A 61-year-old Chinese woman complained of dizziness for 3 weeks and was admitted to our hospital after a bifrontal mass was found radiologically.
Other than dizziness, the patient presented no signs or symptoms that are commonly associated with neurological disease, such as headache, vomiting, sensory disturbances, altered consciousness, or seizures.
Except for a 20-year history of hypertension, which was properly controlled with angiotensin-converting enzyme inhibitors, the patient was otherwise healthy.
No special circumstances were identified regarding her personal or family history, and the patient was found to be normal upon neurological examination.
Plain and contrast-enhanced magnetic resonance imaging (MRI) of the head showed a space-occupying lesion in the bifrontal lobe, mainly on the right side, clinging to the sagittal sinus and the cerebral falx.
The 5.7 × 5.0 × 5.0 cm dural-based mass growing across the sagittal midline revealed isointensity on the T1-weighted image and a slight hyperintensity on the T2-weighted image and was homogenously enhanced with a characteristic “dural-tail” sign (Fig.1).
Diagnosis of a parasagittal-parafalcine meningioma was made, and a craniotomic meningioma resection was chosen as treatment.
The blood cell examination; coagulation function, liver and renal function tests; urinalysis; chest x-rays and electrocardiogram were normal.
The albumin was 36 g/L, the total bilirubin (TBil) was 12.2 μmol/L, and the direct bilirubin (DBil) was 4.1 μmol/L.
Alanine transaminase (ALT) was 17 U/L, and the international normalized ratio (INR) for coagulation values was 1.02.
Because of the patient's advanced age and history of hypertension, we performed an echocardiograph and a blood gas analysis and tested her creatine kinase levels and pulmonary functions.
The results revealed no surgical contraindications.
Written consent was obtained from the patient.
Five hundred milligrams of VPA twice per day was initiated 3 days before the operation.
The patient tolerated the administration well.
A craniotomy was then performed with a radical tumor resection (Simpson II).
The tumor was pink and solid and had a moderate blood supply, and its texture was medium.
Thirty minutes before the end of surgery, 800 mg of VPA was administered by intravenous infusion.
After the operation, the patient regained consciousness within 30 minutes and scored 15 on the Glasgow coma scale (GCS).
Two hours later as she was being transported back to her ward, the patient underwent UGH.
The vomitus (approximately 50 mL) was composed of coffee-colored blood.
Excluding the possible etiology of endotracheal intubation damage, we diagnosed the patient as experiencing acute erosive-hemorrhagic gastritis, a reaction to the craniotomy injury.
The patient was given omeprazole to inhibit gastric acid secretion, and the hematemesis ceased.
The patient was administered VPA (1200 mg, intravenously) during the first 2 postoperative days.
Because of her stomach and intestine functional recovery, the VPA dosage was changed to 500 mg via oral administration twice a day.
A brain MRI was performed on postoperative day 3, and it revealed that the tumor was radically removed and the operative field was clean (Fig.2A and B).
A subsequent paraffin histological examination confirmed the diagnosis of meningioma.
At 3 am on postoperative day 4, the patient was suddenly found in a deep coma.
Her pupils were dilated to 3.0 mm and round, and the light reflex was sensitive.
The neurological examination was unremarkable, and her vital signs were stable; however, her mental state gradually changed to a deep coma (GCS = 8), which we believed was caused by intracranial lesions.
A computerized tomography (CT) scan of the brain was immediately performed; however, it failed to reveal any abnormalities, such as severe brain swelling, intracranial hemorrhage, or cerebral infarction (Fig.2C).
Because a possible cerebral infarction could not be excluded within 24 hours, glucocorticoid, mannitol, and a vasodilator were used.
The patient's routine laboratory results for blood cell, liver, and renal functions were in relatively normal ranges.
The albumin was 33 g/L, the TBil was 13.3 μmol/L, and the DBil was 4.5 μmol/L.
ALT was 12 U/L, and the INR for coagulation values was 1.01.
Because of her history of UGH, we checked her blood ammonia levels and performed a fecal occult blood test and blood gas analysis.
Her blood ammonia was elevated (181.6 μmol/L; normal range is 11–32 μmol/L), whereas the fecal occult blood test was positive.
Thus, considering her history and elevated blood ammonia, she was diagnosed with UGH-induced hepatic encephalopathy, and the oral administration of VPA was changed to intravenous administration to prevent seizures.
Lactulose, vitamin B, and L-arginine were administered, clysis with vinegar was performed, and the patient was fasted.
The patient's blood ammonia level fluctuated (144.8–207.7 μmol/L), and she remained unconscious during the following 3 days.
Because of the unremarkable progress in the patient's mental state and blood ammonia level, we held a multidisciplinary conference to discuss diagnosis and treatment, initially considering hemodialysis or peritoneal dialysis.
After the multidisciplinary discussion, a suspected diagnosis of VHE was finally made, even though the blood VPA level was within the normal range.
We decided to stop VPA administration before performing any dialysis and administered levetiracetam instead of VPA.
The patient's blood VPA and ammonia levels were then routinely monitored.
The patient's mental state began to improve from the first 24 hours of VPA discontinuation, and she achieved complete consciousness within 48 hours (GCS = 15).
The ammonia levels in her blood decreased dramatically and returned to normal within 4 days (Fig.3).
On postoperative day 15 (8 days after the discontinuation of VPA), the patient was discharged with no complications.
The follow-up interviews in postoperative month 5 witnessed her full consciousness and non-recurrence of the primary tumor (Fig.2D).
The patient's GCS score was 15, and she reported enjoying a satisfying quality of postoperative life.