Explore the vast range of titles available.

Purpose Targeted treatment for brainstem lesions requires above all a precise histopathological and molecular diagnosis. In the current technological era, robot-assisted stereotactic biopsies represent an accurate and safe procedure for tissue diagnosis. We present our center’s experience in frameless robot-assisted biopsies for brainstem lesions. Methods We performed a retrospective analysis of all patients benefitting from a frameless robot-guided stereotactic biopsy at our University Hospital, from 2001 to 2017. Patients consented to the use of data and/or images. The NeuroMate® robot (Renishaw™, UK) was used. We report on lesion location, trajectory strategy, histopathological diagnosis and procedure safety. Results Our series encompasses 96 patients (103 biopsies) treated during a 17 years period. Mean age at biopsy: 34.0 years (range 1–78). Most common location: pons (62.1%). Transcerebellar approach: 61 procedures (59.2%). Most common diagnoses: diffuse glioma (67.0%), metastases (7.8%) and lymphoma (6.8%). Non conclusive diagnosis: 10 cases (9.7%). After second biopsy this decreased to 4 cases (4.1%). Overall biopsy diagnostic yield: 95.8%. Permanent disability was recorded in 3 patients (2.9%, all adults), while transient complications in 17 patients (17.7%). Four cases of intra-tumoral hematoma were recorded (one case with rapid decline and fatal issue). Adjuvant targeted treatment was performed in 72.9% of patients. Mean follow-up (in the Neurosurgery Department): 2.2 years. Conclusion Frameless robot-assisted stereotactic biopsies can provide the initial platform towards a safe and accurate management for brainstem lesions, offering a high diagnostic yield with low permanent morbidity.

We aimed to analyze trends in drug-eluting stents (DES) use in four international health care and regulatory settings. Accounts suggest a differential approach to DES internationally and recent reductions in use following reports of late stent thrombosis. Current studies of clinical practice are limited in their scope. Data were pooled from angioplasty registries in Alberta (Canada), Belgium, Mayo Clinic (Rochester, MN), and Scotland (UK) that have routinely recorded consecutive patients treated since 2003. Trend analysis was performed to examine variations in DES use over time and by clinical subgroup. A total of 178,504 lesions treated between January 2003 and September 2007 were included. In the Mayo Clinic Registry, rapid adoption to a peak of 91% DES use for all lesions by late 2004 was observed. In contrast, Alberta and Scotland showed delayed adoption with lower peak DES use, respectively, 56% and 58% of lesions by early 2006. Adoption of DES in Belgium was more gradual and peak use of 35% lower than other registries. Reductions in DES use were seen in all data sets during 2006, although this varied in absolute and relative terms and by clinical subgroup. Adoption and use of DES showed wide variation in four countries. The determinants of use are complex, and it is likely that nonclinical factors predominate. Recent reductions in use may be as a consequence of publicity and concerns regarding late stent thrombosis. The optimum application of DES in clinical practice is unclear and is reflected in the degree of international variation demonstrated.

Individuals with diabetes mellitus have worse outcomes, and particularly a higher rate of restenosis, following revascularization than those without diabetes. The advent of drug-eluting stents has, however, reignited enthusiasm for percutaneous coronary intervention in individuals with diabetes. In this Review, Victor Legrand evaluates drug-eluting stents as an alternative revascularization strategy to surgery in diabetic patients. Individuals with diabetes mellitus usually present with accelerated atherosclerosis, more diffuse disease, concomitant comorbidities and have an increased risk for restenosis. Evidence confirmed the superiority of CABG surgery over balloon angioplasty with or without bare-metal stenting for diabetic patients requiring multivessel revascularization. More recently, drug-eluting stents (DESs) have emerged as the predominant percutaneous strategy in patients with coronary artery disease. This Review summarizes the knowledge on coronary stenting in diabetics. Although the rate of restenosis is dramatically reduced with the use of DESs compared with bare-metal stents, diabetic patients continue to face higher adverse cardiac event rates when compared with nondiabetic patients. Whether there are differences in the effectiveness of paclitaxel-eluting or sirolimus-eluting stents is still debated. Late outcome might be overshadowed by clinical issues such as late stent thrombosis or restenosis, particularly in diabetic patients with renal failure or complex lesions, and after premature interruption of antiplatelet agents. Longer follow-up in larger populations is thus needed to confirm the long-term safety and efficacy. The superiority or the equivalence of DESs over CABG surgery for multivessel disease has not yet been demonstrated. Thus, although evidence supports DES use in diabetics, further data are needed to better define the management of diabetic patients with coronary artery disease. Key Points When considering which revascularization strategy to use, the greater atherosclerotic burden in patients with diabetes must be considered, as well as the accelerated progression of the disease seen in these patients Although the rate of restenosis in patients both with and without diabetes is markedly lower with the use of drug-eluting stents than with bare-metal stents, diabetes remains a significant risk factor for restenosis even when using drug-eluting stents Until now, there is no definite evidence of greater performance of any particular type of drug-eluting stent, leaving the physician to choose the type of drug-eluting stent that seems the most appropriate for the type of lesion to be treated Until more data are available, physicians should be aware of the potentially high risk of stent thrombosis when interrupting antiplatelet agent regimens in patients with diabetes, particularly if renal insufficiency is present or when a bifurcation lesion is treated While waiting for results of ongoing clinical trials (e.g. the FREEDOM and SYNTAX studies), CABG surgery should remain the preferred treatment in diabetic patients with multivessel disease

The purpose of this study was to determine the feasibility, safety, and efficacy of elective stenting with heparin-coated Wiktor stents in patients with coronary artery disease. In experimental studies, heparin coating has been shown to prevent subacute thrombosis and restenosis. Recently, a new method of heparin coating was developed, resulting in a more stable and predictable heparin layer on stent devices. This trial constitutes the first in-human use of this coating procedure, applied on the well-known Wiktor stent device. Heparin-coated Wiktor stent implantation was performed in 132 consecutive patients (132 lesions) in a multicenter international trial from September 1996 to February 1997. Forty-three percent of patients had unstable angina, 33% had previous myocardial infarction, and 10% had diabetes mellitus. Patients were followed for 12 months for occurrence of major adverse cardiovascular events, and 96% of the eligible patients underwent quantitative angiographic control at 6 months. Stent deployment was successful in 95.5% of lesions. Minimal lumen diameter increased by 1.67 ± 0.48 mm (from 1.02 ± 0.38 mm before to 2.69 ± 0.37 mm after the stent implantation). Mean percent diameter stenosis decreased from 67.4 ± 11.3% before to 18.9 ± 7.7% after the intervention. A successful intervention (<50% diameter stenosis and no major adverse cardiac events within 30 days) occurred in 97% of the patients. The subacute thrombosis rate was 0.8%, which compares favorably with historical controls of this stent, and a low incidence of postprocedural increase in creatine kinase-MB was noted. At 6 months, event-free survival was 85% and angiographic restenosis rate was 22% with late loss of 0.78 ± 0.69 mm and a loss index of 0.48 ± 0.44. Heparin-coated Wiktor stents appeared to be an efficacious device to treat Benestent-like lesions, yielding angiographic and clinical results comparable to a heparin-coated Palmaz-Schatz stent. Despite its use in more complex lesions, the incidence of subacute thrombosis appeared to be lower than historical controls with a similar noncoated stent.

•Giant aneurysm can be managed with bypass procedure.•The optimal flow replacement can be defined with intraoperative Doppler.•An insufficient blood flow can lead to ischemic lesions or Moyamoya vessels.•A long term clinical and imaging follow up must be performed.

High-sensitivity C-reactive protein predicts future cardiovascular events in both healthy individuals and patients with unstable and stable coronary syndromes. Few data are available about the incidence and the relation to inflammation of troponin elevation following percutaneous coronary intervention (PCI), a potential predictor of longterm outcome. We sought to confirm the impact of embolization on long-term outcome and evaluate the ability of baseline inflammation to predict troponin elevation induced by PCI. We prospectively analyzed 200 patients treated by PCI for stable or Braunwald IIA class unstable angina. The patients were recruited between January 1997 and May 1999, and the population was followed during a mean follow-up of 32 months. Major adverse cardiac events (MACEs) were defined as the occurrence of death, myocardial infarction or recurrent angina requiring repeat PCI, or coronary artery bypass grafting. During the follow-up period, 58 MACEs were observed. By multivariate analysis, independent predictors for the occurrence of MACEs were unstable angina and troponin I level after PCI ( P < 0.0001 for both). No correlation was found between baseline inflammation and significant troponin I elevation post PCI and by multivariate analysis, no biological variable was a predictor of troponin I elevation post PCI. Baseline inflammation cannot predict onset of minor myonecrosis damage (expressed by troponin elevation) induced by PCI, a significant predictor of long-term outcome in this setting.

OBJECTIVE:--To evaluate whether in stable angina preference for coronary revascularization by either percutaneous coronary intervention (PCI) or coronary artery bypass surgery (CABG) is influenced by diabetes status and whether this has prognostic implications. RESEARCH DESIGN AND METHODS--A total of 2,928 consecutive patients with stable angina who were enrolled in the prospective Euro Heart Survey on Coronary Revascularization were studied. Multivariable analyses were applied to evaluate the relation between diabetes, treatment decision, and 1-year outcome. RESULTS:--Diabetes was documented in 587 patients (20%) who had more extensive coronary disease. Revascularization was intended in 74% of patients with diabetes and in 77% of those without diabetes. In patients selected for revascularization, CABG was intended in 35% of diabetic and in 33% of nondiabetic patients. Multivariable analyses did not change these findings, but in some subgroups diabetes influenced treatment decisions. For example, diabetic subjects with mild heart failure had more often intended revascularization (91%) than those without diabetes (67%, P < 0.001). Treatment decisions in patients with more extensive (left main, multivessel, or proximal left anterior descending artery) disease were not influenced by diabetes status. Diabetes was not associated with an increased incidence of all-cause death, nonfatal cerebrovascular accident, or nonfatal myocardial infarction at 1 year, regardless of preferred treatment. The incidence of the combined end points was 7.3% in diabetic and 6.8% in nondiabetic patients (adjusted hazard ratio 1.0 [95% CI 0.7-1.4]). CONCLUSIONS:--In stable angina, treatment decisions regarding revascularization or the choice for CABG or PCI were not influenced by the presence of diabetes. Diabetes was not associated with a poor prognosis.

The earliest monumentality in Western Europe is associated with megalithic structures, but where did the builders of these monuments live? Here, the authors focus on west-central France, one of the earliest centres of megalithic building in Atlantic Europe, commencing in the mid fifth millennium BC. They report on an enclosure at Le Peu (Charente), dated to the Middle Neolithic (c. 4400 BC), and defined by a ditch with two ‘crab claw’ entrances and a double timber palisade flanked by two timber structures—possibly defensive bastions. Inside, timber buildings—currently the earliest known in the region—were possibly home to the builders of the nearby Tusson long mounds.

Hypertension is a risk factor for both progression of atrial fibrillation (AF) and development of AF-related complications, that is major adverse cardiac and cerebrovascular events (MACCE). It is unknown whether left ventricular hypertrophy (LVH) as a consequence of hypertension is also a risk factor for both these end points. We aimed to assess this in low-risk AF patients, also assessing gender-related differences. We included 799 patients from the Euro Heart Survey with nonvalvular AF and a baseline echocardiogram. Patients with and without hypertension were included. End points after 1 year were occurrence of AF progression, that is paroxysmal AF becoming persistent and/or permanent AF, and MACCE. Echocardiographic LVH was present in 33% of 379 hypertensive patients. AF progression after 1 year occurred in 10.2% of 373 patients with rhythm follow-up. In hypertensive patients with LVH, AF progression occurred more frequently as compared with hypertensive patients without LVH (23.3% vs 8.8%, p = 0.011). In hypertensive AF patients, LVH was the most important multivariably adjusted determinant of AF progression on multivariable logistic regression (odds ratio 4.84, 95% confidence interval 1.70 to 13.78, p = 0.003). This effect was only seen in male patients (27.5% vs 5.8%, p = 0.002), while in female hypertensive patients, no differences were found in AF progression rates regarding the presence or absence of LVH (15.2% vs 15.0%, p = 0.999). No differences were seen in MACCE for hypertensive patients with and without LVH. In conclusion, in men with hypertension, LVH is associated with AF progression. This association seems to be absent in hypertensive women.