Abdominal wall (AW) hernias are a common problem faced by general surgeons. With an essentially clinical diagnosis, abdominal hernias have been considered a simple problem to be repaired. However, long-term follow-up of patients has shown disappointing results, both in terms of complications and recurrence. In this context, preoperative planning with control of comorbidities and full knowledge of the hernia and its anatomical relationships with the AW has gained increasing attention. Computed tomography (CT) appears to be the best option to determine the precise size and location of abdominal hernias, presence of rectus diastase and/or associated muscle atrophy, as well as the proportion of the hernia in relation to the AW itself. This information might help the surgeon to choose the best surgical technique (open vs MIS), positioning and fixation of the meshes, and eventual need for application of botulinum toxin, preoperative pneumoperitoneum or component separation techniques. Despite the relevance of the findings, they are rarely described in CT scans as radiologists are not used to report findings of the AW as well as to know what information is really needed. For these reasons, we gathered a group of surgeons and radiologists to establish which information about the AW is important in a CT. Finally, a structured report is proposed to facilitate the description of the findings and their interpretation. The diagnosis is usually clinical, based on symptoms and physical examination. Increasingly, however, surgeons interested in hernia repair find utility in imaging exams,Ultrasonography (US), computed tomography (CT) or magnetic resonance imaging (MRI) all have value to the hernia surgeon. The value increases when imaging is used in conjunction with a thorough history and physical examination. Nevertheless, the lack of uniform definition of what a hernia is and the lack of standardization in the interpretation of image examinations create difficulties in both clinical care and academic research; there is simply a paucity of high-level scientific evidence on hernia imaging,,,Despite reporting inaccuracies, most studies comparing the accuracy of diagnostic methods point to CT as the exam of choice1.9. Unfortunately, ultrassonography accuracy depends on the operator and the images generated are often of little value to the surgeon. Magnetic resonance imaging is more expensive, less available and there are no studies showing its superiority in relation to CT in the evaluation of abdominal wall defectsUltrasonography, in addition to being less expensive and widely available, is a more dynamic exam and can be very useful with the interaction of the patient, making it possible to perform maneuvers to increase intra-abdominal pressure and point out the site of pain or bulging,The use of the imaging in the context of AW hernias goes far beyond just establishing confirmation of the diagnosis, but it allows the evaluation of complex (large) hernias, their content and the relationships between bone structures and adjacent muscles. This knowledge, combined with the emergence of new surgical techniques and a better understanding of the anatomy of the AW by surgeons, allows surgical planning in an individualized way. For this, the standardization of the necessary information for an image exam is essential, but unfortunately this is not yet routine. To overcome this issue, surgeons must interact more with the interpreting radiologist, or  become experts in the proper evaluation of these imaging studiesTo guide surgeons and radiologists, we created a study group, including representatives of the two specialties, aiming to create guidelines for surgeons and mainly radiologists on the fundamental descriptions for an adequate assessment of the AW from an image perspective. Information was grouped into four topics covering: defect; hernia content; musculature and previous event. In each section, we made a brief correlation of the aspects required for the exam with its relevance from a practical/clinical point of view. The ultimate goal is the proper planning of the surgery. To make reading more dynamic, we organize it in a Q&A format. At the end, we propose a structured report model aimed at standardizing relevant information: the DECOMP report ; Musculature; Previous events).Like any imaging exam, a good interpretation begins with a descriptive indication from the surgeon, for whom the radiologist can seek answers to the main questions about the evaluated case. Good communication between the requesting professionals and the executors is essential and the kickoff is a good and clear indication of the exam and expectations.Technical parameters of the examination do not differ from those when performing “regular” abdominal CT. The only points that deserve more attention are: the use of intravenous (IV) contrast is not essential for assessing the abdominal wall defects and can be avoided. in suspicion of incarceration / strangulation IV contrast may show signs of impairment of vascular supply to the hernia content like reduction or absence of parietal enhancement or even engorgement of the mesenteric vesselsthe same goes for the postoperative evaluation where IV contrast is not necessary, except in cases of collection with suspected infection where it can help to differentiate it. Valsalva maneuver is only necessary if there is diagnostic doubt. In cases where the diagnosis is already established, it usually does not provide additional information. Although some surgeons may consider it different, the diagnosis of loss of domain must be done during the examination without Valsalva.The precise location of the hernia defect is essential for the planning and execution of the surgery. Umbilical stalk, xiphoid and pubic symphysis should be used as a reference for midline hernias; and costal margin, iliac crest, semilunaris line and midline for lateral hernias.In addition, hernias close to bony structures are usually considered more complex for repair. This is since the musculature close to bone structures has less complacency, as well the greater difficulty creating space for overlapping and mesh fixation. This information can alter the operative technique, planned mesh position and fixation method.A simple measurement of the size of the defect is one of the most important aspects for surgical planning. A linear measurement of the largest hernia dimensions in both longitudinal and transverses axis is required . This aldecide the surgical technique to be employed . Very large or large hernias (diameter over 10cm) are less prone to minimally invasive techniques due to the technical difficulty of adequately closing the defect.indicate preoperative patient preparation measures such as the use of botulinum toxin chemodenervation and/or induced progressive pre-operative pnemoperitoneum, aiming to paralyze the lateral muscles and increase abdominal compliance, and allow reduced tension at defect/midline closure.planning for the need for component separation technique(s).define approximate mesh size and type. This is critically important in practice locations where the mesh needs to be requested and acquired preoperatively.When there is more than one defect, information on the locations and the distance between the first and last defect edges. The same goes for incisional hernias with multiple defects . AdditioPresence of viscera such as intestinal loops or bladder inside the hernia sac brings some important information about the case. First, it may indicate a greater risk of complications such as intestinal obstruction and greater severity in the event of a strangulation. The knowledge of this fact can help in defining the need for surgery or at least in planning the time when it should be performed. In addition, the presence of viscera inside the hernia sac is associated with greater difficulty in dissecting it and greater risk of an iatrogenic injury compared to hernias that contain only fat.Incarceration of the hernia content is an indication of greater surgical difficulty. The risk of complications, including possible iatrogenic injury to incarcerated content is greater. The surgeon may need maneuvers for reduction such as external compression, intra-operative enlargement of the hernia defect, among others. Incarceration, defined when the hernia content cannot be reduced manually, is generally of clinical diagnosis and cannot be given by imaging methods alone. Despite this, some of the aspects found may be indicative, increasing the suspicion of hernia incarceration:presence of hernia sac with narrow neck in a small defect in the wall;presence of fluid inside the hernia sac;parietal thickening  and/or distention of the herniated intestinal segment and dilation of the intestinal loops upstream inside the abdominal cavity .Presence of these criteria, with incarcerated intestinal content, is a factor that should draw the attention of both the radiologist and the surgeon to a probable indication for urgent surgery.Strangulated hernia is defined when the vascular supply of the herniated content is compromised, determining ischemia. As image criteria that determine the suspicion of the diagnosis of strangulation of the hernia content we can observe :dilation of the segment of the intestinal loop located inside the hernia sac in the shape of a “U” or “C”, due to obstruction of the afferent and efferent intestinal segments (“closed loop” obstruction).thickening of the intestinal wall.hypo or hyperattenuation of the wall in relation to the usual pattern and parietal low uptake by means of intravenous contrast of the ischemic intestinal segment.intestinal pneumatosis.fluid inside the hernia sac.engorgement of the mesenteric vessels and obliteration of the mesenterial adipose plane of the herniated segment.,Presence of one or more of these findings is suggestive of strangulation of the hernia content and urgent surgical intervention should be considered,The relationship between the volume of the hernia sac versus the volume of the abdominal cavity is the best criterion for defining whether there is a loss of domain (LOD). LOD is defined when the volume of the sac/hernia content is greater than 25% of the volume of the abdominal cavity1there may not be enough space to reduce all herniated contents into the abdominal cavity and still achieve a complete primary fascial closure.the significant increase in intra-abdominal pressure, due to the reduction of a large volume of content in the abdominal cavity, can cause important ventilatory restriction due to the upward compression of the diaphragm. Although rare, patients may even develop abdominal compartment syndrome-With this assessment prior to the procedure, surgeons can use several strategies to reduce the consequences of the condition described above. Although it is not the objective of this work, we can cite as alternatives: preoperative preparation (weight loss and respiratory physiotherapy); progressive preoperative pneumoperitoneum and application of botulinum toxin preoperatively; visceral-reduction surgery; component separation techniques. All these possibilities aim to increase abdominal capacity and/or complianceFor tomographic assessment of the risk of LOD in bulky hernias, we used the method described by Tanaka et al because it is simple to understand and can be performed by most mutislice tomographic equipment, as well as being easily measured by the radiologist at their standard workstation  and 514Volume of the hernia sac or abdominal cavity: CC x T x AP x 0.52 Some pre-established criteria are important for greater precision in calculating the volume:A- The largest measurement of each axis should be used, even in different tomographic sections to calculate the volume of the hernia sac, as well as the volume of the abdominal cavity.B- To determine the abdominal volume cavity (AVC), some reference points must be used: The measurement of the anteroposterior axis of the abdominal cavity is determined by the line that joins the muscle groups of the healthy (anterior) wall and the line that passes through the transverse processes of the vertebra (posterior). The CC distance is made between the first cut showing the diaphragm and the last cut showing the tailbone. The transverse distance (T) through the parietal peritoneum on each side of the abdominal cavity.C- To determine the hernia sac volume (HSV), the following references should be used: Measurement of the limits of the parietal peritoneum of the hernia sac for the CC and T axes. For the AP axis, the distance between the anterior parietal sac peritoneum hernia to a line that joins the muscle groups of the healthy wall (posterior limit).if >25% = loss of domain-RD is defined as the increase in the distance between the medial edges of the two abdominals of the rectus abdominis muscle in the anterior midline, caused by laxity and thinning of the aponeurosis of the alba lineRD is usually asymptomatic, and often not even noticed by patients. It does not cause complications and its treatment, from an aesthetic point of view, is usually addressed by plastic surgeons. However, RD represents a weakness of the midline abdominal wallAlthough we understand that this information is a little more specific, the transverse measurement of the rectus abdominis width on each side (at the height of the largest transverse measurement of the defect) in relation to defect size is used as a predictor for the need for muscle component separation, as described in the Carbonel EquationRR - right rectusLR - left rectusDS - defect sizePatients who have already undergone any surgical intervention may have muscle weakness, atrophy (denervation) or muscle tissue loss. This usually occurs after surgeries with lateral incisions or flanks (lumbotomy type) that can cause damage to the neuro-vascular bundles that supply the central abdomen. Denervation atrophy of the musculature medial to the nerve transection may occur. In addition, denervation may result in bulging without a formal hernia defect (pseudo-hernia). It is important to differentiate between a hernia and a “pseudo-hernia” as denervation related bulging and asymmetry can persist after repair and can progress over time. Setting expectations in the pre-operative period is keyBreast reconstructions with transposition of the rectus abdominis muscle flaps (TRAM) after mastectomy are still common, and may lead to important weakness of the abdominal wall and bulging. All these findings certainly interfere not only in the planning of the surgical tactic but also in the postoperative functional and cosmetic results.Some hernias, especially on the lateral wall of the abdomen, can occur without a defect of all muscle groups layers. In these cases, usually the external oblique muscle/aponeurosis is intact, and the hernia is contained within the muscular layers of the AW . WithoutPresence of a mesh or even tacks for fixation may indicate previous surgical manipulation and therefore a greater degree of technical complexity in an upcoming repair. This may be even more relevant in cases where the mesh was placed in the intraperitoneal position. It is true that in some cases, neither the meshes nor the fixation devices  are detectable, but indirect signs such as loss of contour of anatomical planes can indicate them. The importance of the detailed description of the surgeon regarding possible repairs or previous interventions in the indication of the exam is crucial to allow the interpretation of subtle findings by the radiologist. A comprehensive review of the patient’s prior operative reports can indicate the type of mesh, its location and anatomic plane of implantation, which can make identification possible. Additionally, looking for non-anatomical folds and wrinkles from mesh contracture can facilitate mesh identification on CT imaging. Evaluation of collections or fistulous tracts (sinuses) by imaging is also important to decide on surgical steps such as dividing the treatment into steps to resolve the entire chronic infection or foreign body reaction before a new attempt at definitive repair with a new prosthesis.The concept of a standardized report for abdominal wall imaging exams is proposed here:1- Location of the hernia defect(s):A) Midline: cm from the xiphoid and/or pubic symphysis and/or the umbilical scarB) Lateral: which anatomical position? cm from iliac crest and/or costal margin and/or linea alba / linea semilunaris2-Defect size .3- Presence of more than one hernia defect:- Not.- Yes (distance between the defect ends: -cm) - repetition of the entire description of the second hernia defect according to the structured report above.4- Incarceration and/or strangulation signs:- Not- Yes: what signs:5- Content of the hernia sac:Adipose tissue / omentum / intestinal loop (which segment) / bladder / ureter / vascular structures (which) / solid organ/ other6- Relationship between the volume of the hernia sac in relation to the volume of the abdominal cavity (>25%):- Not- Yes: risk of loss of domain7- Rectus Muscles diastasis:NotYes: width (mm) / extensions (cm) / position8- Transverse width of the rectus muscles (just for midline defects):- width:right: mm- left: mm9- Presence of atrophy and/or denervation of the AW muscles- Not-Yes: location / muscle group(s) / thickness (mm)10- The hernia is intraparietal?- Not- Yes: location11- Signs of previous manipulation, mesh implant or complication in the cavity and/or abdominal wall:- Not- Yes: which / whereThe better understanding between surgeons and radiologists in the evaluation of hernia of the AW will likely improve hernia repair outcomes.We understand that this proposal brings more challenges to radiologists during the evaluation of the image exam. The report may even take a little longer. However, in the same way that not only the description of a nodule of an abdominal organ is important, but also the precise size and location, anatomical and characteristic correlations (flow and contrast enhancement) as they directly interfere in the diagnosis and management, the precise descriptions of abdominal hernias have the same impact mainly on surgical planning. At this moment, for the fastest and widest dissemination of this concept, it is essential that surgeons involve and encourage radiologists to adopt the routine performance of a structured report with the necessary information about AW. And we believe that the structured report proposal, presented in this article, can help radiologists in their work.


Lipoleiomyoma is an uncommon neoplasm of the uterus with a variable incidence in the literature. Histologically, it consists of smooth muscle cells intermixed with mature adipocytes. The histogenesis of this tumor remains obscure and the presence of atypical cells may raise the suspicion of leiomyosarcoma so it is crucial to distinguish between the two. On the other hand, tumor-associated mast cells are being recognized as tumor modulators and potential therapeutic targets. Here, we discuss the case of a 57-year-old female, who presented with a nonspecific symptom of postmenopausal bleeding. She was found to have a large uterine mass and had been treated surgically with a hysterectomy. Histological examination revealed the diagnosis of this uncommon entity. Considering the rarity of the disease, we report this case to add to the existing literature. Furthermore, the significance of these findings is still poorly understood and needs more investigation to fill in the lacking knowledge. Lipoleiomyoma is a benign smooth muscle tumor containing adipose cells. It is considered a rare entity of leiomyoma with a variable incidence in the literature of 0.28%-0.39% . TypicalA 57-year-old female presented with a chief complaint of postmenopausal bleeding, which started two years before her presentation; she had interrupted bleeding and a moderate amount of clots. She had associated symptoms of dizziness and palpitation. Her past medical history included obesity class II , diabetes mellites type 2, hypertension, dyslipidemia, bronchial asthma, and knee osteoarthritis. The patient's past surgical history is significant for a sleeve gastrectomy. Her current medications are aspirin, metformin, liraglutide, candesartan, lisinopril, rosuvastatin, and salbutamol.The pelvic examination revealed a bulky uterus with a fundal level of 20 weeks. An enhanced computed tomography (CT) scan of the pelvis demonstrated a big uterine mass measuring 14.5 x 13.4 x 11 cm, causing a mass effect on the endometrium. It had heterogeneous enhancement and prominent fat content consistent with lipoleiomyoma  articles described bizarre nuclei but none showed an increase in mitotic activity ,5-7. In  articlesAdditionally, a rarer finding is the presence of mast cells in lipoleiomyoma, described in two case reports ,8. Mast Lipoleiomyoma is an uncommon benign neoplasm of the uterus. A typical histological picture consists of mature adipocytes intermixed with smooth muscles. The presence of atypical cells may raise the suspicion of malignancy, namely leiomyosarcoma. So, it is important to distinguish between the two. Also, mast cells are being recognized in the literature as tumor modulators and potential therapeutic targets. Considering the rarity of the disease with its unclear histogenesis, we report a case with a unique histological feature to add to the existing literature. Furthermore, the significance of these findings is still poorly understood and needs more investigation to fill in the lacking knowledge.


Nodular fasciitis (NF) is a rare benign self-limiting lesion that is often mistaken for malignancy due to its progressive nature. Reported cases of nodular fasciitis in the parotid gland are uncommon, and its incidence is variable among different age groups. Histopathological and immunohistochemical studies are helpful in distinguishing these kinds of lesions. We report a case of a six-month-old baby with a two-month history of progressive rapid-growing mass in the left parotid region. Clinical examination showed some mild facial nerve weakness with no other significant findings locally or systemically. Fine-needle aspiration (FNA) was inconclusive, and surgical excision was the choice of treatment. On histological examination, the mass was confirmed to be nodular fasciitis, and on follow-up, the patient had no signs of recurrence. Nodular fasciitis can appear in young infants and, if confirmed histopathologically and immunohistochemically, should be treated conservatively. Nodular fasciitis (NF) is a benign self-limiting pseudosarcomatous myofibroblastic proliferative lesion that affects the muscles, subcutaneous tissue, and fascia . It was A six-month-old baby female, medically free, presented with a two-month history of left cheek swelling and a preauricular mass, which gradually increased over time. There was no history of trauma, insect bite, local injury, birth defects, or any other systemic complaints. Physical examination revealed a 2.5 cm round, firm, well-circumscribed, and slightly mobile mass, which was palpable on the left cheek. Facial nerve examination revealed a slight weakness that was noticeable on close inspection at the left side with a score of 2 on the modified House-Brackmann scale for infants. Other systemic examinations were otherwise unremarkable. Afterward, laboratory examination data was within normal limits. Ultrasonography (USG) revealed a well-defined, hypoechoic solid mass measuring 2.5 cm × 2 cm with slightly mobile and well-circumscribed borders. Magnetic resonance imaging (MRI) with contrast was performed and showed a well-defined lobulated homogeneous soft tissue mass arising within the left parotid gland measuring 2.5 cm × 2 cm. It demonstrated a bright T2 signal intensity and low T1 signal intensity with mild restricted diffusion  with cytoplasmic cells  Figure .Based on the histopathological finding, a decision to excise the mass was made. As a result, an extracapsular excision was performed with further histological confirmation. On first inspection intraoperatively, the mass was firm and well-defined but was lying on the pes anserinus of the facial nerve and was dissected carefully during the operation Figure .The nerve was left completely intact, and facial muscles were all stimulated using the nerve integrity monitor. However, the patient did not show any significant facial nerve weakness postoperatively. The histological examination of the excised lesion revealed a proliferation of spindle-shaped cells with myofibroblastic differentiation within a collagenous stroma. The cellular composition demonstrated a lack of significant nuclear pleomorphism and minimal mitotic activity. Additionally, scattered lymphocytes and plasma cells were present within the lesion, indicating an inflammatory component. These findings were consistent with a diagnosis of NF. Meanwhile, the immunohistochemistry examination of the tumor cells was positive for smooth muscle antibody (SMA), indicative of myofibroblastic differentiation and, thus, supportive of the diagnosis. It was negative for anaplastic lymphoma kinase (ALK), β-catenin, epithelial membrane antigen (EMA), S100, desmin, and myogenin. Therefore, no further workup was needed for the patient, just regular follow-ups in the outpatient clinic.NF is a benign lesion of unknown etiology with some incidents associated with trauma. It is usually self-limiting and is susceptible to multiple recurrences . HoweverCytologically, Gibson et al. reported a mixed finding of fine-needle aspiration (FNA) reports; that is, the most common findings seen are binucleated or multinucleated cells, mitosis, and normal glandular or acinar elements but are separate from the proliferation and negative blending of the epithelium with the spindle cell population . MeanwhiThe treatment of NF can be conservative because it is a self-limiting lesion. However, due to its fast-growing nature, it is often misdiagnosed as a malignant tumor and is often excised surgically ,6,7,9. TNodular fasciitis is difficult to diagnose clinically and cytologically. It can occur in any gender, age group, and region. Confusing it with malignant lesions is possible due to its fast progressive growing nature. The histopathological and immunohistochemical examination of the lesion can help guide the diagnosis in the right direction but is not specific. Even though the lesion is self-limiting, limited surgical excision of the lesion is possible with high rates of eliminating any recurrence.


Intrahepatic cholangiocarcinoma (iCCA)Extrahepatic cholangiocarcinomas:(a)perihilar cholangiocarcinoma —located in the vicinity of the hepatic hilum;(b)distal cholangiocarcinoma (dCCA)—located in the distal section of the common bile duct.Cholangiocarcinomas (CCAs) are a heterogeneous group of malignancies originating from the biliary tract epithelium. Based on the location of the lesion , we distinguish:Due to its specificity of formation and natural course, gallbladder tumors constitute a separate group ,3,4,5,6.Intrahepatic cholangiocarcinomas account for 15–20% of all bile duct malignancies and have a very poor prognosis .ICCA has a close relationship with the ongoing process of chronic inflammation in the bile ducts and the surrounding liver parenchyma, especially with the accompanying chronic cholestasis. This situation is associated with chronic damage to the cholangiocytes, and during the process of their regeneration, an error may occur at some stage of the process, starting the formation of a cancer cell line. Therefore, the common risk factors for biliary tract cancer include diseases, such as: cystic biliary tract disease, primary sclerosing cholangitis, intrahepatic cholelithiasis, liver cirrhosis ), parasitic infections of the bile ducts and exposure to certain chemical agents, including nitrosamines or significant iron load ) ,4. It haThe gold standard in the diagnosis of iCCA remains contrast-enhanced radiological imaging methods, such as multiphasic computed tomography (CT) or magnetic resonance imaging (MRI) of the abdomen, which simultaneously allow for the assessment of the extent of the disease process and the potential resectability of the iCCA lesion. A complementary procedure to radiological imaging, allowing for the final diagnosis of iCCA, is a core-needle biopsy of the liver tumor. This offers the opportunity to state definite diagnosis with a thorough histopathological and pathogenetic assessment in terms of, for example, the availability of potential new treatment regimens using targeted immunochemotherapy. Ca 19-9 and CEA markers may be of some importance in the diagnosis, but the specificity and sensitivity of their presence in iCCA at a level not exceeding 65% does not allow us to use them as one of the main diagnostic tools [BILCAP and PRODIGE 12-ACCORD 18), which clearly demonstrated improvements in CCA treatment results, the therapeutic scheme for patients was supplemented with postoperative systemic chemotherapy with capecitabine and, nowadays, it is included in the standards of management for patients with iCCA [Surgical treatment  has been the only possible radical treatment of iCCA for many years . Howeverith iCCA . Furtherith iCCA . For patith iCCA ,8. Locorith iCCA ,7.In recent years, along with the development of molecular research in modern clinical oncology, significant progress has been made in iCCA research. Many of the common genetic mutations present in iCCA tissue have been identified. It is currently believed that up to 70% of patients with iCCA may have molecular disorders in their cancer cells, which may be a potential target for modern targeted immunochemotherapy. The most frequently identified genetic alterations in iCCA cells include aberrations in genes encoding proteins: TP53, KRAS, SMAD4, MET, EGFR, FGFR2, IDH1/2, RB1, ERBB2 or BAP1 ,9,10. Ac


Currarino syndrome or Currarino triad is a complex condition consisting of congenital anomalies. The triad consists of anterior sacral mass , sacral bone defect , anorectal malformation/congenital anorectal stenosis. This condition is named after Dr Guido Currarino, an Italian-American paediatric radiologist, who first described it in 1975. This needs a multidisciplinary treatment approach. We describe a case of successfully managed young adult with Currarino syndrome. The latest artificial intelligence tool, Chat Generative Pre-Trained Transformer (ChatGPT), helped to write this case report. Anterior sacral meningocele (ASM) is an anomaly where the meninges protrude into retroperitoneal and presacral space through a ventral sacral defect. Currarino syndrome is a complex condition variably comprised of characteristic congenital anomalies of the sacrum, anal and rectal defect with presacral soft tissue mass. It is a triad consisting of anterior sacral mass , sacral bone defect , anorectal malformation/congenital anorectal stenosis. This condition is named after Dr Guido Currarino, an Italian-American pediatric radiologist, who first described it in 1975, however, not all three features are always present. We report a 30-year-old adult with ASM presenting with constipation which improved after surgery.A 30-year-old male presented to our center with complaints of chronic constipation. Patient had noticed that multiple times this constipation was severe and he used to take laxatives and enema as per advice of local practitioner which helped him to pass stools. Since the last three years he started feeling weakness, tiredness, and fatigue for which he visited medical college in Jaipur where he was investigated and diagnosed with severe anemia and had multiple blood transfusion. There was no history associated with pain abdomen, vomiting, difficulty in passing urine, difficulty in walking.The adult weighted 47 kilograms with paleness noted in lower palpebral conjunctiva, nail beds and palmar skin. On chest examination bilateral air entry was normal. Per abdomen examination revealed soft non distended abdomen with no other mass palpable except for fecolith. Bowel sounds were normal. Anal tone was found to be normal on digital rectal examination but the lumen was narrow and finger could not be negotiated, which precluded higher examination. Clinically spine was found to be normal. There was no neurological deficit.Hematological investigations showed hemoglobin 2.8 gm/dl, total leucocyte count 6.73 thousand, platelets 366 thousand; liver function test and kidney function tests were normal.Ultrasound revealed right iliac fossa/left iliac fossa gaseous distended large bowel loops noted. MRI scan of pelvis revealed large heterogenous, non contrast enhancing mass anterior to upper lumbar spine with caliber of 25 × 7.5 centimeter, no diffusion restriction on diffusion weighted image and appearing to be anterior meningocele Figures , 2.Non-contrast computed tomography (NCCT) lumbo-sacral area revealed a large lobulated thick-walled cystic lesion measuring 10.5×9.9×10.7 centimeters seen in pelvis along sacral and coccyx vertebrae, bulging at S2-S3  level, compressing and displacing surrounding bowel loops and soft tissue structures likely anterior meningocele along with ventral defect in S3-S4 vertebrae noted. Water tight closure of dural tube done at the terminal end. Muscle and skin closed in layers. This was followed by diversion loop sigmoid colostomy made in left iliac fossa and matured with Vicryl 3-0. There was no neurological deficit in the immediate postoperative period.Postoperative course was uneventful and stoma was functioning at day two and patient was mobilized from day two postoperative. He was tolerating normal regular diet from postoperative day three. Wound was healthy and he was discharged at day five with advice to come to regular follow-up for anal dilatation. By doing regular anal dilatation, we achieved the target anal canal diameter in six weeks. After that stoma closure was done. Postoperative course was uneventful. He was able to pass stool through anal canal without any difficulty. He was in regular follow up with improving hemoglobin and gaining weight. Patient was neurologically intact. Postoperative follow-up MRI scan at three-month follow-up showed regression of the sacral meningocele Figure .ASM is a rare form of spinal dysraphism consisting of protrusion of dural sac anterior through a defect in the sacrum anteriorly -3. ASM rASM is also a part of Currarino syndrome which includes anorectal malformations, sacral bony defect and presacral mass -7.ASM can remain undiagnosed until adulthood due to its occult nature. Patients with this syndrome can have constipation, urological or neurological problems. ASM may lead to infertility and difficult labor in women and chronic constipation, urinary retention in young adults and children .Secondary infection in the cyst can lead to pyocoele formation or meningitis . Tethere‘Scimitar’ sign, a smooth curved unilateral sacral defect simulating shape of an Arabic sabre on plain X-ray, is considered to be pathognomonic of ASM . UltrasoMost cases are managed surgically. Decompression of the cyst is the primary aim. It can be achieved by disconnecting meningocoele from the spinal subarchnoid space ,17. DorsIn some cases, additional treatments may be necessary to manage symptoms and prevent complications. For example, physical therapy may be recommended to improve muscle strength and mobility, and medication may be prescribed to manage pain or bowel and bladder incontinence.The latest artificial intelligence (AI) tool, Chat Generative Pre-trained Transformer (ChatGPT), was used to write the discussion. The format and information provided by ChatGPT were used after paraphrasing sentences to avoid plagiarism, as seen in the Appendix.It is important to note that the management of Currarino triad can be complex and may require long-term care and monitoring. Individuals with Currarino triad may experience permanent neurological problems and require ongoing care. With early diagnosis and appropriate treatment, most individuals are able to lead normal lives. However, it is always recommended to have regular follow-ups to ensure the best possible outcome.


Down syndrome, also known as trisomy 21, is associated with congenital cervical spine abnormalities, including atlantoaxial instability with or without os odontoideum, atlanto-occipital instability, and hypoplasia of the atlas. Herein, we report a case of Down syndrome complicated by congenital atlanto-occipital dislocation. The patient presented with severe cervical myelopathy at 13 years of age after a 10-year follow-up. Radiography and computed tomography revealed os odontoideum protruding into the foramen magnum and congenital anterior atlanto-occipital dislocation. Additionally, a bifurcated internal occipital crest with a thinned central portion of the occipital bone was noted. Magnetic resonance imaging revealed kyphotic alignment of the spinal cord with severe compression at the foramen magnum level. As the neurological impairment was partially improved by halo vest immobilization, we performed in situ O-C2 fusion with an iliac autograft and decompression of the foramen magnum and posterior arch of C1. An improvement was observed immediately after surgery. Two years after surgery, radiography and computed tomography showed solid O-C2 segment fusion. The accumulation of similar cases is essential for determining the prognosis or optimal treatment for this rare congenital condition. Down syndrome OMIM 190685) is caused by trisomy of all or a critical portion of chromosome 21 and can be associated with congenital cervical spine abnormalities, including atlantoaxial instability with or without os odontoideum, atlanto-occipital instability, and hypoplasia of the atlas 90685 is . Herein,The patient first presented to our department at 3 years of age for abnormal cervical radiography findings. He was diagnosed with Down syndrome at birth. His family history was unremarkable. Radiography showed basilar invagination and kyphotic O-C2 alignment Fig. a, b. SagThe neurological impairment was partially attributed to upper cervical instability associated with os odontoideum because of partial neurological symptom improvement by the halo vest immobilization. Hence, we performed in situ O-C2 fusion using an iliac autograft and decompression of the foramen magnum and posterior arch of C1, in lieu of reducing the congenital atlanto-occipital dislocation. Due to a bifurcated internal occipital crest with a thinned central portion of the occipital bone, we bilaterally placed the occipital plates separately Fig. a, b. TheThere are no reports describing congenital atlanto-occipital dislocation; most reported cases have been trauma-related –6. Down The optimal treatment for this congenital atlanto-occipital condition will be the subject of future studies. In this case, preoperative dynamic radiography of the cervical spine revealed limited cephalocaudal motion of the atlanto-occipital joint; therefore, reduction of the atlanto-occipital dislocation was presumed to be technically demanding. Hence, we conducted an in situ fusion and decompression, which was motivated by the partial neurological recovery from external halo vest immobilization alone. Although the short-term clinical course was favorable in our case, long-term follow-up and accumulation of similar cases are essential for determining the optimal treatment for this condition.Additionally, it remains to be determined whether surgery before the development of myelopathy is recommended in patients with congenital atlanto-occipital dislocation, because the prognosis or natural course of this congenital condition is completely unknown. Retrospectively, our case may have benefitted from prophylactic surgery, given the preoperative severe and rapid neurological deterioration. However, determining the significance of prophylactic surgery for this congenital condition may be premature as neurological impairment in this case may have been affected by concomitant os odontoideum, a well-known predictive factor for neurological deterioration and a proposed indicator for prophylactic surgery due to its high-grade instability –17. NeveA bifurcated internal occipital crest, which is reported in approximately 3% of the normal population, was identified in this case . TherefoIn conclusion, we have reported the first case of Down syndrome complicated by congenital atlanto-occipital dislocation that demonstrated progressive myelopathy and was successfully treated surgically. Although this condition seems to be extremely rare, we provided detailed information about the clinical course, including surgical treatment for future cases with congenital atlanto-occipital dislocation. The accumulation of similar cases is essential to determine the prognosis or optimal treatment for this congenital condition.


A 68-year-old patient presented with persistent hemoptysis and weight loss. A CT scan showing diffuse bilateral ground-glass opacities and nodules was followed by bronchoscopy. While diffuse alveolar hemorrhage (DAH) could be seen, specimens obtained during bronchoscopy did not provide conclusive histological findings. The decision was made to conduct video-assisted wedge resection, after which histological examinations revealed the diagnosis of bifocal nodular manifestation of an epithelioid angiosarcoma in the lung. Being a rare entity even among sarcomas, these kinds of tumors can be primary lung tissue angiosarcomas or metastatic lesions with primaries in places like the skin, breast, and heart. Treatment usually includes chemotherapy, but prognosis remains grim. This case highlights that in DAH, uncommon causes should be considered, and sufficient probe gathering is the key to early diagnosis and treatment. Malignancy is a rare cause of diffuse alveolar hemorrhage (DAH) . Among mWe present a 68-year-old patient who was referred to our hospital with severe weight loss and persistent hemoptysis for almost three months. The patient had a smoking history of 30 pack years but no other known exposure to toxic agents. Preexisting conditions included peripheral artery disease, hypertension, and chronic back pain. An abnormal chest X-ray led to a diagnostic bronchoscopy in another hospital, but the cause of bleeding could not be determined . After aHistological examination revealed small airways, regular lung parenchyma with an alveolar basic structure, and bronchioles lined by regular respiratory epithelium. Microscopic examination also demonstrated subpleural and intraparenchymal nodular proliferates of anastomosing vessels and solid sheets with hemorrhage and patchy necrosis, with maximum diameters of 5 mm . The neoEpithelioid angiosarcoma is a rare subspecies of sarcoma, accounting for around 1% of all sarcomas. The vast majority of angiosarcomas appearing in the lung are actually metastatic lesions from other locations such as the skin, heart, liver, bone, or gastrointestinal tract . PrimaryDue to the very low incidence of this disease, it is difficult to establish risk factors; these may, however, include Lucite plombage, chronic empyema, and tuberculous pyothorax . Males wAs demonstrated in this case, abnormal findings in chest radiography are insufficient for establishing a diagnosis, but they often serve as an impulse to initiate further examinations. Radiological features in CT scans usually include nodules , often surrounded by ground-glass opacities , diffuse infiltrations, pleural effusions, and sometimes hemothorax. Large specimens are usually necessary to provide conclusive pathological findings so that in most cases, the initial bronchoscopy is followed by surgical resection . It is iLikely, due to the low incidence, data on effective treatment remains scarce, and a standard of treatment does not exist. Based on what we know so far, surgical resection is likely the best treatment; however, due to the aggressiveness of these tumors, most patients present in advanced stages. Regarding chemotherapy, a regimen of docetaxel and gemcitabine has been reported to result in complete radiographic response . Recent We herein report a case of DAH, secondary to an epithelioid angiosarcoma of the lung. If common causes for DAH are ruled out and bronchoscopy also fails to provide conclusive pathological material, diagnostic surgical resection can help to ensure a timely diagnosis and initiation of treatment.


Enterocutaneous fistula (ECF) is a common complication of abdominal surgery. Postoperatively, it may be the result of a small intestinal injury or an anastomosis leak, and it typically manifests days or weeks following surgery.A 56-year-old man with a history of a gunshot wound injury in the abdomen with colon injury managed for colocolic anastomosis 17 years earlier presented to our hospital’s general surgery clinic with the complaint of drainage at the scar area. It was discovered that he had an ECF. The patient underwent a laparotomy. Fistula tract excision and segmental colon resection with colocolic anastomosis were done.ECF formation after an extraordinarily long latency due to an anastomotic leak, which has not been previously documented in the literature, is a distinctive aspect of the case. As a result, surgeons should consider ECF in their differentials for patients with a history of abdominal operations.Surgical management is the definitive treatment of ECF after proper resuscitation and stabilization of the patient’s condition. Preoperative imaging is crucial for determining the anatomy of the fistula and any associated intra-abdominal pathology. HighlightsDelayed enterocutaneous fistula after 17 years of colon anastomosis is extremely rare, as in our case.In spite of a sepsis-free interval of conservative management surgical treatment has a good chance of being successful for patients who have a healed wound associated with a fistula opening.Although enterocutaneous fistula presents early postoperatively, it can also present late, as in our case, and always carries higher morbidity and mortality, so careful consideration of the patient’s history with a definitive diagnosis reduces such complications.1. The ECF is a well-known intra-abdominal surgical complication. While iatrogenic causes account for 75–85% of ECFs, the remaining 15–25% are caused by spontaneous processes2. Following both laparoscopic and open surgeries, it may develop as a result of small intestinal damage or an anastomotic leak3.An enterocutaneous fistula (ECF) is an inappropriate connection between the gastrointestinal (GI) tract and the skin or a woundIn this case report, we describe a rare occurrence of colocutaneous fistula that developed 17 years after colocolic anastomosis in trauma and was treated with a definitive surgical procedure.A 56-year-old man arrived at our outpatient clinic complaining of recent mild abdominal pain and barely detectable feculent discharge from his left lower quadrant of the abdomen. He had a history of gunshot wound injuries 17 years ago, including a left colon injury in which he underwent colocolic anastomosis.Clinically, the patient’s vital signs were normal, and a tiny scar with a feculant discharge was visible in the left lower quadrant of the abdomen. The skin around it appeared to be normal.After normal laboratory tests, radiological imaging was done.A computed tomography (CT) abdomen with IV and oral contrast was performed in which there is a fistulous track in the left lower quadrant extending intra-abdominally to reach the descending colon, hence identifying a colocutaneous fistula Fig. .After completing the preoperative workup, an exploratory laparotomy was done, and the abdomen was explored. A fistulous tract was seen communicating with the descending colon. There were also loops of small bowel adhered to the colon Fig. ; adhesioHistopathology was performed on the resected specimen and showed congestion, ulceration, chronic inflammation, and a fistulous tract with colon tissue.The postoperative phase was uncomplicated, and on the sixth postoperative day, the patient was discharged and given instructions for routine follow-up.4. We are reporting an unusually delayed presentation of ECF after 17 years of colon anastomosis in trauma.After abdominal surgery, ECFs are still a terrible consequence that can be difficult to treat. In the postoperative phase, between days 5 and 10, the typical presentation is observed5. In this case, the appearance of a feculant leak and a CT abdomen with IV and oral contrast suggested the diagnosis.On the basis of the patient’s medical history, general nonspecific constitutional symptoms and other particular symptoms, such as feculent or bilious wound discharge, diarrhea, and GI hemorrhage, are discernible. Imaging with GI contrast that traverses the fistula (fistulogram) typically confirms the diagnosis. Nevertheless, a CT scan is frequently the main diagnostic modality of choice, is highly specific in defining the anatomy of the fistulous tract, and frequently excludes the existence of an abdominopelvic abscess, as intra-abdominal abscesses are associated with fistula in 44% of patients6, have no source of sepsis, and can tolerate the resectional technique required for fistula closure7. It is also essential that the process be technically viable without posing a very high risk of damage to the intestine or other important structures.Patients with conventional fistulas and no unfavorable variables should undergo surgical intervention if they are stable6. The patient underwent definitive surgical management, and a favorable outcome was observed during follow-up.Surgical treatment has a good chance of being successful for patients who have a healed wound associated with a fistula opening8.This activity has been documented in line with the Surgical CAse REport (SCARE) 2020 criteriaThis case report highlights the incidence of ECF following colocolic anastomosis, which manifests 17 years after surgery. Although preventing this complication is extremely difficult, it can be lessened with good anastomotic technique and the management of underlying local or systemic disease. As a result, the surgical team performing colon surgery must exercise extreme caution for the early detection of ECFs because they can present themselves either early or late, as in this case. In order to avoid morbidity and complications, definitive surgical intervention is the primary course of treatment.Ethical approval was waived by the ethical committee of Mogadishu Somali Turkey, Recep Tayyip Erdogan Training and Research Hospital. Written informed consent was obtained from the patient for participation.Written informed consent was obtained from the patient for the publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request.No funding was received.N.M.N.: conceptualization, data curation, visualization, investigation writing, original draft preparation; N.M.S.: writing, reviewing, and editing; A.A.A.: reviewed and revised the manuscript for intellectual content critically.This manuscript has not been submitted to, nor is it under review at, another journal or other publishing venue. The authors have no affiliation with any organization with a direct or indirect financial interest in the subject matter discussed in the manuscript.Name of the registry: NA.Unique Identifying number or registration ID: NA.Hyperlink to your specific registration (must be publicly accessible and will be checked): NA.Nuradin Mohamed Nur.The data that support the findings of this study are available in Mogadishu Somali Turkey, Recep Tayyip Erdogan Training and Research Hospital information system. Data are; however; allowed to the authors upon reasonable request and with the permission of the education and research committee.Not commissioned, externally peer-reviewed.The authors acknowledge the education and research committees of Mogadishu, Somalia, Turkey, Recep Tayyip Erdogan Training and Research Hospital. The authors acknowledge S.A, who allowed us to use her clinical information, reports, and images for this case report.


An 84-year-old woman with anemia and a 4-week history of discomfort on the right-side of the abdomen received treatment for hypertension, dyslipidemia, and osteoporosis. She had been treated with the traditional Chinese drug Kami-shoyo-san  for several years for neuropsychiatric symptoms secondary to menopause. Physical examination revealed a soft abdomen with no tenderness.A colonoscopy revealed bluish edematous mucosa, decreased blood vessel permeability, and multiple small ulcers with white slough extending from the cecum to the hepatic flexure  but wereBased on the typical combination of endoscopic and radiological findings, the patient was diagnosed with idiopathic mesenteric phlebosclerosis (IMP); herbal drug treatment was immediately discontinued, conservative treatment was initiated, and regular endoscopic and radiological observations were scheduled.Idiopathic mesenteric phlebosclerosis is a rare disease reported mostly in East Asian countries (including Japan). Herbal medicines containing geniposide  are one of the major causes of IMP.When considering IMP as a differential diagnosis, clinicians should recall typical findings on endoscopic and CT images. It is useful to assess the severity and extent of IMP, such as the involved bowel segment, to indicate conservative treatment outcomes and surgical needs.Most of the IMPs in the literature review were reported in Japan, China, and Korea, but two were reported in Canada and one each in Germany, the United States, and the United Kingdom; in addition, clinicians should be cautious about oral medications in travelers from Asia.


Primary parapharyngeal space tumors are rare, and due to the complex anatomy of the parapharyngeal space, their diagnosis and treatment are challenging. Pleomorphic adenoma is the most common histologic type followed by paragangliomas and neurogenic tumors. They can present as a neck lump or an intraoral submucosal mass with the displacement of the ipsilateral tonsil or might be asymptomatic and discovered incidentally on imaging obtained for other reasons. Magnetic resonance imaging (MRI) with gadolinium is the imaging of choice. Surgery remains the treatment of choice and many approaches have been described. In this study, we present three patients with PPS pleomorphic adenoma (two primary and one recurrent), which were resected successfully with a transcervical-transparotid approach without mandibulotomy. Division of the following anatomical structures: the posterior belly of the digastric muscle, stylomandibular ligament, stylohyoid muscle and ligament, and styloglossus muscle is a very important tip for the surgeons because enables displacement of the mandible providing excellent exposure for complete tumor excision. The only postoperative complication was temporary facial nerve palsy in two patients who fully recovered within two months. The aim of this mini case series is to present our experience, together with some tips and benefits of the transcervical-transparotid approach for the resection of pleomorphic adenomas of the PPS. Primary tumors of the parapharyngeal space are not common, accounting for only 0.5% of all head and neck tumors . Most ofThe differential diagnosis of benign PPS tumors includes pleomorphic adenomas of the salivary glands, which are the most common, followed by paragangliomas and neurogenic tumors . PPS tumSurgical excision remains the best treatment for PPS tumors. Different surgical approaches have been described, including transcervical, transparotid, transoral, infratemporal, and transmandibular . Alone oIn this article, we present three cases of parapharyngeal space pleomorphic adenomas resected with a combined transcervical-transparotid approach without mandibulotomy, together with some tips for better visualization of the tumor with this approach.Case 1A 40-year-old male patient presented to our department two years ago with a left parapharyngeal space tumor that was found incidentally on a pituitary MRI, which he underwent because of pathological prolactin levels. He also complained of snoring and sleep apnea. MRI of the neck revealed a tumor of the left parapharyngeal space with benign characteristics and dimensions 3.9 Χ 3.9 Χ 2.7 cm, which caused narrowing of the oropharynx Figure During physical examination, there was no palpable neck mass but there was an evident bulging of the left lateral pharyngeal wall causing displacement of the left tonsil and left soft palate. The tumor was resected through a transcervical-transparotid approach and a biopsy showed a pleomorphic adenoma. The patient had a temporary facial nerve palsy (House-Brackmann II) postoperatively, which fully recovered (HB I) after one month, and he also mentioned improvement in snoring and sleep apnea in the next postoperative months. The patient was on regular follow-up postoperatively and the latest follow-up was six months ago  with an MRI that showed no signs of recurrence.Case 2A 30-year-old woman presented to our department a year ago with a left parapharyngeal space tumor, of dimensions 3.1 X 2.6 X 3.4 cm, which was found incidentally on a head and neck MRI that she underwent due to episodes of syncope. The possible diagnosis from the MRI was a neurogenic tumor , which fully recovered within two months. She was discharged from the hospital in three days.Case 3A 37-year-old woman with a repeatedly recurrent pleomorphic adenoma of the parapharyngeal space presented to our department 8 months ago. She had undergone three previous surgeries during the last 10 years in other hospitals. According to her medical record, she suffered from thrombophilia. Preoperatively, a complete investigation of the coagulation profile was performed with normal INR, PT, and aPTT values, and in addition, a consult with the hematologist was done. MRI showed a multinodular recurrent pleomorphic adenoma  was used. A skin incision was performed as shown in Figure Next, the main trunk of the facial nerve was recognized while exiting from the stylomastoid foramen Figure .The superficial lobe was mobilized, and its caudal portion (MSGS level II) was resected in order to expose the deep lobe of the gland. With caution, the caudal part of the deep lobe (MSGS level III) was also resected. The posterior belly of the digastric muscle, the stylomandibular ligament, the stylohyoid muscle and ligament, and the styloglossus muscle were recognized and divided. This step of the procedure is very important because it enables the displacement of the mandible upward with a retractor, providing a much better surgical field and access to the parapharyngeal space. The submandibular gland was also mobilized and retracted upward and part of the fat of the submandibular compartment was resected to improve access. It is not necessary to resect the submandibular gland. The facial vein was ligated. The common carotid artery with its bifurcation was recognized, and caution was shown not to damage the internal carotid artery by pressing it on the styloid process during the resection of the tumor near the skull base. The internal jugular vein was preserved. The hypoglossal, accessory, and glossopharyngeal nerves were recognized and protected. For confirmation, we used the neuromonitoring system and delivered electrical pulses to the nerves, especially the hypoglossal and accessory nerves, and we noticed the contraction of the muscles of the tongue and the shoulder.The dissection reached the skull base superiorly and the superior constrictor pharyngeal muscle medially. The position of the internal carotid artery and the glossopharyngeal nerve were continuously monitored during these last steps of the surgery. Then, the tumor was resected with blunt dissection with the capsule intact Figures , 8B.Copious irrigation of the wound is important if there is any tumor spillage. Finally, drain insertion and layered closure were performed. In the third case, because it was a reoperation, it was more difficult to recognize the facial nerve, which was not in its usual place, and there were multiple nodules that should be resected, which prolonged the time of the operation and increased the risk for complication.The parapharyngeal space is one of the most anatomically complex spaces of the neck. Tumors of varying histopathologies develop in this region, with most of them of benign nature. Due to the complex anatomical relationships and histological diversity, the diagnosis and treatment of PPS tumors present a challenge for physicians. It is helpful in determining the possible diagnosis to distinguish whether a lesion arises in the prestyloid or the poststyloid compartment. As a general rule, prestyloid lesions usually displace the internal carotid artery (ICA) posteriorly while poststyloid lesions displace the ICA anteromedially . Most prRegarding clinical presentation, benign PPS tumors usually present as a neck mass or an intraoral swelling causing asymmetry of the ipsilateral tonsil, soft palate, and lateral pharyngeal wall. They can cause symptoms like snoring, glomus sensation, dysphagia, and dysphonia related to mass effect and impaired vagal nerve function. It is not uncommon though for patients to present with a parapharyngeal tumor that was incidentally discovered on imaging obtained for other reasons. Symptoms like otalgia, facial pain, and trismus should raise suspicion of malignancy . In our Imaging studies are crucial for the diagnostic workup of these tumors and are used to predict the origin, side, and size of parapharyngeal tumors. Pre-operative assessment typically includes an MRI and/or CT scan. Angiography is required in cases of vascular lesions. MRI with gadolinium is the examination of choice because it can be typical for many lesions of the parapharyngeal space. Usually on MRI examination, salivary gland neoplasms are typically T2 hyperintense, and it is possible to recognize a fat plane between the parotid and the mass while schwannomas are typically T1 isointense or hypointense, with enhancement during the administration of gadolinium ,10. In oMost patients with parapharyngeal space masses are treated with surgery and the aim of surgery is to entirely remove the lesion with minimal postoperative complications. The selected surgical approach must be wide enough to guarantee the complete removal of the tumor and to prevent injury to the vessels and nerves of the upper neck . Many suThe transcervical approach is most appropriate for the resection of small tumors of the inferior part of the parapharyngeal space .The transcervical-transparotid approach is recommended for tumors adjacent to the facial nerve such as deep-lobe parotid tumors and minor salivary gland tumors. Through this approach, it is not only possible to identify and preserve the facial nerve but also the external and internal carotid arteries, the internal jugular vein, the cranial nerves IX, X, XI, XII, and the sympathetic nervous system chain. Although a superficial parotidectomy might be necessary to be performed to identify and carefully preserve the facial nerve, an effort is made to preserve the superficial lobe of the parotid gland in order to reduce the risk of developing Frey’s syndrome and for better cosmesis , 15,16. The transoral approach has also been described but most authors do not recommend routine use of this technique because the limited exposure has been related to a higher risk of tumor rupture, incomplete removal, facial nerve injury, fistula, and uncontrollable hemorrhage . HoweverTransoral robotic surgery (TORS) has been used in recent years to resect small benign lesions of the parapharyngeal space with promising results. Supporters of the approach claim that TORS provides a better three-dimensional view of the surgical area and safer tumor dissection but due to the limited availability of the expensive equipment and the potential for complication, there are very few centers worldwide that perform this approach ,20.In conclusion, an optimal surgical approach should be the safest and most effective method for providing complete tumor removal and preventing injury to the vessels and nerves of the parapharyngeal space. Intraoperative visibility of all vital anatomical structures is essential in performing a safe and radical dissection of the tumor. On the other hand, the surgical approach should also advocate providing minimal functional and cosmetic side effects.Parapharyngeal space tumors are rare, and their diagnosis and treatment are challenging due to the complex anatomy of the region. They may present with few clinical symptoms or can be entirely asymptomatic until reaching large dimensions. Asymptomatic tumors are usually diagnosed incidentally on radiological examinations of the head and neck for other reasons. The majority are benign tumors and arise from the salivary glands. Pleomorphic adenoma is the most common histologic type. Surgery is considered the treatment of choice after a complete investigation. Surgical strategy is determined by location, size, and pathology. In this mini case series, we demonstrate that the transervical-transparotid approach with a division of the following anatomical structures: stylomandibular ligament, posterior belly of the digastric muscle, stylohyoid muscle and ligament, and styloglossus muscle provides excellent exposure and enables complete excision of primary and recurrent parapharyngeal space pleomorphic adenomas with minimal morbidity. The use of intraoperative nerve monitoring is very important, and we recommend it through this approach for preventing facial nerve damage.


Delayed traumatic intracerebral hematoma (DTICH) is a relatively common occurrence after a traumatic brain injury (TBI). Several case series have been performed to study DTICH, many of which offer different definitions of DTICH. Some definitions involve a delayed progression of an existing hemorrhage, and others involve a de novo intracerebral hematoma that was not evident on the initial trauma evaluation. We propose a classification system for DTICH that accounts for the subtleties in the clinical manifestation and pathophysiology of the different types of DTICH, with the ultimate goal of providing strategies to prevent and manage DTICH.Based on the senior author's clinical experience, we generated a classification system for DTICH, and each type of DTICH was illustrated with a case. We defined type 1A (case 1A), the classic presentation of DTICH as predominantly characterized in the literature, as an intracerebral hematoma unseen on initial computed tomography imaging that typically develops five days to one week following blunt or penetrating head trauma. We defined type 1B (case 1B) as a hematoma that forms after at least one week following trauma in areas of the brain initially hemorrhage-free. We defined type 2 (case 2) as a hematoma that develops rapidly following a surgical evacuation of a different hematoma. We defined type 3 (case 3) as a hematoma that develops after a traumatic head injury in areas of non-hemorrhagic contusion, usually frontal or temporal.A literature review was performed using select terms on PubMed to find articles related to DTICH, excluding articles describing DTICH from an underlying vascular injury. After performing the literature review and screening articles by title and/or abstract, a total of 79 articles were found to meet the inclusion and exclusion criteria. We recorded which type of DTICH from our classification system best correlated with the articles in our literature review.Taken together with results from the literature, the proposed classification system is based on the senior author’s clinical experience. Overall, DTICH is a relatively common occurrence after head trauma, and our pathophysiologic classification has the potential to help outline future studies to recognize and prevent the development of DTICH. Delayed traumatic intracerebral hematoma (DTICH), also referred to as delayed post-traumatic hemorrhage (DPTH), has been described as a sequela of a traumatic brain injury (TBI) since 1891. Bollinger et al. -4. The pDTICH is a relatively common phenomenon, with a reported incidence of up to 7% of head trauma . SeveralThe classic clinical picture described by Bollinger et al.  and subsIn this paper, we propose a classification system for DTICH that accounts for these clinical phenomena and their underlying pathophysiology. The ultimate goal of this research is to offer strategies for both the prevention and management of DTICH.MethodsA retrospective review of cases was performed to illustrate each type of DTICH. The patients were adults treated at our institution, which sees a high volume of patients with traumatic injuries, from 2017-2022. In particular, we analyzed the cases and then de-identified them according to standard practices. The inclusion criteria for the cases required that the initial traumatic injury of the patient be one of the following: subdural hematoma, epidural hematoma, cerebral contusion, traumatic subarachnoid hemorrhage, or skull fracture. Another inclusion criterion was the presence of the delayed formation of an intracerebral hematoma after the patient’s initial injury. For the exclusion criteria, we did not include any patients who had an underlying intracranial vascular injury as identified by computed tomography angiography (CTA) or digital subtraction angiography.A comprehensive literature review was performed to evaluate previous articles that discuss DTICH. All literature searches were made in 2020. We searched the following terms: “delayed,” “traumatic,” “intracerebral” , and “hematoma” (or “hemorrhage”) on PubMed. In addition, a separate review was performed using the terms “vascular,” “pathophysiology,” “traumatic,” “brain,” and “injury” on PubMed. Articles were screened by the title and/or abstract for relevance to the topic of DTICH and included accordingly. Included were case reports, case series, literature reviews, and original research relating to DTICH. Excluded were articles describing delayed traumatic intracerebral or intracranial hematoma or hemorrhage from an underlying vascular injury. For each article that met the inclusion and exclusion criteria in our literature review, we recorded the year of publication, authors, number of cases of DTICH, time to discovery of DTICH, incidence of DTICH, clinical presentation, means of diagnosis of DTICH, method of evaluating for vascular lesion, location of DTICH, and type of DTICH based on our proposed classification system. Several of the articles did not include all of these pieces of information, so we recorded all of the information available. Based on our senior author’s clinical experience and knowledge of the literature, patterns of clinical presentation, and the information obtained from the literature, we generated a classification system to characterize the different types of DTICH.Knowledge obtained from the literature was integrated with the retrospective review of the cases to further characterize each type of DTICH. For each type, we provide the de-identified case description, clinical definition, pathophysiology, and expected imaging findings.Classification system and illustrative casesThe classification system we propose describes three distinct entities in terms of clinical presentation and pathophysiology. The first type is subdivided due to subtle but important differences, primarily in the clinical presentation.Case 1A (DTICH type 1A)Case illustration: The patient is an approximately 50-to-60-year-old man who initially presented with a rapid neurologic decline after being struck by a motor vehicle. On the initial exam, he had a Glasgow Coma Scale (GCS) score of 3, bilaterally non-reactive pupils, and absent brainstem reflexes. On trauma evaluation, he was found to have a massive left-sided acute subdural hematoma with 2 cm shift Figure . He had Definition: Type 1A is the classic presentation of DTICH, as predominantly described in the literature. We define type 1A as an intracerebral hematoma, unseen on initial head CT imaging, that develops typically five days to one week following blunt or penetrating head trauma. The hematoma may develop in areas of prior visualized encephalomalacia. Cases with underlying vascular lesions seen on angiography are excluded. DTICH type 1A is often heralded by an acute change in GCS score, seizure, or new focal neurologic deficit.Pathophysiology: In the initial description, Bollinger et al.  postulatImaging: The initial, non-contrast CT imaging is negative for hematoma in the area that will develop hematoma. Hypodensity may be seen, especially in the frontal or temporal lobes and at the gray-white junction. This hypodensity reflects the ongoing development of the parenchymal softening and perivascular leak, which may be better reflected on magnetic resonance imaging (MRI) where an increased T2-weighted signal can be seen where DTICH will occur .Case 1B (DTICH type 1B)Case Illustration: The patient is a man of approximately 40 to 50 years of age who presented after a gunshot wound to the head. On the initial exam, he had a GCS score of 7 (E1M5V1), localizing on the right and withdrawing with non-antigravity strength on the left. The head CT scan showed a bullet trajectory through the right frontal lobe, right temporal lobe, and right cerebellum. The CTA of the head at the time of injury (and on a delayed basis) showed no vascular abnormality. The patient underwent right hemicraniectomy and external ventriculostomy drain (EVD) placement. Post-operatively, his GCS score was 9 (E4M4V1). On POD 25, the head CT scan showed small hematomas within the frontal and temporal lobes not seen on imaging three days prior . Hematomas may occur in the context of encephalomalacia.Pathophysiology: Similar to type 1A, the etiology of type 1B is likely hematoma formation in areas of encephalomalacia due to a vascular leak and microvascular rupture ,10. The Imaging: Repeat imaging in patients with head trauma will demonstrate hematomas in an area of the brain that was negative for hematomas on the initial non-contrast head CT. The hematoma of type 1B is generally associated with hypodensity representing encephalomalacia .Case 2 (DTICH type 2)Case Illustration: The patient is an approximately 40-to-50-year-old man who was struck by a motor vehicle. On presentation, his GCS score was 4 with a fixed and dilated right pupil. Mannitol was given en route to the operating room, and he was localizing as the best motor exam before surgery. He underwent a right hemicraniectomy and evacuation of a right-sided subdural hematoma. Post-operative head CT Figure  was doneDefinition: DTICH type 2 is typically a postoperative phenomenon, which manifests rapidly following the evacuation of a different hematoma. A new intracerebral hematoma forms in an area of the brain that was normal on the initial CT scan, typically contralateral to the initial hematoma. There is no underlying vascular lesion on angiography. The hematoma often forms within 24 to 48 hours of the initial decompressive craniectomy. However, DTICH type 2 may occur more rapidly and be seen on initial postoperative imaging or even intraoperative imaging.Pathophysiology: The formation of a hematoma likely reflects de-tamponading of potential bleeding diathesis by the removal of the initial hematoma or decompressing bone. With the removal of the initial mass lesion, lowered ICP permits new, delayed hemorrhage, primarily through venous oozing into the areas of cerebral contusion . The iniImaging: Initial CT imaging will demonstrate a hematoma , but no hemorrhage in the future area of DTICH type 2. However, following surgical evacuation, repeat imaging will demonstrate new hemorrhages, often contralateral to the initial hematoma. Furthermore, there may be associated contralateral calvarial fracture or pneumocephalus.Case 3 (DTICH type 3)Case illustration: The patient is an approximately 20-to-30-year-old man with an unclear mechanism of trauma. He had an initial GCS score of 14, and the head CT scan reads as negative. On hospital day 1, the patient underwent exploratory laparotomy and open reduction and internal fixation of a tibia fracture. He had wide variability in his blood pressure measurements in the operating room. He developed right hemiparesis in the post-anesthesia care unit, prompting head CT acquisition. Initial and postoperative head CTs are shown in Figure Definition: A hematoma forms after a traumatic head injury in areas of non-hemorrhagic contusion, usually frontal or temporal. A hematoma typically forms after intraoperative hypotension and rebound hypertension, hypoxia, hypercarbia, blood loss, or rises in intraabdominal or intrathoracic pressure ,8. OftenPathophysiology: Following a traumatic head injury, brain contusion may cause disturbed autoregulation, vasoreactivity, and vascular permeability . FurtherImaging: Initial CT imaging may show intraparenchymal contusion without hemorrhage. Repeat imaging following a further physiologic insult will show intraparenchymal hematomas in the area of the initial contusion.Literature reviewA literature review was performed using PubMed and the terms “delayed,” “traumatic,” "intracerebral" , and “hematoma” (or “hemorrhage”). This yielded a total of 846 peer-reviewed articles. A separate literature review was performed using PubMed and the terms “vascular,” “pathophysiology,” “traumatic,” “brain,” and “injury.” This yielded a total of 791 peer-reviewed articles. After the articles were screened by title and/or abstract, a total of 79 articles met the inclusion and exclusion criteria for DTICH and its underlying pathophysiologic mechanisms, respectively. The most common reasons for exclusion were articles involving cases without a new intracerebral hematoma (rather an extension or worsening of an existing hematoma) and cases involving a vascular lesion underlying the intracerebral hematoma.Articles that we added to our discussion were cited. Others were not cited due to redundancy. The case series describing DTICH that we cited are listed in Table DiscussionDTICH, originally described by Bollinger et al.  in 1891,Some of the past descriptions and definitions of DTICH do not account for other etiologic phenomena reported in the literature, including, for example, contralateral hematoma development after craniectomy  and hemaWe defined DTICH type 1A as hematomas that develop within one week following a TBI in areas initially free of hemorrhage on CT imaging. Type 1A may occur after trauma due to a vascular leak and microvascular rupture with secondary hemorrhage coalescence in areas of encephalomalacia ,10. TypeDTICH type 1B is the formation of hematoma more than one week after head trauma in areas of the brain without hematoma on the initial CT imaging. In contrast to type 1A, these hematomas may be more dependent on vasoreactivity and delayed changes in the blood flow related to seizures and autonomic dysregulation . In our DTICH type 2 is classified as de novo hematomas that form following decompressive craniectomy for an unrelated post-traumatic hematoma. These hematomas typically form contralateral to the initial hematoma and occur due to de-tamponading of venous oozing . DTICH tDTICH type 3 is a hematoma that develops in areas of non-hemorrhagic contusion after physiologic derangements, such as hypotension, rebound hypertension, hypoxia, or hypercarbia . Brain cThe main limitation of our review of the pathophysiology of DTICH is that not all studies obtained vascular imaging. While an absence of a vascular source of delayed hemorrhage was confirmed with CTA or formal angiography in some cases, we cannot rule out vascular injury as a confounder in other reports. Future investigation into the etiologies of DTICH will require angiography to identify any vascular injury. Similarly, pseudoaneurysms are potential sources of small intracerebral hematomas. Post-traumatic intracranial pseudoaneurysms are rare, accounting for less than 1% of intracerebral aneurysms , but theDTICH is a recently underrecognized phenomenon, which deserves renewed interest in the field of neurotrauma, as DTICH is a common sequela of head trauma with a high associated morbidity. We propose a pathophysiologic classification system, which accounts for the distinct, recognized etiologies of DTICH, each of which requires unique management strategies. Future studies are required to continue the characterization of the pathophysiology of the DTICH types  and further define effective strategies for the prevention and early recognition of a developing DTICH.


Schwannomas are benign, generally indolent tumors of neural crest origin and comprise the most common histologic tumor of peripheral nerves. Schwannomas are a rare histology for retroperitoneal tumors and very rare histologic findings for tumors of the adrenal gland with fewer than 50 cases in the reported literature. Here we present a case report of a non-hormonally functional but metabolically active adrenal tumor with indeterminate imaging characteristics with final pathology showing a 6.1 cm adrenal schwannoma as well as historical institutional pathology review revealing two additional cases. A fifty-year-old male patient underwent routine laboratory analysis during an annual primary care visit which was significant for a mild transaminitis. He subsequently underwent an abdominal ultrasound noting hepatic steatosis and an incidental 6 cm left upper quadrant mass. His past medical history is significant for hypertension controlled with combination lisinopril/hydrochlorothiazide, obesity with a BMI of 39, and current smoker. He had no prior surgical history. His family history was significant only for his mother with uterine cancer.He was subsequently evaluated with an MRI abdomen revealing a 6.8 cm well-circumscribed but heterogeneously enhancing left adrenal mass concerning for pheochromocytoma or adrenocortical carcinoma Fig. .Given the size and indeterminate imaging characteristics of the adrenal mass, he underwent an FDG-PET/CT which showed the mass to be intensely FDG-avid without other areas of non-physiologic uptake Fig. .His functional workup was significant for normal levels of cortisol, potassium, aldosterone, plasma renin activity, DHEAS, metanephrine and normetanephrine; thus a non-functional tumor. As there is concern for malignancy for a large heterogeneously enhancing and metabolically active tumor, adrenalectomy was recommended.He underwent hand-assisted laparoscopic left adrenalectomy that was converted to an open procedure due to the large size of the tumor, large spleen, obese body habitus, and bleeding from an accessory renal vein that was controlled. The tumor did not have invasive features and was removed without violation of the tumor or adrenal gland.Microscopic examination showed a well-circumscribed lesion consisting of bland spindle cells with hypercellular (Antoni A) and loosely organized areas (Antoni B) Fig. . VesselsA retrospective analysis of all adrenal pathology ranging from December 2001 to July 2020, including 706 cases of adrenalectomy, revealed two additional cases of adrenal schwannoma. The Institutional Review Board approved this study.The first case was a 77 year-old female with a left adrenal mass who underwent open left adrenalectomy in 2001 revealing a 13 cm left adrenal ancient schwannoma. Histologic examination showed sheets and fascicles of spindle cells in a background of fibrous tissue. Antoni A and Antoni B areas were seen. Occasional large atypical spindle cells were noted. The spindle cells were positive for S-100, Vimentin, SMA , and negative for EMA, desmin, and HMB-45. No mitotic figures were identified. No clinical or histologic images were available.The second case was an 81 year-old female with a well-circumscribed left adrenal mass who underwent laparoscopic left adrenalectomy in 2010 revealing a 7 cm left adrenal schwannoma with ancient change. Microscopy revealed a circumscribed lesion composed of fascicles of spindle cells Fig. . No clinSchwannomas are generally considered benign neoplasms of neural crest origin that are difficult to diagnose preoperatively, potentially necessitating surgical excision and or biopsy for proper diagnosis. These tumors most commonly arise from peripheral nerves of the head, neck and extremities There is a paucity of literature regarding FDG PET/CT for adrenal schwannoma with only three single case reports, all showing increased metabolic activity of the adrenal lesion