Granular cell tumors (GCTs) are uncommon neoplasms of unknown origin that can manifest in multiple locations throughout the body. Physicians should be aware of this type of tumor presenting in unusual locations such as the larynx, particularly in pediatric patients with stridor and dysphonia. We describe an 11-year-old female with a large laryngeal mass that obstructed the majority of the laryngeal lumen. A tracheotomy was performed to secure the patient's airway, followed by a direct suspension laryngoscopy, during which the mass was excised in its entirety. The biopsied mass was histopathologically and immunohistochemically examined to confirm the diagnosis of granular cell tumor. She benefited from treatment and experienced a favorable outcome. This case report emphasizes the critical nature of properly diagnosing this type of tumor in patients who present with vocal or respiratory symptoms. Granular cell tumors (GCTs) are uncommon, usually benign, and of controversial origin. Abrikossoff first described them as myogenous tumors in 1926. Recent evidence, however, indicates an immunohistochemical and electron microscopy association with Schwann cells, implying a neurogenic origin .Granular cell tumors are most frequently encountered in patients in their third to sixth decades of life and are uncommon in children. There appears to be a higher incidence among African-Americans and females, although laryngeal involvement is more prevalent in males -4. ExactAn 11-year-old Dominican female presented to our clinic with her mother, who described a one-year history of progressive dysphonia, vocal fatigue, and respiratory distress during sleep, which were associated with episodes of apnea. The patient's symptoms had been deteriorating for six months, prompting them to seek treatment.During the initial consultation, a flexible laryngoscopy revealed a large, heterogeneous mass obstructing the majority of the laryngeal lumen. The remainder of the examination was uneventful, and hospitalization was warranted.The same day, the patient was taken to the operating room, where a tracheostomy was performed to secure the patient’s airway, followed by a direct suspension laryngoscopy, which visualized a heterogeneous lesion with an indurated regular base and a distal exophytic, irregular and solid component, that emerged from the posterior commissure Figure . Due to Polypoid fragments of squamous mucosa with acanthosis, papillomatosis, and subepithelial proliferation of epithelioid cells with abundant granular eosinophilic cytoplasm and a small nucleus were described in the histopathological report Figure -2B. ThesThe patient experienced no complications during the immediate postoperative period. One week after the procedure, scar tissue was visualized in the left posterior larynx during a control laryngoscopy. The tracheostomy tube was removed. Subsequently, the patient's prior symptoms completely resolved.The patient was scheduled for a general review two years after surgery. Flexible laryngoscopy revealed that both vocal cords appeared and functioned normally. No evidence of recurrence was observed, and vocal and respiratory symptoms remained absent.Granular cell tumors of the larynx are uncommon in the pediatric population, where approximately fewer than 30 cases have been reported . The etiClinical manifestations depend on the size of the lesion, presenting with chronic dysphonia and, less frequently, stridor, hemoptysis, dysphagia, otalgia, and dyspnea. GCTs of the larynx tend to be firm, sessile, small masses (less than 2 cm) covered by intact mucosa that surrounds the posterior third of the true vocal cords, but they have also been found in the anterior commissure, arytenoids, false vocal cords, subglottis, and postcricoid region ,2,7.Histopathology and immunohistochemistry examinations of the excised mass are used to make the diagnosis. Because 50-65% of cases develop pseudoepitheliomatous squamous hyperplasia on top of the tumor, a biopsy of the mucosa alone may result in the misdiagnosis of a well-differentiated squamous cell carcinoma ,2.GCTs cells are large and polygonal, with a granular appearance caused by an accumulation of densely packed cytoplasmic lysosomes . These cThe vast majority of these tumors are benign. Malignancy affects only 0.6 percent of the population ,6.Recurrences have been described in up to 2% to 8% of cases. However, these may be new primary lesions as they can appear in several parts of the body in up to 10% of patients ,8.GCTs of the larynx are a rare cause of upper airway obstruction. Physicians should be aware of this, especially in pediatric patients, where symptoms such as stridor and dysphonia open up a broad range of possibilities. Complete excision with wide negative margins is required for treatment. If appropriate management is provided, recurrence is uncommon, and the prognosis is favorable.Our patient presented with a large mass, hence a higher complication risk. Nevertheless, she benefited from treatment and had an excellent outcome. Due to the limited number of case reports in the literature and the fact that this is the first case reported in our country, patients exhibiting these symptoms should be granted greater attention and considered for this diagnosis. This case report emphasizes the importance of accurately diagnosing this type of tumor, as they can pose a significant risk of upper airway compromise if not detected early.


Developing odontoma is a rare mixed odontogenic tumor that can arise with other odontogenic lesions. The association of COC with ameloblastic fibro‐odontoma is extremely rare. We report an extremely rare case of developing odontoma arising from a calcifying odontogenic cyst in a 17‐year‐old girl. The importance of accurate diagnosis that influence the treatment plan. In this case with accurate diagnosis, conservative treatment was substituted with marginal resection. It has a highly diverse histopathologic characteristic.The combination of COC and ameloblastic fibro‐odontoma has been reported before. However, this combination is extremely rare. This paper reports the first case of developing odontoma as a new entity arising from calcifying odontogenic cyst.2A 17‐year‐old female patient was referred to the Oral and Maxillofacial Pathology Department, Tehran University of Medical Sciences, Tehran, Iran, for consultation and diagnosis of a lesion on the right side of her mandible. The previous histopathologic diagnosis of the lesion was ameloblastoma. Before the incisional biopsy, the patient's chief complaint was a swelling in the right posterior mandible for 2 weeks. There was no facial asymmetry. In the intraoral examination, a slight swelling was observed in the right retromolar area. The swelling was non‐tender and was firm in consistency. Panoramic and CBCT radiographs showed a well‐defined radiolucent lesion that contained areas of radiopacity around the crown of an unerupted third molar. The margins of the lesion were sclerotic  occur concurrently with other odontogenic lesions and the most common concurrent lesion seen in this association is odontoma.Developing odontoma was formerly called AFO until 2017 when WHO changed its name.Developing odontoma is a rare odontogenic tumor. It shows proliferation of odontogenic epithelium and primitive ectomesenchymal tissue in association with tooth structure.Calcifying odontogenic cyst is a rare odontogenic lesion presented as a painless slow‐growing lesion with predilection for the anterior region of the jaws. It affects both maxilla and mandible equally.Calcifying odontogenic cyst may occur in association with an impacted tooth. The distinguishing histopathologic feature of COC is the presence of ghost cells, which may calcify, in an ameloblast‐like epithelium.The first case of calcifying odontogenic cyst with ameloblastic fibro‐odontoma was reported by Farman, et al in 1978.Matsuzaka, et al reported a case of ameloblastic fibro‐odontoma arising from a calcifying odontogenic cyst in 2001. The patient was a 23‐year‐old male with the chief complaint of painful swelling on the left mandibular molar region. It was a multilocular mixed lesion in the panoramic radiograph. Tooth impaction was also evident.Lee et al., in 2014 reported calcifying odontogenic cyst associated with ameloblastic fibro‐odontoma of the anterior mandible in a 4‐year‐old girl. The chief complaint of the patient was swelling swollen jaw. It had caused tooth displacement. It was a unilocular mixed lesion that caused root resorption and cortical perforation. The lesion was also around an impacted tooth.Apart from these two combinations of COC with ameloblastic fibro‐odontoma, there were also two other case reports of COC with two other lesions forming a combination of three odontogenic lesions.On the contrary, Phillips also reported a hybrid odontogenic tumor in a 7‐year‐old boy which consisted of ameloblastic fibro‐odontoma, COC, and adenomatoid odontogenic tumor. The lesion was discovered on panoramic examination by his dentist as a radiolucent lesion around unerupted succedaneous teeth extending from the deciduous left second molar to the left lateral incisor.The mechanism that causes the occurrence of two odontogenic lesions together is not well known. Nevertheless, various theories have been proposed to explain the phenomenon including a transformation of one lesion into another, a collision of two separate lesions, and an inductive effect of one lesion on another.4We report an extremely rare case of developing odontoma arising from calcifying odontogenic cyst. This report highlights the importance of accurate diagnosis that influences the treatment plan.The authors declare no conflict of interest.AA gathered the data from the literature and wrote the first draft of the manuscript. MMKh supervised during the whole process and prepared the images for the manuscript. MMKh and NM performed pathologic diagnosis. NM approved the final manuscript.Written informed consent was obtained from the patient and her parents.Published with written consent of the patient.


Stereotactic biopsies for lesions in the brainstem and deep brain are rare. This study aimed to summarize our 6-year experience in the accurate diagnosis of lesions in the brain stem and deep brain and to discuss the technical note and strategies. From December 2011 to January 2018, 72 cases of intracranial lesions in the brainstem or deep in the lobes undergoing stereotactic biopsy were retrospectively reviewed. An individualized puncture path was designed based on the lesion's location and the image characteristics. The most common biopsy targets were deep in the lobes , including frontal lobe , temporal lobe , parietal lobe , and occipital lobe . There were 12 cases (16.7%) of the brainstem, including 8 cases (11.1%) of midbrain, and 4 cases (5.6%) of pons or brachium pontis. Other targets included internal capsule , thalamus , and basal ganglion . As for complications, one patient developed acute intracerebral hemorrhage in the biopsy area at 2 h post-operation, and one patient had delayed intracerebral hemorrhage at 7 days post-operation. The remaining patients recovered well after surgery. There was no surgery-related death. The CT-MRI-guided stereotactic biopsy of lesions in the brainstem or deep in the brain has the advantages of high safety, accurate diagnosis, and low incidence of complications. It plays a crucial role in the diagnosis of atypical, microscopic, diffuse, multiple, and refractory lesions. The diagnosis of lesions in the brainstem and deep brain is still challenging. Neuroimaging, such as computed tomography (CT), magnetic resonance imaging (MRI) enhanced scan, and positron emission tomography (PET)-CT/MRI, has provided multiple levels of information regarding anatomy, metabolism, and neurological function, so that most common intracranial diseases can be effectively diagnosed according to neuroimaging and clinical diagnosis -4. HowBiopsy of intracranial lesions can be performed by craniotomy , neuronaFrom December 2011 to January 2018, 76 consecutive difficult cases of intracranial lesions in the brainstem or deep in the lobes undergoing stereotactic biopsy were retrospectively reviewed, and 72 of them that received CT-MRI-guided stereotactic biopsy were included. Patients meeting at least one of the following criteria were included: 1) unknown diagnosis and identified as difficult cases by multidisciplinary team discussion; 2) lesions located in the brainstem or deep brain (depth >3 cm); 3) biopsy results were critical for making treatment decisions, such as differential diagnosis of suspicious tumors, inflammation, degenerative lesions, postoperative recurrence of tumor, or necrosis; 4) patient intolerant to open craniotomy; and 5) lesions were small, multiple or diffuse, and difficult to be removed by craniotomy. Patients with surgical contraindications, such as vascular lesions, coagulopathy, local and/or systemic infections were excluded. This study was approved by the Institutional Review Board of the Third Affiliated Hospital of Sun Yat-Sen University and written informed consent was waived by the Board due to the retrospective nature of this study. Of the 72 cases in this study, partial data of 29 cases have been reported in a case series published in a Chinese journal , includiAll patients underwent preoperative contrast-enhanced T1- and T2-weighted MRI scans  and contrast-enhanced CT scans . Field of view (FOV)=280 mm. Scanning direction: from bottom to top; slice increment=1 mm, slice thickness=0.5 mm. The Integra CRW stereotactic system was used to perform the stereotactic biopsy.MRI scans routinely use data from 1 to 7 days before surgery. For patients with complex and variable disease conditions, especially those with small lesions and brainstem lesions in the brain, it is strictly required to collect MRI data from 1-3 days before biopsy to ensure the MR images reflect the latest dynamic changes of the brain lesions as accurately as possible to prevent fluctuations and progression in the brain after treatment and other imaging errors.According to the patient's ability to cooperate, the position of the headgear is chosen. For patients who cannot cooperate and have a disturbance of consciousness, it is necessary to place the stereotactic head frame in the semi-recumbent position or the lying position. Specifically, it is necessary to pay attention to maintaining a good position and proper fixation of the frame.The patient's degree of cooperation determines the methods of stereotactic head frame placement. The position of the frame affects the accuracy of the positioning, especially for small lesions in the brainstem or deep brain. The patient's degree of cooperation was graded as one of three levels as follows: 1) the patient was able to cooperate actively, was awake, with good general condition, and was able to sit autonomously and wear the stereotactic head frame; 2) the patient could not fully cooperate due to mild confusion or a bad body condition and required two medical staff to support their sitting position to wear the stereotactic head frame; and 3) the patient was completely unable to cooperate due to a moderate-to-severe disturbance of consciousness or poor general condition and could not maintain the sitting position, with three medical staff required to raise the patient's head (45°-60°) and maintain a semi-recumbent position for head frame placement.Image Fusion and Omni Sight Excel series  software was used for CT-MRI fusion positioning. The incision and target were set and the coordinate values were recorded. According to the target position and image characteristics, the individualized puncture path was designed based on the following routine biopsy principles: 1) Brainstem target lesions: for lesions in the midbrain and upper pons the conventional ipsilateral frontal lobe approach was adopted. The puncture path follows the principle of parallel brainstem long axis, the incision is usually made 1-2 cm behind the coronal suture, 3-4 cm beside the midline. For the lower and lateral lesions of pons, we adopted contralateral, transfrontal, extraventricular approach, a biopsy path through the internal capsule, thalamus, midbrain, pons, and other structures, avoiding cerebellar canopy occlusion, entering the target lesions in the lower part of the pons and the brachium pontis; 2) For the target lesion in the internal capsule, thalamus, basal ganglion, and frontal lobe, the ipsilateral frontal lobe approach was adopted. The entrance point was located in front of the coronal suture and 2-3 cm from the midline; 3) For the deep target lesions in the parietal lobe, occipital lobe, and temporal lobe, the ipsilateral parietal nodule approach was routinely adopted. The entrance point was located 2-3 cm from the midline.The patient usually adopted a supine position, and the CRW Stereotactic Instrument bow was installed. After skin incision, drilling the skull, and cutting the dura mater, the biopsy needle was used to puncture according to the planned system coordinates. The biopsy tissue block was taken at the 0, 4, and 8 o'clock direction. Using a Sedan side-cutting biopsy needle , a columnar tissue block (1.5×1.5×10 mm) was obtained by a single spin-cutting, and a 2-mL syringe was used for gentle vacuum suction.The sample collector must be familiar with the resistance of the brain tissue, texture and toughness of the lesion when the biopsy needle is inserted to adjust the force needed to push the biopsy needle, avoiding excessive force and rigid puncture. At the same time, when reaching the target lesion, attention should be paid to control negative suction pressure and avoid excessive suction, resulting in bleeding risk.The maximum depth of the target was 160±5 mm. The biopsy should be taken as far as possible through the center of the lesion and the periphery. If the imaging features of the lesion were variable, 2-3 targets can be selected to increase the positive sampling rate. In this study, 56 cases had a biopsy taken from a single target and 16 cases had biopsies taken from multiple targets.The number of samples was determined based on the bleeding condition after the puncture needle was introduced. After sampling was completed, the biopsy needle was slowly withdrawn to terminate the operation. In case of bleeding, 500∼1000 U of thrombin  was injected into the target lesion to promote coagulation.The blood pressure, heart rate, respiration, neurological changes, state of consciousness should be monitored during the whole sampling process. The blood pressure should be maintained at the baseline low level during the puncture process, and fluctuations in vital signs should be timely handled to avoid adverse consequences.In biopsies in high-risk regions, such as brainstem and genu of the internal capsule, patients underwent head CT 2-4 h after surgery to monitor complications, such as bleeding. In the other regions, the head CT scan was routinely performed one day after surgery.Among the 72 cases, 46 patients (63.9%) were able to cooperate actively. Ten cases (13.9%) could not fully cooperate due to mild confusion or bad body condition. Sixteen patients (22.2%) were completely unable to cooperate due to moderate-to-severe disturbance of consciousness or poor general condition.As for anesthesia methods, 42 cases (60%) received local anesthesia and intravenous anesthesia, while 30 cases (40%) underwent general anesthesia.Most patients had stable vital signs intraoperatively and operations were successful. One patient underwent a stereotactic brainstem biopsy via a contralateral approach. When the biopsy needle reached 0.5 cm above the target (brachium pontis), the patient's heart rate decreased rapidly. After the operation was suspended, the heart rate returned to normal until the biopsy was completed.As for post-biopsy complications, there were 3 cases of asymptomatic minor hemorrhage (4.2%), 2 cases of symptomatic minor hemorrhage (2.8%) , 2 casesThe distribution of biopsy targets is shown in Pathological results of the 72 cases of intracerebral lesions from stereotactic biopsy are reported in Four selected cases illustrating stereotactic biopsy strategies for lesions in the brainstem or deep in the lobes are described in the following subsections.A 10-year-old male patient had right hand shaking and was unable to write, accompanied by feet sliding on the right side, changes in memory/personality, and verbal reduction for 2 years, as well as diabetes insipidus, irregular fever, and asymmetric enlargement of the penis and testicles for one year.The patient had a long disease course and underwent misdiagnosis and mistreatment for 2 years. He underwent a variety of blood tests, imaging examinations, and only endocrine abnormalities were identified . MRI  and MR sThe biopsy path passed through the genu of the internal capsule. Two hours after the operation, CT showed a small area of pneumocephalus . AlthougA 62-year-old male patient complained of memory loss for one month. MRI scan found lesions in the bilateral internal capsule, basal ganglion, optic chiasm, pituitary stalk, and pons . ImagingThe right genu of internal capsule enhanced lesions was selected as biopsy targets . There wA 39-year-old female patient complained of repeated headaches for 2 years, aggravated unclear vision, binaural hearing hypersensitivity, left facial numbness, and unstable walking. Physical examination showed the left eye was involuntarily closed, limited abduction of the right eye, inability of abduction and limited adduction of the left eye, the left side showed hypoalgesia and hyperacusis, muscle strength of the left lower extremity was grade 5, the quadriplegia reflex was (+++), and the bilateral pyramidal sign was (+).PET-CT showed no signs of hypermetabolic malignancy, and the pons-medullary junction was slightly thickened. No abnormal increase in metabolism, and the imaging diagnosis considered inflammatory lesions.The patient was diagnosed with brainstem encephalitis in other hospitals, and the symptoms were relieved after hormone treatment but then aggravated again.Brain MRI T1 enhancement showed lesions in the midbrain, pons, and medullary diffuse low-signal lesions, without significant enhancement . A transA 24-year-old male patient had coughing when drinking water and difficulty swallowing for 10 months, aggravated for 1 month. MRI scan showed pons swelling, slightly high pons-medulla signal, indicating non-tumor lesions . Hormone and gamma treatment relieved the symptoms, but aggravation returned. Physical examination showed dysarthria, hoarseness, shallowing of the left nasolabial fold, right deviation of the tongue, hyperreflexia of the extremities, and bilateral Babinski sign (+). MRI plain scan + enhancement + diffusion-weighted imaging+ magnetic resonance spectroscopy + magnetic resonance angiography + magnetic resonance venography only showed a slightly higher signal in the T2 flair sequence. PET-CT showed no highly metabolic lesions in the whole body but limited high metabolism in the brainstem.A transfrontal, extraventricular approach to atypical lesions biopsy in brachium pontis was performed . The patAccumulating evidence has suggested that stereotactic biopsy of the brainstem and deep brain lesions is accurate, safe, and has a low incidence of complications ,17-19. In this study, we focused mainly on difficult lesions in the brainstem and deep brain, and important high-risk areas, such as the brainstem, internal capsule, thalamus, and basal ganglia, accounted for 40.4% of all cases. This study included 2 cases of the genu of internal capsule highlighted lesions and 1 case of pons-medulla junction small lesion biopsy. After internal capsule and brainstem biopsy, transient neurological dysfunction may occur but without permanent neurological dysfunction. These results showed that lesions in high-risk areas can also be safely biopsied, which is worthy of further investigation.The approach to brain lobe lesions can be selected according to the location of the target. For lesions in the frontal lobe, sellar region, and basal ganglia, the access hole can be drilled at 3 cm away from the ipsilateral coronal suture and the sagittal suture. For lesions in the temporal lobe, parietal lobe, occipital lobe, and pineal region, the access hole can be drilled posterior to the parietal tuber. In the brain lobes and basal ganglia biopsies, special attention should be paid to vascular lesions, high signal intensity lesions, and fast-growing malignant lesions. It has been shown that deep-seated primary central nervous system lymphomas have a high risk of biopsy-related morbidity and mortality, mainly due to a high risk of post-biopsy hemorrhage . SupportAs a dense area of the nerve conduction bundle in the brain, the function of the internal capsule region is very important. There is no report of biopsy of internal capsule targets or biopsy via the internal capsule approach, but this study suggested that those are feasible and safe, providing a reference for future research. Nevertheless, when designing a biopsy puncture path strategy, the inner capsule area should be avoided as much as possible to prevent the potential risk of neurological dysfunction.+. These results suggested that the internal capsule was not a restricted area for biopsy.In this study, there were 2 cases of successful biopsy in the internal capsule area (2.8%). The internal capsule lesions can be biopsied after careful evaluation and design of the biopsy path. Case 2 of this study was a high signal enhanced lesion biopsy of the genu of the internal capsule, which was diagnosed as diffuse large B-cell lymphoma by biopsy and no new neurological dysfunction was found postoperatively. The other case was an enhanced lesion biopsy of the posterior limb of the internal capsule. The intraoperative biopsy was performed 8 times. The postoperative CT scan showed that the amount of bleeding was about 0.6 mL. The biopsy was strictly confined to the lesioned tissue, without causing significant bleeding and no new dysfunction after surgery, suggesting that the biopsy procedure only damages the lesion tissue and has little effect on normal tissue. After rehabilitation, the patient's left upper limbs were less flexible, and the muscle strength reached 4Amundson et al.  and PereCase 1 was a tiny lesion biopsy of the left thalamus and midbrain junction. The three-dimensional surgical plan showed that the genu of the internal capsule could be avoided in the puncture route. Two hours after the biopsy, the head CT showed cranial pneumatosis  in the genu of the internal capsule, microbleeding in the basal ganglia, and no new neurological dysfunction in the nervous system examination. The patient developed hemiplegia of the contralateral limbs 3 days after surgery, and the muscle strength was grade 2. After conservative treatment, the limb muscle strength returned to the preoperative state at 7 days after surgery and the patient was discharged. Therefore, this result suggested that the genu of the internal capsule can be used as a puncture route under a rigorous and thorough three-dimensional surgical plan design. Patients may develop transient neurological dysfunction, but generally do not have permanent neurological dysfunction. For the internal capsule area as a puncture route, a rigorous risk-benefit assessment should be performed before surgery. If sufficient biopsy specimens have been obtained for diagnosis, the number of punctures should be reduced as much as possible to decrease the risk of local injury and small bleeding, reducing the incidence of complications, such as neurological dysfunction.It has been suggested that in the biopsy for lesions in the midbrain and upper pons, an ipsilateral frontal approach is recommended, and the drilling hole can be at 2 cm behind the coronal suture and 3 to 4 cm apart from the midline, keeping the puncture path parallel to the long axis of the brainstem (conducting bundle) ,17,25. APrevious large studies have shown that brainstem biopsy has high safety, and the incidence of permanent disability and mortality ranges from 0.7 to 1.5% -27. TobiIn this study, a contralateral, transfrontal, extraventricular approach was used as an alternative for the cerebellar approach to reduce the risk of bleeding when performing a blind puncture into the skull. At present, the mainstream opinion is that the ipsilateral approach to brain lesions should be routinely used for biopsy. The contralateral, transverse approach to the lesion is regarded as an unreasonable and unsafe surgical path, especially for low brainstem lesions. In this long surgical path, the needle needs to puncture a series of the most important functional regions, including the inner capsule, the midbrain, and the pons, which is considered a surgical restriction in most functional neurosurgery, thus counteracting the conventional surgical concept of craniocerebral biopsy. Thus far, only 7 cases of the contralateral extraventricular approach to stereotactic brainstem biopsy have been reported in the USA  and UK .In this study, 2 patients received contralateral, extraventricular approach to low brainstem biopsy, one case of local anesthesia and one case of general anesthesia, and no new postoperative neurological dysfunction was found. Case 3 was a small enhanced lesion in the right pons-medulla junction. It is difficult to obtain sufficient lesioned tissue for biopsy through the ipsilateral cerebellar approach. The three-dimensional surgical planning system showed that the puncture path needed to penetrate the lateral ventricle wall, unable to avoid the cisterna ambiens, leading to a high risk of bleeding. We thus designed a biopsy path via the left frontal lobe, contralateral, extraventricular approach to the pons-medulla junction, and biopsy was successfully carried out. In Case 4, the target lesion was located in the left brachium pontis, and a biopsy path via the right frontal lobe, the extraventricular approach was adopted, passing through the lateral ventricle, internal capsule, thalamus, the midbrain, and the pons, to the target lesion in the pons-medulla junction, achieving accurate and safe biopsy. Compared to previous studies ,24, the One of the limitations of this study was the relatively small sample size. The findings of this study should be validated in a large study.In summary, the CT-MRI-guided stereotactic biopsy of lesions in the brainstem or deep brain has the advantages of high safety, accurate diagnosis, and low incidence of complications. It plays a crucial role in the diagnosis of atypical, microscopic, diffuse, multiple, and refractory lesions. In the extraventricular approach to low-brainstem biopsy, internal capsule biopsy, and genu of internal capsule biopsy, a well-designed individualized surgical strategy can reduce neurological dysfunction and achieve a safe biopsy.


Nasal schwannomas account for about 4% of head and neck schwannomas. We report a rare case of lateral nasal wall schwannoma presenting as a nasal mass in a 70‐year‐old man. Nasal cavity schwannoma is rare, and a definite diagnosis is made only with the histopathological report. In fact, they are an abnormal and usually benign proliferation of Schwann cells (cells involved in the formation of the myelin sheath in the PNS). Hence, any nerve in the PNS that contains a myelin sheath can be the origin of schwannoma, so this type of neoplasm can occur anywhere in the body.2A 70‐year‐old man with unilateral progressive nasal obstruction that started about 2 years ago referred to the otolaryngology department of Taleghani Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran. The patient was employed in the textile industry. There was no positive history of nasal trauma, smell disorders, posterior nasal discharge, epistaxis, chronic cough, rhinorrhea, sneezing, headache, diplopia, and facial pain. His past history included a known subject of type 2 diabetes mellitus. Furthermore, his family history was not remarkable. On nasal endoscopy, there was a space‐occupying mass in the right nasal vestibule that prevented further observation. The remaining ear, larynx, pharynx, head, and neck examinations were normal. Contrast‐enhanced computed tomography showed a soft tissue mass 40–45 HU) with mild heterogeneous enhancement in the right nasal cavity with no destructive effect on adjacent structures Figure . Endonas0–45 HU w3Schwannomas are benign slow‐growing masses with a less destructive pattern.This disorder usually occurs in the fifth and sixth decades of life, and issues related to sex and race do not play a significant role in its occurrence.4Nasal cavity schwannoma is rare, and definite diagnosis is made only with histopathological reports. It seems that nasal cavity schwannomas originate from trigeminal nerve branches, but the issue is open to discussion. Furthermore, endoscopic surgery is an efficient method to remove most of the benign mass of nasal cavity such as schwannoma.The authors made no disclosures.MM and MA contributed to the manuscript preparation. BB, MA, and MM contributed to the patient management. FM is pathologist who contributed to the pathological report. All authors read and approved the final manuscript.Because this report involves no experiment, ethics approval is waived.Written informed consent was obtained from the patient for 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.I felt so astonishing when I saw this huge mass, which was in my nose! I hope that my nose size return to normal.


Slipped capital femoral epiphysis (SCFE) is a hip disorder frequently occurring in adolescence. In adults it is rare and so far very few cases have been documented.This report presents a 25-year-old patient diagnosed with an anterior fossa giant chondroma, hypogonadotropic hypogonadism, and SCFE. The patient underwent surgical and hormonal therapy. His symptoms revealed, and he became a father.Every patient diagnosed with SCFE in adulthood should undergo endocrinological assessment based on physical examination and laboratory tests. Slipped capital femoral epiphysis (SCFE) is a frequent hip disorder in adolescence, which should be quickly diagnosed and treated. The sub-acute and long-term consequences of SCFE are the loss of joint function and osteoarthritis due to femoroacetabular impingement .SCFE affects about 10.8 in 100,000 people . DespiteSo far apparently healthy 25-year-old white male presented to an emergency room with a chief complaint of tonic seizures. The diagnostic imaging (NMR of the head and angio-CT) showed that the man suffered from a large anterior cranial fossa tumour Fig. .Fig. 1AThe tumor was removed by the fronto-parietal craniotomy. Histopathological examination revealed it was a chondroma. The postoperative period was uneventful.Three months after the procedure, the patient presented to the emergency room with severe pain in the left hip joint. The ailment characterized as recurrent started about a year ago. A sudden increase in pain intensity occurred six months later and resulted in patient ambulation on crutches to prevent weight bearing on the affected limb. Physical examination revealed the Drehmann’s sign was positive, the left limb in the extension was rotated 45 degrees, all movements at the hip joint were excruciating. There were no vascular and nervous disturbances. The pelvis A-P and Lauenstein’s axial radiography and Computed Tomography of the pelvis were performed Figs. , 3 and 4Endocrinological consultation was suggested due to clinical features of hypogonadism and revealed that the patient was 194 cm tall and his weight was 83 kg (BMI 22.05 kg/m2). His arm span was 197 cm. He presented features of delayed sexual maturation. Examination of external genitalia showed micropenis and testicular volume of 3.3 ml and 3.6 ml in the right and left testes, respectively (Tanner’s stage of 2). To our knowledge, these signs of delayed puberty were firstly observed during an endocrine consultation on SCFE. Laboratory tests revealed hypogonadotropic hypogonadism with no other features of pituitary insufficiency  and chondrolysis occur more often in the group of patients operated on than in patients without surgical intervention or only with neck and head osteosynthesis in situ (without reduction of deformation) –13. The It is worth emphasizing that complete epiphyseal fusion occurs between 16 and 19 years old in European-American males [Another fact that makes the described case unique is that SCFE mainly occurs in obese patients , 4, whilInteresting is also the fact of late diagnosis  of delayed puberty. There is no doubt that this should have been diagnosed much earlier than at 25. We might speculate that the undiagnosed delayed puberty reflects the weakness of the health care system and cultural and social factors influencing an individual reaction to being different.As was mentioned above, SCFE in adults is extremely rare and is always associated with endocrinopathy. To date, there are very few cases reported of SCFE in adults with panhypopituitarism, hypogonadotrophic hypogonadism, hypothyroidism, acromegaly –23. Ther


Teaching Point: Magnetic resonance imaging allows adequate evaluation of the location, size and subperitoneal lesion extension of deep pelvic endometriosis, providing key information for both the diagnosis and treatment planning. A 22-year-old female has had dysmenorrhea and irregular menstruation since her menarche. Transvaginal ultrasound showed a hypoechoic irregular mass at the posterior vaginal fornix.Figure 1, arrows). T2-weighted images demonstrated small areas of higher SI , delineated by areas of low SI . After intravenous administration of Gadolinium, fat-suppressed T1-weighted images demonstrated a significant enhancement .Pelvic magnetic resonance imaging (MRI) confirmed findings consistent with deep pelvic endometriosis (DPE). There was an irregularly delineated mass in the rectouterine pouch extending in the rectovaginal septum and the anterior rectal wall. Thickening of the mesorectal fascia and partial obliteration of the perirectal fat were noted. On T1-weighted images, the mass was a low-to-intermediate in signal intensity (SI), with punctate areas of hyperintensity  and visceral endometriosis involving the bladder and rectal wall.Clinical symptoms, if present, may include severe pelvic pain, dysmenorrhea, dyspareunia, dyschezia, urinary symptoms, and infertility .DPE can be diagnosed on physical examination and transvaginal ultrasound. However, detailed evaluation of disease extension is difficult. Rectal ultrasound allows evaluation of rectal wall infiltration but shows poor penetration. DPE may be overlooked during exploratory laparoscopy due to adhesions or subperitoneal localisation. MRI allows accurate diagnosis and evaluation of the location, size, and extension into surrounding tissues of DPE .On T1-weighted MRI, small areas of high SI may be present as in our case, representing foci of haemorrhage. On T2-weighted images, low SI may correspond to fibrotic tissue. As in our case, DPE may show heterogeneously higher T2-weighted SI due to a large proportion of glandular tissue which subsequently enhance after contrast administration, contrary to necrosis and haemorrhage [When conservative therapy fails, radical surgery is the standard therapeutic approach. An accurate evaluation of the extension of the lesion is crucial to obtain complete excision and to prevent postoperative recurrence .


Brain arteriovenous malformations (BAVMs) are high-flow vascular lesions that have a propensity to rupture resulting in high rates of morbidity and mortality. Microsurgical resection of BAVMs is the standard of care for high-risk, resectable lesions. Multiple imaging modalities aid in the surgical planning and resection of high-grade BAVMs, but all have hidden variables that would prove useful if available. We present a 20-year-old male with a ruptured BAVM with concern for the involvement of the corticospinal tract (CST) and basal ganglia. We describe the melding of computed tomography angiography (CTA) and diffusion tensor imaging (DTI) in addition to preoperative embolization to aid in the planning and resection of a lesion close to eloquent structures. Post-operative CTA and DTI showed a total resection of the lesion with retained CST white matter tracts, and the patient retained the functional ability of the contralateral limbs. The combination of CTA, brain DTI, and preoperative embolization provides a framework to improve the safety of resection of BAVMs that occur near eloquent brain networks. Brain arteriovenous malformations (BAVMs) are classically defined as congenital or developmental lesions consisting of arteries that drain directly into veins without an intervening capillary network . They arBAVMs are identified with the assistance of digital subtraction angiography (DSA) and computed tomography angiography (CTA). DSA has been the “gold standard” for intracranial vascular imaging due to its high temporal and spatial resolution. However, it provides little information in regard to surrounding structures . CTA proEach of the aforementioned imaging modalities provides useful information in the planning and surgical removal of BAVMs arising in eloquent areas. However, taken individually, each has hidden parameters that would be helpful in the planning for microsurgical resection of BAVMs in eloquent areas. To mitigate these limitations, studies have used DTI combined with T1-weighted MRI with contrast to safely resect rolandic BAVMs ,15. NewtA 20-year-old male presented to an outside hospital after being found unconscious. The emergency department workup and CT of the head revealed a right-sided intraparenchymal hemorrhage with intraventricular extension and evolving hydrocephalus. CTA of the brain revealed a right basal ganglia arteriovenous malformation abutting the internal capsule and measuring 3.9 x 2.9 x 1.7 cm Figures , 1B. He The patient was scheduled for an elective AVM resection two months after the initial presentation and discussion in a multidisciplinary neurovascular conference. Initially, after admission to the hospital for elective surgery, an MRI with diffusion tensor imaging (DTI) was performed. Next, endovascular embolization was attempted to help facilitate resection and establish the medial border of the BAVM. Only two out of the three lateral lenticulostriate artery feeders were successfully embolized Figures , 2B. An A pre- and post-operative three-dimensional reconstruction is provided, which displays the CST wrapping medially and laterally around the posterior aspect of the resection cavity without apparent damage to the CST Figure . A post-The Spetzler-Martin AVM grading scale has provided a useful metric for surgical morbidity and mortality based on imaging characteristics since it was initially described in 1986 . AVMs wiThe grading of an AVM should not be considered static over time. The plasticity of eloquent networks may serve to rearrange WMTs such that a previously unresectable AVM may become resectable. In addition, hemorrhagic events may mobilize or destroy eloquent networks, at which point microsurgical resection can be performed without causing further morbidity to the patient. In this article, a patient with a grade IV AVM in an eloquent location presented with a hemorrhagic event. The hemorrhage pushed the cortical spinal tracts and basal ganglia away from the nidus, providing a safe pathway for microsurgical resection. The use of static imaging  is critical for surgical planning. However, its reliability decreases after dura opening and intradural dissection. This is particularly true for deep lesions. To navigate the BAVM in real time and identify the medial border, preoperative embolization of the lateral lenticulostriate artery feeders was performed. The usefulness of preoperative embolization was recently studied by Catapano et al. after conducting a propensity-adjusted analysis from a double institution cohort of SM grade III AVMs . They foThe combination of fused CTA and brain DTI imaging with preoperative embolization of arterial feeders provides a framework to improve the safety of resection of high-grade BAVMs that occur near eloquent brain networks. Preoperative embolization delineated the deep border of the BAVM in real time while the fused CTA and DTI image helped navigate around the corticospinal tract. The ability of our patient to move the corresponding side of his body and subsequently regain additional function provides evidence that his AVM was microsurgically resected with sparing of the surrounding eloquent networks.


Craniopharyngioma (CP) is a slow-growing, benign tumor of the central nervous system located within the sellar and suprasellar regions. The tumor may extend from the suprasellar region to other areas. CPs are generally believed to originate from squamous remnants of an incompletely involuted craniopharyngeal duct that also develops from Rathke’s pouch. Primary parasellar craniopharyngioma is a relatively rare tumor, and nasal endoscopy, computed tomography, and enhanced magnetic resonance imaging can be applied to better evaluate the invasiveness and characteristics of these tumors.We report a case of right parasellar craniopharyngioma in a 49-year-old female patient with a 10-day history of dizziness and blurred vision. Preoperative imaging examination revealed right parasellar space-occupying lesions, and the patient underwent transnasal neuroendoscopic resection of the right parasellar space-occupying lesion. The postoperative pathological result confirmed craniopharyngioma.Primary ectopic parasellar craniopharyngioma is a relatively rare tumor, and preoperative imaging examination can assist in the evaluation of tumor characteristics. However, the final diagnosis continues to depend on the histopathological results. Craniopharyngioma (CP) is relatively rare, accounting for only 3 % of all intracranial tumors ; this coThe patient was a 49-year-old female who complained of dizziness and blurred vision for more than 10 days. Neurological examination showed no significant abnormal signs, and the patient reported no history of irradiation, chemical exposure, or trauma. Brain magnetic resonance imaging (MRI) was performed in the outpatient department: Mixed-signal shadows were observed in the sphenoid sinus and right parasellar region, along with an uneven distribution of high T1 weighted image (WI) signal; T2 weighted image (WI) shows that the upper layer is of high intensity and the lower layer is of equal intensity, and there is a clear dividing line between them. The tumor showed no enhancement on contrast-enhanced MRI. The length of the lesion was approximately 33 mm  demonstrated a localized defect of the sphenoid and right occipital slope in the sphenoid sinus, with a low-density shadow in the corresponding area and local envelopment of the right internal carotid artery. Based on the preoperative imaging examination, the patient was diagnosed with a space-occupying lesion in the right parasellar region. The patient underwent transnasal neuroendoscopic resection of the right parasellar space-occupying lesion. We used a 0.01 % adrenaline saline tampon to push aside the turbinate and nasal septum on both sides to provide enough operating space for the endoscope. We then used a rigid 30° endoscope with an outside diameter of 4 mm  to remove the tumor. Cystic tumor lesions were identified during the operation Fig. a, along The histopathological diagnosis of the tumor was CP, the tumor was characterized by partial keratosis Fig. a, and thCraniopharyngioma is a benign tumor that occurs in the intrasellar or suprasellar region . EctopicCPs arise from the squamous epithelial remnants of Rathke’s pouch . This powas characterized by partial keratosis, and the cystic contents were accompanied by significant cystic changes.CT and MRI are the first-choice diagnostic tools for the diagnosis of craniopharyngioma . In partPrimary ectopic parasellar craniopharyngioma is extremely rare. One possible explanation is the migration of the remaining craniopharyngeal squamous cells. The diagnosis of this tumor is relatively difficult, leading to frequent misdiagnosis. The diagnostic process should include nasal endoscopy and imaging to better assess the tumor characteristics, and the definitive diagnosis should rely on the results of a histopathological examination. We also recommend that patients with CP undergo regular MRI follow-up after surgical resection to ensure that no relapse occurs.


Rhinoliths are rare calcified entities in the nasal fossa, frequently originating around a nidus near the midway point in the inferior meatus, where the passage is the narrowest. They can be clinically asymptomatic and undetected for years. In this study, we present a rare case of large rhinolith mimicking atypical odontogenic pain in a 40-year-old Caucasian female in the left nasal cavity. The lesion was detected in the CBCT and removed uneventfully. Rhinolith is an uncommon calcification in the nasal fossa. Calcareous concretions that occur in the nose arise from the slow accumulation of inflammatory mineral salts such as calcium phosphate, calcium carbonate, and magnesium, around a nidus . The nidA 40-year-old female was referred to a private oral and maxillofacial radiology clinic with recent two months history of facial and periorbital pain, headache, upper jaw pain, nasal discharge, epistaxis, and fetid odor sensation. The patient had no history of trauma or previous interventions. A medium FOV CBCT scan was acquired from maxilla and paranasal sinuses. The left inferior meatus was completely filled with a well-defined, irregular calcified mass with peripheral mucosal thickening . There wA rhinolith is a calcification around exogenous or endogenous nidus in the nasal cavities. Approximately, 15 years are needed for rhinoliths to form; therefore, they are initially asymptomatic . FurtherPrevious studies show that rhinolith is usually found in female in their third decade of life. However, it is also detected in younger ages , 12. ThiIn this case, the calcified entity was detected in the inferior meatus, where the passage is the narrowest in the nasal cavity. Rare locations for rhinolith have also been detected. Ersozlu et al. reported calcification and presence of rhinolith in a concha bullosa . In thisClinical examination of the patient may include nasal endoscopy, anterior rhinoscopy, and probing of the mass . The cliIn the absence of obvious clinical dental pathology, sinonasal cavity should be completely assessed for pathology, including the presence of rhinolith .


The precise etiology of anterior inferior cerebellar artery (AICA) infarction is difficult to identify because of the high anatomic variability of vertebrobasilar arteries and the limitations of conventional vascular examinations. Basi-parallel anatomic scanning magnetic resonance imaging (BPAS-MRI) can reveal the outer contour of the intracranial vertebrobasilar arteries, which may be helpful to distinguish the arteriosclerosis from congenital dysplasia and dissection.In this study, we reported 3 cases of AICA infarction and discussed the diagnostic value of BPAS-MRI in the evaluation of vascular etiology.The BPAS-MRI could be considered as an important supplementary in the diagnosis of vascular etiology of infarction in AICA territory. The anterior inferior cerebellar artery (AICA) infarction may cause vertigo, hearing loss, facial weakness, Horner’s syndrome, ataxia or other neurological symptoms. As the treatments might vary due to different etiologies, the accurate identification of etiology is of great significance to the management. Conventional vascular imaging methods, including the time-of-flight magnetic resonance angiography (TOF-MRA) and computed tomographic angiography (CTA), have limitations in the diagnosis of AICA's own lesions. First, AICA is not typically visualized on CTA due to the limited detection of the smaller branches . Second,A 69-year-old woman with history of diabetes mellitus and hypertension presented with sudden vertigo, left hearing loss, and left ataxia. MRI showed hyperintensity in left brachium pontis and left superior lateral cerebellum on diffusion-weighted image (DWI) Fig. a, indicaA 64-year-old male patient with hypertension presented with vertigo, left peripheral facial palsy and left ataxia. DWI revealed left AICA territorial infarction  Fig. a. On MRAA 60-year-old male patient presented with vertigo and right ataxia. The DWI showed acute infarction involving right inferolateral pons, brachium pontis and superior cerebellum Fig. a. The riThe etiology of AICA infarction is difficult to diagnose due to the high anatomic variability in vertebrobasilar system, even both of the patients in Case 1 and Case 2 had atherosclerotic risk factors in our study. It’s reported that only 35% of patients had normal vestebrobasilar arteries, and approximately 29% of the posterior circulation anatomic variability is related to AICA [Compared with conventional methods, such as TOF-MRA, CTA or DSA, BPAS-MRI could provide an accurately visualization of the outer contour of vascular wall regardless the influence of blood flow or thrombus, even when the artery is occluded. In Case 2, the absent of left AICA on TOF-MRA and the presence of AICA on BPAS-MRI imaging led to a straightforward diagnosis of AICA occlusion due to atherosclerosis or thrombus. This suggested the supplementary role of BPAS-MRI to TOF-MRA in the diagnosis of AICA occlusion. In Case 3, though the topography of infarction was consistent with AICA territory, the absence of AICA on MRA and BPAS-MRI indicated the congenital aplasia of AICA. If we simply attributed the cause to AICA occlusion, we might miss the real etiology and take inappropriate treatment.In the future, large-scale case studies with multiple imaging modalities are needed to validate the supplementary role of BPAS-MRI in the diagnosis of etiology of AICA.The BPAS-MRI could be considered as an important supplementary in the diagnosis of vascular etiology of infarction in AICA territory.


Spontaneous rupture of an incisional hernia leading to the evisceration of the intra-abdominal organs is one of the malefic complications seen in these patients. In addition to its rarity, it gets accompanied by possible lethality in the form of incarceration, sequential strangulation, necrosis, and eventual gangrene. If not treated aptly, the clinical scenario could lead to a life-threatening condition with a delay in timely intervention. With less than 20 documented cases, herein, we report a 48-year-old female with a previous history of a midline laparotomy who presented to us with an acute spontaneous evisceration of the small bowel. The patient was immediately decided on surgical management with exploratory laparotomy, adhesiolysis, and primary repair of the abdominal wall defect. Postoperatively, the patient improved without any complications. An incisional hernia can be defined as an incomplete abdominal wall defect that develops at the site of maximum tension on a previous surgical scar of a full-thickness abdominal wall incision . The higA 48-year-old female presented with a slow, progressive swelling in the umbilicus for ten days, which spontaneously eroded at the top to expel the bowel in one day. The patient did not have a fever, obstipation, or vomiting. She had a history of midline laparotomy 15 years ago; however, she did not remember the exact reason of the surgery, and there were no records available. On examination, she was poorly built with mild pallor. The patient’s vitals were stable. Examination of other systems was within normal limits. Abdominal examination was suggestive of a 5 cm × 3 cm incisional defect with eviscerated small bowel covered with slough in the infraumbilical region (Figure Rectal examination showed a rectum loaded with hard stools with no blood staining. Blood investigations showed hemoglobin of 10.4 g/dl with normal liver and renal function tests. An abdominal x-ray was suggestive of mid-dilated small bowel loops proximal to the incarcerated loop at the umbilicus with a maximal diameter of 3 cm.The patient was admitted as a case of spontaneously ruptured incarcerated incisional hernia. The patient was taken up for an emergency laparotomy to reduce the bowel loop Figure .The patient was given adequate fluid resuscitation and systemic antibiotics with ceftriaxone and metronidazole. Extensive adhesions were noted between the prolapsed contents and the edge of the defect in the abdominal wall. The herniated loops were released from each other, and the hernia defected. The viability of the contents was confirmed. The herniated loops were identified as viable ileal loops, which were pushed back into the abdomen. The abdomen was closed with tension sutures after removing the redundant skin from the previous incisional hernia site. The patient improved postoperatively without any complications and was discharged after one week.Incisional herniations have been a part of the surgical abdomen for as long as we know, with spontaneous ruptures being a rare phenomenon. It has been seen to complicate around 20% of laparotomies . It is uComplications in the form of adhesions, incarcerations, strangulations, or frank bowel gangrene have been documented well on the side of incisional hernia . Most caThe evisceration of the bowel must be treated immediately without any delay as it may cascade into bowel strangulation, gangrene, and perforation . In mostIf the bowel is viable in emergency surgical ministration, a reduction of the contents into the abdomen followed by a primary meshplasty of the abdominal wall should be performed. Alternatively, primary closure of the abdominal wall with a delayed secondary mesh repair can be performed . In the Spontaneous ruptures of incisional hernias leading to an evisceration of the bowel are rarely reported. Given the associated mortality in the case of delayed treatment due to fulminant metamorphosis, clinicians need to act rapidly and take for surgical repair at the earliest. An early surgical ministration in exploratory laparotomy followed by case-based reduction, stoma or resection, and anastomosis heralds a favorable prognosis. This case is also vital in spreading awareness about this seemingly rare scenario and makes the clinicians aware of the approach to take at the outset to mitigate the accompanying fatalities in the form of life-threatening gut gangrene or perforation peritonitis.


The second branchial cleft cyst lacks typical symptoms, and its clinical manifestations are complex and varied. Among them, the second branchial cleft cyst manifested by sleep snoring is relatively rare, and it can easily lead to missed diagnosis or misdiagnosis. This paper reports a case of a second branchial cleft abscess with snoring as the main manifestation. The branchial cleft cyst was removed using an endoscopic branchial cleft. Among them, the second BCC was the most common. Studies have shown that the second BCC accounts for 95% of all BCCs.,4 The second BCC can occur in any part from the anterior one-third of the sternocleidomastoid muscle to the tonsillar fossa through the internal and external carotid arteries. It lacks specific symptoms and is prone to clinical misdiagnosis or missed diagnosis. Clinically, most children present with painless cervical masses; however, cases of snoring during sleep as the initial symptom have not been reported. In this study, we describe an abnormal case of a second BCC with snoring during sleep as the initial symptom and review the literature.Branchial cleft cyst (BCC) is the second most common cause of congenital cervical mass in children, followed by thyroglossal duct cysts.A child  was admitted on November 13, 2019, because of snoring for more than 3 years, aggravation for 2 months, and a nasopharyngeal mass detected for 1 week. Three years before admission, the child gradually presented with nasal congestion and snoring, occasionally accompanied by mouth breathing secondary to catching cold. In the last 2 months, the above symptoms aggravated daily. One week before admission, physical examination in the outpatient department of our hospital revealed a smooth mass in the right nasopharynx, without cough, expectoration, swallowing pain, foreign body sensation, bleeding, or fever. Special examination showed slightly congested pharyngeal mucosa and a mass behind the right palatopharyngeal arch, with a diameter of approximately 3 cm, smooth surface, and no rupture. Electronic laryngoscopy (Fig. On November 19, 2019, the child underwent endoscopic BCC resection under general anesthesia. During surgery, the soft palate was suspended to expose the mass fully. The lower end of the mass was parallel to the palatopharyngeal arch, and the right pharyngotympanic tube protruded at the round pillow. After fully exposing the mass, the normal mucosa around the cyst was incised with an electric knife, the bleeding point was fully stopped by bipolar electrocoagulation, and the mass was separated along the cystic wall using a detacher under the endoscope. When separating the depth, the cyst ruptured and the cystic fluid flowed out, and separation continued along the cystic wall to the cystic root, followed by cutting off. Postoperative pathology confirmed that the right pharyngeal mass was the second most common BCC. Six months after the surgery, nasopharyngeal MRI Fig.  demonstrThis case report was approved by the review committee of Shenzhen Children's Hospital, and informed consent was obtained from the patients’ parents.2–7 The second BCC can occur at any age, without obvious gender tendencies. It usually occurs in children, mostly in the neck. Its growth can compress important blood vessels or tracheae in the neck, causing symptoms that lack specificity. A typical second BCC is presented as a cervical mass in the anterior one-third of the sternocleidomastoid muscle and may have an open passage to the pharynx. Based on the relationship between the second BCC and the surrounding tissues of the neck, Bailey classified it into the following 4 types: Type I cysts are located in the deep surface of the platysma and the anterior margin of the sternocleidomastoid muscle; type II cyst is located in the deep surface of the sternocleidomastoid muscle, lateral carotid space, and behind the mandibular gland; type III cyst is located between the internal carotid and the external carotid; type IV cyst is close to the pharyngeal mucosal wall and can extend upward to the skull base. Among them, type I was the most common, while type IV was rare. In this case, the initial symptoms of the child were snoring during sleep. The pharyngeal tumor originated from the right parapharynx and had a smooth surface. According to the classification, it was classified as rare type IV and second BCC.The second BCC was first reported by Bailey in 1929 and is a residue formed by incomplete degeneration of the second branchial arch. Because cysts take a long time to expand and appear in the clinic, they always appear later, and their diagnosis is difficult. Imaging examination also has good application value in the diagnosis of second BCC and can make localization and qualitative diagnosis. Typical CT findings of the patients show a homogeneous low-density cystic mass with clear boundaries and a uniform surrounding thin and smooth wall. MRI findings present that cystic fluid show low to slightly high signal intensity on T1WI and high signal intensity on T2WI.,10The second BCC lacks specific clinical or imaging features and can only be definitively diagnosed by surgical resection and biopsy. Preoperative ultrasound examination of the neck is simple, convenient, and rapid, but it is not good to display the details of the anatomical structure around the cyst. It has been reported that the sensitivity, specificity and accuracy of color Doppler ultrasonography in detecting BCCs are 91.67%, 50% and 90%, respectively. Surgical methods mainly include traditional surgery and minimally invasive surgery. Although traditional surgery can fully expose the mass through full-thickness incision and separation in the neck, there is a large amount of intraoperative blood loss and a large scar after surgery. Minimally invasive surgery is directly performed in the neck through a small incision approach without cutting off the muscles, which reduces surgical trauma and completely removes the cyst by reducing the cyst. However, endoscopic BCC resection has not been reported in the literature. In this case, the visible cyst and cystic wall were completely resected under the endoscope, with intraoperative blood loss of approximately 10 mL, no loss of peripheral blood vessels or nerves, and good postoperative prognosis. No recurrence occurred during the follow-up.At present, the second BCC is mainly treated by complete surgical resection at home and abroad.The second BCC lacks typical symptoms, and its clinical manifestations are complex and diverse. Among them, the second BCC with snoring during sleep as the initial symptom is relatively rare. Lacking relevant knowledge, otolaryngologists are prone to missed diagnosis or misdiagnosis. In this study, a case of a second BCC with snoring during sleep was reported as the main manifestation. Endoscopic BCC resection was performed, and the postoperative efficacy was good. However, more cases need to be considered.Conceptualization: Zhixiong Xian, Saihong Han, Lan Li.Data curation: Zhixiong Xian, Yongchao Chen.Formal analysis: Yishu Teng, Lan Li.Investigation: Yongchao Chen.Project administration: Yishu Teng.Resources: Yishu Teng.Supervision: Yongchao Chen, Zhixiong Xian.Visualization: Saihong Han, Lan Li.Writing – original draft: Zhixiong Xian, Yongchao Chen, Yishu Teng, Saihong Han.Writing – review & editing: Yishu Teng, Saihong Han.


Primary liposarcoma arising from the liver is exceedingly rare. There have been very few reports documenting primary hepatic liposarcoma, especially of the pleomorphic subtype. Surgery is currently the only established treatment method, and the prognosis remains poor. In this report, we present an unusual case of hepatic liposarcoma of the pleomorphic subtype with literature review. In addition, we discuss theories regarding pathogenesis and the pathological and clinical features of primary hepatic liposarcoma to better outline this rare entity.An asymptomatic 65-year-old female was found to have a right hepatic mass on a computed tomography scan 2 years after surgical resection of the left adrenal gland and kidney for adrenocortical carcinoma. Laboratory examinations were unremarkable. Magnetic resonance imaging demonstrated a 16-mm mass in the right hepatic lobe. Adrenocortical carcinoma metastasis was suspected. Laparoscopic partial hepatectomy completely removed the tumor with clear margins. Macroscopically, the surgical specimen contained a nodular, yellow–white mass lesion 20 mm in diameter. On pathologic examination, pleomorphic, spindle-shaped tumor cells containing hypochromatic, irregularly shaped nuclei of various sizes formed fascicular structures. Scattered lipoblasts intervened in varying stages. Mitotic cells were frequent. Ki-67 labeling index was 15%. Immunohistochemically, the tumor cells were diffusely positive for vimentin and focally positive for CD34 and alpha-SMA; lipoblasts were focally positive for S-100. Tumor cells were nonreactive for SF-1, inhibin alpha, desmin, HHF35, HMB45, Melan A, MITF, c-kit, DOG1, cytokeratin AE1/AE3, h-caldesmon, STAT6, CD68, MDM2, CDK4, c17, DHEAST, 3BHSD, CD31, Factor 8, and ERG. From these findings, primary hepatic liposarcoma of pleomorphic subtype was diagnosed. The tumor recurred intrahepatically 3 years later, and the patient died 5 months after recurrence.In our report, we discussed the rarity, theories regarding pathogenesis, and a review of the literature of this atypical condition. To the best of our search, this is the 14th case of primary hepatic liposarcoma and the 2nd case of the pleomorphic subtype reported throughout the world. Further research regarding the etiology of this unusual clinical entity is warranted to establish effective diagnostic and management protocols. Liposarcoma is a rare malignant adipocyte tumor derived from mesenchymal cells. Representing approximately 15–20% of all soft tissue tumors, liposarcoma usually develops in the extremities and retroperitoneum [In this report, we present a rare case of primary pleomorphic liposarcoma originating from the liver with literature review. Due to the particular rarity of the pleomorphic variety, very few cases have been reported thus far. In addition, we discuss theories regarding pathogenesis and the pathological and clinical features of primary hepatic liposarcoma to better outline this rare entity.A 65-year-old Japanese woman was found to have a heterogeneous, ring-enhancing, 11-mm mass in the right hepatic lobe on follow-up contrast-enhanced abdominal computed tomography (CT) 2 years after surgical resection of the left adrenal gland and kidney for left-sided adrenocortical carcinoma. Medical and family histories were negative for hepatic disorders. The patient reported no symptoms and was subsequently referred to our department for further evaluation and treatment.On admission, physical examination revealed a well-appearing woman in no acute distress. Laboratory examinations were unremarkable. Serologic testing for hepatitis B and C was negative. Alpha-fetoprotein and des-γ-carboxy prothrombin levels were within normal limits. Dynamic contrast-enhanced T2-weighted images (T2WI) on magnetic resonance imaging (MRI) of the abdomen showed a 16-mm mass lesion with both cystic and solid, lipid-containing components , circulating MSCs, and hepatic progenitor cells (HPCs) are potential alternative origins Fig. . Hepaticsine qua non of liposarcoma diagnosis, dedifferentiated liposarcoma, myxoid liposarcoma, and myxoid pleomorphic liposarcoma were also differential diagnoses. Other differentials included epithelioid gastrointestinal stromal tumor (GIST), solitary fibrous tumor (SFT), and angiosarcoma due to positive staining for CD34. Adrenocortical carcinoma metastasis was also considered from the patient’s past medical history. Immunohistochemically, the lipoblasts stained positive for S-100. The tumor cells were negative for desmin, HHF35, HMB45, Melan A, MITF, c-kit, DOG1, cytokeratin AE1/AE3, h-caldesmon, STAT6, CD68, CD31, Factor 8, and ERG, making diagnoses of PEComa, GIST, SFT, and angiosarcoma unlikely. The presence of lipoblasts further ruled out angiosarcoma. Negative staining of CDK4 and MDM2 ruled out well-differentiated liposarcoma and dedifferentiated liposarcoma. Furthermore, negative results for SF-1, inhibin alpha, c17, DHEAST, and 3BHSD ruled out adrenocortical carcinoma metastasis. Split-signal FISH results negative for significant DDIT3 signal splitting ruled against myxoid liposarcoma. Similarly, low split signals for CREB1 and ATF1 lowered the possibility of angiomatoid fibrous histiocytoma. Myxoid pleomorphic liposarcoma was ruled out from the lack of characteristic myxoid matrix and oval cells. From these pathological and immunohistochemical findings, the patient’s tumor was classified as a hepatic liposarcoma of pleomorphic subtype.In 2020, the WHO renewed its classification criteria for liposarcoma to recognize five distinct subtypes based on pathological features , 2. The Pleomorphic liposarcoma is an aggressive neoplasm with an overall poor prognosis. According to previous studies focusing on pleomorphic liposarcoma from the orthopedic field , 5, the A PubMed literature search yielded 13 previous cases of primary hepatic liposarcoma (Table We reported a case of pleomorphic liposarcoma originating from the liver. Liposarcoma arising from the liver is so rare that clinicians may struggle to reach a definitive diagnosis. Due to the high recurrence rate and highly malignant progression, further research regarding the etiology of this unusual and highly malignant clinical entity is warranted to establish effective diagnostic and management protocols.


Left-sided acute appendicitis (LSAA) is a very rare cause of acute abdomen, developing in association with two types of congenital anomalies like as situs viscerum inversus (SVI) and midgut malrotation (MM). Preoperative diagnosis of LSAA is a challenge because of its rarity and atypical presentation. Imaging may be helpful for determining the correct diagnosis. Surgery represents the standard treatment of LSAA.A 67-year-old Caucasian male with presented to the Emergency Department with a two-day history of left lower quadrant (LLQ) abdominal pain, nausea, vomiting, diarrhea and fever. Physical examination revealed LLQ abdominal rebound tenderness with guarding. Laboratory tests reported high levels of C-reactive protein and neutrophilic leukocytosis. Abdominal contrast-enhanced computed tomography showed a LSAA with intraluminal appendicoliths, fat infiltration and pericecal fluid collection in a patient with SVI. The patient underwent laparoscopic appendectomy: a gangrenous and perforated appendicitis was sectioned and removed with drainage of pericecal abscess. The postoperative course of the patient was uneventful.LSAA is characterized by anatomical variation of appendix and atypical presentation. Preoperative clinical diagnosis of LSAA is very difficult and imaging may be helpful for determining the correct diagnosis, as well as confirming SVIT or MM. Laparoscopic appendectomy represents the correct treatment of LSAA.LSAA is a rare surgical emergency that should be considered in the differential diagnosis of patients with LLQ abdominal pain. Preoperative diagnosis of LSAA needs a high index of suspicion and is facilitated by imaging. Surgery represents the appropriate treatment of LSAA. •Left-sided acute appendicitis (LSAA) is a very rare cause of acute abdomen.•LSAA develops in association with situs viscerum inversus or midgut malrotation.•Diagnosis of LSAA is a challenge because of the absence of specific clinical presentation.•Laparoscopic appendectomy is the standard treatment of LSAA. The patient was initially managed with fluids, intravenous broad-spectrum antibiotics and bowel rest. A chest X-ray confirmed dextrocardia  abdominal pain, nausea, vomiting, diarrhea and fever (38 °C); others vital signs were normal. The patient was aware of having SVIT and was on hypertensive medications for ten years. He referred habit on smoking but denied alcohol consumption, his familial medical history was normal. The patient was retired from the work, married and of medium socio-economic status. Physical examination revealed mild abdominal distention, LLQ abdominal rebound tenderness with guarding and hypoactive bowel sound. Laboratory tests reported high levels of C-reactive protein (135.5 mg/L) and neutrophilic leukocytosis  when the organs in both thoracic and abdominal cavities are transposed or partial when only one of these cavities is affected. SVIT commonly occurs with dextrocardia and rarely with levocardia 4LSAA represents a rare surgical emergency that should be considered in the differential diagnosis of patients with LLQ abdominal pain. Its diagnosis is a challenge because of the absence of specific clinical presentation and needs a high index of suspicion. Imaging and/or laparoscopy are helpful in establishing the differential diagnosis of LLQ abdominal pain and in detecting LSAA as well as confirming SVIT or MM. Laparoscopic appendectomy is the standard treatment of LSAA.This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.Ethical approval has been exempted by our institution because this is a case report and no new studies or new techniques were carried out.Written informed consent was obtained from the patient, for 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.Not applicable.Giuseppe Evola.Not commissioned, externally peer-reviewed.Giuseppe Evola: Operated on the patient, drafting the manuscript, literature research.Francesco Ferrara: Operated on the patient, drafting the manuscript.Giovanni Francesco Di Fede: Drafting the manuscript, literature research.Marco Patanè: Operated on the patient and literature research.Salvatore Sarvà: Drafting the manuscript and literature research.Luigi Piazza: Revising the manuscript.The authors have no conflict of interest to declare.


Patients with recurrent unclear causes of postprandial abdominal pain should have median arcuate ligament syndrome as a differential diagnosis which is thought to be caused by celiac artery compression. Diagnosis is by imaging such as CT angiography. Patients with recurrent unclear causes of postprandial abdominal pain should have median arcuate ligament syndrome as a differential diagnosis which is thought to be caused by celiac artery compression. Diagnosis is by imaging such as CT angiography. One such condition to keep in mind, which requires the need of extra vigilance during diagnostic workup for abdominal pain, is median arcuate ligament syndrome (MALS).The diagnostic workup for abdominal pain presenting to the Emergency Department (ED) is sometimes fraught with considerable uncertainties.2A seventy‐one‐year‐old male patient of Middle‐Eastern, well known to the Emergency Department (ED) due to recurrent monthly visits with abdominal pain, presented to the ED with a similar presentation of greater severity for the past 1 day, along with few episodes of vomiting. On this visit, his pain was dull and diffuse, however, felt more intensely in the Right hypochondrium radiating all over the abdomen. Food intake consistently made the pain worse, and no relieving factors were known aside from immediate resolution of pain during prior ED visits with analgesic medications including intravenous (IV) opioids.Review of his comorbidities included hypertension, type 2 diabetes mellitus, and dyslipidemia, all of which were well controlled with medications. He had a history of gastritis non‐responsive to proton pump inhibitor (PPI) therapy. He was known to physicians taking care of him in the past as a chronic case of irritable bowel syndrome refractory to medical management. Aside from these, he had history of a hiatal hernia, managed conservatively, and had undergone a laparoscopic appendectomy 10 years prior.Physical examination similar to prior episodes revealed epigastric tenderness out of proportion to the severity of pain, and aside from this was unremarkable.A routine panel of investigations recurrently ordered, aside from mild corrected hypercalcemia of 2.58 mmol/L, was entirely unremarkable including liver function tests and pancreatic enzymes. C‐reactive protein was mildly elevated at 10.7 mg/L.Computed tomography (CT) of the abdomen was then performed which showed re‐demonstration of a narrowed segment in the proximal celiac artery with a hook‐like configuration due to indentation of the median arcuate ligament in the superior aspect of the celiac artery. The patient received IV Morphine and IV Esomeprazole and was admitted under the care of Internal Medicine. However, his pain improved, and he was discharged with a schedule to be seen in vascular surgery outpatient department.A review of past records remarkably revealed that the patient had been frequently visiting the ED since the past 15 years with on average more than 10 visits annually with the same complaint of postprandial pain. The location would vary on each presentation but was consistently dull, diffuse and worsened with eating. It would occasionally be associated with episodes of vomiting and anorexia; however, there was no weight loss. Examination findings on each visit would reveal tenderness out of proportion to the pain experienced by the patient. Laboratory findings would be unremarkable; however, the lactic acid level during these visits was variable with a range of 0.8–5.2 mmol/L with a mean of above 2.0 mmol/L. His liver, pancreatic enzymes along with tumor markers, thyroid function tests, and autoimmune panel all failed to reveal any abnormality. He even underwent bowel screen for occult blood, which was negative.Helicobacter pylori (H.pylori) testing being positive once. However, its eradication using stool antigen testing was documented later on. Ultrasonography of the abdomen would be performed on each visit which would be unremarkable. His first CT abdomen (with contrast) was unable to reveal any evidence of celiac artery compression with no other radiological findings that would account for his recurrent abdominal pain.Owing to the frequency of his presentations which at times would be twice in the same day, he underwent an exhaustive diagnostic workup over the past 15 years which included two gastroscopies which revealed mild gastritis each time with Three years later, a second CT abdomen demonstrated the presence of a "hook"‐shaped configuration of the celiac trunk, with indentation on its superior surface and focal luminal narrowing at this level with mild poststenotic dilation of the celiac artery, concerning for median arcuate ligament syndrome. He was scheduled to be seen by the vascular surgery in an outpatient setting and was discharged after resolution of pain with IV analgesics, yet he missed his appointment. Subsequently, few months later, on one similar presentation of abdominal pain, CT angiography was done Figure  suspectiEventually, patient underwent a third CT abdomen that revealed no interval changes, and 3 months later, he presented to our care for the current presentation.He was discharged with a follow‐up with vascular surgery for definitive management; however, he was lost to follow‐up.3The above case highlights the degree of uncertainty that precedes a diagnosis of median arcuate ligament syndrome (MALS). MALS or Dunbar syndrome as it is known since being described by Dunbar et alOwing to the fact that 40% of patients with MALS present with classic findings of abdominal angina, one of the proposed theories for its pathophysiology is compression of celiac trunk leading to mesenteric angina.Despite the presence of typical findings in the presence of classic angiographic demonstration of celiac artery compression, the diagnosis of MALS may prove to be a diagnostic conundrum due to it being attributed to 2 out of 100,000 cases of upper abdominal pain.The mainstay of treatment is open, robotic, or laparoscopic ligament release, and although angioplasty remains an option, its role is limited by its inability to address the underlying compression resulting in the symptoms.4This case highlights the need for extra vigilance in the diagnostic workup of patients with recurrent presentations with unexplained abdominal pain. Comprehensive review of all radiological imaging of the abdomen may assist in providing the requisite diagnostic breakthrough including the possibility of syndromes such as MALS.None declared.AC involved in first author, manuscript writing, and literature review. NMK involved in case‐presentation writing. AE involved in literature review. MID involved in mentorship, manuscript writing, and literature review.Ethical approval was obtained by Medical Research Center (MRC) under ID MRC‐04–19–436 on November 9, 2019.Published with written consent of the patient.


Meningiomas are common neoplasms representing 14.3–19% of all intracranial tumors. Among all the meningiomas, only 1.8–3.2% arises at the foramen magnum (FM) level.Most of the lesions (68%–98%) arising anterolaterally, followed by postolateral, purely posterior and, more rarely, purely anterior.We report a case of A 42-year-old female presented with a history of neck pain with progressive spastic hemiparesis.MRI revealed well-defied pure anterior and on both sides of vertebral artery, foramen magnum lesion. Through conservative transcondylar approach, Lesion was removed totally in a piecemeal fashion. Histopathology revealed meningothelial meningioma. The patient had a dramatic recovery.The exposure allowed by the far-lateral retrocondylar or partial transcondylar approach is adequate for resecting even anterior intradural FMMs.Reports about Foramen magnum meningioma aren't common, but reports on pure anterior foramen magnum meningioma are very rare. The prerequisite for treating FM meningiomas (FMMs) is the perfect knowledge of the surgical anatomy. The opportunity to give the patient a symptom-free and normal life should not be missed in such cases. •Only 1.8–3.2% of all meningiomas are located at foramen magnum (FM).•Foramen magnum meningiomas (FMMs) represent a common histological tumor in a rare and eloquent location.•FMMs are one of the most surgically complex conditions in neuro-oncologic surgery.•The transcondylar approach is a more advanced technique and the total removal of ventral lesion could be achieved. Among all the meningiomas, only 1.8–3.2% arises at the foramen magnum (FM) level [Most of the time, these are strictly intradural. Ten percent have an extradural extension: Most are intra- and extradural, and a few may be entirely extradural .According to Boulton and Cusimano, the spinal dentate ligament delineate the anterior an posterior compartments with most of the lesions (68%–98%) arising anterolaterally, followed by postolateral, purely posterior and, more rarely, purely anterior .FMMs are typically slow growing with an indolent course, but when they become symptomatic, they most commonly present with quadriparesis, sensory abnormalities, ataxia, and dysfunction of cranial nerves (CN) IX,X and XI .FM contains several critical neuroanatomical and vascular structures. The neural structures include the cerebellar tonsils, inferior vermis, fourth ventricle, caudal aspect of the medulla, lower cranial nerves (CNs) (IX–XII), rostral aspect of the spinal cord, and upper cervical nerves (C-1 and C-2).The exposure allowed by the far-lateral retrocondylar or partial transcondylar approach is adequate for resecting even anterior intradural FMMs. The prerequisite for treating FM meningiomas (FMMs) is the perfect knowledge of the surgical anatomy.This work has been reported in line with the SCARE criteria ,19.2A 42-year-old female presented to our department via community referral, with a history of neck pain with progressive spastic hemiparesis for 3 months. She had recent worsening of her limb weakness with no bowel and bladder involvement. Other symptoms were dysphagia and frequent disturbed sleep during night. Preoperatively, her Clinical examination revealed paralysis of sternocleidomastoid muscle and trapezius muscle and she had muscle power Medical Research Council (MRC) grade 3 on the right side.All her deep tendon reflexes were exaggerated with bilateral planter extensor.There were no subcutaneous nodules, hypopigmented macules, or other stigmata of NF.The patient's review of systems and additional medical history surgical, family, psychosocial and pharmacologic were unremarkable.Magnetic resonance imaging (MRI) revealed well-defieddural-based mass lesion at foramen magnum, located anterior to neuroaxis and extending both up and down. causing severe compression of spinal cord. The cervicomedullary junction and upper cervical cord were sandwiched between the lesion and posterior border of foramen magnum .Fig. 1A:The differential diagnosis of a foramen magnum meningioma can include dermoids, epidermoids, teratomas, lipomas, hemangioblastomas, cavernous angiomas, giant thrombosed aneurysms of the vertebral artery, intramedullary cervical spinal cord tumors, and syringomyelia.After obtaining the patient's informed consent, surgery was planned.The procedure was done by a consultant neurosurgeon.Through conservative transcondylar approach, approximately 10% of the posterior condyle was removed. The VA was identified and the posterior arch of C1 was resected. The tumor was decompressed preserving the neural and vascular structures. the lesion was removed totally in a piecemeal fashion. Simpson grade I was achieved.Histopathology revealed a meningothelial meningioma (WHO-Grade 1).Patient had a dramatic recovery from her symptoms postoperatively. After 4 months of follow up she showed marked improvement of power in her all limbs. MRC grade improves to 5 in all limbs which enable her to walk independently.Routine follow-up by clinical observation and MRI was done.Post-operative MRI after 4 months shows no residual tumors.Fig. 2Po3Meningiomas are extra-axial central nervous system (CNS) tumors that arise from the arachnoid cells of the dura mater. Meningiomas represent 14.3–19% of all intracranial tumors, the most common non-glial primary intracranial tumor .A meningioma is considered to arise from the foramen magnum if the origin of the tumor is in the region bounded anteriorly by the lower third of the clivus and the upper edge of the body of C2, laterally by the jugular tubercles and the upper aspect of the C1 laminas, posteriorly by the anterior edge of the squamous occipital bone and C2 spinous process .FMMs having the possibility to develop above, below, and on both sides of the VA. Meningiomas are more often located below the VA.CN IX through CN XI arise as a series of rootlets along the anterior medulla, with the spinal component of the CN XI arising midway between the anterior and posterior spinal rootlets of the spinal cord.Only 1.8–3.2% of all meningiomas are located at foramenmagnum (FM). Foramen magnum meningiomas (FMMs) represent a common histological tumor in a rare and eloquent location. As these tumors are indolent, there occurs a long interval between onset of symptoms and diagnosis .The pathologic entity of FMM was first described in 1872. The first publication describing surgical removal was in 1922 .The dorsolateral approach introduced by Koos et al., in1985 and later described by Perneczski in 1986, a member of the same school , 12, resIn general, lateral, far lateral and extreme lateral approaches have been recommended for anteriorly placed foramen magnum meningiomas ,16.The far-lateral transcondylar approach is a very useful approach to lesions located ventrolateral and even ventral to the brainstem and upper cervical spinal cord .Due to the complexity of the region of the FM, the therapeutic and surgical strategy of FMM should be decided as per case. In our case, we reviewed the regional anatomy that helped us for a safe dissection of the neurovascular structures and aided in the avoidance of complications. Eventually, we achieved the favorable outcomes.4FMMs are one of the most surgically complex conditions in neuro-oncologic surgery, requiring special considerations due to the vicinity of the medulla oblongata, the lower cranial nerves, and the VA. There is no single best approach for FMMs and the optimal approach should be defied according to the localization and the extent of the tumor to minimize the extent of resultant morbidity.The transcondylar approach is a more advanced technique than the far lateral approach And the total removal of ventral lesion could be achieved.The opportunity to give the patient a symptom-free and normal life should not be missed in such cases.This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.This study was not applicable for ethical approval.I have obtained written consent for publication of this case report from the patient and I can provide this should the Editor ask to see it.Dr. Ali Hammed (corresponding author): Contribution to the paper: first author, data collection, data analysis and interpretation, writing the paper. PHD Dr. Moufid Mahfoud: Contribution to the paper:Main Surgeon. Treatment and examination of the patient. Writing Case Presentation. Dr. Salah Hammed: Contribution to the paper: Writing the paper. Dr. Alaa Sulaiman: Contribution to the paper: Writing the paper. Dr.Adnan Najm: Contribution to the paper: Writing the paper.The case report at hand is not a first-in-man case report of a novel technology or surgical technique, therefore a registration of these case reports according to Declaration of Helsinki 2013 is not required.Not commissioned, externally peer-reviewed.All authors declared no conflict of interest.