Until very recently, no specific therapies have been demonstrated to improve outcome after spontaneous intracerebral haemorrhage (ICH). The STICH (surgical treatment for intracerebral haemorrhage) study showed no overall benefit from early surgery when compared with initial conservative treatment. In contrast, the stereotactic aspiration technique can be safely performed and in a uniform manner. Despite the reduction of ICH volume, no improvement in mortality and functional result was obtained. Endoscopy is a new therapeutic option for ICH with good results for hematoma removal. Based on these feasibility studies, a randomized control trial regarding this procedure would be required to assess the efficacy of this procedure. Due to the lack of benefit observed in the recent STICH trial, emergency surgical evacuation should be reserved for patients with large lobar haemorrhage, mass effect and rapidly deteriorating clinical condition.

Until very recently, no specific therapies have been demonstrated to improve outcome after spontaneous intracerebral haemorrhage (ICH). The STICH (surgical treatment for intracerebral haemorrhage) study showed no overall benefit from early surgery when compared with initial conservative treatment. In contrast, the stereotactic aspiration technique can be safely performed and in a uniform manner. Despite the reduction of ICH volume, no improvement in mortality and functional result was obtained. Endoscopy is a new therapeutic option for ICH with good results for hematoma removal. Based on these feasibility studies, a randomized control trial regarding this procedure would be required to assess the efficacy of this procedure. Due to the lack of benefit observed in the recent STICH trial, emergency surgical evacuation should be reserved for patients with large lobar haemorrhage, mass effect and rapidly deteriorating clinical condition.

Background With the advent of antiretroviral therapy regimens in HIV positive patients, it is crucial to consider their long-term benefits to risk ratios. The responsibility of treatment in premature atherosclerosis is not clear. Thus, the aim of this study is to evaluate the impact of exposure to reverse transcriptase inhibitors (nucleosidic and non-nucleosidic) and to protease inhibitors on the cardiovascular status of an entire hospital based cohort of patients. Methods 154 patients were included. Using a linear analysis, we sought an association between the cumulative time of exposure to these three classes of antiretroviral drugs and the carotid intima-media thickness measured by ultrasonography and a cardiovascular composite score. Results The study confirms premature atherosclerosis, which not only correlates with the usual risk factors, such as triglyceride level, but also with protease inhibitor exposure, especially that of lopinavir. Nevertheless as regards current drug exposure, the clinical impact was low: five clinical complications of atherosclerosis and only one out of 35 scintigraphic and ECG exercise tests warranted a coronary angiography which was negative. Conclusion These data should not lead to the rejection of protease inhibitors but should strengthen the prevention of cardiovascular diseases as an integral part of the management of HIV patients.

Drug addiction which entails cardiovascular risks unknown or misknown to physicians, currently involves an increasing number of miscellaneous drugs, existing in manifold forms. There appears to be no bounds on the way of intake. All territories of the body may be affected with more or less severity. In young people, the cardiac, coronary, cerebral and peripheral vascular systems are generally involved. Two illicit drugs, cannabis and cocaine, showing a permanent increase in misuse, prevail. This drug addiction comes along with intercurrent pathologies which have their own vascular toxicity, especially HIV infection. Moreover, the advent of new illicit substances emphasizes the complexity of the clinical presentations. These complex situations have a real social and medical impact. We are currently in a phase of permanently increasing risk of cardiovascular complications. The pathophysiological mechanisms involved are intertwined and complicated by the frequent association of polytoxicomania or by the effects excipients added to these drugs: direct vascular toxicity, angeitis, arterial and venous thrombosis. Arsenic, a common component of these drugs, is also found in cigarettes; arsenic toxicity mainly affects the lower limbs. Treatment of these complications is non-specific; the ideal solution being weaning which, unfortunately in this peculiar population of patients, may entail serious complications due to the misuse of substitution products.

Les traitements antirétroviraux permettent actuellement une survie importante des patients infectés par le virus VIH, en faisant reculer les complications infectieuses. Trois classes thérapeutiques antirétrovirales contre le VIH sont disponibles. Parallèlement, chez cette population jeune, sont apparues des complications cardiovasculaires inhabituelles, en rapport avec des anomalies biologiques iatrogénes (dyslipidémies et insulino-résistance), même si cette population est exposée aux facteurs de risque classiques d’athérosclérose. Les traitements antirétroviraux semblent à l’origine de ces complications en induisant un diabète de type 2 dans 4 à 20 % des cas, une insulino-résistance chez 15 à 60 % des patients, une hypertriglycéridémie dans 15 à 74 % des cas selon les études et une hypercholestérolémie chez 20 à 60 % des sujets, surtout en cas de lipodystrophie associée. La mise en route d’un traitement antirétroviral motive un bilan préalable lipidique, comprenant un dosage du cholestérol total, HDL et triglycérides, et glycémique après 12 heures de jeûne. La surveillance évolutive de ces paramètres biologiques paraît souhaitable tous les 3 à 6 mois en cas d’anomalie, même si d’autres causes surajoutées de dyslipidémies secondaires doivent être évoquées. En cas d’élévation isolée des taux de LDL-cholestérol persistante, l’introduction d’un traitement par statine paraît licite. En prévention secondaire, quel que soit le contexte, les recommandations rejoignent actuellement le consensus de la population générale. Ces patients nécessitent donc une surveillance et une prise en charge spécifiques en dehors du problème de leur immunodéficience. (J Mal Vasc 2004 ;29 : 192-199).

La toxicomanie fait courir des risques cardiovasculaires ignorés ou mal connus du médecin. Elle fait appel à des produits de plus en plus variés, se présentant de multiples façons, et dont le mode d’administration ne connaît pas de limites. Tous les territoires peuvent être touchés, chez des personnes jeunes en grande majorité, avec plus ou moins de sévérité : cardiaque, coronaire, cérébral, vasculaire périphérique. Deux drogues illicites en constante augmentation dominent : le cannabis et la cocaïne. Cette toxicomanie s’accompagne de pathologies intercurrentes ayant leur propre toxicité cardiovasculaire, en particulier par le biais du virus de l’immunodéficience humaine. L’apparition de nouvelles substances illicites ne fait qu’accentuer la complexité des tableaux cliniques. Ces fléaux n’ont pas qu’une répercussion sociale mais aussi médicale ; la fréquence des complications cardiovasculaires ne fait qu’augmenter. La physiopathologie est complexe et compliquée par la polytoxicomanie souvent associée ou par les excipients ajoutés à ces drogues : toxicité vasculaire propre, vascularite, thrombose artérielle ou veineuse. Un point commun à ces drogues est l’arsenic, retrouvé également dans la cigarette et dont la toxicité s’exprime essentiellement au niveau des membres inférieurs. Le traitement de ces complications n’est pas spécifique, la solution idéale étant le sevrage qui malheureusement, dans cette classe particulière de patients, peut entraîner des complications graves par mésusage des produits de substitution. (J Mal Vasc 2004 ; 29 : 243-248)

Current antiretroviral therapy protocols enable long-term survival of HIV-infected patients, decreasing the risk of infectious complications. Three classes of anti-HIV treatments are available. With longer survival, unusual cardiovascular complications related to iatrogenic biological anomalies (dyslipidemia and impaired glucose tolerance) have appeared among this young population which is exposed to usual risk factors of atherosclerosis. Antiretroviral therapies are suspected to cause these complications, inducing maturity-onset diabetes in 4 to 20% of patients, impaired glucose tolerance in 15 to 60%, hypertriglyceridemia in 15 to 74% depending on the survey, and hypercholesterolemia in 20 to 60%, especially in case of associated lipodystrophia. A lipid battery including total cholesterol, HDL, and triglycerides, and 12-h fasting blood glucose should be obtained before initiating antiretroviral therapy. Any anomalous finding should be followed carefully with regular surveillance every 3 to 6 months and search for other causes of secondary dyslipidemia. In the event of casual and persisting elevation of LDL-cholesterol levels, a statin treatment can be introduced. For secondary prevention, irrespective of the context, recommendations currently merge with the consensus applying to the general population. These patients require careful surveillance of cardiovascular risk factors and a specific care in addition to treatment of their immunodeficiency.