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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. [ABSTRACT FROM AUTHOR]

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. 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. 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. 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. [ABSTRACT FROM AUTHOR]

Presents a reply to the letter to the editor concerning the treatment of chronic tension-type headache with botulinum toxin, published in previous issues.