Case report: gastric ischemia, a fatal disease of gastric pneumatosis

Background Gastric pneumatosis indicates the presence of air within the stomach wall. The etiologies included gastric ischemia, gastric intramural infection, gastric mucosal disruption, and secondary to pneumomediastinum. Gastric ischemia is rare because of the rich collateral blood supply to the stomach. Case presentation An 82-year-old man presented to the emergency department with a 2-day history of epigastric fullness, following by fever and low blood pressure. Chest X-ray and abdominal computed tomography revealed gastric pneumatosis at the gastric fundus. The esophagogastroduodenoscopy confirmed the ischemic change of mucosa at the gastric fundus. After antibiotics and medical management, the patient became better and was eventually discharged. Conclusion For the diagnosis of gastric ischemia, physicians should be alert to the hints of gastric pneumatosis from X-ray and computed tomography. It is important to distinguish between gastric ischemia and the other causes of gastric pneumatosis to judge clinical management.

Successful Surgical Intervention of Strangulated Ileus with a Simple Cut of the External Iliac Vein without Vein Reconstruction

A 67-year-old woman with epigastralgia was referred to our hospital. The patient had undergone hysterectomy, bilateral oophorectomy, omentectomy, and radical pelvic and para-aortic lymph node dissection for her ovarian cancer 6 years before. Despite the gastrointestinal decompression therapy under the presumed diagnosis of adhesive ileus, computed tomography scans taken 3 days after the onset of epigastralgia showed marked dilatation of the small intestine and an oval high-density mass, that is, thrombi, in the right femoral vein. Aggravation of ileus with the thrombi in the femoral vein made us to treat the patient with surgery. Intraoperative findings showed that the terminal ileum was strangulated by a gap between the exposed right external iliac vein and artery presumably formed by pelvic lymph node dissection. Distal ileum strangulated by the gap, however, showed no ischemic change with no surgically available peritoneum left around the external iliac vein. To prevent the pulmonary embolism and the recurrence of this type of ileus due to both the thrombi and the persistent gap, we released the strangulated ileum with a simple cut of the external iliac vein without vein reconstruction. The patient recovered uneventfully and was discharged on the 13th day after operation. The patient has been well with nominal right leg edema. In this situation, that is, internal hernia caused by external iliac vessels with thrombi in the femoral vein and no leg edema, a simple cut of the external iliac vein without vein reconstruction is a feasible treatment option.

Awake craniotomy with transcortical motor evoked potential monitoring for resection of gliomas within or close to motor-related areas: validation of utility for predicting motor function

OBJECTIVE The authors previously showed that combined evaluation of changes in intraoperative voluntary movement (IVM) during awake craniotomy and transcortical motor evoked potentials (MEPs) was useful for predicting postoperative motor function in 30 patients with precentral gyrus glioma. However, the validity of the previous report is limited to precentral gyrus gliomas. Therefore, the current study aimed to validate whether the combined findings of IVM during awake craniotomy and transcortical MEPs were useful for predicting postoperative motor function of patients with a glioma within or close to motor-related areas and not limited to the precentral gyrus. METHODS The authors included 95 patients with gliomas within or close to motor-related areas who were treated between April 2000 and May 2020. All tumors were resected with IVM monitoring during awake craniotomy and transcortical MEP monitoring. Postoperative motor function was classified into four categories: “no change” or “declined,” the latter of which was further categorization as “mild,” “moderate,” or “severe.” The authors defined moderate and severe deficits as those that impact daily life. RESULTS Motor function 6 months after surgery was classified as no change in 71 patients, mild in 18, moderate in 5, and severe in 1. Motor function at 6 months after surgery significantly correlated with IVM (p < 0.0001), transcortical MEPs (decline ≤ or > 50%) (p < 0.0001), age, preoperative motor dysfunction, extent of resection, and ischemic change on postoperative MRI. Thirty-two patients with no change in IVM showed no change in motor function at 6 months after surgery. Five of 34 patients (15%) with a decline in IVM and a decline in MEPs ≤ 50% had motor dysfunction with mild deficits 6 months after surgery. Furthermore, 19 of 23 patients (83%) with a decline in IVM and decline in MEPs > 50% had a decline in motor function, including 13 patients with mild, 5 with moderate, and 1 with severe deficits. Six patients with moderate or severe deficits had the lowest MEP values, at < 100 µV. CONCLUSIONS This study validated the utility of combined application of IVM during awake craniotomy and transcortical MEP monitoring to predict motor function at 6 months after surgery in patients with a glioma within or close to motor-related areas, not limited to the precentral gyrus. The authors also validated the usefulness of the cutoff value, 100 µV, in MEP monitoring.

Unaffected fellow eye neovascularization in patients with type 3 neovascularization: Incidence and risk factors

Purpose To evaluate the incidence and risk factors of neovascularization in unaffected fellow eyes of patients diagnosed with type 3 neovascularization in Korea. Methods This retrospective study included 93 unaffected fellow eyes of 93 patients diagnosed with type 3 neovascularization. For initial type 3 neovascularization diagnosis, optical coherence tomography and angiography were conducted. These baseline data were compared between patients with and without neovascularization in their fellow eyes during the follow-up period. Results The mean follow-up period was 66.1±31.1 months. Neovascularization developed in 49 (52.8%) fellow eyes after a mean period of 29.5±19.6 months. In the fellow eye neovascularization group, the incidence of soft drusen and reticular pseudodrusen was significantly higher than that in the non-neovascularization group (83.7% vs. 36.5%, p<0.001; 67.3% vs. 40.9%, p = 0.017, respectively), but the choroidal vascularity index (CVI) showed a significantly lower value (60.7±2.0% vs. 61.7±2.5%; p = 0.047). The presence of reticular pseudodrusen was related with the duration from baseline to development of fellow eye neovascularization (p = 0.038). Conclusion Neovascularization developed in 52.8% of unaffected fellow eyes. The presence of soft drusen, reticular pseudodrusen, and lower CVI values can be considered risk factors of neovascularization in unaffected fellow eyes of patients with type 3 neovascularization. The lower CVI values suggest that choroidal ischemic change may affect the development of choroidal neovascularization in these patients.

Mechanical Thrombectomy and Stenting for Radiation-Induced Carotid Stenosis-Related Stroke: A Case Report

Radiation-induced stenosis of the carotid artery is a significant risk factor for large-vessel ischemic stroke, which usually leads to significant impairment of neurological function. We performed intra-arterial thrombectomy on a 63-year-old male patient who had laryngeal cancer and postradiation carotid stenosis. He presented with acute-onset dysarthria and left hemiplegia. Brain computed tomography perfusion scan showed right middle cerebral artery ischemic change. Angiography confirmed total occlusion of the right internal carotid artery. Intra-arterial mechanical thrombectomy with carotid stenting was performed immediately, and recanalization was achieved. The patient fully recovered and was discharged after a 1-week hospitalization. Our experience suggests that early intervention for radiation-related carotid stenosis might be essential and beneficial for the outcome of large-vessel ischemic stroke.

Laparoscopic repair of a Bochdalek hernia in an elderly patient: a case report with a review from 1999 to 2019 in Japan

Background A Bochdalek hernia (BH) is a congenital defect of the diaphragm that generally presents in the newborn as life-threatening cardiorespiratory distress. In contrast, the diagnosis of a BH in adults is rare. Surgical repair for adult BH is recommended, but the optimal surgical method remains unclear. Case presentation A 75-year-old woman presented with progressive dyspnea and back pain, and a diagnosis of BH was made based on chest X-ray and computed tomography. Laparoscopic evaluation revealed a defect in the left posterior attachment of the diaphragm, and a left-sided BH without hernia sac was diagnosed. Parts of the stomach, small intestine, colon, pancreas, and spleen had prolapsed into the left thoracic cavity, without ischemic change, and these herniated organs were reduced to the abdominal cavity. A direct closure of the hernia orifice was possible by the laparoscopic suture technique using a mesh reinforcement. The patient made an uneventful recovery, and no recurrence was found in the 2-year follow-up. Conclusion A recently published study reviewing detailed cases of repair of adult BH from 1999 to 2019 identified 96 cases, including the present case. The number of reports on laparoscopic and/or thoracoscopic surgery for BH in adults has recently increased, and the approach for repairing BH should be selected carefully on a case-by-case basis.

Endovascular Treatment for Vertebrobasilar Artery Tandem Occlusion Beyond 24 Hours From Onset of Stroke—Case Report

We report a case in which endovascular treatment (EVT) was performed for vertebral and basilar artery (VA and BA) tandem occlusion beyond 24 hours from onset of stroke. A 78-year-old man was admitted to our institution with dysarthria and disturbance of gait. MRI revealed occlusion of the BA with acute ischemic change in bilateral cerebellum and brain stem. At 36 hours after onset and 30 hours after administration, EVT was performed because of deteriorating neurological symptom. Successful revascularization was achieved with percutaneous transluminal angioplasty for VA and thrombectomy for BA occlusion. The neurological symptoms were improved in postoperative course.

Evaluation of stroke thrombectomy including patients where IV thrombolysis is contraindicated or has failed: a randomized trial of two novel thrombectomy devices

Background Study was a PROBE design phase II randomized controlled trial (RCT). We assessed trial feasibility and technical efficacy and safety of two novel thrombectomy devices – ERIC (a retriever device) and SOFIA (a distal access catheter) – used alone or in combination depending on operator preference. Methods Four UK neuroscience centers enrolled adults with proximal large artery occlusion (LAO) stroke on imaging where arterial puncture was achievable within 5.5 hours (8.5 hours for posterior circulation) of symptom onset; National Institutes of Health Stroke Scale (NIHSS) ≥6 with limited ischemic change on CT imaging. Randomization was 2:1 into intervention arm (ERIC and/or SOFIA). Patients and core lab were blinded to allocation. Primary outcome was independent core lab adjudication of reperfusion (modified Thrombolysis in Cerebral Infarction (mTICI) scale). Secondary outcomes were modified Rankin score (mRS) at 90 and 365 days (independence and shift analysis), 30-day mortality, symptomatic intracranial hemorrhage (sICH), procedural complications and NIHSS change. Results Sixty-six patients were enrolled. TICI 2B/3 reperfusion was achieved in 72% in intervention compared with 90% in control arm on intention to treat (ITT) analysis (P=0.2) and 78% compared with 86% on per protocol analysis (P=0.7). Functional independence at 90 days was 40% (intervention) compared with 43% (control) on ITT analysis (P=1.0). sICH rates were low at 0% and 5%, respectively (P=0.3). The 30-day mortality was 9% intervention compared with 14% control (P=0.7). Conclusions Study indicated feasibility of a phase II RCT trial approach for assessing new thrombectomy devices. In a broad LAO stroke population ERIC and SOFIA were not statistically different from control devices. Larger trials are needed.

Experimental myocardial infarction in rats: features of modeling and course within the first 48 hours after ligation of the coronary artery

Objective: to identify the features of modeling and give a morphofunctional assessment of the course of experimental myocardial infarction (EMI) in rats within the first 48 hours after ligation of the left coronary artery (LCA). Material and methods. EMI was reproduced according to the method of H. Selye [1] in Jian Ye`s modification [2] by means of LCA ligation in 24 Wistar rats. Electrocardiographical, histological, biochemical studies were performed. The control group consisted of 7 falsely operated animals in which the chest had been opened without manipulation on the LCA. Results. 5-15 minutes after LCA ligation, an ischemic change in the (Q)RST complex was observed as a monophasic curve. The Q wave appeared on the EGG after 1 hour of EMI in 20% cases, after 7 hours in 88% cases, in 100% cases after 27 hours and remained by 48 hours of EMI. Histologically, within the first 7 hours there was acute alterative myocardial damage followed by a quantitative increase in diffusely located necrotic cardiomyocytes (CMC) by 27 hours and the appearance of a clear zone of coagulation necrosis by 48 hours; which was accompanied by corresponding changes in the level of troponin I. Conclusion. The course of EIM after LCA ligation is characterized by the staging of myocardial changes similar to that in humans, which provides a prerequisite for possible extrapolation of the results of the studies to humans.