Critical neural targets for (the level of) human consciousness: Arousal arrest and unconsciousness after sumatriptan administration

Abstract

Background: Insufficient understanding of the mechanisms of consciousness can make unconsciousness a diagnostic challenge, directly effecting the treatment and the outcome of the patient. Consciousness is a product of brainstem arousal (wakefulness, the level of consciousness) and cortical information integration (awareness, the contents of consciousness). The thalamus serves as a critical hub in the arousal pathway. The nuclei within the internal medullary lamina, together with the associated thalamocortical connections, have been implicated as being especially important for human consciousness.

Case study: A 17-year old male migraineur developed a sudden episode of unconsciousness after receiving a single dose of intranasal sumatriptan for the treatment of prolonged migraine-associated symptoms. Diffusion-weighted magnetic resonance imaging revealed a small bilateral thalamic infarction affecting the centromedian and parafascicular nuclei and the associated non-specific thalamocortical connections as the likely reason for the impairment of consciousness. With the exception of occasional fatigue due to a persistent lesion on the left thalamus, the patient experienced full recovery. Corresponding to the injury, diffusion tensor tractography imaging revealed a distinctive defect on the thalamocortical fibres originating from the left centromedian/parafascicular nuclei complex.

Conclusions: The presented case offers an outstanding example of the importance of the arousal system and non-specific thalamocortical connectivity for normal waking consciousness.

Keywords:

• Intralaminar nuclei
• centromedian thalamus
• thalamocortical connectivity
• electroencephalography
• diffusion-weighted MRI
• diffusion tensor imaging
• tractography
• DBS
• neuromodulation
• stroke

Declaration of interest

The authors report no conflicts of interest. This study was funded by Seinäjoki Central Hospital (EVO grant no. 1133), the Finnish Medical Foundation, the Paulo Foundation and the Emil Aaltonen Foundation.