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Background: Vertebral artery (VA) stump syndrome (VASS) is an embolic source for cerebral infarction (CI) in the posterior circulation after VA occlusion. Case Description: A 63-year-old patient with a history of hypertension presented to our emergent department with dizziness, vomiting, and gait disturbance. Head magnetic resonance imaging (MRI) showed acute CIs in the bilateral cerebellar hemispheres and the vermis. Magnetic resonance angiography revealed patency of the VA and basilar artery. Left subclavian artery digital subtraction angiography (DSA) revealed severe left VA orifice stenosis and collateral flow from the deep cervical artery into the left V2 segment. Right VA angiography showed retrograde flow to the left V4 segment, branching bihemispheric posterior inferior cerebellar artery (PICA), and to-and-flow appearance in the proximal PICA segment and VA. VASS was diagnosed, and conservative treatment with aspirin was administered. Worsened nausea and gait disturbance had developed during hospitalization. MRI revealed an enlarged posterior circulation CI. Follow-up DSA revealed proximal to-and-flow appearance translocation to the proximal V4 segment and poor PICA flow. We performed proximal V4 segment parent artery occlusion (PAO) by endovascular therapy. No recurrence of symptoms or CI was observed. The patient was discharged on day 32 of hospitalization with 1 on the modified Rankin scale. Conclusion: We reported a rare case of VASS involving bihemispheric PICA. No CI recurrence was observed after performing PAO of the proximal V4 segment. When treating acute cases of bilateral cerebellar CI due to VASS, the contribution of PICA variations should be considered.
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Background: Central giant cell granuloma (CGCG) is an uncommon, benign intraosseous lesion that most frequently occurs in the mandible and maxilla. Case Description: A 31-year-old female with a medical history of Kawasaki disease presented to our hospital complaining of a clogged right ear. Head computed tomography revealed a mass in the squamous part of the right temporal bone, with osteolytic changes and invasion of the external auditory canal, middle ear, temporomandibular joint, and mastoid air cells. Enhanced magnetic resonance imaging (MRI) showed a strong signal in the intraosseous lesion. Digital subtraction angiography revealed tumor staining from multiple feeders, including the middle meningeal, posterior deep temporal, and posterior auricular arteries. Preoperative feeder embolization using a detachable coil and Embosphere Microspheres were performed for the middle meningeal artery under general anesthesia. After the endovascular treatment, we operated on the temporal bone lesion. Postoperative enhanced MRI showed subtotal resection and residual tumor near the external auditory canal, which was left in place to prevent opening the external auditory canal. The histopathological examination showed proliferation of mononuclear cells intermingled with osteoclast-like multinucleated giant cells. A diagnosis of CGCG was made. The postoperative course was uncomplicated, and the patient was discharged on day 10 of hospitalization. Conclusion: We reported a rare case of CGCG in the temporal bone, managed by endovascular therapy and surgical resection. This combination therapy resulted in subtotal resection, preserving surrounding normal structures, such as the external auditory canal and tympanic cavity.
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BACKGROUND: Myasthenia gravis (MG) is an autoimmune disease, and early thymectomy is recommended. Since the introduction of video-assisted thoracoscopic surgery, the safety and effectiveness of carbon dioxide insufflation in the thoracic cavity (capnothorax) has been controversial. This study aimed to compare the safety and effectiveness of ventilation methods in bilateral video-assisted thoracoscopic extended thymectomy (BVET) with capnothorax. METHODS: We retrospectively investigated the medical records of patients with MG who underwent BVET between August 2016 and January 2018. Patients were divided into two groups: group D (n = 26) for one-lung ventilation and group S (n = 28) for two-lung ventilation. We set nine anesthesia time points (T0-T8) and collected respiratory and hemodynamic variables, including arterial O2 index (PaO2/FiO2). RESULTS: SpO2 at T1-T3 and T8 was significantly lower in group D than in group S. The FiO2 in group S was lower than that in group D at all time points. The number of PaO2/FiO2 ≤ 300 and PaO2/FiO2 ≤ 200 events was significantly higher in group D than in group S. Hemodynamic variables were not significantly different between the two groups at any time point. The duration of surgery and anesthesia was shorter in group S than in group D. CONCLUSIONS: This retrospective study suggests that anesthesia using two-lung ventilation during BVET with capnothorax is a safe and effective method to improve lung oxygenation and reduce anesthesia time.
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PURPOSES: To compare hearing recovery levels after initial treatment or salvage intratympanic dexamethasone injection (ITDI), and to find the prognostic factor on salvage ITDI therapy in profound ISSNHL. METHODS: We retrospectively reviewed 115 patients with profound ISSNHL. All patients were treated with combination or systemic steroid therapy as the initial treatment. Next, we used salvage ITDI therapy on patients who showed slight or no improvement according to Siegel's criteria. To find the prognostic factors for the effectiveness of salvage ITDI therapy, we analyzed clinical data, such as, age, sex, vertigo, symptom duration, diabetes, hypertension, initial PTA, pre-salvage PTA, and treatment methods, using multiple regression analyses. RESULTS: The rate of serviceable hearing recovery were 10.4% (12/115) in the initial-treatment group and 20.4% (21/103) in the salvage group. The difference was statistically significant (p = 0.041). Pre-salvage PTA, diabetes mellitus, and symptom duration were affective factors for the effectiveness of salvage ITDI therapy in profound ISSNHL refractory to initial treatment, with odds ratios of 1.169 (95% confidence interval, 1.088-1.256), 0.069 (95% confidence interval, 0.005-0.889), and 9.242 (95% confidence interval, 1.079-79.146). CONCLUSIONS: Salvage therapy should be considered for profound ISSNHL, which is expected to result in poor prognosis or hearing recovery: ITSI therapy might be an effective treatment as salvage therapy.