Simultaneous subdural, subarachnoideal and intracerebral haemorrhage after rupture of a peripheral middle cerebral artery aneurysm.

The cause of intracerebral, subarachnoid and subdural haemorrhage is different, and the simultaneous appearance in the same case is extremely rare. We describe the case of a patient with a ruptured aneurysm on the distal segment of the middle cerebral artery, with a concomitant subdural and intracerebral haemorrhage, and a subsequent secondary brainstem (Duret) haemorrhage. The 59-year-old woman had hypertension and diabetes in her medical history. She experienced anomic aphasia and left-sided headache starting one day before admission. She had no trauma. A few minutes after admission she suddenly became comatose, her breathing became superficial. Non-contrast CT revealed left sided fronto-parietal subdural and subarachnoid and intracerebral haemorrhage, and bleeding was also observed in the right pontine region. The patient had leucocytosis and hyperglycemia but normal hemostasis. After the subdural haemorrhage had been evacuated, the patient was transferred to intensive care unit. Sepsis developed. Echocardiography did not detect endocarditis. Neurological status, vigilance gradually improved. The rehabilitation process was interrupted by epileptic status. Control CT and CT angiography proved an aneurysm in the peripheral part of the left middle cerebral artery, which was later clipped. Histolo-gical examination excluded mycotic etiology of the aneu-rysm and "normal aneurysm wall" was described. The brain stem haemorrhage - Duret bleeding - was presumably caused by a sudden increase in intracranial pressure due to the supratentorial space occupying process and consequential trans-tentorial herniation. This case is a rarity, as the patient not only survived, but lives an active life with some residual symptoms.

[Resection of vena cava inferior infiltrating by liver tumors]. / A vena cava inferiort infiltráló májtumorok kapcsán végzett reszekciókról.

Introduction: Despite all new promising agents of oncotherapy, it is still liver resection that gives potential curative solution for primary and secondary liver tumors. The size of tumorous liver section for resection means no question any more but major vessel infiltration of tumor proposes challenge in liver surgery. Patients and method: Retrospective analysis was carried out covering 33 patients who underwent liver resection in St. Janos Hospital Surgery Department between 1st May 2017 and 1st May 2019. Demographic, surgical, histological data and postoperative course were taken into consideration and comparison with two of our patients who needed vena cava excision simultaneously with liver resection. Results: Patients with liver resection only (LR) had a mean operation time of 91.7 minutes, while operation time for patients with cava resection (CR) was 250 minutes. The average amount of blood transfusion was 1.2 units (200 ml) in group LR and 5 units in group CR. Among LR patients, resection was rated R0 in 23 and R1 in 8 cases, R2 resection could be performed in 2 cases, in group CR in both cases R1 resection was registered. 5 patients with colorectal liver metastasis were operated after previous chemotherapy. Two patients underwent laparoscopic liver resection and two had synchronous colorectal and liver resection, one of these was treated via laparoscopic approach. Conclusion: Liver resections in case of large vessel (vena cava, hepatic vein) infiltrating by liver tumors are indicated the most challenging procedures of liver surgery. The relating literature refers to oncological liver resections with vena cava excision and reconstruction to be safe and applicable. Orv Hetil. 2019; 160(33): 1304-1310.

[Benign multicystic peritoneal mesothelioma]. / Benignus multicysticus peritonealis mesothelioma.

Benign multicystic peritoneal mesothelioma is a rare benign tumor originating from the peritoneum, affecting mostly young, fertile women. Its presentation is non-specific, thus the final diagnosis is made after the histological examination. A young female patient presented with incarcerated inguinal hernia of which an emergency surgery was performed. During the operation a cystic mass neighboring the round ligament in the canal of Nuck was removed. No inguinal hernia was found. The histological examination confirmed the diagnosis of benign multicystic mesothelioma. The patient was referred to a center performing hyperthermic intraperitoneal chemotherapy, where laparoscopic exploration was performed. The second surgery revealed no residual tumor or any other pathology. A 41-year-old male patient, 4 years before presenting at our ward, had an elective umbilical hernia repair surgery. During the operation 2 cm big cystic mass was removed from the peritoneum, and the histological examination revealed benign multicystic mesothelioma. In 2018, acute surgery was performed due to a periappendicular abscess, while during the surgery a multicystic mass situated on the distal end of the appendix was also removed. The pathological finding confirmed the recurrence of the first tumor. The radiological examination did not find any signs of residual tumor mass anywhere else. The chances of malignant transformation in cases of benign multicystic peritoneal mesothelioma are low. The suggested treatment is en bloc surgical removal of the mass, however, in these cases recurrence is still 50%. If during follow-ups the recurrence of the tumor is found, a total peritonectomy or hyperthermic intraperitoneal chemotherapy is advisable. Orv Hetil. 2019; 160(21): 839-843.

[Ileal duplication: challenging differential diagnosis caused by a rare abnormality. Case report]. / Ileum duplex: egy ritka elváltozás okozta differenciáldiagnosztikai kihívás.

Gastrointestinal tract duplications (GSD) are rare congenital abnormalities. Eighty percent of GSDs are diagnosed before the age of two. These lesions can be seen anywhere from the oral cavity to the anus, but ileum is the most commonly affected site. Their clinical presentation is widely variable and unspecific, making the differential diagnosis really hard. Thus despite performing a long line of radiological scans, the diagnosis can be made during a surgery and by the pathologist. A 23-year-old female patient presented at the emergency room (ER) with abdominal cramps. Examinations revealed an unidentified intraabdominal mass. This could not been identified through the next years despite having tons of examinations: intravaginal and abdominal ultrasonographies, CT and MRI scans, colonoscopies, laparoscopies, surgical, gynecological and gastroenterological visits. Amongst the diagnoses were: ovarian cyst, bowel enlargement, Crohn's disease. Due to the latter, she received therapy which temporarily eased her symptoms. But after these, because of abdominal pain, fever and an ultrasonography that showed an intramural abscess in her abdomen, she went through a surgery having an ileocecal resection. Pathological examination showed a duplication of the ileum that might have caused her symptoms all through the years. Despite facing this rare abnormality, it is important to keep this in mind in differentiating abdominal symptoms. It is true that in no case there could be a diagnosis made without surgery, it raises attention to the importance of precise medical history taking and also cooperation between specialties. Orv Hetil. 2018; 159(52): 2217-2221.