Acta Chir Belg
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Some controversy exists on the best moment to treat symptomatic carotid artery disease. This controversy concerns mainly neurologically unstable patients and patients who suffered a minor stroke. The authors discuss recent literature data on the feasibility and the safety of performing urgent (within 24 to 72 hours) carotid endarterectomy (CEA) in patients presenting repetitive transient ischaemic attacks or progressing stroke. Neurologically unstable patients, suffering ischemic brain deficit caused by carotid artery stenosis, are defined according to the following criteria: two or more transient ischaemic attacks (crescendo TIAs) or a fluctuating neurological deficit evolving no longer than 24 hours (progressing stroke), no impairment of consciousness, cerebral infarct of limited size on diffusion-weighted magnetic resonance imaging of the brain and a carotid artery stenosis of 70% or more on the appropriate side. In the past, these patients were often considered at too high risk to undergo immediate carotid surgery. Many neurologists remain reluctant to confine these neurologically unstable patients for urgent carotid endarterectomy and prefer to stabilise the neurological status, arguing the increased stroke morbidity in the urgent setting. Nevertheless, the natural history of stroke- in-evolution or repetitive transient ischemic attacks is far from benign, exposing the patient to a high risk of subsequent spontaneous stroke, even under best medical treatment. Another controversy exists on the timing of surgery in patients who suffered a minor, non-disabling stroke. Is a waiting period of 6 weeks safe? Once more, the operative risk should be balanced against the anticipated natural history. Published series, and sub-analysis of the recent carotid surgery trials (NASCET, ECST) plaid for carotid surgery within two weeks of a minor stroke. ⋯ Contemporary literature argues that neurologically unstable patients, presenting repetitive transient ischaemic attacks or progressing stroke, should be managed by urgent (within 24 to 72 hours) carotid endarterectomy, even if the peri-operative stroke-death rate is slightly higher than in the elective setting. Despite an inherent increased operative morbidity-mortality, urgent carotid endarterectomy seems to us justified by the fact that waiting for the surgery may lead to the development of a more profound stroke in these neurologically unstable patients. Their only chance for neurological recovery (partial or complete) is in the early phase (12 to 60 hours after the acute onset of the neurological syndrome of crescendo-TIAs or stroke-in-evolution). For patients presenting a minor stroke, with limited brain infarction, carotid endarterectomy should preferentially be done in a semi-urgent fashion, within two weeks.
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Gastrointestinal stromal tumors (GISTs) are the most common mesenchymal neoplasms of the gastrointestinal (GI) tract. They are believed to originate from the interstitial cells of Cajal (ICCs) or from the precursors of ICCs. Most GISTs show an activating mutation in either the c-kit or platelet-derived growth factor receptor alpha (PDGFRA) gene. Tumor size, mitotic rate, and anatomic location correlate with potential malignancy and recurrence rate. ⋯ Tumors classified as GISTs with low and very low risk of progression are associated with a very good prognosis, with virtually all patients surviving 5 years. In patients with high risk or progressive diseases, the prognosis of 5-year survival is much poorer. The main therapeutic option is surgical removal of the tumor (resection or broad excision). Agents showing promise for patients with malignant forms of GISTs are tyrosine kinase receptor inhibitors. Although imatinib is currently used as a first line treatment for all patients with metastatic or unresectable GISTs, it is likely that this treatment will change in the future based on the underlying mutational status.