28403092 Visualization

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