Hypnic headache syndrome is a rare, sleep-related, benign headache disorder. We report 19 new cases (84% females) with follow-up data. The mean age at headache onset was 60.5 +/- 9 years (range 40-73 years). Headache awakened the patients from the night's sleep at a consistent time, usually between 1.00 and 3.00 a.m. (63%); three patients (16%) reported that identical headaches could occur also during daytime naps. Headache frequency was high, occurring more than 4 nights/week in 68% of the patients. Headache resolution occurred within 2 h in 68% of patients. Neurologic examination, laboratory studies, and brain imaging were unrevealing at the time of diagnosis. Headache severity largely remains unchanged or attenuates over time, but frequency may vary in either direction. Only one patient had spontaneous relief from headache. Four patients (24%) achieved permanent suppression of headache with medication, and two were able to abort individual headache attacks. Caffeine in a tablet or beverage was helpful in four patients. Lithium carbonate therapy caused side effects requiring cessation of treatment in four patients.

The authors report their initial experience with the use of interposition saphenous vein grafts between the external carotid artery and the proximal posterior cerebral artery. The indications, results, and technical aspects of the operation are reviewed. All patients accepted for surgery were at high risk for a posterior circulation infarct, and all patients with ischemic symptomatology had continued to progress while on anticoagulant drugs or anti-platelet agents. Thus, all patients were at high risk, and 11 of the 14 patients operated on were confined to bed before surgery. Intraoperative graft flows varied from 35 to 170 ml/min, and postoperative graft flows ranged from 75 to 311 ml/min in the patent grafts. There were three early graft occlusions and two late graft occlusions; these all occurred in patients with relatively low flows at the time of surgery (40 ml/min or lower). Subdural hygroma was the next most frequent complication to graft occlusion. It was thought to be caused by the pulsating graft anastomosed to a major vessel through a small opening in the basal arachnoid, which provided a new path for cerebrospinal fluid flow in patients with a degree of preexisting atrophy. One patient with a large aneurysm in the posterior circulation underwent proximal intracranial clipping of the vertebral artery and bypass grafting simultaneously. There were seven excellent results and two good results in nine patients in whom the graft remained patent. In the five patients with graft occlusion, there were two minor strokes, two major strokes, and one death.

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Cluster headache (CH) is a rare form of headache occurring in both episodic and chronic forms. The painful attacks are short-lived, occur unilaterally, and are associated with signs and symptoms of autonomic involvement. Attacks frequently occur at night and can be precipitated by ingestion of alcohol. In the episodic form, attacks occur daily for some weeks followed by a period of remission. In the chronic form, attacks can continue for years. Inheritance is not a factor in CH. Treatment can be symptomatic or prophylactic. Agents used to treat individual attacks include inhalation of oxygen, rapidly acting forms of ergotamine and dihydroergotamine, and sumatriptan. Prophylactic treatment employs calcium-channel-blocking agents, methysergide, lithium, and corticosteroids. Surgical modalities, notably thermocoagulation of the gasserian ganglion, can provide relief in those who are resistant to medical management.

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One hundred forty-one patients with cerebral or cerebellar infarction were examined by computed tomography (CT) as soon after the ictus as possible. The examination was repeated in 7 days, and a radionuclide brain scan was performed. The overall detection rate for ischemic infarction was approximately equal for both techniques, ranging from 58% for radionuclide scanning to 66% for the delayed CT. Almost half of the supratentorial infarcts examined by CT on the day of the ictus were demonstrated. Mass effect was observed as early as the first day and as late as the 25th day.

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Twenty patients with thoracic outlet syndrome (TOS) seen at the Mayo Clinic between October 1984 and November 1985 were studied prospectively with routine nerve conduction studies, concentric needle examination, and bilateral median and ulnar somatosensory evoked potentials (SEPs). Results of nerve conduction studies and needle examination were abnormal in 30% of the patients, one patient having a reduced ulnar sensory nerve action potential amplitude and five others having neurogenic motor unit potential changes in the hand muscles. Ulnar SEPs were abnormal in three patients (15%), and median SEPs were abnormal in one patient, who also had abnormalities in ulnar SEPs. In patients with TOS, routine nerve conduction studies and needle examination were the most helpful electrophysiologic studies in excluding more common conditions. The routine use of ulnar SEPs in the evaluation of patients with TOS is probably not worthwhile.