[Effectiveness of endarterectomy for symptomatic stenosis of the internal carotid artery; more risk factors important than only the severity of the stenosis]. / Effectiviteit van endarteriëctomie voor symptomatische stenose van de A. carotis; meer factoren belangrijk dan alleen de ernst van de stenose.

Carotid endarterectomy prevents ischaemic stroke in patients who have suffered either a transient ischaemic attack (TIA) or a non-disabling ischaemic stroke and are also diagnosed with severe stenosis of the internal carotid artery (ICA). In order to prevent the occurrence ofa single stroke, 6 patients with a symptomatic 70 to 99% ICA stenosis will have to be operated upon. A meta-analysis of individual patient data from 3 randomised trials shows that the decision whether to advise endarterectomy to an individual patient should not be based solely on the degree of the ICA stenosis, but also on the time interval between symptoms and surgery, the type and severity of symptoms and the plaque morphology. In general, endarterectomy is more effective in men than in women, it is very effective in the elderly, and it is even more effective when performed within two weeks of the symptoms occurring. A decision scheme has been set up enabling one to predict the absolute risk of an ipsilateral stroke in the next 5 years in individual patients who have symptomatic ICA stenosis. This is based on 5 factors: sex, age, the most severe symptom in the last 6 months (stroke, TIA, or ischaemic retinopathy), the number of weeks since the last incident and the morphological characteristics of the plaque.

[Surgery for a recently symptomatic severe carotid stenosis, indicated or not? Clinical application of 'evidence-based' medicine]. / Operatie van een recentelijk symptomatisch geworden ernstige carotisstenose of niet? 'Evidence-based' geneeskunde in de praktijk.

Two trials have shown that carotid surgery reduced the risk of stroke or death for patients with a recently symptomatic severe carotid stenosis. Nevertheless, it remains difficult to advise in individual cases. The risk of a stroke is about 20% in the next 3 years on medical treatment alone. This means that surgery is of no value in about 80% of the patients. With the help of prediction rules (developed by Rothwell and Warlow) it is possible to further individualize the decision whether or not to operate, by incorporating factors such as the angiographic roughness of the stenosis lining, the time since the cerebrovascular symptoms appeared, the extent of the stenosis, increased operation risk, sex, peripheral vascular disease and systolic blood pressure. If these prediction rules prove to be correct, doctors will be able to better advise their individual patients.

[Surgical treatment of carpal tunnel syndrome: endoscopic or classical (open)? A prospective randomized trial]. / Operatieve behandeling wegens carpaletunnelsyndroom: endoscopisch of klassiek (open)? Een prospectief gerandomiseerd onderzoek.

OBJECTIVE: To compare the results of open with endoscopic release of the carpal tunnel in patients with the carpal tunnel syndrome. DESIGN: Randomised prospective study. SETTING: General hospital Zeeuws-Vlaanderen, Oostburg and Terneuzen, the Netherlands. METHOD: 178 patients were randomised for open or endoscopic release. The symptom severity score and functional status score were completed before and three months after the procedure. One week after the operation the patients' postoperative pain was measured on a 10-point visual analogue scale. Differences were analysed using the Chi-square test or the t-test. RESULTS: Randomisation failed in two patients; 85 patients had an endoscopic release and 91 patients had an open release. The postoperative pain was significantly less in the endoscopic group. Improvement in symptom severity score and functional status score was the same in both groups. There was no difference in absence from work. Two local complications occurred in the endoscopically treated group. Of the patients 25% were not or only slightly satisfied with the results. CONCLUSION: Endoscopic release of the carpal tunnel is as effective as the open release but it gives less postoperative pain. Because of the risk of complications and the additional costs, the endoscopic release is not the preferred method for treatment of the carpal tunnel syndrome, however.

[An abscess as an unexpected complication following epidural anesthesia]. / Een abces als onverwachte complicatie na epidurale anesthesie.

A 58-year-old man underwent surgery for an inguinal hernia. Surgery was performed under epidural anaesthesia. The patient afterwards developed increasing low back pain. Magnetic resonance imaging showed an epidural abscess, which was drained by laminectomy. The patient recovered without neurological sequelae.

Syncope or seizure? A matter of opinion.

We studied the diagnostic interpretation by physicians of written histories of 118 patients with a transient loss of consciousness. Considerable disagreement about a diagnosis of either syncope or seizure was found. Overall agreement was only 31%; an erroneous diagnosis was made in 16% of cases. We concluded that the diagnosis of a seizure after a single event is often too unreliable to justify early treatment.

Syncope or seizure? The diagnostic value of the EEG and hyperventilation test in transient loss of consciousness.

In a prospective study of consecutive patients (age 15 or over) with transient loss of consciousness 45 patients had a history of seizure and 74 patients had a history of syncope. All patients had an EEG, ECG, laboratory tests and a hyperventilation test and were followed for an average of 14.5 months. Epileptiform activity in the interictal EEG had a sensitivity of 0.40 and a specificity of 0.95 for the diagnosis of a seizure. Epileptiform activity nearly doubled the probability of a seizure in doubtful cases. If no epileptiform activity was found, this probability remained substantially the same. The hyperventilation test had a sensitivity of 0.57 and a specificity of 0.84 for the diagnosis of syncope. A positive test increased the probability of syncope half as much in doubtful cases. A negative test did not exclude syncope. Laboratory tests were not helpful except for an ECG which was helpful in elderly patients.

Transient loss of consciousness: the value of the history for distinguishing seizure from syncope.

We studied 94 consecutive patients (age 15 or over) to investigate which aspects of the history and clinical findings help to distinguish seizures from syncope and related conditions. Clonic movements or automatism observed by an eyewitness classified an event as a seizure. The seizure group consisted of 41 patients and the syncope group of 53 patients. The likelihood ratio was used to calculate the predictive power of single findings and logistic regression to analyse combinations of findings. The best discriminatory finding was orientation immediately after the event according to the eyewitness and the age of the patient in the absence of an eyewitness report (P less than 0.001). We found a seizure five times more likely than syncope if the patient was disoriented after the event and three times more likely if the patient was less than 45 years of age. Nausea or sweating before the event were useful to exclude a seizure. Incontinence and trauma were not discriminative findings.

Sciatic neuritis as initial symptom of spontaneous clostridial myonecrosis.

A 21-year-old woman is reported with aplastic anaemia, who presented with pain in the leg. Rapid loss of sciatic nerve function followed. MRI showed irregular streaks of low intensity in the muscles of the pelvic region. A diagnosis of sciatic neuritis as initial symptom of clostridial myonecrosis was made.

Diagnosis of a primary non-Hodgkin's lymphoma of the central nervous system by examination of the cerebrospinal fluid.

This paper is a report on a case of primary Non-Hodgkin's lymphoma of the central nervous system, diagnosed by cytological and immunological examination of the cerebrospinal fluid. The relevant literature on the subject is reviewed. The importance of examination of the cerebrospinal fluid in cases suspected of this disease is stressed.