Key messages

• Two major neuroanatomic structures are necessary for consciousness: the reticular activating system and the cerebral hemispheres.

• Evaluation must be rapid, since morbidity is often related to how quickly therapy is begun. Many of the diffuse metabolic or toxic causes of coma resolve without long-term damage to the central nervous system, whereas acute structural disease, particularly if causing herniation, may be rapidly fatal.

• Damage to the midbrain affects both the reticular activating system and pupil reactivity, whereas metabolic disease produces coma but usually leaves the light reflex intact.

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