• Tommer Nir, Ayelet Or-Borichev, Evgeny Izraitel, Talma Hendler, Yulia Lerner, and Idit Matot.
• Division of Anaesthesia, Intensive Care and Pain Medicine, Tel Aviv Medical Center, Tel Aviv, Israel. Electronic address: Tommer.Nir@mountsinai.org.
• Br J Anaesth. 2019 Sep 1; 123 (3): 298-308.

BackgroundEmergence from sedation entails rapid increase in the levels of both awareness and wakefulness, the two axes of consciousness. Functional MRI (fMRI) studies of emergence from sedation often focus on the recovery period, with no description of the moment of emergence. We hypothesised that by focusing on the moment of emergence, novel insights, primarily about subcortical activity and increased wakefulness, will be gained.MethodsWe conducted a resting state fMRI analysis of 17 male subjects (20-40 yr old) gradually entering into and emerging from deep sedation (average computed propofol concentrations of 2.41 and 1.11 μg ml-1, respectively), using target-controlled infusion of propofol.ResultsFunctional connectivity analysis revealed a robust spatiotemporal signature of return of consciousness, in which subcortical seeds showed transient positive correlations that rapidly turned negative shortly after emergence. Elements of this signature included four components of the ascending reticular activating system: the ventral tegmentum area, the locus coeruleus, median raphe, and the mammillary body. The involvement of the rostral dorsolateral pontine tegmentum, which is specifically impaired in comatose patients with pontine lesions, in emergence was previously unknown.ConclusionsEmergence from propofol sedation is characterised, and possibly driven, by a transient activation of brainstem loci. Some of these loci are known components of the ascending reticular activating system, whereas an additional locus was found that is also impaired in comatose patients.Copyright © 2019 British Journal of Anaesthesia. Published by Elsevier Ltd. All rights reserved.

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