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The only person who does not appear to suffer is the patient With lesser degrees of anoxic-ischemic injury, the patient improves after a period of coma lasting hours or less Some of these patients quickly pass through this acute posthypoxic phase and proceed to make a full recovery; others are left with varying degrees of permanent disability The ndings on imaging studies vary The most common early change in cases of severe injury is a loss of the distinction between the cerebral gray and white matter (Fig 40-1); both ischemia and hypoxia are usually involved Patient with this nding are invariably comatose and few awaken with a good neurologic outcome With less severe and predominantly hypotensive-ischemic events such as cardiac arrest, watershed infarctions become evident in the border zones between the anterior, middle, and posterior cerebral arteries (Fig 40-2) The clinical syndromes associated with watershed infarction are discussed below.

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1. The sum of two numbers is 10. Three times the smaller plus 5 times the larger number is 42. What are the numbers 2. The di erence between two numbers is 12. Twice the smaller plus four times the larger is 108. What are the two numbers 3. The di erence between two numbers is 8. The sum of one and a half times the smaller and four times the larger is 54. What are the numbers 4. The sum of two numbers is 11. When twice the larger is subtracted from 5 times the smaller, the di erence is 6. What are the numbers

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thalamus, raphe nuclei, nucleus ceruleus, and other regions of the brainstem); blocking such activity by drugs or by destruction of the amygdala eliminates anxiety and fear-like behavior Admittedly the concepts of fear, stress, and anxiety are used interchangeably in these models, but repeated stimuli that produce fear and stress may eventually induce a state akin to anxiety, and the amygdala appears to be involved in the perpetuation of this anxiety state The meaning of these effects, ie, whether they are primary or secondary, is not certain, but it is evident that prolonged and diffuse anxiety is associated with certain biochemical abnormalities of the blood and probably of the brain In addition to the role of the amygdala, animal studies have related acute anxiety to a disturbance of function of the locus ceruleus and the septal and hippocampal areas the principal norepinephrine-containing nuclei.

It is noteworthy that the locus ceruleus is involved in rapid-eye-movement (REM) sleep and that drugs such as the tricyclic antidepressants and monoamine oxidase inhibitors, which suppress REM sleep, also decrease anxiety Certain of the serotonin receptors in the brain, different from those implicated in depression, have been related to anxiety Other parts of the brain must also be involved; bifrontal orbital leukotomy diminishes anxiety, possibly by interrupting the medial forebrain connections with the limbic parts of the brain Positron emission tomography (PET) studies in subjects who anticipate an electric shock show enhanced activity in the temporal lobes and insula, implicating these regions in the experience of acute anxiety (see also page 444) Other credible studies have demonstrated a role for the anterior cingulate gyrus in eliciting many of the autonomic features (particularly increased heart rate) of excessive arousal and anxiety.

Most motivational speakers and authors myself included place special emphasis on goals. Without personal and professional goals, I tell my audiences, we wither and we die. But goals don t float in space. They must be anchored in the bedrock of conviction, meaning, and purpose, because without this foundation of purpose, we re all too likely to throw our goals overboard at the first sign of adversity. Without purpose, we fail to connect with our core, our driving force. Without purpose, life is soft and always in danger of falling apart. Without purpose, we can t use the tools that God has given us. And without purpose, we don t have a way to make a difference. And by this, I mean a difference through and to others. It s an interesting paradox. To find purpose, you go within yourself. Your life s purpose is intimate, proprietary. To realize purpose, you must go outside yourself. You create purpose on purpose. Purpose becomes real is realized only when it goes public. How do we discover purpose In part, a sense of purpose grows out of the questions we ask ourselves. For example: Am I going to allow my life to be governed by daily activities, or do I choose to live my life in accordance with noble principles True, the car needs to be inspected, the baby needs to be changed, the laundry is piling up, and the grass needs mowing. But do these day-to-day needs always have to shove higher order concerns to one side Always In other words, do I have an overriding purpose in my life, a purpose that is vivid and precise, a purpose I am committed to, a

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