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The combined resection of skull-infiltrating tumours and immediate cranioplastic reconstruction predominantly relies on freehand-moulded solutions. Techniques that enable this procedure to be performed easily in routine clinical practice would be useful. A cadaveric study was developed in which a new software tool was used to perform single-stage reconstructions with prefabricated implants after the resection of skull-infiltrating pathologies. A novel 3D visualization and interaction framework was developed to create 10 virtual craniotomies in five cadaveric specimens. Polyether ether ketone (PEEK) implants were manufactured according to the bone defects. The image-guided craniotomy was reconstructed with PEEK and compared to polymethyl methacrylate (PMMA). Navigational accuracy and surgical precision were assessed. The PEEK workflow resulted in up to 10-fold shorter reconstruction times than the standard technique. Surgical precision was reflected by the mean 1.1±0.29mm distance between the virtual and real craniotomy, with submillimetre precision in 50%. Assessment of the global offset between virtual and actual craniotomy revealed an average shift of 4.5±3.6mm. The results validated the 'elective single-stage cranioplasty' technique as a state-of-the-art virtual planning method and surgical workflow. This patient-tailored workflow could significantly reduce surgical times compared to the traditional, intraoperative acrylic moulding method and may be an option for the reconstruction of bone defects in the craniofacial region.

Objective To report long-term results after Pipeline Embolization Device (PED) implantation, characterize complex and standard aneurysms comprehensively, and introduce a modified flow disruption scale. Methods We retrospectively reviewed a consecutive series of 40 patients harboring 59 aneurysms treated with 54 PEDs. Aneurysm complexity was assessed using our proposed classification. Immediate angiographic results were analyzed using previously published grading scales and our novel flow disruption scale. Results According to our new definition, 46 (78%) aneurysms were classified as complex. Most PED interventions were performed in the paraophthalmic and cavernous internal carotid artery segments. Excellent neurologic outcome (modified Rankin Scale 0 and 1) was observed in 94% of patients. Our data showed low permanent procedure-related mortality (0%) and morbidity (3%) rates. Long-term angiographic follow-up showed complete occlusion in 81% and near-total obliteration in a further 14%. Complete obliteration after deployment of a single PED was achieved in all standard aneurysms with 1-year follow-up. Our new scale was an independent predictor of aneurysm occlusion in a multivariable analysis. All aneurysms with a high flow disruption grade showed complete occlusion at follow-up regardless of PED number or aneurysm complexity. Conclusions Treatment with the PED should be recognized as a primary management strategy for a highly selected cohort with predominantly complex intracranial aneurysms. We further show that a priori assessment of aneurysm complexity and our new postinterventional angiographic flow disruption scale predict occlusion probability and may help to determine the adequate number of per-aneurysm devices.

Objectives The study aim was to evaluate the utility of 2-fraction, dose-staged Gamma Knife radiosurgery (GKRS) in patients with large, high-risk brain metastases (BMs). Methods A total of 63 large BMs in eloquent areas in 61 patients were treated with GKRS in 2 reduced doses. Treatment planning was conducted on the 50% isodose line and included the whole tumor volume as seen on T1 contrast-enhanced and T2-weighted magnetic resonance imaging sections. The median margin and central dose were 12 Gy and 24 Gy, respectively, for both fractions. Patients were assessed using the Graded Prognostic Assessment, Recursive Partitioning Analysis, and Score Index for Radiosurgery. Results Thirty-two patients (53%) had been diagnosed with multiple BMs, and extracranial metastases were present in a majority of patients before GKRS treatment. Significant decreases in tumor volume were observed between the first and second treatment stages. At 3-month follow-up, a majority of patients presented with stable or decreased lesion volumes. The remaining patients showed intralesional hemorrhaging or increasing edema that was managed conservatively. Three patients were diagnosed with tumor progression at the last follow-up and received microsurgical treatment. The median time to radiologic progression was 7 months. The median survival time after initial BM diagnosis was 6 months. Survival times were significantly longer than 3 of 4 calculated prognostic survival estimates. Conclusion The new 2-fraction, dose-staged GKRS concept seems to be a well-tolerated and effective treatment option for large BMs. This method may be indicated in elderly patients or patients with surgical contraindications with large or high-risk brain metastases.

To assess the relationship between left anterior descending (LAD) coronary artery myocardial bridging detected by 64-slice computed tomography (CT) and clinical findings.221 consecutive patients were examined with coronary 64-slice CT angiography. 21 patients with coronary stenosis50% were excluded. The length, depth, and luminal narrowing of LAD myocardial bridges during systole and diastole were measured. CT findings were compared with the treadmill ECG-stress test, and clinical symptoms.Myocardial bridges of the LAD were found in 23% of patients (51/221) (length, 14.9+/-6.5mm; depth, 2.6+/-1.6mm). A significant difference was noted between the LAD luminal diameter before the intramyocardial course and intramyocardially, for both diastole and systole (p0.001); with a higher diameter reduction of 27% for end-systole compared to end-diastole with 15% (p=0.006). Systolic LAD intramyocardial luminal narrowing50% was found in 3/25 (8%). 30/51 (59%) of bridges were "deep" (2mm myocardial depth), 21/51 (41%) were "superficial". The prevalence of a positive ECG-stress tests for the anterior myocardial region was significantly higher in patients with LAD myocardial bridges (34/50; 68%) compared to those without (28/144; 19.4%) (p0.001). There was no difference between "superficial" and "deep" LAD myocardial bridges in regard to a positive treadmill ECG-stress test. Typical angina was rare with 6%.LAD myocardial bridges are common findings and can possibly explain a positive exercise ECG-stress test for anterior myocardial ischemia. Intramyocardial LAD segments show mild-to-moderate luminal narrowing at rest, which is higher during end-systolic phase.

The use of endoluminal stent-grafts to treat different thoracic aortic pathologies is emerging as a less invasive alternative to conventional surgery in patients with serious coexisting illnesses. Many advances have been made since Parodi and coworkers 1 described their first experience using a stent-graft to treat an abdominal aneurysm and it has since become possible to treat thoracic as well as abdominal aortic diseases. 2,3 The endovascular technique is minimally invasive and is associated with acceptable morbidity and mortality rates. This article describes our experience with endovascular management of different thoracic aortic pathologies. In addition, treatment strategies and indications are discussed and current limitations of endovascular techniques are shown.

Resume Au cours de cette recherche, nous avons etudie l'influence de la salinite sur l'activite biologique des sols; les experiences ont ete realisees a partir d'un sol sale a alcali d'origine tunisienne (climat mediterraneen semi-aride) en comparaison avec un pelosol developpe sous climat semi-continental (Lorraine, France). Les deux sols ont ete enrichis en paille de mais uniformement marquee au 14 C. La biomasse microbienne etait estimee, d'une part a l'aide de la methode de Jenkinson, et, d'autre part, par la mesure de l'ATP. L'activite biologique etait determinee par les mesures de degagement de CO 2 . Les resultats ont montre une correlation inverse entre le degre de salinite exprime par les variations de la conductivite electrique et la biomasse microbienne et son activite: les plus hautes teneurs en ATP (141,5 ng · 100 g −1 de sol) etaient constatees dans le pelosol alors que ces valeurs n'atteignent que 99,4 ng · 100 g −1 de sol dans le cas du sol a alcali. D'autre part, le carbone biologique respectivement degage correspondait a 114 et 54 mgC · 100 g −1 de sol. Enfin, la cinetique de degagement de 14 CO 2 etait de 0,82 et 0,45 mgC 100 g −1 de sol. Les resultats ont egalement permis de demontrer la double origine du flux de CO 2 apres fumigation et reinoculation; la mineralisation etant liee a la biomasse microbienne mais egalement a une interaction de la matiere organique avec le chloroforme; celle-ci etant plus accusee dans le sol sale a alcali.