Altered mental status pathophysiology: Difference between revisions

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====Parkinson's disease====
====Parkinson's disease====
The [[pathogenesis]] of [[Parkinson's disease]] is a depletion of [[dopamine]] due to the following mechanisms:


* The [[pathogenesis]] of [[Parkinson's disease]] is a depletion of [[dopamine]] due to the following mechanisms:
*[[Protein]] misfolding with decreased function and [[plasticity]].<ref name="pmid12951565">{{cite journal |vauthors=Maries E, Dass B, Collier TJ, Kordower JH, Steece-Collier K |title=The role of alpha-synuclein in Parkinson's disease: insights from animal models |journal=Nat. Rev. Neurosci. |volume=4 |issue=9 |pages=727–38 |date=September 2003 |pmid=12951565 |doi=10.1038/nrn1199 |url=}}</ref><ref name="pmid9278044">{{cite journal |vauthors=Spillantini MG, Schmidt ML, Lee VM, Trojanowski JQ, Jakes R, Goedert M |title=Alpha-synuclein in Lewy bodies |journal=Nature |volume=388 |issue=6645 |pages=839–40 |date=August 1997 |pmid=9278044 |doi=10.1038/42166 |url=}}</ref><ref name="pmid26790375">{{cite journal |vauthors=Calo L, Wegrzynowicz M, Santivañez-Perez J, Grazia Spillantini M |title=Synaptic failure and α-synuclein |journal=Mov. Disord. |volume=31 |issue=2 |pages=169–77 |date=February 2016 |pmid=26790375 |doi=10.1002/mds.26479 |url=}}</ref>
* [[Protein]] misfolding with decreased function and [[plasticity]].<ref name="pmid12951565">{{cite journal |vauthors=Maries E, Dass B, Collier TJ, Kordower JH, Steece-Collier K |title=The role of alpha-synuclein in Parkinson's disease: insights from animal models |journal=Nat. Rev. Neurosci. |volume=4 |issue=9 |pages=727–38 |date=September 2003 |pmid=12951565 |doi=10.1038/nrn1199 |url=}}</ref><ref name="pmid9278044">{{cite journal |vauthors=Spillantini MG, Schmidt ML, Lee VM, Trojanowski JQ, Jakes R, Goedert M |title=Alpha-synuclein in Lewy bodies |journal=Nature |volume=388 |issue=6645 |pages=839–40 |date=August 1997 |pmid=9278044 |doi=10.1038/42166 |url=}}</ref><ref name="pmid26790375">{{cite journal |vauthors=Calo L, Wegrzynowicz M, Santivañez-Perez J, Grazia Spillantini M |title=Synaptic failure and α-synuclein |journal=Mov. Disord. |volume=31 |issue=2 |pages=169–77 |date=February 2016 |pmid=26790375 |doi=10.1002/mds.26479 |url=}}</ref>
*Defective [[proteolysis]] with aggregation of this [[protein]] and [[neuronal]] death.<ref name="pmid23580245">{{cite journal |vauthors=Lim KL, Zhang CW |title=Molecular events underlying Parkinson's disease - an interwoven tapestry |journal=Front Neurol |volume=4 |issue= |pages=33 |date=2013 |pmid=23580245 |pmc=3619247 |doi=10.3389/fneur.2013.00033 |url=}}</ref><ref name="pmid23580333">{{cite journal |vauthors=Dehay B, Martinez-Vicente M, Caldwell GA, Caldwell KA, Yue Z, Cookson MR, Klein C, Vila M, Bezard E |title=Lysosomal impairment in Parkinson's disease |journal=Mov. Disord. |volume=28 |issue=6 |pages=725–32 |date=June 2013 |pmid=23580333 |pmc=5131721 |doi=10.1002/mds.25462 |url=}}</ref><ref name="pmid24211851">{{cite journal |vauthors=Ghavami S, Shojaei S, Yeganeh B, Ande SR, Jangamreddy JR, Mehrpour M, Christoffersson J, Chaabane W, Moghadam AR, Kashani HH, Hashemi M, Owji AA, Łos MJ |title=Autophagy and apoptosis dysfunction in neurodegenerative disorders |journal=Prog. Neurobiol. |volume=112 |issue= |pages=24–49 |date=January 2014 |pmid=24211851 |doi=10.1016/j.pneurobio.2013.10.004 |url=}}</ref>
* Defective [[proteolysis]] with aggregation of this [[protein]] and [[neuronal]] death.<ref name="pmid23580245">{{cite journal |vauthors=Lim KL, Zhang CW |title=Molecular events underlying Parkinson's disease - an interwoven tapestry |journal=Front Neurol |volume=4 |issue= |pages=33 |date=2013 |pmid=23580245 |pmc=3619247 |doi=10.3389/fneur.2013.00033 |url=}}</ref><ref name="pmid23580333">{{cite journal |vauthors=Dehay B, Martinez-Vicente M, Caldwell GA, Caldwell KA, Yue Z, Cookson MR, Klein C, Vila M, Bezard E |title=Lysosomal impairment in Parkinson's disease |journal=Mov. Disord. |volume=28 |issue=6 |pages=725–32 |date=June 2013 |pmid=23580333 |pmc=5131721 |doi=10.1002/mds.25462 |url=}}</ref><ref name="pmid24211851">{{cite journal |vauthors=Ghavami S, Shojaei S, Yeganeh B, Ande SR, Jangamreddy JR, Mehrpour M, Christoffersson J, Chaabane W, Moghadam AR, Kashani HH, Hashemi M, Owji AA, Łos MJ |title=Autophagy and apoptosis dysfunction in neurodegenerative disorders |journal=Prog. Neurobiol. |volume=112 |issue= |pages=24–49 |date=January 2014 |pmid=24211851 |doi=10.1016/j.pneurobio.2013.10.004 |url=}}</ref>
*[[Mitochondrial]] dysfunction with the following [[cell]] damage.<ref name="pmid15377875">{{cite journal |vauthors=Przedborski S, Tieu K, Perier C, Vila M |title=MPTP as a mitochondrial neurotoxic model of Parkinson's disease |journal=J. Bioenerg. Biomembr. |volume=36 |issue=4 |pages=375–9 |date=August 2004 |pmid=15377875 |doi=10.1023/B:JOBB.0000041771.66775.d5 |url=}}</ref><ref name="pmid22446186">{{cite journal |vauthors=Selvaraj S, Sun Y, Watt JA, Wang S, Lei S, Birnbaumer L, Singh BB |title=Neurotoxin-induced ER stress in mouse dopaminergic neurons involves downregulation of TRPC1 and inhibition of AKT/mTOR signaling |journal=J. Clin. Invest. |volume=122 |issue=4 |pages=1354–67 |date=April 2012 |pmid=22446186 |pmc=3314472 |doi=10.1172/JCI61332 |url=}}</ref><ref name="pmid2566813">{{cite journal |vauthors=Schapira AH, Cooper JM, Dexter D, Jenner P, Clark JB, Marsden CD |title=Mitochondrial complex I deficiency in Parkinson's disease |journal=Lancet |volume=1 |issue=8649 |pages=1269 |date=June 1989 |pmid=2566813 |doi= |url=}}</ref>
* [[Mitochondrial]] dysfunction with the following [[cell]] damage.<ref name="pmid15377875">{{cite journal |vauthors=Przedborski S, Tieu K, Perier C, Vila M |title=MPTP as a mitochondrial neurotoxic model of Parkinson's disease |journal=J. Bioenerg. Biomembr. |volume=36 |issue=4 |pages=375–9 |date=August 2004 |pmid=15377875 |doi=10.1023/B:JOBB.0000041771.66775.d5 |url=}}</ref><ref name="pmid22446186">{{cite journal |vauthors=Selvaraj S, Sun Y, Watt JA, Wang S, Lei S, Birnbaumer L, Singh BB |title=Neurotoxin-induced ER stress in mouse dopaminergic neurons involves downregulation of TRPC1 and inhibition of AKT/mTOR signaling |journal=J. Clin. Invest. |volume=122 |issue=4 |pages=1354–67 |date=April 2012 |pmid=22446186 |pmc=3314472 |doi=10.1172/JCI61332 |url=}}</ref><ref name="pmid2566813">{{cite journal |vauthors=Schapira AH, Cooper JM, Dexter D, Jenner P, Clark JB, Marsden CD |title=Mitochondrial complex I deficiency in Parkinson's disease |journal=Lancet |volume=1 |issue=8649 |pages=1269 |date=June 1989 |pmid=2566813 |doi= |url=}}</ref>
*[[Oxidative stress]] with the following [[neuronal]] damage.<ref name="pmid15155938">{{cite journal |vauthors=Greenamyre JT, Hastings TG |title=Biomedicine. Parkinson's--divergent causes, convergent mechanisms |journal=Science |volume=304 |issue=5674 |pages=1120–2 |date=May 2004 |pmid=15155938 |doi=10.1126/science.1098966 |url=}}</ref><ref name="pmid14645467">{{cite journal |vauthors=Sherer TB, Betarbet R, Testa CM, Seo BB, Richardson JR, Kim JH, Miller GW, Yagi T, Matsuno-Yagi A, Greenamyre JT |title=Mechanism of toxicity in rotenone models of Parkinson's disease |journal=J. Neurosci. |volume=23 |issue=34 |pages=10756–64 |date=November 2003 |pmid=14645467 |doi= |url=}}</ref>
* [[Oxidative stress]] with the following [[neuronal]] damage.<ref name="pmid15155938">{{cite journal |vauthors=Greenamyre JT, Hastings TG |title=Biomedicine. Parkinson's--divergent causes, convergent mechanisms |journal=Science |volume=304 |issue=5674 |pages=1120–2 |date=May 2004 |pmid=15155938 |doi=10.1126/science.1098966 |url=}}</ref><ref name="pmid14645467">{{cite journal |vauthors=Sherer TB, Betarbet R, Testa CM, Seo BB, Richardson JR, Kim JH, Miller GW, Yagi T, Matsuno-Yagi A, Greenamyre JT |title=Mechanism of toxicity in rotenone models of Parkinson's disease |journal=J. Neurosci. |volume=23 |issue=34 |pages=10756–64 |date=November 2003 |pmid=14645467 |doi= |url=}}</ref>
*[[Iron metabolism]] with following increase of storage in the [[substantia nigra]].<ref name="pmid17515544">{{cite journal |vauthors=Oakley AE, Collingwood JF, Dobson J, Love G, Perrott HR, Edwardson JA, Elstner M, Morris CM |title=Individual dopaminergic neurons show raised iron levels in Parkinson disease |journal=Neurology |volume=68 |issue=21 |pages=1820–5 |date=May 2007 |pmid=17515544 |doi=10.1212/01.wnl.0000262033.01945.9a |url=}}</ref><ref name="pmid22266337">{{cite journal |vauthors=Dusek P, Jankovic J, Le W |title=Iron dysregulation in movement disorders |journal=Neurobiol. Dis. |volume=46 |issue=1 |pages=1–18 |date=April 2012 |pmid=22266337 |doi=10.1016/j.nbd.2011.12.054 |url=}}</ref><ref name="pmid22286308">{{cite journal |vauthors=Lei P, Ayton S, Finkelstein DI, Spoerri L, Ciccotosto GD, Wright DK, Wong BX, Adlard PA, Cherny RA, Lam LQ, Roberts BR, Volitakis I, Egan GF, McLean CA, Cappai R, Duce JA, Bush AI |title=Tau deficiency induces parkinsonism with dementia by impairing APP-mediated iron export |journal=Nat. Med. |volume=18 |issue=2 |pages=291–5 |date=January 2012 |pmid=22286308 |doi=10.1038/nm.2613 |url=}}</ref>
* [[Iron metabolism]] with following increase of storage in the [[substantia nigra]].<ref name="pmid17515544">{{cite journal |vauthors=Oakley AE, Collingwood JF, Dobson J, Love G, Perrott HR, Edwardson JA, Elstner M, Morris CM |title=Individual dopaminergic neurons show raised iron levels in Parkinson disease |journal=Neurology |volume=68 |issue=21 |pages=1820–5 |date=May 2007 |pmid=17515544 |doi=10.1212/01.wnl.0000262033.01945.9a |url=}}</ref><ref name="pmid22266337">{{cite journal |vauthors=Dusek P, Jankovic J, Le W |title=Iron dysregulation in movement disorders |journal=Neurobiol. Dis. |volume=46 |issue=1 |pages=1–18 |date=April 2012 |pmid=22266337 |doi=10.1016/j.nbd.2011.12.054 |url=}}</ref><ref name="pmid22286308">{{cite journal |vauthors=Lei P, Ayton S, Finkelstein DI, Spoerri L, Ciccotosto GD, Wright DK, Wong BX, Adlard PA, Cherny RA, Lam LQ, Roberts BR, Volitakis I, Egan GF, McLean CA, Cappai R, Duce JA, Bush AI |title=Tau deficiency induces parkinsonism with dementia by impairing APP-mediated iron export |journal=Nat. Med. |volume=18 |issue=2 |pages=291–5 |date=January 2012 |pmid=22286308 |doi=10.1038/nm.2613 |url=}}</ref>
*[[Immunological|Immunologic]] and [[Inflammation|inflammatory]] mechanisms due to infiltration of [[CD4+ T cells]].<ref name="pmid19296921">{{cite journal |vauthors=Hirsch EC, Hunot S |title=Neuroinflammation in Parkinson's disease: a target for neuroprotection? |journal=Lancet Neurol |volume=8 |issue=4 |pages=382–97 |date=April 2009 |pmid=19296921 |doi=10.1016/S1474-4422(09)70062-6 |url=}}</ref><ref name="pmid19104149">{{cite journal |vauthors=Brochard V, Combadière B, Prigent A, Laouar Y, Perrin A, Beray-Berthat V, Bonduelle O, Alvarez-Fischer D, Callebert J, Launay JM, Duyckaerts C, Flavell RA, Hirsch EC, Hunot S |title=Infiltration of CD4+ lymphocytes into the brain contributes to neurodegeneration in a mouse model of Parkinson disease |journal=J. Clin. Invest. |volume=119 |issue=1 |pages=182–92 |date=January 2009 |pmid=19104149 |pmc=2613467 |doi=10.1172/JCI36470 |url=}}</ref>
* [[Immunological|Immunologic]] and [[Inflammation|inflammatory]] mechanisms due to infiltration of [[CD4+ T cells]].<ref name="pmid19296921">{{cite journal |vauthors=Hirsch EC, Hunot S |title=Neuroinflammation in Parkinson's disease: a target for neuroprotection? |journal=Lancet Neurol |volume=8 |issue=4 |pages=382–97 |date=April 2009 |pmid=19296921 |doi=10.1016/S1474-4422(09)70062-6 |url=}}</ref><ref name="pmid19104149">{{cite journal |vauthors=Brochard V, Combadière B, Prigent A, Laouar Y, Perrin A, Beray-Berthat V, Bonduelle O, Alvarez-Fischer D, Callebert J, Launay JM, Duyckaerts C, Flavell RA, Hirsch EC, Hunot S |title=Infiltration of CD4+ lymphocytes into the brain contributes to neurodegeneration in a mouse model of Parkinson disease |journal=J. Clin. Invest. |volume=119 |issue=1 |pages=182–92 |date=January 2009 |pmid=19104149 |pmc=2613467 |doi=10.1172/JCI36470 |url=}}</ref>


=== Delirium ===
===Delirium===


====Template Sentences[edit | edit source]====
====Template Sentences[edit | edit source]====

Revision as of 05:48, 20 February 2021

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Moises Romo, M.D., Pratik Bahekar, MBBS [2]

Overview

Altered mental status is a state of a variety of diseases, hence, there is no single pathophysiology mechanism. Although, the neural science behind alertness, wakefulness, and arousal are not fully understood, it is known that the reticular formation plays an important role in these.

Pathogenesis

Altered mental status is a state of a variety of diseases, hence, there is no single pathophysiology mechanism. It is known that the reticular formation plays an important role in the state of alertness. We explain the most important subtypes of altered mental status:

Dementia

Alzheimer's disease

While the pathogenesis of AD remains unclear, It is thought that dementia is the result of:

Parkinson's disease

The pathogenesis of Parkinson's disease is a depletion of dopamine due to the following mechanisms:

Delirium

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Gross Pathology[edit | edit source]

  • Gross pathology refers to macroscopic or larger scale manifestations of disease in organs, tissues and body cavities. The term is commonly used by pathologist to refer to diagnostically useful findings made during the gross examination portion of surgical specimen processing or an autopsy.
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Pathophysiology

Dementia is a symptom

Although the neural science behind alertness, wakefulness, and arousal are not fully known, the reticular formation is known to play a role in these. The ascending reticular activating system is a postulated group of neural connections that receives sensory input and projects to the cerebral cortex through the midbrain and thalamus from the retucular formation. Since this system is thought to modulate wakefulness and sleep, interference with it, such as injury, illness, or metabolic disturbances, could alter the level of consciousness.

Normally, stupor and coma are produced by interference with the brain stem, such as can be caused by a lesion or indirect effects, such as brain herniation. Mass lesions in the brain stem normally cause coma due to their effects on the reticular formation.[26] Mass lesions that occur above the tentorium cerebelli (pictured) normally do not significantly alter the level of consciousness unless they are very large or affect both cerebral hemispheres.

References

  1. ↑ Beach TG, Walker R, McGeer EG (1989). "Patterns of gliosis in Alzheimer's disease and aging cerebrum". Glia. 2 (6): 420–36. doi:10.1002/glia.440020605. PMID 2531723.
  2. ↑ DeKosky ST, Scheff SW (1990). "Synapse loss in frontal cortex biopsies in Alzheimer's disease: correlation with cognitive severity". Ann. Neurol. 27 (5): 457–64. doi:10.1002/ana.410270502. PMID 2360787.
  3. ↑ Terry RD, Masliah E, Salmon DP, Butters N, DeTeresa R, Hill R, Hansen LA, Katzman R (1991). "Physical basis of cognitive alterations in Alzheimer's disease: synapse loss is the major correlate of cognitive impairment". Ann. Neurol. 30 (4): 572–80. doi:10.1002/ana.410300410. PMID 1789684.
  4. ↑ Selkoe DJ (1989). "Amyloid beta protein precursor and the pathogenesis of Alzheimer's disease". Cell. 58 (4): 611–2. PMID 2504495.
  5. ↑ Tanzi RE, Gusella JF, Watkins PC, Bruns GA, St George-Hyslop P, Van Keuren ML, Patterson D, Pagan S, Kurnit DM, Neve RL (1987). "Amyloid beta protein gene: cDNA, mRNA distribution, and genetic linkage near the Alzheimer locus". Science. 235 (4791): 880–4. PMID 2949367.
  6. ↑ Walsh DM, Selkoe DJ (2004). "Oligomers on the brain: the emerging role of soluble protein aggregates in neurodegeneration". Protein Pept. Lett. 11 (3): 213–28. PMID 15182223.
  7. ↑ Ittner LM, Ke YD, Delerue F, Bi M, Gladbach A, van Eersel J, Wölfing H, Chieng BC, Christie MJ, Napier IA, Eckert A, Staufenbiel M, Hardeman E, Götz J (2010). "Dendritic function of tau mediates amyloid-beta toxicity in Alzheimer's disease mouse models". Cell. 142 (3): 387–97. doi:10.1016/j.cell.2010.06.036. PMID 20655099.
  8. ↑ Delacourte A, Flament S, Dibe EM, Hublau P, Sablonnière B, Hémon B, Shérrer V, Défossez A (1990). "Pathological proteins Tau 64 and 69 are specifically expressed in the somatodendritic domain of the degenerating cortical neurons during Alzheimer's disease. Demonstration with a panel of antibodies against Tau proteins". Acta Neuropathol. 80 (2): 111–7. PMID 2117840.
  9. ↑ Boekhoorn K, Joels M, Lucassen PJ (2006). "Increased proliferation reflects glial and vascular-associated changes, but not neurogenesis in the presenile Alzheimer hippocampus". Neurobiol. Dis. 24 (1): 1–14. doi:10.1016/j.nbd.2006.04.017. PMID 16814555.
  10. ↑ Maries E, Dass B, Collier TJ, Kordower JH, Steece-Collier K (September 2003). "The role of alpha-synuclein in Parkinson's disease: insights from animal models". Nat. Rev. Neurosci. 4 (9): 727–38. doi:10.1038/nrn1199. PMID 12951565.
  11. ↑ Spillantini MG, Schmidt ML, Lee VM, Trojanowski JQ, Jakes R, Goedert M (August 1997). "Alpha-synuclein in Lewy bodies". Nature. 388 (6645): 839–40. doi:10.1038/42166. PMID 9278044.
  12. ↑ Calo L, Wegrzynowicz M, Santivañez-Perez J, Grazia Spillantini M (February 2016). "Synaptic failure and α-synuclein". Mov. Disord. 31 (2): 169–77. doi:10.1002/mds.26479. PMID 26790375.
  13. ↑ Lim KL, Zhang CW (2013). "Molecular events underlying Parkinson's disease - an interwoven tapestry". Front Neurol. 4: 33. doi:10.3389/fneur.2013.00033. PMC 3619247. PMID 23580245.
  14. ↑ Dehay B, Martinez-Vicente M, Caldwell GA, Caldwell KA, Yue Z, Cookson MR, Klein C, Vila M, Bezard E (June 2013). "Lysosomal impairment in Parkinson's disease". Mov. Disord. 28 (6): 725–32. doi:10.1002/mds.25462. PMC 5131721. PMID 23580333.
  15. ↑ Ghavami S, Shojaei S, Yeganeh B, Ande SR, Jangamreddy JR, Mehrpour M, Christoffersson J, Chaabane W, Moghadam AR, Kashani HH, Hashemi M, Owji AA, Łos MJ (January 2014). "Autophagy and apoptosis dysfunction in neurodegenerative disorders". Prog. Neurobiol. 112: 24–49. doi:10.1016/j.pneurobio.2013.10.004. PMID 24211851.
  16. ↑ Przedborski S, Tieu K, Perier C, Vila M (August 2004). "MPTP as a mitochondrial neurotoxic model of Parkinson's disease". J. Bioenerg. Biomembr. 36 (4): 375–9. doi:10.1023/B:JOBB.0000041771.66775.d5. PMID 15377875.
  17. ↑ Selvaraj S, Sun Y, Watt JA, Wang S, Lei S, Birnbaumer L, Singh BB (April 2012). "Neurotoxin-induced ER stress in mouse dopaminergic neurons involves downregulation of TRPC1 and inhibition of AKT/mTOR signaling". J. Clin. Invest. 122 (4): 1354–67. doi:10.1172/JCI61332. PMC 3314472. PMID 22446186.
  18. ↑ Schapira AH, Cooper JM, Dexter D, Jenner P, Clark JB, Marsden CD (June 1989). "Mitochondrial complex I deficiency in Parkinson's disease". Lancet. 1 (8649): 1269. PMID 2566813.
  19. ↑ Greenamyre JT, Hastings TG (May 2004). "Biomedicine. Parkinson's--divergent causes, convergent mechanisms". Science. 304 (5674): 1120–2. doi:10.1126/science.1098966. PMID 15155938.
  20. ↑ Sherer TB, Betarbet R, Testa CM, Seo BB, Richardson JR, Kim JH, Miller GW, Yagi T, Matsuno-Yagi A, Greenamyre JT (November 2003). "Mechanism of toxicity in rotenone models of Parkinson's disease". J. Neurosci. 23 (34): 10756–64. PMID 14645467.
  21. ↑ Oakley AE, Collingwood JF, Dobson J, Love G, Perrott HR, Edwardson JA, Elstner M, Morris CM (May 2007). "Individual dopaminergic neurons show raised iron levels in Parkinson disease". Neurology. 68 (21): 1820–5. doi:10.1212/01.wnl.0000262033.01945.9a. PMID 17515544.
  22. ↑ Dusek P, Jankovic J, Le W (April 2012). "Iron dysregulation in movement disorders". Neurobiol. Dis. 46 (1): 1–18. doi:10.1016/j.nbd.2011.12.054. PMID 22266337.
  23. ↑ Lei P, Ayton S, Finkelstein DI, Spoerri L, Ciccotosto GD, Wright DK, Wong BX, Adlard PA, Cherny RA, Lam LQ, Roberts BR, Volitakis I, Egan GF, McLean CA, Cappai R, Duce JA, Bush AI (January 2012). "Tau deficiency induces parkinsonism with dementia by impairing APP-mediated iron export". Nat. Med. 18 (2): 291–5. doi:10.1038/nm.2613. PMID 22286308.
  24. ↑ Hirsch EC, Hunot S (April 2009). "Neuroinflammation in Parkinson's disease: a target for neuroprotection?". Lancet Neurol. 8 (4): 382–97. doi:10.1016/S1474-4422(09)70062-6. PMID 19296921.
  25. ↑ Brochard V, Combadière B, Prigent A, Laouar Y, Perrin A, Beray-Berthat V, Bonduelle O, Alvarez-Fischer D, Callebert J, Launay JM, Duyckaerts C, Flavell RA, Hirsch EC, Hunot S (January 2009). "Infiltration of CD4+ lymphocytes into the brain contributes to neurodegeneration in a mouse model of Parkinson disease". J. Clin. Invest. 119 (1): 182–92. doi:10.1172/JCI36470. PMC 2613467. PMID 19104149.
  26. ↑ Tindall SC (1990). "Level of consciousness". In Walker HK, Hall WD, Hurst JW. Clinical Methods: The History, Physical, and Laboratory Examinations. Butterworth Publishers. Retrieved 2008-07-04. Mass lesions within the brainstem produce coma by virtue of direct effects on the reticular formation

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