-encéphalographie dans le diagnostic des atrophies cérébrales. Rev Neurol 76: 263, 1944.

[24] 24. Deleu D, de Keyser J - Flunitrazepam intoxication simulating a structural brainstem lesion. J Neurol Neurosurg Psychiat 50: 236, 1987.

[25] 25. Dick JPR, Gledhill RF, Sheehy MP - Loss of consciousness in migraine: clinical and EEG findings during an attack. Ann Neurol 19: 514, 1986.

[26] 26. Dougherty JH, Rawlison DG, Levy DE, Plum F - Hypoxic-ischemic brain injury and the vegetative state: clinical and neuropathology correlation. Neurology 31: 991, 1981.

[27] 27. Façon E, Steriade M, Wertheim N - Hypersomnie prolongée engendrée par des lésions bilatérales du système activateur médial: le syndrome thrombotique de la bifurcation du tronc basilaire. Rev Neurol 98: 117, 1958.

[28] 28. Ferguson JM, Bennett DR: Sleep in a patient with a pontine infarction. Electroenceph Clin Neurophysiol 36: 210, 1974.

[29] 29. Flügel KA - Alphakoma, Pseudoalpha-Koma und Alpha-Pseudokoma: Zur Differentialdiagnose des sogenannten Alphakomas. Fortschr Neurol Psychiat 50: 371, 1982.

[30] 30. Fox JH, Penn R, Clasen R - Pathological diagnosis in clinically typical Alzheimer's disease. N Eng J Med 313: 1419, 1985.

[31] 31. Fung PC, Tucker RP - Alpha rhythm and alpha-like activity in coma. Clin Electroenceph 15:167, 1984.

[32] 32. Gordon EB, Sim M - The EEG in presenile dementia. J Neurol Neurosurg Psychiat 30: 285, 1967.

[33] 33. Grigg MM, Kelly MA, Celesia GG, Ghobrial MW, Ross ER - Electroencephalographic activity after brain death. Arch Neurol 44:948, 1987.

[34] 34. Grindal AB, Suter C - «Alpha-pattern coma» in high voltage electrical injury. Electroenceph Clin Neurophysiol 38: 521, 1975.

[35] 35. Grindal AB, Suter C, Martinez AJ - Alpha pattern coma: 24 cases with 9 survivors. Ann Neurol 1: 371, 1977.

[36] 36. Groen JJ, Endtz LJ - Hereditary Pick's disease: second examination of a large family and discussion of other hereditary cases with particular reference to electroencephalography and computerized tomography. Brain 105: 443, 1982.

[37] 37. Guiloff RJ, Cobb WA - Diagnosis of coma. Lancet 2: 1351, 1977.

[38] 38. Gurvitch AM, Zarzhetsky Yu V, Trush VD, Zonov VM - Experimental data on the nature of postressucitaLon alpha frequency activity. Electroenceph Clin Neurophysiol 58: 426, 1984.

[39] 39. Guterman B, Sebastian P, Sodha N - Recovery from alpha-coma after lorazepam overdose. Clin Electroenceph 12: 205, 1981.

[40] 40. Hansotia PL - Persistent vegetative state: review and report of electrodiagnostic studies in eight cases. Arch Neurol 42: 1048, 1985.

[41] 41. Hari R, Sulkava R, Haltia M - Brainstem auditory evoked responses and alpha-pattern coma. Ann Neurol 11: 187, 1982.

[42] 42. Higashi K, Hatano M, Abiko S. Ihara K, Katayama S, Wakuta Y, Okamura T, Yamashita T - Five-year follow-up study of patients with persistent vegetative state. J Neurol Neurosurg Psychiat 44: 552, 1881.

[43] 43. Homan RW, Jones MG - Alpha-pattern coma in a 2-month-old child. Ann Neurol 9: 611, 1981.

[44] 44. Hughes JR, Cayaffa J, Leestma J, Mizuna Y - Alternating «waking» and «sleep» EEG patterns in a deep comatose patient. Clin Electroenceph 3: 86, 1972.

[45] 45. Ingvar DH - Cerebral blood flow and metacolism in complete apalic syndromes, in states of severe dementia and in akinetic muism. Acta Neurol Scand 49: 233, 1973.

[46] 46. Ingvar DH, Brun A - Das komplette apaluscne Syndrom. Arch Psychiat Nervenkr 215: 219, 1972.

[47] 47. ingvar DH, Brun A, Hagberg B, Gustafson L - Reg.onal blood flow in the dominant hemisphere in connrmed cases of Alzheimer's disease, Pick's disease, and multi-infanct dementia: relationship to clinical symptomatology and neuropathological findings, in Katzman R, Terry RD, Bick KL (eds): Alzheimer's Disease: Senile Dementia and Related Disorders. Raven, New York, 1978, pg 203.

[48] 48. Iragui VJ, McCutchen CB - Physiologic and prognostic significance of «alpha-coma». J Neurol Neurosurg Psychiat 46: 632, 1983.

[49] 49. Jasper HH, Andrews HL - Electroencephalography: III. Normal differentiation of occipital and precentral regions in man. Arch Neurol Psychiat 39: 96, 1938.

[50] 50. Jasper HH, van Buren HL - Interrelationship between cortex and subcortical structures; clinical and electroencephalographic studies. Electroenceph Clin Neurophysiol suppl 4:168, 1953.

[51] 51. Jennett B, Plum F - Persistent vegetative state: a syndrome in search of a name. Lancet 1: 734, 1972.

[52] 52. Jóhannesson G, Brun A, Gustafson I, Ingvar DH - EEG in presenile dementia related to cerebral blood flow and autopsy findings. Acta Neurol Scand 56: 89, 1977.

[53] 53. Jouvet M, Michel F, Courjon J - Sur un stade d'activité électrique cérébrale, rapide au cours du sommeil physiologique. C R Soc Biol (Paris) 153: 1024, 1959.

[54] 54. Kaada BR, Karkmark W, Stokke O - Deep coma associated with desynchronization in EEG. Electroenceph Clin Neurophysiol 13: 785, 1961.

[55] 55. Katzman K - Alzheimer's disease. N Eng J Med 314: 964, 1986.

[56] 56. Keane JR, Zaias B, Itabashi HH - Levator-sparing oculomotor nerve palsy caused by a solitary midbrain metastasis. Arch Neurol 41: 210, 1984.

[57] 57. Kretschmer E - Das apallische Syndrom. Z ges Neurol Psychiat 169:576, 1940.

[58] 58. Kuroiwa Y, Furukawa T - EEG prognostication in drug-related alpha-coma. Arch Neurol 38: 200, 1981.

[59] 59. Kuroiwa Y, Furukawa T, Inaki K - Recovery from drug-induced alpha-coma. Neurology 31: 1359, 1981.

[60] 60. Lee SI - Coexistence of triphasic waves and alpha-coma pattern. Electroenceph Clin Neurophysiol 51:108, 1981.

[61] 61. Lersch DR, Kaplan AM - Alpha-pattern coma in childhood and adolescence. Arch Neurol 41: 68, 1984.

[62] 62. Letemendia F, Pampiglione, G - Clinical and electroencephalographic observations in Alzheimer's disease. J Neurol Neurosurg Psychiat 21: 167, 1958.

[63] 63. Lindsley DB, Bowden JW, Magoun HW - Effects upon the EEG of acute injury to the brain stem activating system. Electroenceph Clin Neurophysiol 1: 475, 1949.

[64] 64. Loeb C - Electroencephalographic changes during the state of coma. Electroenceph Clin Neurophysiol 10: 589, 1958.

[65] 65. Loeb C, Poggio GF - Electroencephalogram in a case with ponto-mesencephalic hemorrhage. Electroenceph Clin Neurophysiol 5: 295, 1953.

[66] 66. Loeb C, Rosadini G, Poggio GF - Electroencephalograms during coma: normal and borderline records in 5 patients. Neurology 9: 610-18 (1959).

[67] 67. Lundervold A - EEG in patients in coma due to localized brain lesions. Handbook Electroenceph Clin Neurophysiol 12: 37, 1975.

[68] 68. Lundervold A, Hauge T, Loken AC - Unusual EEG in unconscious patient with brain stem atrophy. Electroenceph Clin Neurophys ol 8: 665, 1956.

[69] 69. Marshall DW - Recovery from drug-induced coma. Neurology 34: 406, 1984.

[70] 70. Masson C, Mear JY, Masson M, Cambier J - «Ictus hypersomnique» symptomatique d'une hémorragie thalamique postérieure. Presse Méd 16: 79, 1987.

[71] 71. McGeachie R, Fleming J, Sharer L, Hyman RA - Diagnosis of Pick's disease by computed tomography. J Comput Assist Tomogr 3: 113, 1979.

[72] 72. McKahn G, Drachman D, Folstein M, Katzman R, Price D, Stadlan EM -Clinical diagnosis of Alzheimer's disease: report of the NINCDS-ADRDA Work Group under the auspices of the Department of Health and Human Services Task Force on Alzheimer's disease. Neurology 34: 939, 1984.

[73] 73. Meienberg O, Mumenthaler M, Karbowski K - Quadriparesis and nuclear oculomotor palsy with total bilateral ptosis mimicking coma: a mesencephalic «locked-in syndrome»: Arch Neurol 36: 708, 1979.

[74] 74. Mingazzini G - On aphasia due to atrophy of the cerebral convolutions. Brain 36: 493, 1914.

[75] 75. Moruzzi G, Magoun HW - Brain stem reticular formation and activation of the EEG. Electroenceph Clin Neurophysiol 1: 455, 1949.

[76] 76. Muñoz-Garcia D, Ludwin SK - Classic and generalized variants of Pick's disease: a clinicopathological, ultrastructural, and immunocytochemical comparative study. Ann Neurol 16: 467, 1984.

[77] 77. Neary D, Snowden JS, Bowden DM, Sims NR, Mann DMA, Benton JS, Northen B, Yates PO, Davison AN - Neuropsychological syndromes in presenile dementia due to cerebral atrophy. J Neurol Neurosurg Psychiat 49: 163, 1986.

[78] 78. Neary D, Snowden JS, Northen B, Goulding P - Dementia of frontal lobe type. J Neurol Neurosurg Psychiat 51: 353, 1988.

[79] 79. Neumann MA - Pick's disease. J Neuropath Exp Neurol 8: 255, 1949.

[80] 80. Neumann MA, Cohn R - Reticular formation and coma in man. Trans Am Neurol Ass 89: 235, 1964.

[81] 81. Neundörfer B, Meyer-Wahl D, Meyer JG: Alpha-EEG und Bewustlosigkeit: ein kasuistischer Beitrag zur lokaldiagnostischen Bedeutung des _a-EEG beim bewustlosen Patienten. Z EEG-EMG 5: 106, 1974.

[82] 82. Nyström S - A case of decortication following a severe head injury. Acta Neurol Scand 35: 101, 1960.

[83] 83. Obeso JA, Iragui MI, Marti-Masso JF, Maravi E, Teijeira JM, Carrera N, Teijeira N - Neurophysiological assessment of alpha pattern coma. J Neurol Neurosurg Psychiat 43: 63, 1980.

[84] 84. Obrador S, Reinoso-Suarez F, Carbonell J, Cordoba A, Martinez-Moreno E, Navarro V, Oliva H, Oliveros JC - Comatose state, maintained during eight years following a vascular ponto-mesencephalic lesion. Electroenceph Clin Neurophysiol 38: 21, 1975.

[85] 85. Obrist WD - Electroencephalography in aging and dementia. In Katzman R, Terry RD, Bick KL (eds): Alzheimer's Disease: Senile Dementia and Related Disorders. Raven, New York, 1978, pg 227.

[86] 86. Pilleri G - The Klüver-Bucy syndrome in man: a clinico-anatomical contribution to the function of the medial temporal lobe structures. Psychiat Neurol (Basel) 152: 65, 1966.

[87] 87. Plum F, Posner J - The Diagnosis of Stupor and Coma. Ed 3. Dairs, Philadelphia, 1980.

[88] 88. Pulst SM, Lombroso CT - External ophtalmoplegia, alpha and spindle coma in imipramine overdose: case report and review of the literature. Ann Neurol 14: 587, 1983.

[89] 89. Radermecker J - Severe acute necrosis of the pons with long survival: electro-clinical symptoms and absence of cerebral lesions. Electroenceph Clin Neurophysiol 23: 281, 1967.

[90] 90. Rae-Grant A, Blume W, Lau C, Hachinski VC, Fisman M, Merskey H - The electroencephalogram in Alzheimer-type dementia. Arch Neurol 44: 50, 1987.

[91] 91. Roger J, Roger A, Gastaut H - Electro-clinical correlations in 30 cases of vascular syndromes of the brain and brain stem. Electroenceph Clin Neurophysiol 16: 164, 1954.

[92] 92. Rosadini G, Gentilomo A - Sleep EEG patterns during the apallic syndrome. Electroenceph Clin Neurophysiol 25: 87, 1968.

[93] 93. Routtemberg A - The two-arousal hypothesis: reticular formation and limbic system. Psychol Rev 75:51, 1954.

[94] 94. Segarra J - Cerebral vascular disease and behavior: I. The syndrome of the mesencephalic artery (basilar artery bifurcation). Arch Neurol 22:408, 1970.

[95] 95. Sheridan PH, Sato S, Foster N, Bruno G, Cox C, Fedio P, Chase TN - Relation of EEG alpha background to parietal lobe function in Alzheimer's disease as measured by positron emission tomography and psychometry. Neurology 38:747, 1988.

[96] 96. Sieben G, de Reuck J, Vander Eeecken H - Thrombosis of the mesencephalic artery: a clinico-pathologic study of two cases and its correlation with the arterial vascularization. Acta Neurol Belg 77:151, 1977.

[97] 97. Silverman D - Retrospective study of EEG in coma. Electroenceph Clin Neurophysiol 15:486, 1963.

[98] 98. Stigsby B, Johannesson G, Ingvar DH - Regional EEG analysis and reg.onal cerebral blood flow in Alzheimer's and Pick's disease. In Katzman R, Terry RD, Bick KL (eds): Alzheimer's Disease: Senile Dementia and Related Disorders. Raven, New York, 1978.

[99] 99. Sulkava R, Haltia M, Pateau A, Wikstrom J, Palo J - Accuracy of clinical diagnosis in primary degenerative dementia: correlation with ncuropathological findings. J Neurol Neurosurg Psychiat 46:9, 1983.

[100] 100. Swain JM - Electroencephalographic abnormalities in presenile atrophy. Neurology 9:722, 1959.

[101] 101. Tavy DLJ, van Woerkom TCAM, Bots GTAM, Endtz LJ - Persistence of the blink reflex to sudden illumination in a comatose patient. Arch Neurol 41:323, 1984.

[102] 102. Thompson GN, Nielsen JM - Area essential to consciousness: cerebral localization of consciousness as established by neuropathological studies. J Am Med Ass 137:285, 1948.

[103] 103. Tomassen W, Kamphuisen HAC: Alpha coma. J Neurol Sci 76:1, 1986.

[104] 104. Turazzi S, Bricolo A - Acute pontine syndromes following head injury. Lancet 2:62, 1977.

[105] 105. Vignaendra V, Wilkus RJ, Copass MK, Chatrian GE - Electroencephalographic rhythms of alpha frequency in comatose patients after cardiopulmonary arrest. Neurology 24:582, 1974.

[106] 106. Walshe TM, Leonard C - Persistent vegetative state: extension of the syndrome to include chronic disorders. Arch Neurol 42:1045, 1985.

[107] 107. Walter WG, Griffiths GM, Nevin S - The electro-encephalogram in a case of pathological sleep due to hypothalamic tumor. Br Med J 1:107, 1939.

[108] 108. Wechsler AF, Verity A, Rosenschein S - Pick's disease: a clinical, computed tomographic, and histologic study with Golgi impregnation observations. Arch Neurol 39:287, 1982.

[109] 109. Westmoreland B, Klass D, Sharbrough FW, Reagan TJ - Alpha coma: electroencephalographic, clinical, pathological and etiologic correlations. Arch Neurol 32:713, 1975.

[110] 110. Wilkus RJ, Harvey F, Ojeman LM, Lettich E - Electroencephalogram and sensory evoked potentials: findings in an unresponsive patient with pontine infarct. Arch Neurol 24:538, 1971.

[111] 111. Wisniewski HM, Coblents JM, Terry RD - Pick's disease: a clinical and ultrastructural study. Arch Neurol 26:97, 1972