Abstract/References

Caution:Patient-specific preoperative preparations combined with procedure-specific 5-aminolevulinic acid may lead to critical events

Shuto Yoshizawa, Junya Yoshida, Akioh Yoshihara, Chiaki Nemoto, Satoki Inoue

Abstract

5-Aminolevulinic acid (5-ALA) is orally administered 2-4 hours before surgery to identify tumor location. Hypotension is sometimes observed after 5-ALA administration.

Case reoprt

We present a case of a patient with 5-ALA-induced hypotension that resulted in the development of cerebral infarction. An 83-year-old man with a bladder tumor was scheduled for photodynamic diagnosis-assisted transurethral resection of bladder tumor (PDD-TURBT) and right radical nephroureterectomy. 5-ALA was orally administered and his ordinary antihypertensive and antianginal agents were also administered an hour after 5-ALA administration. Following this, his blood pressure dropped, and he developed muscle weakness and paralysis in his left upper extremity. Magnetic resonance imaging showed evidence of cerebral infarction.

Conclusions

We cannot conclude definitively that our patient’s cerebral infarction was solely caused by 5-ALA-induced hypotension because hypotension under these circumstances is not rare. We consider that additional factors, such as patient-specific doses of antihypertensive and antianginal agents may have played a role in the development of his cerebral infarction.

The content of research paper

References

1. Inoue K. 5-Aminolevulinic acid-mediated photodynamic therapy for bladder cancer. Int J Urol, 24:97-101, 2017.
2. Owada G, Nishizawa H, Matoyama Y, et al. Effect of arginine vasopressin on intraoperative hypotension caused by oral administration of 5-aminolevulinic acid. Case Rep Anesthesiol, 6:1745373, 2023.
3. Bondad J, Aboumarzouk OM, Moseley H, Kata SG. Oral 5-aminolevulinic acid induced photodynamic diagnostic ureterorenoscopy—does the blood pressure require monitoring? Photodiagnosis Photodyn Ther, 10:39-41, 2013.
4. Shiratori T, Hotta K, Satoh M, Kiuchi C, Ogawa N, Kamigaito T. Preanesthetic severe postural hypotension following 5-aminolevulinic acid pretreatment in patients for photodynamic diagnosis-assisted urological surgery. JA Clin Rep., 5:74, 2019.
5. Morisawa S, Jobu K, Ishida T, et al. Association of 5-aminolevulinic acid with intraoperative hypotension in malignant glioma surgery. Photodiagnosis Photodyn Ther, 37:102657, 2022.
6. Tarkin JM, Kaski JC. Vasodilator Therapy:Nitrates and Nicorandil. Cardiovasc Drugs Ther 2016 ;30(4):367-378.
7. Chung IW, Eljamel S. Risk factors for developing oral 5-aminolevulinic acid-induced side effects in patients undergoing fluorescence guided resection. Photodiagnosis Photodyn Ther, 10:362-367, 2013.
8. Yancey R. Anesthetic Management of the Hypertensive Patient:Part II. Anesth Prog 2018 ;65(3):206-213.
9. Miller RD, Pardo MC Jr. Basics of Anesthesia 6th ed. Elsevier saunders, Philadelphia, 385-386, 2011.
10. Miyakawa J, Kawai T, Makino K, et al. Impact of age, body mass index, and renal function for severe hypotension caused by oral 5-aminolevulinic acid administration in patients undergoing transurethral resection of bladder tumor Photodiagnosis Photodyn Ther 2021: 33:102179.
11. Thomalla G, Rossbach P, Rosenkranz M, et al. Negative fluid-attenuated inversion recovery imaging identifies acute ischemic stroke at 3 hours or less. Ann Neurol, 65:724-732, 2009.
12. Lee AY. Cancer and thromboembolic disease:pathogenic mechanisms. Cancer Treat Rev, 28:137-140, 2002.

Figures