1351
Indeed, as we pointed out, the referring agent was never left unsupported and was always offered constructive alternative help for his patient (e.g., outpatient treatment and/or community psychiatric care). Dr Harris seems to imply that he would prefer asylum (presumably admission) for his patients. We feel that admission is not always in the best interest of patients or their relatives. Academic Department of Mental Health, University College Hospital Medical School, London WC1E 6AS
D. A. STURGEON
M. J. BOWMAN
DIAGNOSIS OF COMA
SiR,-Dr Turazzi and Dr Bricolo (July 9, p. 62) described thirteen patients who, in their opinion, had acute pontine syndromes following blunt head injury and stated that these syndromes "can be identified by careful clinical examination and by repeated electroencephalography". They stressed that a clue to the recognition of these syndromes is an electroencephalogram (E.E.G.) "similar to the normal waking pattern" and cited Loeb and Poggiol and others to support their view that an E.E.G. with alpha-like activity in patients with coma is nearly always associated with pontine or pontomesencephalic lesions. Turazzi and Bricolo have disregarded convincing evidence that the association of coma and background activity in the alpha range can be seen in patients with widespread supratentorial damage, usually anoxic, and no detectable brainstem lesion,.2-s We have lately seen a case which illustrates this point. A 54-year-old man, a patient of Dr J. Newsom-Davis, had a sudden onset of confusion on March 15, 1976, and, later, right-sided focal seizures. Whilst having computerised tomography on the same day, he had sudden cardiorespiratory arrest. The estimated total cardiac-arrest time before resuscitation was 2 min. Just prior to this event tomography showed 1. Loeb, C., Poggio, G. Electroencephal. clin. Neurophysiol. 1953, 5, 295. 2. Binnie, C. D., Prior, P. F., Lloyd, D. S. L., Scott, D. F., Margerison, J. H. Br. med. J. 1970, iv, 265. 3. Westmoreland, B. F., Klass, D. W., Sharbrough, F. W., Reagan, T. J. Archs
Neurol. 1975, 32, 713. 4.
Vignaendra, V., Wilkus, R. J., Copass, 1974, 24, 582. 5. Chokroverty, S. ibid. 1975, 25, 655.
M.
K., Chatrian, G. E. Neurology,
Fig. 2-E.E.G. Unresponsive 9-12 Hz rhythms posteriorly and, in addition, lowvoltage theta and some delta waves in the left posterior quadrant. International 10-20 system of reference to electrodes.
abnormalities. He remained in deep flaccid coma until his on March 19. The only reaction to pain was an occasional symmetrical decerebrate response. There was a blot haemorrhage in the left fundus. The eyes were in the mid-position. Pupils were small (2 mm) and reacted sluggishly to light. All oculocephalic responses were absent. Occasional spontaneous blinking was observed. Cold-water stimulation of the ° ears produced 150 conjugate deviation to the right and 25’ deviation to the left. Gag reflex was present. Tendon jerks and plantar responses were absent. Initially he had Cheyne-Stokes respiration but later assisted ventilation was required. He had tachycardia of around 120/min. Blood-pressure fluctuated between 140/90 and 210/140 mm Hg. Repeated tomography on March 17 showed a low-density area in the left occipital region (fig. 1). The E.E.G. on March 16 is shown in fig. 2. Relevant post-mortem findings including histology (Prof W. Blackwood) were: (1) a line of separation between cortex and underlying grey-matter in the territory of the left middle cerebral artery with marked ischaemic changes in the left occipital cortex; (2) irregular areas of grey colouration in the deep white matter of both occipitoparietal lobes; (3) recent anoxic changes in both hippocampal regions and in the Purkinje cell layer of the cerebellum; (4) disappearance of many nerve cells and astrocytic hyperplasia in the cerebral cortex; (5) no brainstem lesions. It is interesting that Turazzi and Bricolo report that in nine of their patients the E.E.G. was unreactive. In a study of twelve comatose patients with alpha-like rhythms after cardiac arrest, Chokroverty6 found that they were only occasionally reactive. In his opinion, however, alpha-like rhythms in brainstem coma are frequently reactive. no
death,
,
National Hospital for Nervous Diseases, London WC1
R.
J. GUILOFF
W. A. COBB
TRANSITORY, POST-TRAUMATIC "LOCKED-IN" SYNDROME man was admitted to hospital with a diagnosis of "post-traumatic coma". The patient had been dragged along by a car after a traffic accident, suffering cephalic hyperextension and rotation. Afterwards he remained motionless on the ground because of paralysis of all four limbs, with amblyo-
SiR,—A 21-year-old
Fig. 1--Computerised tomography. Low-density area extending from the occipital ventricle backwards into left occipital lobe.
horn of left lateral
Indeed, as we pointed out, the referring agent was never left unsupported and was always offered constructive alternative help for his patient (e.g., outpatient treatment and/or community psychiatric care). Dr Harris seems to imply that he would prefer asylum (presumably admission) for his patients. We feel that admission is not always in the best interest of patients or their relatives. Academic Department of Mental Health, University College Hospital Medical School, London WC1E 6AS
D. A. STURGEON
M. J. BOWMAN
DIAGNOSIS OF COMA
SiR,-Dr Turazzi and Dr Bricolo (July 9, p. 62) described thirteen patients who, in their opinion, had acute pontine syndromes following blunt head injury and stated that these syndromes "can be identified by careful clinical examination and by repeated electroencephalography". They stressed that a clue to the recognition of these syndromes is an electroencephalogram (E.E.G.) "similar to the normal waking pattern" and cited Loeb and Poggiol and others to support their view that an E.E.G. with alpha-like activity in patients with coma is nearly always associated with pontine or pontomesencephalic lesions. Turazzi and Bricolo have disregarded convincing evidence that the association of coma and background activity in the alpha range can be seen in patients with widespread supratentorial damage, usually anoxic, and no detectable brainstem lesion,.2-s We have lately seen a case which illustrates this point. A 54-year-old man, a patient of Dr J. Newsom-Davis, had a sudden onset of confusion on March 15, 1976, and, later, right-sided focal seizures. Whilst having computerised tomography on the same day, he had sudden cardiorespiratory arrest. The estimated total cardiac-arrest time before resuscitation was 2 min. Just prior to this event tomography showed 1. Loeb, C., Poggio, G. Electroencephal. clin. Neurophysiol. 1953, 5, 295. 2. Binnie, C. D., Prior, P. F., Lloyd, D. S. L., Scott, D. F., Margerison, J. H. Br. med. J. 1970, iv, 265. 3. Westmoreland, B. F., Klass, D. W., Sharbrough, F. W., Reagan, T. J. Archs
Neurol. 1975, 32, 713. 4.
Vignaendra, V., Wilkus, R. J., Copass, 1974, 24, 582. 5. Chokroverty, S. ibid. 1975, 25, 655.
M.
K., Chatrian, G. E. Neurology,
Fig. 2-E.E.G. Unresponsive 9-12 Hz rhythms posteriorly and, in addition, lowvoltage theta and some delta waves in the left posterior quadrant. International 10-20 system of reference to electrodes.
abnormalities. He remained in deep flaccid coma until his on March 19. The only reaction to pain was an occasional symmetrical decerebrate response. There was a blot haemorrhage in the left fundus. The eyes were in the mid-position. Pupils were small (2 mm) and reacted sluggishly to light. All oculocephalic responses were absent. Occasional spontaneous blinking was observed. Cold-water stimulation of the ° ears produced 150 conjugate deviation to the right and 25’ deviation to the left. Gag reflex was present. Tendon jerks and plantar responses were absent. Initially he had Cheyne-Stokes respiration but later assisted ventilation was required. He had tachycardia of around 120/min. Blood-pressure fluctuated between 140/90 and 210/140 mm Hg. Repeated tomography on March 17 showed a low-density area in the left occipital region (fig. 1). The E.E.G. on March 16 is shown in fig. 2. Relevant post-mortem findings including histology (Prof W. Blackwood) were: (1) a line of separation between cortex and underlying grey-matter in the territory of the left middle cerebral artery with marked ischaemic changes in the left occipital cortex; (2) irregular areas of grey colouration in the deep white matter of both occipitoparietal lobes; (3) recent anoxic changes in both hippocampal regions and in the Purkinje cell layer of the cerebellum; (4) disappearance of many nerve cells and astrocytic hyperplasia in the cerebral cortex; (5) no brainstem lesions. It is interesting that Turazzi and Bricolo report that in nine of their patients the E.E.G. was unreactive. In a study of twelve comatose patients with alpha-like rhythms after cardiac arrest, Chokroverty6 found that they were only occasionally reactive. In his opinion, however, alpha-like rhythms in brainstem coma are frequently reactive. no
death,
,
National Hospital for Nervous Diseases, London WC1
R.
J. GUILOFF
W. A. COBB
TRANSITORY, POST-TRAUMATIC "LOCKED-IN" SYNDROME man was admitted to hospital with a diagnosis of "post-traumatic coma". The patient had been dragged along by a car after a traffic accident, suffering cephalic hyperextension and rotation. Afterwards he remained motionless on the ground because of paralysis of all four limbs, with amblyo-
SiR,—A 21-year-old
Fig. 1--Computerised tomography. Low-density area extending from the occipital ventricle backwards into left occipital lobe.
horn of left lateral
