The influence of hypoglycemia on cerebral blood flow in cases of hypoglycemic coma

The authors report two cases of hypoglycemic coma in which both diffusion-weighted imaging (DWI) and single photon emission computed tomography (SPECT) were used. A 74-year-old woman (case 1) presented with deep coma associated with hypoglycemia (blood glucose level: 20 mg/dl), and DWI on admission revealed extensive hyperintensity lesions. SPECT obtained on the second hospital day revealed diffuse hyperperfusion and a follow-up SPECT on the eighth hospital day showed relative hypoperfusion. An 89- year- old woman (case 2) presented with coma associated with hypoglycemia (blood glucose level: 45 mg/dl), and DWI showed diffuse hyperintensity lesions in both hemispheres. SPECT obtained on the ninth hospital day showed relative hypoperfusion compared to the first scan obtained on the third hospital day. Although the blood glucose level was rapidly corrected, the level of consciousness remained unchanged in both cases. Our results suggest that cerebral blood flow may increase even after glucose correction and that relative hypoperfusion could occur in the subacute stage of hypoglycemic coma

転移性精巣腫瘍に対する化学療法施行中に発症した前立腺膿瘍に経尿道的前立腺切除による外科的ドレナージを行った1例

We report a case of prostatic abscess in a 22-year-old man with metastatic testicular cancer being treated by BEP (bleomycin, etoposide and cisplatin) chemotherapy. This abscess was successfully treated by surgical drainage with transurethral resection of the prostate (TURP) under the guidance of transrectal ultrasound, allowing the patient to continue be receiving BEP without significant interruption. Drainage TURP is suggested to be a useful strategy for prostate abscess, when prompt control of symptoms caused by prostatic abscess is required.症例は22歳, 男性。転移性精巣腫瘍に対してブレオマイシン, エトポシドおよびシスプラチン併用化学療法(BEP療法)中に, P.aeruginosa感染が原因と考えられる前立腺膿瘍を発症した。本症例には化学療法の速やかな再開が必要であることを考慮し, 迅速かつ完全な感染制御効果を得るために, 経直腸的前立腺エコーによるモニタリング下に経尿道的前立腺切除(TURP)を行い, 外科的ドレナージを施行した。術後経過は良好で病巣の完全消退を確認の上, ドレナージ施行7日後に化学療法を再開しえた。以上より, 迅速な病勢制御を要する前立腺膿瘍に対するドレナージTURPは有効な治療手段であると考えられた。(著者抄録

Awake craniotomy for cortical language mapping and resection of an arteriovenous malformation adjacent to eloquent areas under general anesthesia — A hybrid approach

AbstractSurgery of arteriovenous malformation (AVM) is sometimes challenging and carries a high risk of morbidity, especially when the AVM is located in an eloquent area of the brain. Unlike gliomas, awake craniotomy has not been widely used for resection of AVM. The authors present a case of an AVM in the left frontal lobe which was successfully removed with the aid of awake craniotomy with cortical language mapping. In conclusion, awake craniotomy for functional cortical mapping is beneficial for AVM resection, especially when the lesion is located in or adjacent to eloquent areas of the brain. A hybrid approach with functional mapping in the awake condition and AVM resection under general anesthesia may be useful in selected cases. Furthermore, en bloc resection with the nidus embedded in the brain parenchyma may be a useful means of removal to reduce operation time and intraoperative blood loss if there is no apparent functional cortex surrounding the AVM, as in the present case

Robot‐assisted laparoscopic pyeloplasty in the management of lower pole ureteropelvic junction obstruction in a patient with an incomplete duplicated collecting system

Introduction The performance of robot‐assisted laparoscopic pyeloplasty has recently been increasing in frequency. However, patients with duplicated renal pelvises and ureters can present challenges. Case presentation A 71‐year‐old woman presented with flank pain and was diagnosed with ureteropelvic junction obstruction with an incomplete duplicated collecting system. Preoperative imaging did not reveal the details of the stenosis. Therefore, three reconstructive procedures were prepared: The Anderson–Hynes procedure, end‐to‐side pyeloureterostomy, and upper pole ureter to lower pole pyeloplasty with the Anderson–Hynes procedure for the lower pole. These procedures were determined by the length of the intact ureter and the presence of crossed vessels. During the surgery, the crossing vein was severed, allowing successful reconstruction with Anderson–Hynes anastomosis. Conclusion Preoperative evaluation and preparation of multiple surgical techniques are crucial in robot‐assisted laparoscopic pyeloplasty for incomplete duplicated collecting systems

Cine magnetic resonance imaging in evaluating retroperitoneal leiomyosarcoma arising from the inferior vena cava

Introduction Leiomyosarcoma of the inferior vena cava is associated with poor prognosis. Complete resection is the only curative treatment. We present a patient with this disease in whom cine magnetic resonance imaging was valuable in selecting the surgical strategy and mitigating invasiveness. Case presentation A 68‐year‐old woman presented with right‐sided abdominal pain. Computed tomography revealed an 86 mm tumor in the right retroperitoneal space that extended into the inferior vena cava and reached superiorly to the right atrium. Percutaneous needle biopsy confirmed leiomyosarcoma. Cine magnetic resonance imaging demonstrated no adhesions between the tumor and the upper segment of inferior vena cava wall, nor with the right atrial wall, indicating resectability. Radical tumor resection was successfully performed without requiring thoracotomy. Conclusion Cine magnetic resonance imaging appears to be useful in inferior vena cava leiomyosarcoma for evaluating adhesions between the tumor and vessel wall

Cine magnetic resonance imaging predicts thrombus adhesion in metastatic renal cell carcinoma with an inferior vena cava tumor thrombus: A case of pathological complete response with pembrolizumab plus lenvatinib

Introduction Renal cell carcinoma with an inferior vena cava tumor thrombus is a challenging disease that requires a multimodal treatment approach. Pembrolizumab plus lenvatinib has displayed promising efficacy in metastatic renal cell carcinoma. Case presentation A 61‐year‐old man was diagnosed with metastatic renal cell carcinoma and a tumor thrombus adhering to the inferior vena cava wall by cine magnetic resonance imaging. After 6 months of pembrolizumab and lenvatinib therapy, tumor shrinkage was detected, excluding the advanced portion of the inferior vena cava thrombus, and nephrectomy and thrombectomy were performed. Adhesion of the tumor thrombus to the inferior vena cava wall was observed during surgery. Resection produced a remarkable pathological complete response with no viable cells in the resected specimens, including the thrombus site. Conclusion This case highlights the potential of pembrolizumab plus lenvatinib for treating advanced renal cell carcinoma with an inferior vena cava thrombus and the utility of cine magnetic resonance imaging for evaluating thrombus adhesion to the inferior vena cava