Dr Guaraldi and colleagues raise several important considerations regarding the thalamic contribution to arousal. Their comments offer us an opportunity to clarify our findings in the context of the broader literature on the thalamus and its role in arousal.First, we should highlight the important distinction between what is evidence for the necessity of a structure for a particular function (in this case, maintaining conscious wakefulness) and what is evidence for the participation of that structure in modulating a function without being necessary for it. Our study design was aimed at evaluating whether the thalamus is necessary for maintaining a waking level of consciousness. This question is important if we wish to understand the human brain circuits underlying basic, conscious wakefulness. Many neural structures can modify cortical electroencephalographic (EEG) activity and, when stimulated, awaken subjects from sleep. These structures range from peripheral nerves to the spinal cord, brainstem and cerebral cortex, 1-4 yet the distribution of regions that are actually necessary for maintaining wakefulness is quite small. [5][6][7][8][9] We do not dispute the abundant evidence that thalamocortical function is necessary for a variety of cognitive processes 10-12 that constitute, collectively, the "contents" of consciousness. 13 If, however, the thalamus is necessary for maintaining wakefulness, one would expect that a lesion disrupting the entire thalamus would severely impair arousal, resulting in stupor or coma. Experimental lesion studies conducted in animals have consistently shown that the thalamus is not necessary for sustaining wakefulness. 5,[14][15][16] Ours is the first systematic analysis addressing this question in humans, and our findings are congruent with the animal studies; of 33 thalamic stroke patients, there were no patients with ischemia restricted to the thalamus that had a major effect on arousal. Furthermore, all patients with severely impaired arousal (coma or stupor) had clear-cut lesion extension into the midbrain and/or pons tegmentum. These findings are consistent with our own inpatient clinical experience and are consistent with a critical review of the literature, where comatose patients with "thalamic" strokes typically have ophthalmoplegia or other clear-cut clinical signs of brainstem involvement in a posterior-circulation stroke syndrome, or have direct imaging evidence of the "thalamic" stroke extending into the midbrain and/or pons tegmentum. 12,17,18 The most parsimonious conclusion to be drawn from the existing literature, in our view, is that there are regions of the upper brainstem necessary for maintaining consciousness via projections to the forebrain, but that the thalamus itself does not play a necessary role in sustaining basic arousal.When making a claim like ours (that the thalamus itself is not necessary for basic, conscious wakefulness) it is important to set out criteria for what sort of evidence would falsify the claim. In our case, that evidence would include o...