[A Case of Transorbital Penetrating Cavernous Sinus Injury by a Bamboo Stick Treated by Craniotomy in the Hybrid Operating Room].

Herein, we report a rare case of penetrating transorbital cavernous sinus injury caused by a bamboo stick, treated by craniotomy in a hybrid operating room. A 63-year-old gardener presented at our hospital with right upper orbital injury after falling on a bamboo basket. Neurological examination revealed right II, III, IV, and VI cranial nerve palsies. CT and MRI revealed a right transorbital penetrating injury by a small sharp wooden foreign body, extending from the orbit to the cavernous sinus via the superior orbital fissure. Preoperative digital subtraction angiography revealed partial occlusion of the right cavernous sinus by the foreign body and no internal carotid artery(ICA)injury. There was a nine-day waiting period after the injury because the patient was on dual antiplatelet therapy for ischemic heart disease. Subsequently, the bamboo stick was completely removed through the right fronto-temporo-orbito-zygomatic approach in a hybrid operating room. To treat the potential massive hemorrhage, a five-French balloon catheter was inserted in the right ICA at its origin via the right transfemoral approach before the craniotomy. The bamboo stick was completely removed with minor hemorrhage in the cavernous sinus; this was controlled using hemostatic materials. The postoperative course was uneventful. The patient was discharged with blindness and total ophthalmoplegia in the right eye but he was able to return to his prior job. This is the first report of such a treatment of a transorbital penetrating injury in a hybrid operating room.

[An Unusual Case of Acute Epidural Hematoma Showing Rapid Spontaneous Resolution with Delayed Recurrence].

A 16-year-old boy collided with a passenger car while riding a motorcycle. He was thrown to a distance and experienced a head injury on impact. When brought to our medical facility, he was alert, had no neurological abnormalities, and did not complain of headache. A head computed tomography(CT)scan indicated a left cranial fracture and an acute epidural hematoma(15mm thick)directly under the fracture. Follow-up head CT performed 3 hours after the injury indicated no change in the size of the hematoma. The head CT performed on the following day indicated that most of the hematoma had disappeared. As the patient had neither headache nor neurological symptoms, he was placed under observation. However, a head CT performed 7 days after the injury indicated the formation of an epidural hematoma approximately the same size as the initial hematoma and located at the same site. We performed craniotomy to evacuate the hematoma, identify the source of the bleeding, and restore hemostasis. Although cases in which an acute epidural hematoma rapidly and spontaneously resolves have been reported, these are extremely rare. Recurrence of an epidural hematoma despite normal blood coagulation function after its initial rapid resolution has not been reported yet. We report on this rare case of acute epidural hematoma with reference to relevant literatures.

[Severe mitral regurgitation associated with systolic anterior motion of mitral valve occurring after aortic valve replacement and myectomy for aortic stenosis and hypertrophic obstructive cardiomyopathy].

We treated a patient with severe mitral regurgitation associated with systolic anterior motion of the mitral valve that occurred after aortic valve replacement and a myectomy for aortic stenosis and hypertrophic obstructive cardiomyopathy. A 76-year-old woman with aortic stenosis and hypertrophic obstructive cardiomyopathy underwent aortic valve replacement and a myectomy. Following these procedures, transesophageal echocardiography showed severe mitral regurgitation associated with systolic anterior motion. Neither adequate volume loading nor beta-blocker administration was effective for improvement of the systolic anterior motion, but vasoconstrictor administration was effective. We also performed mitral valve replacement. To the best of our knowledge, this is the first reported case of intraoperative management following aortic valve replacement and myectomy for aortic stenosis complicated with hypertrophic obstructive cardiomyopathy. Transesophageal echocardiography was very useful for intraoperative assessment and developing a strategy for improving severe mitral regurgitation.

Granulomatous amoebic encephalitis caused by Balamuthia mandrillaris.

A 51-year-old immunocompetent Japanese woman presented with a rare case of granulomatous amoebic encephalitis (GAE) caused by Balamuthia mandrillaris. She was brought to our hospital with epilepsy. Magnetic resonance imaging of the brain revealed a homogeneously enhanced solitary mass in the left frontal lobe. Histological diagnosis was made by a biopsy, which suggested lymphomatoid granulomatosis. After that, her neurological condition got worse. New masses were found and had spread across the whole brain. She died 2 months later of cerebral hernia. Autopsy revealed that the patient had GAE caused by Balamuthia mandrillaris. GAE is usually fatal, and is difficult to diagnose except at autopsy. Therefore, awareness of this disease is important, and earlier diagnosis and the development of a better therapeutic strategy will improve clinical outcome.