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Carotid artery stenosis is an important cause of transient ischaemic attacks (TIAs) and ischaemic strokes, and is associated with a particularly high risk of recurrent stroke both in the acute phase and the long-term. Early secondary preventive measures would therefore seem warranted. Carotid endarterectomy (CEA) is an effectively therapy in patients with a severe symptomatic stenosis. Hypertension is an important risk factor for recurrent stroke both in the acute phase and the long-term. Moreover, hypertension is an important risk factor for complications of CEA. In patients on the waiting list for CEA, following a TIA or a non-disabling ischaemic stroke, it would seem worthwhile to attempt to start antihypertensive treatment after approximately 24 h, and to at least strive after a preoperative systolic blood pressure of180 mmHg and a diastolic blood pressure of90 mmHg. In patients who cannot undergo surgery in the desirable short run, hypotensive treatment must be considered in the context of secondary prevention. The blood pressure target level depends on the presence or absence of a severe unilateral or bilateral stenosis (70% lumen diameter). In postoperative hypertension one must strive after a blood pressure140/90 mmHg, thereby avoiding an excessively rapid hypotensive response (25% daily). Patients with a TIA or an ischaemic stroke and a carotid artery stenosis must also be treated with antiplatelet agents and a statin, while other vascular risk factors must be controlled.

A 71-year-old man is discussed in whom the oral and maxillofacial surgeon observed, by chance, a radiopacity on the panoramic radiograph that was highly suggestive of a calcification at the bifurcation of the internal and external carotid artery. While, on the basis of international literature, various treatments are advanced with respect to the importance of vascular investigation and possible surgical removal of significant calcification, at present the view in The Netherlands is that the family doctor has the responsibility to assess whether such patient should be referred for further evaluation by the neurologist or vascular surgeon. The same applies to the possible indication for prescription of antitrombotics.

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Willems DL, Hak A, Visser F, Van der Wal G. Hoe denken patienten met vergevorderd hartfalen over het sterven? Huisarts Wet 2005;48(12):608-14. Doel Wij onderzochten over een periode van 1 jaar de gedachten en opvattingen van patienten in het eindstadium van hartfalen over het sterven. Methode Prospectief longitudinaal multipel gevalsonderzoek met kwalitatieve interviewtechnieken. We sloten 31 patienten uit 2 ziekenhuizen in die voldeden aan een of meer van de volgende criteria: NYHA-klasse III of IV, ejectiefractie

A 41-year-old woman had a 15-year history of pain in her thighs and arms, which also became weaker, and a decrease in visual acuity. Her 35-year-old brother, their 38-year-old sister and their 64-year-old mother also had myalgia, myotonia and proximal muscle weakness, and the women also had cataracts. Additional examinations and tests led to a diagnosis of proximal myotonic myopathy (PROMM) in all four cases. Neurological and ophthalmological follow-up was provided on a yearly basis, including ECG. The clinical features of PROMM display similarities to the adult form of myotonic dystrophy (MD) but differ in the proximal localisation of the muscle weakness and the frequent occurrence of pain in the affected muscles. PROMM is an autosomal dominant hereditary multisystemic disorder with a less serious course than MD and is rarely accompanied by cognitive disorders. In most cases, a genetic defect on chromosome 3q21 is the cause of the disease. A probable diagnosis can be made on the basis of the clinical symptoms and the results of simple laboratory tests, and can be confirmed via DNA analysis. As yet, the disorder can only be treated symptomatically, preferably via a multidisciplinary approach by a neurologist, an ophthalmologist, a cardiologist and a rehabilitation specialist.

To a considerable extent, the neurological outcome of patients with severe brain trauma is determined by the primary injury caused by the accident. Substantial progress has been made in our understanding of the pathophysiological processes resulting in secondary brain damage after brain trauma, partly as a result of the introduction of advanced techniques of neuromonitoring. Early recognition and treatment of the symptoms leading to this type of brain damage seems crucial to the effort to improve the neurological outcome in these patients. Useful modern neuromonitoring techniques include: measurement of the intracranial and cerebral perfusion pressure and continuous electroencephalography. Methods that are also reliable and readily applicable, but less relevant clinically, include cerebral microdialysis of fluid from the extracellular space, determination of the parenchymal oxygen tension, and determination of the venous oxygen saturation. Other techniques that are not clinically applicable include: determination of the cerebral blood flow, the cortical tissue perfusion or the regional cerebral oxygenation.

A 45-year-old man called for the hospital in a confused and anxious state. Another man of around 30 walked into a hospital sweating and complaining of abdominal pain, and subsequently suffered several epileptic seizures and died before being recognised as a body packer. A 39-year-old man suffered an epileptic seizure on the aeroplane and a 21-year-old man was found dead, having suffered from abdominal pain the previous day. All were found to have swallowed cocaine packets. The two eldest men underwent emergency surgery: one died as the result of cocaine intoxication and one recovered. Body packers, people carrying cocaine packets in their bodies, are arriving in Europe in increasing numbers, mainly from South America. Body-packer syndrome consists of intestinal occlusion or potentially lethal intoxication caused by rupture of the packets. Awareness of the body packers' circumstances and the clinical signs of body-packer syndrome makes early recognition possible. In Amsterdam, the identification of body packers after arrival at the airport by the Schiphol-team and the medical follow-up by the Forensic Medicine Department of the Municipal Health Service of Amsterdam, result in a relatively low mortality risk. Early detection of intoxication will save lives.

To examine the use of the Rankin scale for the assessment of disability in patients with ischaemic heart disease.University Hospital Utrecht.Prospective interobserver study.Fifty-two outpatients with heart disease (previous myocardial infarction, angina or both) were separately interviewed by four physicians (residents or specialists), viz., two cardiologists and two neurologists. The degree of disability was recorded by each observer on two different scales: the modified Rankin scale, a six-point scale developed from a neurological background, and the four-point scale developed by the New York Heart Association (NYHA). The agreement rates for the observers (23 in all) were corrected for chance (kappa-statistics; maximum 1.0).Total agreement on both scales was found for six of the participating 51 patients and for 10 and 11 patients when the Rankin scale and the NYHA scale were considered separately. Kappa values were 0.21 for the Rankin scale and 0.24 for the NYHA scale. The weighted kappa values were 0.56 and 0.47, respectively. The agreement among neurologists and cardiologists was comparable.The agreement rates of cardiologists and neurologists in the use of the Rankin scale and the NYHA scale in outpatients with heart disease are at best satisfactory. The good results of an earlier study with the Rankin scale in stroke patients were not achieved. This study indicates that the Rankin scale may be useful for the assessment of disability from heart disease particularly in patients with neurological disease, but there is room for further improvement.