Successful endonasal transsphenoidal surgery to treat acute internal carotid artery occlusion caused by pituitary apoplexy: Usefulness of arterial spin labeling imaging for emergency decision.

Background: Pituitary apoplexy (PA) is a rare clinical condition presenting with acute headache, visual disturbance, and disorientation. PA can cause strokes due to acute internal cervical artery occlusion (ICO), which is an extremely rare condition. Arterial spin labeling (ASL) on magnetic resonance imaging (MRI) is a popular technique, which is a quantitative perfusion imaging useful for the diagnosis of ischemia. We report a treatment with acute pseudo-ICO in which ASL on MRI was useful for the decision of surgery timing. Case Description: A 50-year-old male presented with a sudden headache and nausea. MRI and magnetic resonance angiography revealed a large pituitary tumor and left ICO. However, the left middle cerebral and anterior cerebral arteries were depicted due to a cross-flow through the anterior communicating artery. ASL on MRI showed decreased perfusion of the left hemisphere, suggesting acute ICO. As he had no neurological deficit, we treated him conservatively, following the guidelines. Two days after admission, he presented with sensory aphasia and incomplete right paralysis. Emergency head computed tomography revealed a low-density area in his left temporal lobe. We decided on emergency tumor decompression surgery to prevent ischemic progression. We performed endonasal transsphenoidal surgery. Postoperative MRI showed recanalization of the left internal carotid artery (ICA). His incomplete right paralysis improved immediately after surgery but remains mild sensory aphasia. Conclusion: ICO-related PA is a very rare occasion but there are few similar reports. Some cases of successful ICO treatment due to PA have been reported, but the question of whether emergency or elective surgery is better remains unanswered. Our case may have been no neurological deficit if we had decided to have surgery on admission. Hypoperfusion of the ICA area due to PA may be an adaptation of emergency surgery. Perfusion images like ASL could be a useful technique to decide on surgery or conservative treatment.

Combined thoracoscopic and laparoscopic surgery for epiphrenic diverticulum with associated gastroesophageal reflux disease: a case report.

BACKGROUND: Surgery is indicated for symptomatic epiphrenic esophageal diverticula. Based on the features of a case, thoracoscopic or laparoscopic approaches may be used. Epiphrenic diverticula are often associated with esophageal motility disorders, but cases of reflux esophagitis have rarely been reported. In this report, we describe a case of an epiphrenic esophageal diverticulum with reflux esophagitis, which was successfully treated by thoracoscopic diverticulectomy and laparoscopic fundoplication. CASE PRESENTATION: A 69-year-old man visited the hospital with a chief complaint of eructation and hiccup. Upper gastrointestinal endoscopy revealed a diverticulum in the left wall of the esophagus, which was 37-45 cm distal to the incisors. High-resolution manometry (HRM) showed no esophageal motility disorders. Due to the large size of the diverticulum, a thoracoscopic resection of the esophageal diverticulum was performed. Additionally, the patient had reflux esophagitis due to a hiatal hernia. The anti-reflux mechanism would be more impaired during the diverticulectomy; therefore, we decided that anti-reflux surgery should be performed simultaneously. Thoracoscopic esophageal diverticulectomy and laparoscopic Dor fundoplication were performed. The patient had an uncomplicated postoperative course and was discharged on the tenth operative day. He has been symptom-free without acid secretion inhibitors for 21 months after the surgery. CONCLUSIONS: We described a rare case of a large epiphrenic diverticulum with reflux esophagitis. A good surgical outcome was achieved by thoracoscopic resection of the diverticulum and laparoscopic Dor fundoplication.

Cor triatriatum sinister with dextrocardia in association with ostium secundum atrial septal defect, subpulmonary ventricular septal defect and bicuspid pulmonary valve in a pig.

Necropsy of a 52-day-old Camborough pig revealed numerous cardiac malformations. The positional relationship of the atria, ventricles and great vessels was a mirror image type (I, L and L): inverted arrangement of the atria, with a left-sided right atrium and right-sided left atrium (situs inversus); inverted arrangement of the ventricles, with a left-sided morphological right ventricle and right-sided morphological left ventricle (L-loop); and aortic valve to the front left relative to the pulmonary valve (L-malposed). The major malformations included an ostium secundum atrial septal defect, cor triatriatum sinister (CTS), a subpulmonary ventricular septal defect and a bicuspid pulmonary valve. Histological examination revealed myocyte hypertrophy, focal myocardial necrosis and calcification in the left morphological right ventricle of the heart. To the best of our knowledge, this is the first report of CTS in pigs. Although the individual malformations found in the present case are not unique, an unusual combination of these cardiac malformations has not been described in animals.

Laparoscopic Heller myotomy and Dor fundoplication following an unsuccessful peroral endoscopic myotomy.

BACKGROUND: Achalasia is an esophageal motility disorder that presents as dysphagia and severely affects quality of life. An esophageal myotomy has been the golden standard for treatment. Peroral endoscopic myotomy (POEM) as a first-line therapy has an acceptable outcome. However, after the clinical failure of POEM, appropriate second-line therapy is rather controversial. Here, we present the first published case in English of a patient who was successfully treated using laparoscopic Heller myotomy (LHM) with Dor fundoplication following an unsuccessful POEM. CASE PRESENTATION: A 64-year-old man with type 1 achalasia who had been previously treated with POEM visited our hospital for further treatment. After undergoing LHM with Dor fundoplication, his Eckardt score improved from 3 to 0 points. On a timed barium esophagogram (TBE), the barium height improved from 119 mm/119 mm (1 min/5 min) to 50 mm/45 mm. No significant complications have occurred postoperatively for 1 year. CONCLUSION: Treating refractory achalasia is challenging, and treatment options are controversial. LHM with Dor fundoplication after POEM could be a safe and efficient option for the treatment of refractory achalasia.

Essential updates 2020/2021: Recent topics in surgery and perioperative therapy for esophageal cancer.

In this review, we focused on four topics, namely, minimally invasive esophagectomy (MIE), robot-assisted minimally invasive esophagectomy (RAMIE), conversion and salvage surgery, and neoadjuvant and adjuvant therapy, based on notable reports published in the years 2020 and 2021. It seems that while the short-term outcomes of minimally invasive Ivor Lewis esophagectomy (MIE-IL) were better than those of open Ivor Lewis esophagectomy (OE-IL), there were no significant differences in the long-term outcomes between MIE-IL and OE-IL. Similarly, the short-term outcomes of minimally invasive McKeown esophagectomy (MIE-MK) were better than those of open McKeown esophagectomy (OE-MK), while there were no significant differences in the long-term outcomes between MIE-MK and OE-MK. Furthermore, the short-term outcomes of robot-assisted minimally invasive Ivor Lewis esophagectomy (RAMIE-IL) were superior to those of completely minimally invasive Ivor Lewis esophagectomy (CMIE-IL). On the other hand, there were advantages and disadvantages in relation to the short-term outcomes of robot-assisted minimally invasive McKeown esophagectomy (RAMIE-MK) as compared with completely minimally invasive McKeown esophagectomy (CMIE-MK). However, there were no significant differences in the long-term outcomes between RAMIE-MK and CMIE-MK. Further research is needed to evaluate of short-term and long-term outcomes of transmediastinal esophagectomy with and without robotic assistance. Both induction chemotherapy and induction chemoradiotherapy appear to be promising to secure a higher rate of conversion surgery. Neoadjuvant chemoimmunotherapy and chemoimmunoradiotherapy have shown promising results and are expected as new powerful therapies.

Two cases of new-born puppies with transient pulmonary edema.

Acute pulmonary edema in puppies generally occurs due to congenital left-right shunts such as patent ductus arteriosus or large ventricular septal defects. Herein, we presented two cases of puppies with no apparent congenital cardiovascular disease. Case 1: A 12-day-old male Labrador Retriever, weighing 1.15 kg, was unable to suckle sufficiently from its dam and exhibited laboured breathing. Pulmonary edema was identified in all lung lobes by radiography, furthermore, echocardiography revealed significant enlargement of the left side of the heart. Pulmonary edema secondary to volume overload was suspected and furosemide was administered. The respiratory status was improved on the following day. Pimobendan was administered orally in addition to furosemide and both were withdrawn 6 weeks later when the heart size was normalized. Case 2: A 15-day-old female Standard Poodle, weighing 0.68 kg, was less active than other littermates and exhibited laboured breathing. Radiography revealed pulmonary edema in the right posterior lobe, dilatation of the caudal vena cava and ascites. Echocardiography revealed significant enlargement of the left atrium and ventricle perhaps owing to decreased left ventricular contractility. Furosemide and pimobendan were administered. One week later, appetite was improved and supraventricular tachycardia of 375 bpm was observed. Therefore, tachycardia-induced dilated cardiomyopathy was suspected which returned to sinus rhythm with diltiazem treatment, however, it was recurred. Upon sotalol monotherapy, a normal heart size was observed seven months later. In conclusion, we encountered two new-born puppies with transient pulmonary edema that were temporarily treated with pimobendan and furosemide.

Combination of the Modified Loop Technique and De Vega Annuloplasty in Dogs with Mitral Regurgitation.

Background: Detailed surgical techniques for treating canine mitral regurgitation have not been previously reported. Method: This case series included six consecutive client-owned dogs with mitral regurgitation. All dogs underwent a combined protocol, including the modified loop technique and De Vega annuloplasty (MODEL surgery), in 2021. Artificial loops covering 80% of the length of the strut chordae tendineae were used for chordal replacement. Mitral annuloplasty was subjectively performed, targeting the circumference of the septal leaflet. Results: The breeds were Chihuahua-mixed breed, Spitz, Pomeranian, Cavalier King Charles Spaniel, and Chihuahua, with average ages and weights of 11.4 ± 2.3 years and 5.49 ± 2.98 kg, respectively. The aortic cross-clamp, pumping, and surgery times were 64.0 ± 7.5 min, 168.5 ± 39.1 min, and 321.0 ± 53.1 min, respectively. After MODEL surgery, left atrial-to-aortic ratios significantly decreased from 2.20 ± 0.18 to 1.26 ± 0.22 (p < 0.01), and left ventricular end-diastolic internal diameter normalized to body weight significantly decreased from 2.03 ± 0.26 to 1.48 ± 0.20 (p < 0.01). In all cases, the clinical signs disappeared or improved significantly. Conclusions: MODEL surgery increased mitral valve coaptation, normalized heart sizes, and significantly improved clinical signs in dogs with mitral regurgitation.

Late recanalization after complete occlusion of patent ductus arteriosus in a Pembroke Welsh Corgi with von Willebrand disease.

A 36-month-old female Pembroke Welsh Corgi with a cardiac murmur weighing 12.6 kg was referred to the Matsubara Animal Hospital cardiology service. Echocardiography revealed a patent ductus arteriosus. The dog underwent ductus arteriosus closure using an Amplatz Canine Duct Occluder. After the operation, we suspected coagulation and a platelet disorder because of the slightly increased haemorrhage during the operation, postoperative purpura around the surgical wound inside of the thigh, and dog breed, which is known to be commonly affected with von Willebrand disease (vWD). Subsequently, type 1 vWD was confirmed. Complete occlusion was achieved 1 month after the operation; however, 2 months after the operation, recanalization appeared. Recanalization progressed gradually; cardiac redilation was not detected 6 years after the operation. The late recanalization was most likely associated with vWD. In canine breeds pre-disposed to developing vWD, pre-operative testing may be indicated prior to patent ductus arteriosus occlusion, though the prevalence of vWD is rare.

Massive intracerebral hemorrhages due to peripheral middle cerebral artery aneurysm rupture: A case report with a surgical video.

BACKGROUND: Saccular aneurysm in the distal segment of the middle cerebral artery (DMCA) occurs very rarely and often represents with a rupture. We report a successful surgical case of a DMCA aneurysm rupture with large cerebral and subarachnoid hemorrhage. CASE DESCRIPTION: A 44-year-old female presented a sudden onset headache and coma (the Glasgow Coma Scale was 3). Head computed tomography (CT) revealed a subarachnoid hemorrhage around the right Sylvian fissure and large intracranial hematoma in the right parietal lobe. The CT angiography showed a saccular aneurysm in the peripheral cortical segment of the right angular branch of the right DMCA. We decided to perform a right craniotomy to evacuate hematoma and interrupt the aneurysm. Just after the dural incision, the aneurysm ruptured again. We applied a temporary clip on the artery proximal to the aneurysm before excising it. CONCLUSION: Aneurysm in DMCA can be treated safely with surgical excision and risk of sudden recurrent hemorrhage needs to be anticipated.

Symptomatic Chiari type 1 malformation associated with acromegaly: A case report.

BACKGROUND: Here, we report a patient who presented with both symptomatic acromegaly and symptomatic Chiari I malformation (CM1) with a C2-T5 syrinx. CASE DESCRIPTION: A 63-year-old female presented with bilateral arm dysesthesias and back pain. For approximately the past 30 years, she had chronic signs of acromegaly (i.e. an enlarged forehead, jaw, and nose, and enlarged hands and feet). When the cervical magnetic resonance showed a CM1 (tonsillar herniation) with C2-T5 syringomyelia, she underwent foramen magnum decompression and C1 posterior arch resection. Postoperatively, she was asymptomatic. The added finding of a growth hormone (GH)-producing pituitary lesion was treated medically with endocrine therapy, as she had incidentally required surgery/chemotherapy for a newly diagnosed colon cancer. CONCLUSION: Symptomatic CM1, syrinx, and acromegaly may occur together. Appropriately treatment may include a suboccipital decompression, and C1 arch resection surgery, followed by either surgical or medical treatment for the GH-producing pituitary adenoma.

Cardiac Autonomic Nervous System Activity during Slow Breathing in Supine Position.

The purpose of this study is to clarify cardiac autonomic nervous system activity during slow breathing exercises in a supine position. Eighteen healthy young males were participated. Heart rate variability was measured for 5 minutes at rest, 5 minutes at slow breathing, and then 5 minutes at rest. As a result, the LF/HF ratio increased with slow breathing, but HF value did not change. We suggest that the increased LF/HF ratio may be due to increased airway resistance. Cardiac autonomic nervous system activity during slow breathing in the supine position was revealed.

Acute central nervous system vasculitis as a manifestation of neurosarcoidosis: A case report and literature review.

Neurosarcoidosis (NS) affects various sites of the central nervous system, including the cranial nerve, meninges, brain parenchyma, hypothalamus, and pituitary gland. NS rarely causes intracerebral vasculitis and subsequent strokes, or cerebral infarction and hemorrhage, which are associated with high mortality. Herein, we report a 71-year-old woman's case of stroke associated with NS, which showed aggressive cerebral vasculitis with brain herniation; it was resolved with corticosteroid therapy after accurate histopathological diagnosis. This case highlights the necessity of expecting NS to sometimes follow an aggressive course, presenting with vasculitis. Most patients with NS satisfactorily respond to corticosteroids, but this is not always the case. In cases of unfamiliar ischemic or hemorrhagic lesions, the possibility of NS must be considered.

Longitudinal evaluation of cardiovascular function in six healthy cats aged 1-8 years.

OBJECTIVES: The purpose of this study was to determine the impact of ageing on the cardiovascular system of healthy adult cats. METHODS: Six experimental cats were used. Echocardiography and measurements of systolic blood pressure (SBP) were performed every year for 8 years (from 1 year of age to 8 years of age) in all cats. Age-related changes to left ventricular (LV) structures, LV systolic and diastolic function, and SBP were assessed. RESULTS: There were no significant changes in LV structures and SBP. Peak longitudinal strain rate during systole was decreased at 8 years of age, and peak longitudinal strain rate during diastole was decreased from 6 years of age. CONCLUSIONS AND RELEVANCE: This study revealed that some measures of cardiac function recorded in six healthy cats from 1 to 8 years of age were affected as the cats got older; however, there were no structural changes or changes in measurements that are routinely assessed in clinical practice.

Endovascular Mechanical Thrombectomy for Basilar Artery Occlusion Caused by Thrombosis as an Initial Manifestation of Acute Myelogenous Leukemia: A Case Report.

We report a rare case of a basilar artery occlusion (BAO) caused by thrombosis as an initial magnification of acute myelogenous leukemia (AML) and performed mechanical thrombectomy (MT) to treat it. A 67-year-old female presented left hemiparalysis of her arm and right-sided blindness. Magnetic resonance imaging (MRI) and magnetic resonance angiography revealed acute infarction in the left occipital and anterior lobes of the cerebellum and incomplete BAO. Her blood test showed hyperleukocytosis with precursor cells and high levels of C-reactive protein, and we diagnosed AML and disseminated intravascular coagulation (DIC). We decided to treat conservatively with rapid rehydration and heparin, but three hours after admission, she suddenly lost consciousness. We performed acute MT with a direct aspiration first-pass technique (ADAPT). A white elastic embolus was aspirated, and DSA showed successful recanalization of the basilar artery. The next day, MRI revealed acute infarction in the midbrain and bilateral thalamus. The patient remained unconscious after MT and so chemotherapy to treat the acute leukemia could not be performed. The patient died of the primary disease 14 days after BAO. Thrombosis in association with AML is very rare disease and could occur in arterial vessels because of hypercoagulation, and this tendency may not respond to anticoagulation therapy. Although ADAPT might be performed safety without complications even in cases of DIC, indications for treatment with MT should be carefully considered in patients in whom hemorrhage is a possibility.

A Case of Stanford Type A Aortic Dissection Complaining Only of Headache With a History of Migraine.

Stanford type A aortic dissection (SAAD) is a fatal condition in which patients often present with severe chest or back pain that radiates along the direction of propagation. In this report, we present the first published case of a patient complaining of migraine with aura as an initial manifestation of SAAD without the typical chest pain, back pain, or neurologic deficits. A 35-year-old, tall, male, night-shift taxi driver with a history of migraines arrived at the emergency department complaining of a slow-onset frontal headache that he attributed to migraine. Intravenous acetaminophen administration with fluid infusion did not improve his symptoms. An electrocardiogram showed ST depressions and a transthoracic echocardiogram showed severe aortic regurgitation with an aortic flap. He was diagnosed with Marfan syndrome complicated by SAAD and underwent surgical aortic root replacement. Aortic dissection may have a variety of initial manifestations; cardiovascular workup should be considered for migraine patients, especially those with Marfan-like features.

Brønsted Base-Catalyzed Transformation of α,ß-Epoxyketones Utilizing [1,2]-Phospha-Brook Rearrangement for the Synthesis of Allylic Alcohols Having a Tetrasubstituted Alkene Moiety.

A stereoselective transformation of α,ß-epoxyketones into alkenylphosphates having a hydroxymethyl group on the ß-carbon was established by utilizing the [1,2]-phospha-Brook rearrangement under Brønsted base catalysis. The reaction involves the catalytic generation of an α-oxygenated carbanion located at the α-position of an epoxide moiety through the [1,2]-phospha-Brook rearrangement and the following epoxide opening. Further transformation of the alkenylphosphates by the palladium-catalyzed cross-coupling reaction with Grignard reagents provided allylic alcohols having a stereodefined all-carbon tetrasubstituted alkene moiety.

Atrial septal defect closure in a midget toy poodle.

Background: Atrial septal defect (ASD) is a rare congenital cardiac disease, and there have been no reports about the treatment of ASD in midget breed dogs. Case Description: A 7-month-old female toy poodle weighing 1.4 kg presented with cardiac enlargement. Echocardiography revealed a secundum-type ASD, right ventricular and atrial enlargement, and pulmonary hypertension. Blood flow through the ASD exhibited left-to-right shunting. The dog underwent ASD closure through a hybrid approach, in conjunction with catheter techniques and thoracotomy. Ten months after treatment, cardiac enlargement and pulmonary hypertension were improved. Conclusion: Even in midget dog breeds, ASD can be corrected through a hybrid approach.

Assessment of diastolic function using mitral flow propagation velocity in cats.

The objectives of this study were to investigate the usefulness of mitral flow propagation velocity (Vp) in cats by evaluating the effect of the flow pattern summation and evaluation of Vp variables in cats with hypertrophic cardiomyopathy (HCM). Healthy cats were categorized into summation (Sum) and separation (Sepa) groups to evaluate the effects of the flow pattern summation on Vp. Cats with HCM were categorized into HCM left atrial (LA) (-), LA (+), and LA (++) groups according to the degree of LA enlargement to investigate the feasibility of Vp. There were no significant differences noted in Vp between the Sum and Sepa groups and no significant correlation between Vp and heart rate. Decline of Vp was associated with the degree of LA enlargement. Mitral flow propagation velocity appeared to be clinically feasible in cats and could possibly be useful in the detection of diastolic dysfunctions in cats with HCM.

Les objectifs de la présente étude étaient d'examiner l'utilité de la vélocité du flux de propagation mitral (Vp) chez les chats en évaluant les effets du résumé du schéma de flux et l'évaluation de variables de Vp chez des chats avec cardiomyopathie hypertrophique (HCM). Des chats en santé ont été catégorisés dans les groupes résumé (Sum) et séparation (Sepa) afin d'évaluer les effets sur Vp du résumé du schéma de flux. Les chats avec HCM furent catégorisés en groupes HCM atrial gauche (LA) (−), LA (+) et LA (++) selon le degré d'hypertrophie de LA dans le but d'examiner la faisabilité de Vp. Il n'y avait pas de différence significative notée dans la Vp entre les groupes Sum et Sepa et aucune corrélation significative entre Vp et le rythme cardiaque. Une diminution de Vp était associée avec le degré d'hypertrophie de LA. La vélocité du flux de propagation mitral semble être cliniquement réalisable chez les chats et pourrait possiblement être utile dans la détection de dysfonction diastolique chez les chats avec HCM.(Traduit par Docteur Serge Messier).

Effects of atenolol on left atrial and left ventricular function in healthy cats and in cats with hypertrophic cardiomyopathy.

This study aimed to assess the effects of atenolol on left ventricular (LV) and left atrial (LA) function in healthy cats and investigate the relationship between atenolol administration and LA enlargement (LAE) in cats with hypertrophic cardiomyopathy (HCM). In study 1, nine experimental cats were used to assess the effects of atenolol in healthy subjects. Cats were administered one of three medication protocols for 7 days: atenolol 6.25 mg/cat twice daily, 12.5 mg/cat twice daily, or placebo (biofermin) 1 tab/cat twice daily. In study 2, cats with HCM were retrospectively recruited and divided into four groups according to atenolol administration [(control group (Cont) or atenolol administration group (Ate)] and the presence or absence of LAE as follows: Cont LAE (-) group (n=42), Cont LAE (+) group (n=20), Ate LAE (-) group (n=17), and Ate LAE (+) group (n=12). LV and LA functions were compared in both studies. LV and LA functions were decreased by atenolol administration in study 1. In study 2, the peak myocardial velocity during early diastole (E') was significantly decreased in the Cont LAE (+), Ate LAE (-), and Ate LAE (+) groups compared to that in the Cont LAE (-) group, but there were no significant differences between LAE (+) groups. Multivariate logistic analysis revealed that atenolol administration was not associated with LAE. Diastolic dysfunction may be associated with LAE; however, atenolol administration did not affect LAE in cats with HCM.

Structural effect of amine N-oxides on the facilitation of α-glucosidase-catalyzed hydrolysis reactions.

Activation and stabilization of enzymes is an important issue in their industrial application. We recently reported that synthetic betaines, derived from cellular metabolites, structure-dependently increased the activity and stability of various enzymes including hydrolases, oxidases, and synthetases simply by mixing them into the reaction buffer. In this report, we focus on amine N-oxides, which are similarly important metabolites in cells with a highly polarized N-oxide bond, and investigate their enzyme stabilization and activation behavior. It was revealed that synthetic amine N-oxides structure-dependently activate α-glucosidase-catalyzed hydrolysis reactions similarly to betaines. The subsequent comparison of the kinetic parameters, the optimal concentration range for activation, and the maximal activity, suggested that amine N-oxides facilitate hydrolysis reactions via the same mechanism as betaines, because no differences were confirmed. However, the enzyme stabilization effect of amine N-oxides was slightly superior to that of betaines and the temporal stability of the enzyme in aqueous solutions was higher in the low amine N-oxide concentration range. The rheological properties, CD spectra, and dynamic fluorescence quenching experiments suggested that the suppression of unfavorable conformational perturbation was related to the difference in the hydration environments provided by the surrounding water molecules. Thus, we clarified that amine N-oxides facilitate enzyme reactions as a result of their similarity to betaines and provide a superior stabilizing effect for enzymes. Amine N-oxides show potential for application in enzyme storage and long-term reactions.