© News of the World

Maybe just one comment. As someone who has had a close family member treated for endometrial cancer recently (similar, but not identical to the treatment for cervical cancer which has spread to the uterus), can I just say how well Jade looks in this video clip. She must be wearing false eyelashes and pencilled-in eyebrows, because they fall out at the same time your hair does when you are having chemotherapy.

As far as this writer is aware, there are never any post mortem signs of epilepsy itself. It is after all electrical discharge in the brain – not something you can see after the event! Perhaps what the pathologist (medical examiner) means is that no other pathology was found, leaving a seizure as the only other conclusion. The sixteen-year-old’s body has now apparently been cremated.

The web has been alive with speculation surrounding this family tragedy. Not least because of the reports of autism, and the fact that Scientologists do not believe in autism. It has also been reported that Jett Travolta suffered from Kawasaki syndrome. This quite rare condition usually occurs in very young children, and is hardly ever life-threatening. It can occasionally lead to heart problems (particularly aneurysms of the coronary arteries) but is not associated with epilepsy later in life.

Apple CEO Steve Jobs

The boss of Apple has had a particularly nasty, and very rare condition called a neuroendocrine tumour. They often crop up in the pancreas, but can also grow inside other organs.

‘Pancreatic cancer’ is something different altogether, and usually taken to mean a cancer of the pancreatic tissue itself – an adenocarcinoma. Unfortunately your outlook if you have this condition is bleak indeed. The cancer is aggressive, and it usually ‘presents late’ – that is that by the time you notice anything wrong (the first thing is usually that you are going yellow – jaundiced – but with no other symptoms except perhaps weight loss) the cancer is well advanced.

Neuroendocrine tumours produce various hormones, and the exact symptoms will depend on what particular type of tumour is growing. They only usually spread locally – so after an operation to remove the tumour there is no need for other treatment like radiotherapy or chemotherapy. In fact a relative of mine had his pancreas removed for a neuroendocrine tumour a few months ago. His was secreting steroid-like hormones, and he was initially diagnosed with Cushing’s syndrome.

This will be why Mr. Jobs is reportedly having problems with a hormone imbalance. We wish him well, and a speedy return to good health. As a huge fan of everything ‘Apple’, I want him releasing pretty new gadgets for many years to come.

Paul Gascoigne

On the recent documentary aired on the Channel 4 – ‘Saving Gazza’, Paul Gascoigne’s 12 year old son was asked what he thought was wrong with his dad. “Everything” was the reply. The lad should definitely consider clinical psychology as a career. This link to a previous documentary – ‘Surviving Gazza‘ – has some video clips. These were filmed prior to the documentary ‘Saving Gazza.’
Whether or not Paul Gascoigne (the former England footballer) has a formal psychiatric diagnosis is an arguable point, but probably not one worth arguing. However you label the poor guy, he appears to be very ill indeed and possibly beyond recovery.
According to some sources he has suffered at various times from ‘manic depression’ (also known as bipolar disorder), paranoia, bulimia, obsessive-compulsive disorder (OCD), attention deficit and hyperactivity disorder (ADHD) and a mild form of Tourette’s syndrome.

Certainly on his wedding video there were facial twitches and grimaces suggestive of Tourette’s. His need to count things and only be comfortable with certain combinations of numbers is indicative of OCD. He seemed to have a distorted body image in keeping with someone who may have an eating disorder. And he displayed some frankly paranoid delusions about persecution and being followed. Maybe he does have a bit of everything. Tragically, it seems that he is self-medicating primarily with alcohol as a way of coping with his many demons. Not at all what the doctor ordered.

When I were a lad, we’d get one or two ruptured AAAs (triple As, Abdominal Aoritc Aneurysms) into the resus room every month. Most of them died. The aorta is the large blood vessel that leads from the top of the heart, and curves down toward the rest of the body, throwing off smaller branches on the way.

In the abdomen, it should be no more than about 4-5mm in diameter in an adult. An aneurysm is a weakening in the wall of a blood vessel – in the case of the aorta, it means that the vessel bulges. This bulge can be measured using ultrasound. Once it has got to a certain critical size, planned surgery can be undertaken to repair the defect. Before this sort of ultrasound screening, the first thing most people knew about their AAA was when it ruptured.

Mortality from planned surgery is a lot lower then from emergency repair, but it’s still a risky operation. Risk factors include ‘co-morbidity’ (other diseases the patient – usually elderly – may suffer from), and also the exact level at which the aneurysm lies, and how extensive it is. Some aortic aneurysms extend into the thoracic aorta (within the chest) and these are particularly deadly.

I’m not of course privy to the exact details of Mr. Lyttleton’s case, but it would seem that the combination of age and surgical risk were simply too much. A loss to us all.

The film director and screenwriter Anthony Minghella has died unexpectedly, a week after undergoing surgery for what sounds like tonsillar cancer.

Ever since I found out about its existence, tonsillar cancer has been top of my list of things-I-don’t-want-to-get. It’s a horrible disease, just like other forms of cancer. But this one is particularly nasty as it tends to present late, and the treatment is particularly aggressive and often disfiguring.

By ‘present late’ we doctors mean that a disease is quite well advanced by the time it is spotted. If you take skin cancer on the face as an opposite example, this is usually picked up early because the patient, or an acquaintance, notices that strange spreading mole on the cheek. But when the cancer is tucked away at the very back of your throat, there can be nothing in the way of symptoms for a long time. In fact a secondary deposit of the cancer in another part of the body, or in a lymph node in the neck or head area, may be the first sign of tonsillar cancer.

The disfiguring treatment is also related to the anatomical site of the cancer. Many of the organs in the head and neck share lymphatic drainage, and this needs to be taken into account when planning surgery. As well as the actual tumour (which can be difficult to locate exactly) portions of the jaw, neck, tongue and even face may have to be operated on. This experience was detailed by John Diamond, the journalist husband of Nigella Lawson, who died of oral cancer in 2001.

But from all accounts, the initial operation appears to have gone well for Anthony Minghella. He suffered a fatal haemorrhage several days after the operation.

Bleeding several days ‘post-op’ is usually caused by infection. Many wounds get infected after surgery – modern so-called ’superbugs’ usually have nothing to do with it. Most of the time the body shrugs off the infection and the surgical tampering heals. But if you’re unlucky, the infection will become established. And if you’re really unlucky, the infection will involve a large blood vessel (of which there are plenty around the head and neck). If a small abscess erodes through the wall of even a fairly small artery, the bleeding can be catastrophic. And once again, the position of the operation site is a factor here. Bleeding from any artery can usually be stopped very efficiently simply by pressing on the bleeding point. But if the bleeding is coming from somewhere deep in the neck or throat, pressing on it is simply impossible.

The ‘bleeding post-op tonsil’ is a classic exam scenario for both surgeons and anaesthetists. It doesn’t just happen in cancer treatments – in fact the vast majority of postoperative tonsillar haemorrhages occur in young people having ‘routine’ tonsillectomies (a far rarer operation nowadays than in the past – for a brief glimpse of the operation’s shady history, click here.) About 7-10 days after the apparently successful operation, a child can present with copious bleeding from the mouth, enough to require intravenous fluid and/or blood replacement. They also need to be anaesthetised for an operation to stop the bleeding. But their blood pressure is low (because of the bleeding) which limits the anaesthetic techniques which can be used. And the back of their throat is full of blood, so it is difficult to ‘maintain an airway’ (ensure an unobstructed passage for air to get into the lungs.) Bleeding post-op tonsils are a nightmare, and can be a challenge for even the most experienced physicians.

In Mr. Minghella’s case it would seem that he has succumbed to just that event, albeit one complicated by the presence of a tumour of some kind – so his surgery will have been more extensive than that for a simple tonsillectomy.

It has been a strange week for celebrity deaths caused by bleeding from major neck vessels. There’s another one here.

The British newsreader Carol Barnes has sadly died, from ‘a stroke’, and the actress Samantha Morton has just revealed a stroke as the reason for her 18 month disappearance from Hollywood.

In English medical vernacular, the term ’stroke’ is usually used to describe a catastrophic Cerebro-Vascular Accident (CVA). In more common English, that means something really nasty and unpredicted (catastrophic and accidental) in your brain (cerebral) to do with your blood vessels or blood supply (vascular).

Quite why we insist on calling them ’strokes’ in the UK is a bit of a mystery, but has something to do with the supposed Stroke of God’s hand, according to the OED.

expand and reduce the OED definition of ‘Stroke’ by clicking here…

In the United States they’re increasingly known as ‘Brain Attacks’, in an attempt to excite people’s attention. Because sometimes they can be treated if caught in time.

The blood supply to your brain can be interrupted in one of two ways (there are a couple of other very rare ways, but they need not detain us here.) Those ways are thrombotic (also known as ‘occlusive’) and haemorrhagic.

It’s not rocket science, or indeed even brain surgery, in its complexity. The arteries supplying the brain with blood (and therefore oxygen and nutrients – the very stuff of life) are little tubes. They can get blocked (by a thrombus, a blood clot) or they can burst – releasing free blood into the brain tissue where it is really not welcome. The latter is often referred to as a brain haemorrhage. But it is also just a slightly different form of ’stroke’.

The tricky bit is deciding quickly enough whether your patient has a tiny blood clot in an artery in their head, or has an artery that has burst. Because while the symptoms can be very similar, the treatment for the two conditions is so different that if you get it wrong you can very quickly make things even worse.

Again, it’s not that difficult to get your head around. Blood clots have to be dissolved. But if you do that to someone who’s just had an artery burst inside their skull, you’re going to fast-track them straight to the pathology out-patient department (that’s jokey medical speak for the morgue.) Just to re-iterate: blood clots need to be dissolved quickly; burst blood vessels need the exact opposite (unfortunately there does not yet exist the medical equivalent of Rad-Weld for brains, but what you should definitely not do in the event of a leaky vessel is make things even worse by making the blood less clottier.)

You can protect yourself to some extent against the clot / occlusion type of stroke by looking after your general health, keeping an eye on your blood pressure, perhaps taking an aspirin tablet every day, that sort of thing. Some also say that your cholesterol levels matter, but you should at least read the Cholesterol Skeptics before worrying too much about that. Protecting yourself against a burst artery inside your brain is, unfortunately, outside most people’s control. As many as a third of us unfortunately have the propensity for this.

As doctors what we can now do is carry out a CT scan of the brain of someone who appears to have had a ’stroke’, to determine whether or not it is safe to give them ‘clot-busting’ drugs, which in the event of an occlusive or thrombotic stroke can dramatically improve the outcome. In the case of Carol Barnes it seems likely that she had a major haemorrhagic stroke (a brain haemorrhage) or else an occlusive/thrombotic stroke that was either too large or too late to respond to treatment.

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