The diurnal variation in the onset of stroke was examined in 557 consecutive patients aged over 70 years. These included 194 patients with subarachnoid hemorrhage, 118 with intracerebral hemorrhage, and 245 with thromboembolic cerebral infarction. All three types of strokes exhibited a peak incidence between 1000 and 1200 hours. Intracerebral hemorrhages occurred less frequently between 0400 and 0600 hours, but there were no differences between the groups for the other time periods. There was no difference in the time of onset of stroke between normotensive and treated or untreated hypertensive patients. There were more untreated hypertensive patients in the intracerebral hemorrhage group than in the other stroke type groups. Subarachnoid hemorrhage occurred more frequently in the lavatory and during sexual and sporting activity. Intracerebral hemorrhage occurred more commonly during driving or the consumption of alcohol. Cerebral infarction occurred more frequently during sleep or was noticed on waking. No differences were found for the other activities examined. The relationship between diurnal variation in stroke and the known variation in blood pressure is discussed.
One hundred patients with a verified subarachnoid haemorrhage were studied in a double blind, placebo-controlled trial at a single centre to determine the value and relative risks of tranexamic acid (TXA) in the management of ruptured intracranial aneurysms. The incidence of recurrent haemorrhage between active and placebo groups was identical (12%) and the mortality from recurrent haemorrhage was 7% and 5%, respectively. The overall incidence of cerebral infarction before surgery, at discharge and at 6 months follow-up was greater in the TXA group (27%) than in the control group (11%). Post-operative cerebral ischaemia was significantly more frequent in the active, 18 of 29 as compared to 6 of 32 patients, in the placebo group. In a fifth of the patients in whom cerebral blood flow was estimated there was a significant reduction of cerebral blood flow (CBF) on the side of the ruptured aneurysm in the TXA treated group. It is suggested that this may be the cause of the increased incidence of cerebral ischaemia in this group. There was no significant difference in the incidence of cerebral vasospasm, hydrocephalus, visual disturbances and gastrointestinal disturbances. More fatalities were encountered from ischaemia and recurrent haemorrhage in the TXA group but these differences did not reach statistical significance at the 5% level. Given that disability was due to either vasospasm or recurrent haemorrhage than a patient under TXA treatment was significantly more likely to have disability due to vasospasm (p less than 0.04); the reverse was true for the placebo patient (p less than 0.05).
The first spinal commissurotomy was performed by Armour and reported in 1927. The patient, suffering from tabetic gastric pain, died post-operatively. Putnam (1934) devised a similar procedure independently and advocated it for intractable pain in the arms and shoulders. The operation aimed at interrupting the decussating fibres passing to the spinothalamic tracts and, since the decussation was believed to take place over two to three segments for each dermatome, an attempt was made to split the commissure over several segments. Putnam's first patient was completely relieved of pain, and analgesia was produced from C5 to approximately T9 by splitting the commissure from C4 to T3, subsequently confirmed at necropsy. His second patient had only incomplete relief and a third patient died post-operatively. The method soon fell into disrepute because of cases of paralysis caused by injury to the anterior spinal artery. Leriche performed commissurotomy at lower levels in 1928 and reported it in 1936. It is now an established pain-relieving procedure, notably by French workers.Theoretically, cervical commissurotomy would be ideal for bilateral shoulder, arm, or upper chest pain which is uncommon. Unilateral arm or chest pain due to bronchial carcinoma, however, is relatively common and, although such pain can be relieved by high cervical cordotomy, pre-operative respiratory inadequacy may make the procedure hazardous due to injury to descending respiratory pathways (Belmusto, Brown, and Owens, 1963; Hitchcock and Leece, 1967). The advantages of a procedure which would not interfere with these pathways encouraged a reappraisal of the operation of cervical commissurotomy.The extensive laminectomy and myelotomy required, with the risk of injury to the anterior spinal artery, seemed to demand the use of a more precise method. Percutaneous stereotactic spinal tractotomy had been described, using a special stereotactic instrument (Hitchcock, 1969), and a similar technique has been used to interrupt the spinal commissure at the first cervical segment or cervico-medullary junction. MATERIAL AND METHODPatients with intractable pain due to advanced malignant disease were offered this procedure after conservative methods had failed.The patient was seated in the upright posture with the head moderately flexed on the neck and the stereotactic frame applied. The midline of the cord was assumed to lie in the midline of the odontoid process and spinal canal. A posterior-anterior radiograph was taken to determine the offset of the frame in respect of the midline and to enable necessary corrections of the electrode carrier.A lateral view was then taken, again using the odontoid as a bony landmark and assuming that, with the head in the mildly flexed position, the anterior surface of the cord was approximately.2 to 3 mm behind the odontoid line and the thickness of the cord was 10 mm. The cord equator was marked on the film and a suitable point chosen along it to permit the entry of an electrode by direct percutaneous track through the ...
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