Perioperative stroke during carotid endarterectomy: benefits of multimodal neuromonitoring - a case report.

BACKGROUND: Carotid endarterectomy is routinely performed after ischemic stroke due to carotid stenosis. Perioperative, cerebral blood flow and oxygenation can be monitored in different ways, but there is no clear evidence of a gold standard and a uniform guideline is lacking. Electroencephalography and near-infrared spectroscopy are among the most frequently used methods of neuromonitoring. Clinicians should be aware of their pitfalls and the added value of transcranial doppler. CASE PRESENTATION: We present the case of an 85-year old male with perioperative haemodynamic stroke during carotid endarterectomy. Ischemic stroke was caused by suddenly increased carotid stenosis resulting in major neurologic deficit. This was registered only by transcranial doppler, while surface electroencephalography and near-infrared spectroscopy failed to detect any significant change in cerebral perfusion, despite a large perfusion defect on computed tomography. Circulation was restored with endovascular treatment and neurologic deficit quickly resolved. CONCLUSION: We strongly advocate the practice of multimodal neuromonitoring including transcranial doppler whenever possible to minimize the risk of persistent neurologic deficit due to perioperative stroke during carotid endarterectomy.

Acute scrotal pain from idiopathic ilioinguinal neuropathy: diagnosis and treatment with EMG-guided nerve block.

Ilioinguinal nerve entrapment presents with a clinical triad of pain in the iliac fossa and inguinal region, sensory abnormalities in the cutaneous distribution of the nerve and tenderness on palpation 2-3 cm medial and below the anterior superior iliac spine. The syndrome poses diagnostic difficulties, as genitofemoral nerve entrapment and non-neurological conditions of the lower abdomen may cause similar pain. We report on a patient with acute groin pain radiating towards the scrotum, caused by ilioinguinal nerve entrapment. The clinical diagnosis was strongly suggested by electromyographic examination, using the monopolar needle as a deep stimulating electrode. Subsequent nerve blockade caused complete relief of symptoms. The technique is described. Future applications for treatment of post-surgical pain are discussed.

Neck pain in chronic whiplash syndrome treated with botulinum toxin. A double-blind, placebo-controlled clinical trial.

OBJECTIVES: Neck pain in chronic whiplash syndrome is a major burden for patients, healthcare providers and insurance companies. Randomized data on treatment of botulinum toxin in chronic whiplash syndrome are scarce. We conducted a randomized, placebo-controlled clinical trial to prove efficacy of botulinum toxin for neck pain in chronic whiplash syndrome. METHODS: 40 patients with chronic whiplash syndrome (whiplash associated disorders grade 1 and 2) were randomly assigned to receive botulinum toxin (maximum 100 units) or placebo (saline) in muscles with increased tenderness. RESULTS: After 12 weeks there was no significant difference between the two treatment groups in decrease of neck pain intensity on VAS (-7.0 mm, 95% confidence interval (CI) [-20.7 to +6.7]), mean number of neck pain days (-1%; 95% CI [-15% to +13%]), neck pain hours per day (-0.14; 95% CI [-3.0 to +2.7]), days on which symptomatic treatment was taken (-0.7%; 95% CI [-15% to +13%]) number of analgesics taken per day (-0.14; 95% CI [-0.6 to +0.4]) and total cervical range of motion (-11 degrees; 95% CI [-40 to +17]). There also was no significant difference in patient's assessment of improvement after week 4, 8 and 12. CONCLUSIONS: Botulinum toxin was not proven effective in treatment of neck pain in chronic whiplash syndrome. Increased muscle tenderness alone might not be the major cause of neck pain in whiplash syndrome.

Interobserver variation in the interpretation of SSEPs in anoxic-ischaemic coma.

OBJECTIVE: To study interobserver variation in the interpretation of median nerve SSEPs in patients with anoxic-ischaemic coma. METHODS: SSEPs of 56 consecutive patients with anoxic-ischaemic coma were interpreted independently by 5 experienced clinical neurophysiologists using guidelines derived from a pilot study. Interobserver agreement was expressed as kappa coefficients. RESULTS: Kappa ranged from 0.20 to 0.65 (mean 0.52, SD 0.14). Disagreement was related with noise level and failure to adhere strictly to the guidelines in 15 cases. The presence or absence of N13 and cortical peaks caused disagreement in 5 cases each. For recordings with a noise level of 0.25 microV or more, mean kappa was 0.34; for recordings with a noise level below 0.25 microV mean kappa was 0.74. CONCLUSIONS: Interobserver agreement for SSEPs in anoxic-ischaemic coma was only moderate. Since the noise level strongly influenced interobserver variation, utmost attention should be given to its reduction. If an artefact level over 0.25 microV remains, absence of N20 cannot be judged with sufficient certainty and the SSEP should be repeated at a later stage. SIGNIFICANCE: Because of its moderate interobserver agreement, great care has to be given to accurate recording and interpretation of SSEPs before using the recordings for non-treatment decisions.

Treatment of chronic tension-type headache with botulinum toxin: a double-blind, placebo-controlled clinical trial.

Botulinum toxin is increasingly advocated as effective treatment in chronic tension-type headache. We conducted a randomized, placebo-controlled clinical trial to prove efficacy of botulinum toxin in chronic tension-type headache. Patients were randomly assigned to receive botulinum toxin (maximum 100 units) or placebo (saline) in muscles with increased tenderness. After 12 weeks there was no significant difference between the two treatment groups in decrease of headache intensity on VAS (-3.5 mm, 95% confidence interval (CI) - 20 to +13), mean number of headache days (-7%; 95% CI - 20 to +4), headache hours per day (-1.4%; 95% CI - 3.9 to +1.1), days on which symptomatic treatment was taken (-1.9%; 95% CI - 11 to +7) and number of analgesics taken per day (-0.01; 95% CI -0.25-0.22). There was no significant difference in patient's assessment of improvement after week 4, 8 and 12. Botulinum toxin was not proven effective in treatment of chronic tension-type headache. Increased muscle tenderness might not be as important in pathophysiology of chronic tension-type headache as hitherto believed.

In vivo analysis of end-plate noise of human extensor digitorum brevis muscle after intramuscularly injected botulinum toxin type A.

To evaluate changes occurring in the neuromuscular junction after injection with botulinum neurotoxin type A (BoTx), three healthy volunteers were injected with 10 U BoTx in the right extensor digitorum brevis muscle. In agreement with previous observations, amplitude of compound muscle action potential (CMAP) decreased to approximately 30% of the initial value at approximately day 8 and slowly returned to baseline values around day 250. Values of the acetylcholine receptor (AChR) open time were determined by spectral analysis of end-plate noise and from single exponential fits to the decay phase of individual miniature end-plate potentials (MEPPs). At baseline, the mean channel open times determined by end-plate noise analysis and the exponential fits were 1.1 +/- 0.2 ms and 1.20 +/- 0.04 ms, respectively. After BoTx injection, initially no end-plate noise could be recorded. From day 9 onwards, however, a gradual recurrence of end-plate noise was observed, with mean channel open times of approximately 2-5 ms, being maximal between days 20 to 140. In addition, the shape of many recorded MEPPs was different from the typical fast rising MEPPs observed at baseline. After day 80, end-plate noise gradually returned to normal and mean channel open times decreased slowly to baseline values. Our findings reflect the changed AChR characteristics of newly formed neuromuscular junctions, which are created after BoTx injection and gradually removed after restoration of the original neuromuscular junctions.