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Microsurgical anatomy of the brainstem surface facing an acoustic neuroma
Surg Neurol 1987;27:403-4
403
Letters to the Editor The Palmomental Reflex To the Editor: I found the editorial "The Palmomental Reflex" (SURGICAL NEUROLOGY 1986;26:521) of great interest. However, I do not agree with the authors that this is a virtually worthless phenomenon. I have entertained, for many years now, the impression that a strongly positive palmomental reflex appearing soon after the onset of trauma-induced coma was a very strong indication that the patient would not regain consciousness. Unfortunately, I am not able to designate the number of cases except to say that this was the finding in many cases and in sufficient numbers for me to develop a feeling that this was a very strong and important finding in the evaluation of these cases of traumatic coma, or as we now call it, the "persistent vegetative state." From my review of the literature and from my own cases I have formed some concepts that I have found useful, and, although I am sure they are open to challenge, they nevertheless continue to stand up with the passage of time. They are as follows: 1. A strongly positive palmomental reflex in a person below the age of 50 indicates that one must rule out the presence of some neurologic disease process. 2. The presence of a strongly positive palmomental reflex indicates the likely involvement of the pyramidal tracts in the disease process and may indicate some diffuse cortical disturbance as well. 3. It is always present in general paresis of the insane. 4. In cases of severe neurologic damage, this reflex can be elicited from other areas in addition to that described in the original palmomental description. 5. The lesions are usually supratentorial, and the responses are absent in an infratentorial lesion such as a tumor or abscess of the cerebellum. 6. To reiterate, in my experience, when the reflex is strongly present in an unconscious patient, there has not been a return of consciousness. In their original paper, Marinesco and Radovicci particularly made it clear that, while the response was present in many normal people, it was brief, fast, and as a rule not repetitive in character. Thompson, who also did a rather intensive review of this reflex, believed that it should be considered in the same way we consider the knee jerk reflex, which is always present but is evaluated as to its positivity by individual response. I would concur that a brief nonrepetitive response is not significant, but that the repetitive, slow, strong responses are significant, particularly if they are bilateral. I think this is of significance as well. Ernest W. Mack, M.D. Reno, Nevada
Microsurgical Anatomy of the Brainstem Surface Facing an Acoustic Neuroma To the Editor: I would like to comment on the article by Albert L. Rhoton entitled "Microsurgical Anatomy of the Brainstem Surface Facing an Acoustic Neuroma" (SURGICAL NEUROLOGY 1986;25: 326--39). There is, of course, a great deal of useful information in this article. Dr. Rhoton points out the relationships of the brainstem to nerves, arteries, and veins, and also gives a description of the Rand-Kurze suboccipital transmeatal operation for removal of acoustic neuromas. There is only one slight problem--Dr. Rhoton, in this and a number of his other articles on the same subject, does not give references or credit to Dr. Theodore Kurze or to myself for developing the operation that he describes as if it were his own and which has been used worldwide for the past 20 years. As a matter of fact, Dr. Rhoton was not even involved in microneurosurgery when he came to the first symposium on this subject here at UCLA Hospital in 1967. The operation that Dr. Kurze and I developed was described in 1964. Robert W. Rand, Ph.D., M.D. Los Angeles, California
Photochemotherapy Applied Stereotactically to Brain Tumors To the Editor: We read with considerable interest the article by Cheng et al which appeared in SURGICALNEUROLOGY(1986;25:423--35). We believe that stereotactically applied photochemotherapy (PDT) has its place along with the other methods described in this article. We have begun a preliminary study without controls at the Regional Hospital Center in Nantes, France, concerning the feasibility of stereotactically applied PDT (Talairach technique). In view of the poor results obtained with conventional methods in the treatment of tumors of the brain, it seemed valid to propose PDT to 6 patients (mean age 48.5 years, range 3 2 - 5 6 years) (Table 1) who presented histologically with a grade II astrocytoma (2 cases), a glioblastoma (3 cases), and a cystic glioblastoma (1 case). Topographic definition of the lesion included the following: CT scan, arteriography, stereotactic biopsy specimens and, depending on histologic results, an electrostereoencephalographic study. In terms of tumor volume thus defined, we constructed phantoms composed of spheres 10 mm in diameter corresponding to the theoretical volumes of light diffusion at the tip of the optic fiber. The
403
Letters to the Editor The Palmomental Reflex To the Editor: I found the editorial "The Palmomental Reflex" (SURGICAL NEUROLOGY 1986;26:521) of great interest. However, I do not agree with the authors that this is a virtually worthless phenomenon. I have entertained, for many years now, the impression that a strongly positive palmomental reflex appearing soon after the onset of trauma-induced coma was a very strong indication that the patient would not regain consciousness. Unfortunately, I am not able to designate the number of cases except to say that this was the finding in many cases and in sufficient numbers for me to develop a feeling that this was a very strong and important finding in the evaluation of these cases of traumatic coma, or as we now call it, the "persistent vegetative state." From my review of the literature and from my own cases I have formed some concepts that I have found useful, and, although I am sure they are open to challenge, they nevertheless continue to stand up with the passage of time. They are as follows: 1. A strongly positive palmomental reflex in a person below the age of 50 indicates that one must rule out the presence of some neurologic disease process. 2. The presence of a strongly positive palmomental reflex indicates the likely involvement of the pyramidal tracts in the disease process and may indicate some diffuse cortical disturbance as well. 3. It is always present in general paresis of the insane. 4. In cases of severe neurologic damage, this reflex can be elicited from other areas in addition to that described in the original palmomental description. 5. The lesions are usually supratentorial, and the responses are absent in an infratentorial lesion such as a tumor or abscess of the cerebellum. 6. To reiterate, in my experience, when the reflex is strongly present in an unconscious patient, there has not been a return of consciousness. In their original paper, Marinesco and Radovicci particularly made it clear that, while the response was present in many normal people, it was brief, fast, and as a rule not repetitive in character. Thompson, who also did a rather intensive review of this reflex, believed that it should be considered in the same way we consider the knee jerk reflex, which is always present but is evaluated as to its positivity by individual response. I would concur that a brief nonrepetitive response is not significant, but that the repetitive, slow, strong responses are significant, particularly if they are bilateral. I think this is of significance as well. Ernest W. Mack, M.D. Reno, Nevada
Microsurgical Anatomy of the Brainstem Surface Facing an Acoustic Neuroma To the Editor: I would like to comment on the article by Albert L. Rhoton entitled "Microsurgical Anatomy of the Brainstem Surface Facing an Acoustic Neuroma" (SURGICAL NEUROLOGY 1986;25: 326--39). There is, of course, a great deal of useful information in this article. Dr. Rhoton points out the relationships of the brainstem to nerves, arteries, and veins, and also gives a description of the Rand-Kurze suboccipital transmeatal operation for removal of acoustic neuromas. There is only one slight problem--Dr. Rhoton, in this and a number of his other articles on the same subject, does not give references or credit to Dr. Theodore Kurze or to myself for developing the operation that he describes as if it were his own and which has been used worldwide for the past 20 years. As a matter of fact, Dr. Rhoton was not even involved in microneurosurgery when he came to the first symposium on this subject here at UCLA Hospital in 1967. The operation that Dr. Kurze and I developed was described in 1964. Robert W. Rand, Ph.D., M.D. Los Angeles, California
Photochemotherapy Applied Stereotactically to Brain Tumors To the Editor: We read with considerable interest the article by Cheng et al which appeared in SURGICALNEUROLOGY(1986;25:423--35). We believe that stereotactically applied photochemotherapy (PDT) has its place along with the other methods described in this article. We have begun a preliminary study without controls at the Regional Hospital Center in Nantes, France, concerning the feasibility of stereotactically applied PDT (Talairach technique). In view of the poor results obtained with conventional methods in the treatment of tumors of the brain, it seemed valid to propose PDT to 6 patients (mean age 48.5 years, range 3 2 - 5 6 years) (Table 1) who presented histologically with a grade II astrocytoma (2 cases), a glioblastoma (3 cases), and a cystic glioblastoma (1 case). Topographic definition of the lesion included the following: CT scan, arteriography, stereotactic biopsy specimens and, depending on histologic results, an electrostereoencephalographic study. In terms of tumor volume thus defined, we constructed phantoms composed of spheres 10 mm in diameter corresponding to the theoretical volumes of light diffusion at the tip of the optic fiber. The