Gastric adenocarcinoma is the fifth most common cancer worldwide and the third leading cause of death. The major risk factors include Helicobacter pylori infection, genetic factors, environmental factors, and atrophic gastritis. Gastric remnant cancer is gastric carcinoma that develops in the remnant stomach more than five years after distal gastrectomy for benign disease, incidence ranging from 1% to 8%. However, gastric carcinoma after loop gastro-jejunostomy without gastric resection for benign etiology is rare. We report a case of a 45-year-old lady with gastro-jejunostomy without gastric resection done in childhood, presenting with adenocarcinoma at the anastomotic site after 35 years. Gastric cancer is the fifth most common cancer worldwide and the third leading cause of death . AdenocaA 45-year-old lady presented to the emergency with multiple episodes of non-bilious vomiting, containing undigested old food particles, for the past two months. The vomitus was associated with epigastric pain, on and off post-prandial abdominal distension, early satiety, decreased appetite, and significant weight loss over the past two months. However, there was no history of hematemesis, melena, or jaundice. The patient gave a history of an upper abdominal surgery in her childhood (around 35 years ago), details of which were not known, and no records were available. At presentation, she had tachycardia (110/min) and was dehydrated. The abdomen was soft with distension of the upper abdomen, and the succussion splash was positive. There was an upper midline vertical scar present, healed with primary intention. Blood investigations showed hemoglobin of 7.7 g/dL, urea of 12 mg/dL, creatinine of 0.28 mg/dL, sodium of 129 mEq/L, and potassium of 4.2 mEq/L.Upper gastrointestinal endoscopy (UGIE) revealed an ulcero-proliferative circumferential growth involving the lesser curvature, body, and the antro-pyloric region of the stomach. Multiple biopsies taken from the growth were suggestive of gastric adenocarcinoma. Contrast-enhanced computed tomography (CECT) revealed a circumferential growth involving the body and antro-pyloric region of the stomach. The growth was adherent to bowel loops with loss of fat planes with liver and pancreas. She was taken up for staging laparoscopy. Due to the absence of liver or peritoneal metastasis, and no infiltration of the growth into the liver or pancreas, we proceeded with total gastrectomy. However, growth was found adherent to the jejunal loops traversing through the transverse mesocolon. On further dissection, the adherent jejunal loop was found to be retro-colic posterior loop GJ Figures , 1B.Total gastrectomy with excision of previous GJ loops for a length of 10 cm along the afferent and efferent jejunal loop was done Figure .Intestinal continuity was restored by Roux-en-Y esophago-jejunostomy and jejuno-jejunostomy. The patient had an uneventful postoperative recovery and was started on capecitabine-based adjuvant chemotherapy.Except for malignant conditions, loop GJ is commonly done for benign gastric outlet obstruction (GOO) due to peptic stricture, caustic ingestion, inflammatory diseases such as Crohn’s disease or tuberculosis or as part of surgical procedures such as mini gastric bypass bariatric procedure, and pyloric exclusion in complex gastro-duodenal perforations. In the past, distal gastrectomy with loop GJ was used for patients with peptic ulcer disease. Due to the advent of acid inhibitory medications, this surgical procedure is rarely done nowadays. However, it is still done at our center for complications like bleeding ulcers. The most common complication following GJ is stenosis, followed by marginal ulcers and perforation . GastricBiliary reflux plays a vital role in the pathogenesis of post-GJ malignancy. Bile is the most significant content of reflux, damaging the gastric mucosa, and disrupting the gastric mucosal barrier. In patients with GJ, the gastric mucosa is exposed to continuous biliary reflux leading to alkaline gastritis and intestinal metaplasia, a precancerous condition. This alkaline medium with intestinal metaplasia allows bacterial colonization, which reduces nitrates in the food into nitrosamines which are carcinogenic and proven to cause gastric carcinoma . Given tPatients with loop GJ develop carcinoma commonly at the anastomosis site and rarely in the stomach away from the anastomosis site ,10. The In the case of resectable tumors, subtotal or total gastrectomy with gastro-jejunal anastomotic site resection with a wide margin must be performed ,6,8. GivThough there are no studies available regarding the screening for gastric carcinoma in patients with loop GJ without gastrectomy, annual screening with biopsy of the suspicious region is recommended in patients at risk for GRC ,6,11. HoAlthough rare, gastric malignancy post-GJ for benign etiology can occur. Although these tumors are prone to extensive local disease, curative or en-bloc resection is possible in most cases. Therefore, the survival of these patients is similar to patients with stage-matched primary gastric carcinoma. Routine annual screening with biopsy of the suspicious region is recommended in patients for early diagnosis.


Extrarenal malignant rhabdoid tumor (EMRT) is a rare and high-mortality malignant tumor, which is more common in infants and rarely seen in adults. We firstly report a case of liver malignant rhabdoid tumor (MRT) with a loss of SMARCB1 gene  expression in a middle-aged woman, and preliminarily summarize the clinical characteristics and discuss its potential treatment of liver MRT by reviewing 55 cases reported in the past.We report a 40-year-old woman who was admitted to our hospital for right epigastric pain. Previously, the patient was treated with liver hematoma in another hospital until she came to our hospital for abdominal pain again. In our hospital, we performed surgical treatment on her and the pathology diagnosed EMRT with negative expression of SMARCB1. After surgery, the patient underwent genetic testing, but failed to screen for sensitive targeted or conventional chemotherapy drugs, and she did not receive further treatment. Due to lack of timely diagnosis and effective chemotherapy drugs, tumor recurrence and metastasis occurred one year after surgery. Then the patient chose traditional Chinese medicine for treatment. And the metastatic tumors had still progressed after one year of treatment, but the patient didn’t have obvious discomfort symptoms.Liver MRT is a highly aggressive tumor with high metastatic potential and poor prognosis. It lacks specific symptoms and signs and is easy to be ignored and misdiagnosed. The mortality rate is extremely high as there is no effective treatment. But most tumors are accompanied by SMARCB1 deficiency, which may offer new research directions for cancer therapeutics. For the present, early detection, early diagnosis and early resection remain the key to improve the prognosis of patients. Malignant rhabdoid tumor (MRT) is a rare and highly aggressive tumor characterized by high metastatic risk, poor prognosis and high mortality. It’s most commonly encountered in the kidney, and has a low extrarenal incidence. Extrarenal malignant rhabdoid tumors (EMRTs) tend to occur in the body's central axis, mainly in infants and early childhood. Currently, only a few cases of adult primary liver MRT have been reported. In this paper, we describe a case of liver MRT in a 40-year-old woman for the first time.A 40-year-old woman was admitted to the hospital with the chief complaint of right upper abdominal pain for more than 4 months.The patient had no previous medical history or family history of tumors.More than 4 months before admission, the patient had a sudden outbreak of pain in the right upper abdomen without obvious inducement. The initial ultrasonography showed heterogeneous echo around the right liver, while computed tomography (CT) suggested subcapsular mass shadow with regular shape, clear boundary and uneven density, suggesting subcapsular haematoma. Magnetic resonance imaging (MRI) presented with an irregular mass with mixed short T1-weighted imaging (T1WI), mixed long T2-weighted imaging (T2WI) and high diffusion-weighted imaging (DWI) . The tumor had a large amount of bleeding, but the patient's vital signs were stable. In this case, hepatic arterial embolization and then assessment of the cancer biology before surgery, or direct surgery were feasible treatment options. After communication with the patient and her family, they directly chose exploratory laparotomy. Intraoperatively, there was approximately 4000 ml old hemorrhage in the abdominal cavity. A large cystic mass with a size of 15 × 11 cm, was observed between the right hepatic lobe and diaphragm. There was no cirrhosis or obvious abnormalities in other abdominal tissues or organs. To ensure an adequate residual liver volume, we performed modified right hemihepatectomy .Postoperative pathology revealed pleomorphic tumor cells with vesicular nuclei, prominent nucleoli, and eosinophilic cytoplasm Fig. a. ImmunoAfter surgery, the patient underwent genetic testing. Considering the patient's frail condition and while waiting for genetic testing results, the patient was discharged from hospital without immediate chemotherapy. Later, the results of genetic testing failed to screen out effective chemotherapy and targeted therapy drugs.After discharge, the patient underwent abdominal CT examinations every 3–6 months, but did not receive further treatment. When abdominal CT in another hospital one year after surgery revealed metastatic tumors in the abdominal and pelvic cavity, the patient chose to be treated with traditional Chinese medicine . After one year of treatment with traditional Chinese medicine, based on what the patient described, abdominal CT reexamination showed that the metastatic tumors had progressed compared with before, but the patient was generally in good condition without obvious symptoms and signs.The histologic morphology of liver MRT, a rare subtype that portends a grim prognosis, is consistent with that of rhabdoid tumor in the kidney, and its histological origin is unclear . InfantsImaging plays an indispensable role in disease diagnosis. Due to its rarity, there is no summative imaging feature of liver MRT. Reviewing the previous cases, liver MRT mostly manifests as solid or cystic masses with a heterogeneous echo by ultrasonography. CT usually exhibits single or multiple heterogeneous low-density masses, while the tumor exhibits heterogeneous enhancement after enhancement, possibly accompanied by calcification, necrosis and hemorrhage. The MRI findings have been described as hypointense on T1WI and heterogeneous hyperintense on T2WI, with mild enhancement or peripheral enhancement during enhancement.The diagnosis of liver MRT still relies on the pathology. Microscopically, the tumor cells are round or polygonal, and composed of frequent mitosis, prominent nucleoli and abundant eosinophilic cytoplasm . In immuCurrently, there are still no standard treatments for liver MRT. In previous cases, surgery, chemotherapy, radiotherapy and combinations of the three methods were used, and nearly all patients were treated with commonly used chemotherapy drugs such as vincristine, doxorubicin, etoposide, cyclophosphamide, carboplatin, cisplatin and ifosfamide. Although multimodal therapies were adopted, the survival time of most patients was very short; 82% of patients died within 6 months and 94% died within 1 year of diagnosis. The targeted drug bevacizumab has also been used to treat MRT but ended in failure . For thoTo the best of our knowledge, this is the first report of liver MRT in an adult female, mainly manifesting as rupture and hemorrhage. The imaging and pathological findings of the patient were basically consistent with those that were previously reported. Unfortunately, one year after surgery, the patient developed abdominal and pelvic metastasis, suggesting that the tumor was highly aggressive. Moreover, gene detection failed to screen for sensitive chemotherapeutic drugs. Therefore, there is an urgent need to develop an effective treatment for liver MRT.Genetic and epigenetic alterations play crucial roles in the initiation and progression of tumors. As a product of genetic and epigenetic dysregulation, gene and epigenetic therapy may provide new directions for MRT treatment. Deletion of the SMARCB1 locus  in chromosome 22q11.2 is the most specific change in MRT . ExogenoSeveral inhibitors of histone modifiers have been shown to sensitize MRT cells to radiotherapy and chemotherapy, such as enhancer of zeste homolog 2 (EZH2) and histone deacetylase (HDAC) . The MCLNotably, approximately 5% of MRTs do not have SMARCB1 deletions but lack SMARCA4 gene expression, and its function is still unclear . The absIn conclusion, liver MRT is a rare tumor but also one of the most lethal malignancies. Despite the existence of intensive multimodal therapy currently, the curative effect is fairly dismal. The SMARCB1 deficiency, along with the changes in various signaling pathways, may offer new research directions for cancer therapeutics. Nevertheless, the mechanisms of the occurrence and development of liver MRT are still unclear, and we are obliged to carry out more in-depth researches to elucidate it. With the progress of medicine, we have faith that more patients will receive efficacious treatment and better prognosis.


Urachal adenocarcinoma is a rare but highly malignant epithelial cancer that accounts for <1% of all bladder malignancies and commonly presents with hematuria. We report a case of metastatic urachal adenocarcinoma presenting as bowel obstruction.A 54-year-old male patient with a history of alcohol abuse presented to the emergency with acute-onset, diffuse, cramping abdominal pain, worst in the epigastrium and lasting one day. Abdominal examination revealed moderate guarding and generalized tenderness with hypoactive bowel sounds. Imaging confirmed an evolving small bowel obstruction and a urachal remnant with a superimposed mass lesion. The patient underwent an exploratory laparotomy and a high-grade small bowel obstruction due to the mass was identified. An intraoperative frozen section identified adenocarcinoma. A biopsy of the urachal mass confirmed urachal adenocarcinoma. The final diagnosis was moderately differentiated urachal adenocarcinoma. The tumor was deemed unresectable due to the involvement of multiple loops of the small bowel and the mesentery of the small and large bowels. Systemic chemotherapy with 5-fluorouracil (5-FU), leucovorin, and oxaliplatin (modified FOLFOX-6) was initiated.Our patient did not report any prior urinary symptoms or recurrent abdominal pain, which are the common symptoms that urachal adenocarcinoma presents with. Bowel obstruction is a rare presentation of urachal adenocarcinoma since the spread of the disease to the viscera occurs much later in the course. This case report highlights a rare presentation of an even rarer malignancy. Urachal carcinoma is a rare non-urothelial malignancy of the bladder that arises from the urachal ligament and constitutes less than 1% of all bladder tumors . While iA 54-year-old male with a history of alcohol abuse presented to the emergency with acute-onset, diffuse, cramping abdominal pain, worst in the epigastrium and lasting one day. He denied fever, vomiting, loss of appetite or weight loss, diarrhea, constipation, or rectal bleeding, or any prior similar episodes. He had no prior abdominal surgeries. On examination, he was in distress and had moderate guarding and generalized tenderness with hypoactive bowel sounds. He was afebrile. Laboratory evaluation showed microcytic anemia and thrombocytopenia on complete blood count, hypokalemia on basic metabolic profile, and a normal lipase level Table .Abdominal X-ray showed an evolving small bowel obstruction Figure , which wA decision was made to go forward with an emergent surgery to release the small bowel obstruction. After receiving a platelet transfusion, the patient underwent an exploratory laparotomy. He was found to have a high-grade small bowel obstruction due to an extensive mass concerning for a malignancy. A frozen section was intraoperatively sent and read as adenocarcinoma Figure .An incisional biopsy of the urachal mass was also sent. The final pathology specimen was reported as a moderately differentiated urachal adenocarcinoma Figure  with posThe patient was staged at Stage IIID (Sheldon staging) due to the spread to local viscera other than the bladder. The tumor was deemed unresectable due to the involvement of multiple loops of the small bowel and the mesentery of the small and large bowels. Systemic chemotherapy with 5-fluorouracil (5-FU), folinic acid, and oxaliplatin (modified FOLFOX-6) was initiated. The patient has received six cycles of chemotherapy so far. He has tolerated chemotherapy well enough and is still awaiting additional imaging to evaluate the response to therapy.Urachal carcinoma is a rare non-urothelial malignancy of the bladder that arises from the urachal ligament . The uraThe incidence of urachal carcinoma ranges between 0.35-0.7% of all bladder tumors. The most common histopathological type is adenocarcinoma, which accounts for 90% of all urachal carcinomas and 10-40% of the primary bladder adenocarcinomas . Our patIn the early stages, urachal carcinoma remains asymptomatic . HematurThe diagnosis of urachal carcinoma is difficult due to low tumor incidence and overlapping histopathological features with adenocarcinomas of other origins . InitialA cystoscopy is essential for the visualization and histological diagnosis of urachal carcinoma in the midline of the bladder ,5. AdditTumor markers such as CEA, CA 125, and CA19-9 can be elevated due to peritoneal carcinomatosis, a frequent finding in metastatic disease [In resectable cases, partial cystectomy with en-bloc resection of the urachal ligament with the umbilicus and bladder dome is done to decrease the risk of relapse . Our patOur patient has received six cycles of the modified FOLFOX-6 regimen and has tolerated it so far. However, tumors often recur and the majority of the patients die within two years of the diagnosis .Urachal carcinoma is a rare but highly malignant tumor that is difficult to diagnose clinically. While urinary complaints such as hematuria and dysuria or abdominal mass are the more common presenting symptoms, in rare cases, the clinical picture could be more severe. This was the clinical presentation of our patient. He had experienced no symptoms until he presented with bowel obstruction due to metastatic urachal carcinoma. Our case highlights a rare presentation of an even rarer malignancy.


The authors present the first case of concurrent upper eyelids eversion, umbilical hernia, and clubfeet.A four-hour-old newborn male presented with bilateral red upper eyelids swelling. Ophthalmic examination revealed bilateral upper eyelids eversion and severe bilateral chemosis. The further pediatric evaluation showed a painless reducible umbilical hernia and clubfeet. Treatment of the eyelids eversion was conservative, combining topical steroids, antibiotics and lubricants. Chemosis reduced progressively. We obtained a complete resolution on day 21. We referred the neonate to the pediatric surgery, and orthopedic department for umbilical hernia and clubfeet management.Most infants with CUEE may show excellent anatomic and functional results with conservative treatment if managed timely and promptly.The innocuous appearance of CUEE must not prevent clinicians from investigating possible systemic associations and initiating appropriate treatment. •Congenital upper eyelid eversion is a very rare congenital condition, few cases have been published in the literature.•This condition is usually isolated. However, a higher prevalence is reported in Down syndrome and colloidal skin disease.•To the best of our knowledge, we present the first case of concurrent upper eyelids eversion, umbilical hernia and clubfeet.•Management is often conservative, most infants with congenital upper eyelid eversion may show excellent results if managed timely and promptly. It is associated with severe conjunctival chemosis . This coOur case report aimed to describe a previously unreported association of CUEE, umbilical hernia, and clubfeet in a white neonate. It also highlighted the potentially severe ocular impact of CUEE and its therapeutic options, including conservative management.This case report has been reported in line with the SCARE 2020 criteria .2A four-hour-old white male neonate with no family history was referred to our emergency department for severe red swelling in his upper eyelids, precluding eyeballs identification. He was the third child of a 26-year-old woman. Pregnancy was uneventful and regularly followed up. The child was full-term. He was born through vaginal delivery with no instrumentation.Ophthalmic examination revealed severe bilateral chemosis with complete eversion of the upper lids and exposure of the tarsal plate A. The eyFurther detailed pediatric assessment disclosed a painless reducible umbilical hernia B. Both fWe diagnosed an unknown association of CUEE, umbilical hernia, and clubfeet. A genetic study could not be performed due to socio-economic issues. As we timely established the diagnosis at birth, the prognosis was good. There was no other diagnosis to discuss.Management of the eyelids eversion was conservative. The patient was started on moist dressings, a topical antibiotic-corticosteroid ophthalmic ointment, and lubricants three times per day. The medical treatment aimed to reduce chemosis, prevent infection, and lubricate the cornea.Chemosis reduced progressively within seven days allowing manual repositioning of the eyelids . CompletWe referred the neonate to the pediatric surgery and orthopedic department for associated abnormalities management.The parents were relieved after the fast resolution of the swelling as they thought it was a potentially blinding disease. They will continue the treatment and clinical follow-up in the ophthalmology and surgery departments.3Congenital upper eyelid eversion is an uncommon condition, first described by Adams in 1896 as “double congenital ectropion” ,5.The exact pathogenesis of CUEE is not yet known. Anatomical variations of the upper eyelid are mainly involved. They include hypotonia of the orbicularis oculi, absence of effective lateral canthal ligaments, lateral elongation of the eyelid, and vertical shortening of the anterior lamella or lengthening of the posterior lamella. The failure of the orbital septum to fuse with the levator aponeurosis can also be responsible for CUEE ,5. HowevOnce everted, vascular congestion within the eyelid causes chemosis and swells the lid tissues enough to exacerbate orbicularis spasm. It leads to a vicious circle of worsening lid eversion. Thus, the eyelid cannot be repositioned ,5,6.To the best of our knowledge, no one reported the association of CUEE, umbilical hernia, and clubfeet. Authors described clubfeet in several congenital syndromes such as Down syndrome, probably due to ligamentous laxity . HoweverAlthough its etiology remains unclear, clinicians should be aware of this unreported congenital abnormality of the ocular, abdominal and musculoskeletal system.Congenital upper eyelid eversion is usually benign. Nevertheless, it can expose to keratopathy, corneal scarring, and perforation leading to severe ocular morbidity .The conservative management often aims to prevent infection and reduce sufficiently conjunctival chemosis. It usually allows spontaneous upper eyelids inversion ,5,10.The different treatment modalities are moist dressings, pressure patching, topical antibiotics, and lubricant. Antibiotic is an adjunct treatment that prevents exposed ocular surface infection. Some authors also proposed topical 5% hypertonic NaCl to dehydrate the swollen conjunctiva ,10.In the current case, topical corticosteroids helped address any inflammatory component of the subconjunctival edema. Witherspoon et al. recommended a subconjunctival injection of steroids, lidocaine, and epinephrine for resistant conjunctival chemosis . Daniel We often reserve surgical treatment for refractory cases to a conservative approach. It includes scarification of the exposed conjunctivae, temporary tarsorrhaphy, fornix sutures, full-thickness skin graft to the upper lid, and subconjunctival hyaluronic acid injection ,9,10.To conclude, this case report is quite interesting, as we describe a new congenital syndromic association. Management of CUEE is still controversial, mainly due to its scarcity.4Most infants with CUEE usually show excellent anatomic and functional results. We can avoid risky and unnecessary surgery with early and prompt management. Moreover, the innocuous appearance of CUEE must not prevent clinicians from investigating possible systemic associations.This case report followed the ethical standards of the declaration of Helsinki and its later amendments. Anonymous case reports are approved by the ethics committee of our institution as long as we have written consent.Not applicable.Patient's management: JS and AC.Data collecting: MM and JS.Manuscript drafting: YA, JS, DG, and IM.Manuscript revision: JS, MM, DG, IM, and LN.All authors approved the final version of the manuscript.Name of the registry:Unique Identifying number or registration ID:Hyperlink to your specific registration (must be publicly accessible and will be checked):Not commissioned, externally peer-reviewed.We obtained written informed consent from the patient's father to publish this case report and accompanying images. A copy of the written is available for review by the Editor-in-Chief of this journal on request.Dr. Jihene Sayadi is the corresponding author and the guarantor of this case report.No conflict of interest.


Aneurysms from the vertebrobasilar system are rare, accounting for only 5%-10% of all intracranial aneurysms. The most common sites in which these lesions occur are the bifurcation of the basilar artery and the origin of the posterior inferior cerebellar artery (PICA). When the aneurysms present in the distal portion of the PICA, they represent from 0.5% to 6%. These aneurysms are called giant when they exceed 25 mm in diameter. We present a case of a 49-year-old male who presented with acute obstructive hydrocephalus, which required ventriculoperitoneal shunting and left hemispheric cerebellar syndrome. The magnetic resonance imaging study revealed an occupative mass located in the fourth ventricle, and diagnostic angiography showed a partially thrombosed giant saccular aneurysm in the posterior inferior cerebellar artery. He underwent surgical management via a lateral suboccipital approach. The aneurysm was remodeled and clipped successfully without complications, with an uneventful postoperative course.Although rare, PICA aneurysms should always be considered when posterior fossa syndrome occurs, including brainstem and cranial nerve compression symptoms. It can easily be misdiagnosed as a neoplastic lesion, especially when the aneurysm reaches big or giant size. Therefore, complete diagnostic studies, such as cerebral angiography, must be performed. Surgical clipping must be offered as the first line of treatment. It provides occlusion of the aneurysm and relieves compressive symptoms. The posterior inferior cerebellar artery (PICA) is the largest branch of the vertebral artery and is divided into five segments: anterior medullary, lateral medullary, tonsillomedullary, telovelotonsillar, and cortical . PICA anA 49-year-old man was admitted to our emergency department with an intense, new-onset headache, followed by nausea, vomiting, and altered consciousness. A CT scan revealed acute hydrocephalus due to an occupative lesion that filled the fourth ventricle. Emergency ventriculoperitoneal shunting was performed with no further complications. Postoperatively, the presenting symptoms improved, but the patient remained with left dysmetria, dysdiadochokinesia, and lateropulsion. A left hemispheric cerebellar syndrome was established. MRI revealed a heterogeneous tumoral lesion, wholly occupying the fourth ventricle, with brainstem compression and edema Figure -C.Diagnostic cerebral angiography revealed a 27-mm giant, partially thrombosed, saccular aneurysm in the left PICA (Figure The patient was operated on via a lateral suboccipital approach, in which the angiographic findings were corroborated: a giant saccular aneurysm in the fourth segment of the PICA. Surgical clipping of the remnant neck with a 7-mm fenestrated clip was uneventful, and remodeling the aneurysm's dome relieved the mass effect exerted over the brainstem. Postoperative CT angiography revealed aneurysm exclusion and patency of distal vessels Figure .The cerebellar symptoms improved in the following weeks after the operation.Aneurysms from the vertebrobasilar system are rare, accounting for only 5%-10% of all intracranial aneurysms. The most common sites where these lesions occur are the bifurcation of the basilar artery and the origin of the PICA. When present in the distal portion of the PICA, they have been reported to represent from 0.5% to 6%. These lesions are referred to as giant when they exceed 25 mm in diameter. Most of these aneurysms present as partially thrombosed, but sometimes they can be occluded, making differential diagnosis with tumors a defying task .Giant intracranial aneurysms often present with brainstem mass effect symptoms, multiple cranial nerve palsies, brainstem dysfunction, or hydrocephalus, which can be mistaken for neoplasms, as illustrated in our case, especially those that are entirely thrombosed ,6. Only Murrone et al. reported in their study that only 17 cases, in addition to the one previously published by them, of distal PICA aneurysms treated surgically have been reported so far. In most cases, good results are achieved, demonstrating that despite being a rare pathology, surgical management in highly specialized centers with vascular neurosurgeons is a viable option .Recent studies proposed using methods such as standard endosaccular occlusion or stenting to manage vertebrobasilar circulation aneurysms by endovascular therapy. Endovascular parent artery sacrifice is a good option for distal PICA aneurysms, as the length and tortuosity of the vessel make selective catheterization unsuitable. If an occlusion occurs, it is typically well-tolerated clinically. On the other side, surgical management remains the mainstay of treatment when compressive symptoms due to the mass effect are present, as in the present case. Hall et al. also mentioned that giant distal PICA aneurysms can be managed surgically with relatively low morbidity and good results .Giant aneurysms may be approached in many ways. CT scans appear as round- or oval-shaped masses, with distinct appearances depending on the amount of intra-aneurysmal thrombosis and can be easily mistaken for neoplastic lesions. Partially thrombosed aneurysms may enhance moderately and show the “target sign,” while complete thrombosis may appear as a homogeneous mass without enhancement. However, a CT scan may not be enough to make a specific diagnosis. Angiography remains the most accurate diagnostic modality to get to a precise diagnosis. It shows the origin and definitive characteristics of the lesion used in the treatment planning.


Glomus tympanicum is a slow-growing benign tumor that can be locally destructive, spreading along the path of least resistance. Conventionally seen as soft tissue mass in the middle ear, it is difficult to distinguish glomus tympanicum from other soft tissue masses of the tympanic cavity, especially as it hides behind an intact tympanic membrane. The primary diagnostic modalities are CT scan and MRI for evaluation of the exact anatomical extent and size of the glomus tumors. Embolization following an angiographic study helps to identify the feeding arteries with subsequent blocking of the same, thus helping in the reduction of intraoperative hemorrhage. The currently available modalities of treatment are mainly surgery and radiotherapy.Here, we report a case of a 40-year-old female who presented with unilateral deafness and tinnitus, with no co-morbidities. She showed a red bulging mass behind an intact tympanic membrane on otoscopy and otomicroscopy with mild conductive hearing loss. MRI showed an intensely enhancing lesion in the mesotympanum and hypotympanum along the cochlear promontory. A diagnosis of glomus tympanicum was made based on clinical, audiological, and radiological findings. Pre-operative embolization was carried out 48 hours before the surgery. Complete resection of the tumor was achieved by microsurgery.  Glomus tumors, also called nonchromaffin cell paragangliomas, arise from neural crest cells . In the Glomus tympanicum commonly develops in the fifth to sixth decades of life. The most common presenting symptoms are conductive hearing loss and pulsatile tinnitus and are typically seen as a soft tissue mass behind the intact tympanic membrane . Glomus Morbidity is associated by virtue of the anatomical location of the tumor at the skull base adjacent to the posterior cranial fossa as well as the lower cranial nerves affecting deglutition and phonation, even though the tumor is indolent and generally benign in nature. Glomus tumors spread from their site of origin along the tracts of least resistance, the most important of which are the air cells of the temporal bone. Spread occurs along several fronts simultaneously and is multidirectional. Cochleovestibular destruction is caused by ischemic necrosis . CranialBy consensus, the management of glomus tumors is surgical. Nevertheless, the surgery versus radiation therapy and stereotactic radiosurgery debate continues to rage. A 40-year-old female patient presented to the outpatient department (OPD) with chief complaints of gradually progressive left ear hearing loss and pulsatile tinnitus for one month. She also complained of dizziness of a similar duration, which was of a spinning type not related to any postural variation. There was no history of any ear discharge, otalgia, aural fullness, or any other ear complaints. There was no history of nausea or vomiting.On otoscopic examination, the left ear showed a bright reddish hue present over an intact bulging tympanic membrane, suggestive of a vascular mass behind the tympanic membrane Figure . On applHigh-resolution computed tomography (HRCT) temporal bone showed a contrast-enhanced lesion occupying the mesotympanum on the left side. MRI scan of temporal bones was suggestive of a well-defined soft tissue intensity, intensely-enhancing lesion in the middle ear cavity along the cochlear promontory occupying the mesotympanum and hypotympanum with no evidence of extension into the aditus or left mastoid antrum or external auditory canal (EAC) Figure . This waThe patient was subjected to preoperative prophylactic tumor embolization after doing digital subtraction angiography (DSA), which showed the hyper-vascular tumor being supplied by the inferior tympanic branch of ascending pharyngeal artery, petrous branch of the middle meningeal artery, and stylomastoid branch of the occipital artery. The post-procedure angiogram showed a significant reduction in tumor blush with a small residual supply from the petrous branch of the middle meningeal artery and the stylomastoid branch of the occipital artery Figure .Post embolization, the patient was then taken for tumor excision by the post-auricular approach. After posterior meatotomy, the tympanomeatal flap was raised to inspect the tumor in the middle ear. The tumor was found to be adherent to the mucosal layer of the tympanic membrane, ossicles, and the promontory occupying mesotympanum and hypotympanum Figure . CompletHistopathological examination showed well-circumscribed and well-capsulated tumors composed of vascular spaces lined by endothelial cells. Focal areas showed cells arranged in zellballen pattern or nested pattern. Immunohistochemistry was positive for synaptophysin, chromogranin, and CD 34 in blood vessels. This favored a diagnosis of Glomus tympanicum.Postoperatively, the audiometric evaluation of the patient showed closure of the air-bone gap and, clinically, the patient improved significantly with no complaints of tinnitus and significant hearing loss anymore.Arising from the neuroectodermal tissue, paragangliomas are slowly progressive, benign tumors. There are two groups of paragangliomas that are seen to occur in the head and neck region: cervical paragangliomas and temporal bone (jugulo-tympanic) paragangliomas. The jugulo-tympanic type of paragangliomas comprises glomus tympanicum and glomus jugulare while the cervical group consists of carotid body and glomus vagale tumors . The incGuild, in 1941 described “glomic tissue” in temporal bone as a vascular tissue in the dome of the jugular bulb and the promontory of the middle ear for the first time . SubsequThe jugulo-tympanic paraganglions are spherical, lobulated structures measuring 0.1-1.5 mm in diameter . The infThe biochemical capacity of the glomus tumors is indeed rich. Its potential to produce neuroendocrine secretory products permits anticipation of a variable clinical symptomatology and those tumors that secrete sufficient quantities are known as "functional" tumors or "secretors." Norepinephrine levels elevated three to five times normal generally produce the symptoms and signs of catecholamine secretion, such as headaches, excessive perspiration, palpitations, pallor, and nausea .Perioperative management is essential to safeguard against grave consequences of catecholamine overload on anesthesia induction or intraoperatively on tumor manipulation. Modern protocols for pharmacologic blockade employed for a pheochromocytoma are used . Alpha- The clinical features of glomus tumors serve to alert the physician to a disorder of the ear, temporal bone and jugular fossa. The patient with glomus tumor usually complains of pulsatile tinnitus and/or hearing loss. Conductive hearing loss occurs as a result of the tumor growth into the mesotympanum and the labyrinthine invasion determines the degree of the sensorineural component depending on the level of extent. Tympanic membrane erosion and bleeding are late symptoms . CranialA mesotympanic vascular mass is characteristic but rarely may be absent. Superior mesotympanic masses can occur in glomus tumors but are rare and diagnostically confusing. Margins visible 360 degrees about the circumference of a mesotympanic mass permit the diagnosis of a tympanicum lesion . WithoutIn view of its location, a successful resection of these tumors may become a very challenging process for the treating surgeon. This may further be complicated by the vascular nature of the tumor. As a measure of caution, an elective preoperative embolization can be planned, which will help bleeding complications . TherefoOur patient presented with a classical combination of features viz. conductive hearing loss, tinnitus and a red bilging mass behind an intact tympanic membrane. MRI showed a vascular mass occupying the middle ear completely (Glasscock-Jackson Type II tumor). Inferior tympanic branch of the ascending pharyngeal artery, petrous branch of the middle meningeal artery, and stylomastoid branch of the occipital artery. Blood supply was mainly noted from the inferior tympanic branch of the ascending pharyngeal artery, petrous branch of middle meningeal artery and stylomastoid branch of the occipital artery. After appropriate embolization, a residual blood supply from the middle meningeal artery was noted. The patient underwent surgical excision during which the tumor was found exclusively in the middle ear, over the promontory, around the handle of malleus and near the incudostapedial joint. This coincided with the radiological finding of the Glasscock-Jackson type II tumor. Excision was in toto with tumor size being 0.8 cm approximately. As in our case, the treating physician should also consider the differential diagnosis of a glomus tumor so as to prevent any disastrous complication such as an intraoperative hemorrhage. Physicians should be open to modalities such as preoperative embolization as it has shown promising prevention of excessive intraoperative hemorrhage, as was done in our case. Preoperative planning and approach should also be planned with due consideration of all the risks involved.Therefore, in any patient presenting with reduced hearing, vertigo, and tinnitus, a careful otological and otomicroscopic examination is absolutely necessary during a clinical examination by all treating physicians. Also, the role of imaging and interventional radiology cannot be stressed more for better diagnostic and therapeutic management.


Middle cerebral artery (MCA) duplication is a rare anatomical arrangement where an anomalous MCA arises from the distal end of the internal carotid artery. If occluded, a duplicated MCA can present with significant deficits comparable to an occlusion of the M2 vessel without obvious findings on vessel imaging via computed tomography angiography (CTA) or magnetic resonance angiography.A female in her 30s with no past medical history presented with suspected acute stroke 8 hours after last known normal-featuring new-onset right-sided weakness, facial droop, and slurred speech, which corresponds to a National Institutes of Health Stroke Scale score of 13. Head CTA was interpreted as preserved patency of intracranial vessels. CT perfusion was suggestive of a large area of penumbra. Emergent cerebral angiography demonstrated MCA duplication on the left side with proximal occlusion of the M1 branch supplying the traditional M2 territory. Mechanical thrombectomy achieved grade TICI 2b reperfusion. Throughout her hospital stay, her aphasia started to resolve, and the patient was discharged to inpatient rehabilitation.This case presents a diagnostic challenge and learning point in identifying similar patients in the future. We suggest the clinician, given a high clinical suspicion for large vessel occlusion, even if CTA is negative, to continue with CT perfusion to not miss stroke in patients with MCA duplication. If CT perfusion shows substantial deficit in an MCA distribution, one must consider that the patient may have an MCA duplication. In 1973, Teal et al. defined a middle cerebral artery (MCA) duplication as an anatomical arrangement where an anomalous MCA arises from the distal end of the internal carotid artery (ICA) ,3. When This discrepancy between the clinical presentation and imaging findings can lead to a delay in revascularization, and in turn potentially reversible deficits becoming permanent. In the report below, we describe a case with an acutely obstructed, duplicated MCA in a patient who then received mechanical thrombectomy to bring awareness of this possibility to readers to avoid missing similar arrangements.A female in her 30s with no reported past medical history presented to the emergency department (ED) with suspected acute stroke 8 hours after her last known normal. She had awoken with new-onset right-sided weakness, facial droop, and slurred speech, corresponding to a National Institutes of Health Stroke Scale (NIHSS) score of 13. While in the ED, she became increasingly confused with new-onset aphasia resulting in further worsening of her NIHSS. Emergent non-contrast head CT showed a small area of hypodensity in the left parietal lobe. Head CTA was obtained and was interpreted by an on-call radiologist as preserved patency of intracranial vessels though later re-interpretation with hindsight revealed a proximal MCA occlusion as seen in Figure Cerebral angiography demonstrated that the patient had MCA duplication on the left side, with proximal occlusion of one of the two M1 branches as seen in Figure This case demonstrates the difficulties in diagnosing a proximal MCA stroke in a patient with MCA duplication. Prompt diagnosis of this emergent large vessel occlusion (ELVO) is vital so that the patient can be taken for mechanical thrombectomy as soon as possible to restore perfusion to the penumbra before temporary deficits become permanent. In the above-mentioned patient, though there was high clinical suspicion for an ELVO given her hemiparesis and aphasia, CTA was initially interpreted as no occlusion since the second MCA on that side was still patent. However, the CT perfusion scan revealed a large area of ischemic penumbra, suspected at the time to be due to an ELVO not shown on the CTA. The diagnosis of proximal MCA occlusion in one of two left MCAs was then made by digital subtraction angiogram (DSA). Only after a thorough review of the initial CTA under the bias of hindsight were we able to identify the second MCA with proximal occlusion superimposed with the ‘normal’-appearing MCA as demonstrated in Figure The case described above presents a diagnostic challenge in identifying similar patients in the future. Since the duplicated MCA arises from the ICA terminus, it is easy for a practitioner to glance at the CTA and note patency of the intracranial vessels without catching the obstructed anomaly. To prevent this, we suggest the clinician, who has a high clinical suspicion for ELVO, as in the case described above, even if a CTA is negative, to continue with CT perfusion so as to not miss a stroke in a patient with MCA duplication or another similar anomaly. Automated applications for ELVO detection such as those provided by RAPID.AI and VIZ.AI are designed to automatically identify potential thrombectomy-eligible cases on CT or MR angiogram images ,6. WhileThough this report details merely one patient’s presentation, it suggests that if CT perfusion shows substantial deficit in an MCA distribution, one must consider that the patient may have an MCA duplication, or other rare anatomic variant, thus skewing the normal interpretation of the CTA. They should then be taken for emergent DSA and thrombectomy to preserve the susceptible penumbra seen on CT perfusion.MCA duplication is a rare anatomical arrangement where an anomalous MCA arises from the distal end of the ICA. Timely identification of an acutely occluded duplicated MCA is critical in reversing its ‘M2-like’ neurologic deficits. Recognition of this anatomic variant is challenging because in these patients CTA appears to show patency of all intracranial vessels.


Aortocaval fistula (ACF) is a rare complication of abdominal aortic aneurysm (AAA), occurring in less than 1% of all AAAs.Paradoxical embolism can rarely be associated with ACF, pulmonary embolism may originate from dislodgment of thrombotic material from the AAA in the inferior vena cava (IVC) through the ACF.We report a case of a patient admitted to the emergency department with abdominal pain and shortness of breath who immediately underwent thoraco-abdominal CT. Imaging allowed a prompt pre-operative diagnosis of an ACF between an AAA and the IVC, also identifying CT signs of right heart overload and the presence of a paradoxical pulmonary embolism. A 57-year-old male patient was admitted to our emergency department (ED) with diffuse abdominal pain, shortness of breath, cold sweat and palpitations.On physical examination the patient, with a BMI of 30.7, presented mottled skin of umbilical region and lower extremities; femoral pulses were symmetrically present, while distal ones were absent and he referred leg pain. He was a heavy smoker, without medical history.Vital signs were as follows: body temperature 36.5°C, blood pressure 100/60 mm Hg, heart rate 120 beats/min and polypnea.Laboratory analysis  revealedThe patient underwent a bedside ultrasound in the ED, which showed a large abdominal aortic aneurysm (AAA), without clear signs of rupture. Therefore, a contrast-enhanced multi-detector CT scan was immediately requested.−1 at 4 mL/s) was performed using a 128-slice Flash Dual-Source CT scanner . A bolus tracking in the descending aorta, with an attenuation threshold of 120 HU, was used to optimize the imaging of the aorta; an arterial phase with a 10 s delay after reaching the threshold and a venous phase (60 s delay) were obtained. Images were reconstructed with 3 mm and 1 mm collimation. Post-processing included multiplanar reformation (MPR), maximum intensity projection (MIP) and volume rendering technique (VRT) reconstructions.A multi-phases thoraco-abdominal CT with contrast injection  and hepatic veins associated with a large aorto-bisiliac aneurysm , extended into the iliac bifurcation bilaterally. On axial images, an aortocaval fistula was identified, confirmed on MPR reconstructions, located just above the level of the confluence of the iliac veins. No signs of retroperitoneal rupture of AAA were detected .AAA was characterized by concentric thrombotic apposition (thickness 20 mm) with adequate proximal neck. Other findings included dilatation of the IVC  and CT signs of right heart overload: atrial and ventricle dilatation, cardiac axis clockwise rotation, straightened interventricular septum .Last but not least, bilateral acute pulmonary embolism was detected, without CT signs of parenchymal infarctions. Segmental and subsegmental arteries were involved with often complete filling defect ; main anAfter a prompt multidisciplinary evaluation, a surgical approach was chosen, mainly due to a lack of bilateral distal neck necessary for an endovascular treatment.The patient was submitted to open repair. After median laparotomy, aorta, iliac arteries, IVC and right common femoral vein were isolated to obtain proximal and distal bleeding control. Systemic heparinization with 5000 UI was performed. Aorta and iliac arteries were clamped before sac’s incision.®. Subsequently, an aorto-bisiliac reconstruction with Dacron ® prosthesis (20 × 10 mm) was performed; right hypogastric artery was closed while the left one was saved using Gore® vascular graft   was identified and repaired using continues suture with 3/0 Prolene na, USA) .At the end of the procedure a good refill of IVC, without apparent stenosis, and a valid hypogastric pulsation were obtained.1The rupture of an AAA into the inferior vena cava with fistula formation is a rare condition, occurring in less than 1% of all AAA and in 0.3–11.3% of ruptured AAA, but is associated with a high mortality rate.2 Less common causes of spontaneous ACF include mycotic aneurysm, syphilis, and disorders of connective tissue, such as the Ehlers–Danlos and Marfan syndromes.3The most common site of the ACF is the inferior vena cava, with iliac veins being rarely affected. ACF may coexist with a retroperitoneal rupture or may be isolated, as in our case.1,4The presence of an ACF determines a diversion of blood flow from the high-resistance arterial circuit to the low-resistance venous circuit. This produces a decrease in total peripheral resistance and an increase in venous resistance, pressure and volume, causing right heart overload and high-output cardiac failure.1,4,5To our knowledge very few cases of pulmonary embolism associated with ACF have been so far described in the literature. Pulmonary embolism may originate from dislodgement of thrombotic material from the AAA in the IVC through the ACF . Another source may be the presence of clots developed from venous stasis due to cava compression from the aortic aneurysm.1,3,6Clinical symptoms and findings vary in a wide range and early diagnosis and intervention can be lifesaving. The classic clinical triad of ACF, although not always present, is: abdominal or low back pain, palpable aneurysm and abdominal bruit. Other clinical signs may be present and most likely related to the arterio-venous shunt.In our case, patient presented with abdominal pain and clinical sign of a palpable abdominal mass. The abdominal bruit was retrospectively investigated after the CT and reported positive. He also presented shortness of breath, palpitations, leg pain due to peripheral ischemia, and marbled legs related to venous hypertension.Diagnosis of ACF may be challenging for clinicians, so a prompt emergent imaging is mandatory.1,7,8Typical CT findings of ACF include early detection of the contrast medium in the IVC and occasionally the direct visualization of the pathological shunt between abdominal aorta and IVC or iliac veins.In our case, CT diagnosis was immediately established due to the early full enhancement of the dilated IVC with direct visualization of the fistula. Bilateral segmental and subsegmental pulmonary embolism was observed.9 Although no CT findings suggestive for COVID-19 pneumonia were present, and although the patient did not present any other pulmonary symptoms suggestive for COVID-19, a RT-PCR testing on intra operative broncho-alveolar lavage (BAL) was performed and SARS-CoV-2 infection was excluded.Our country is currently frontline in the management of the novel Coronavirus pandemic, therefore, ruling out a potential relationship between pulmonary embolism and SARS-CoV2 infection was necessary.As a result, pulmonary embolism was attributed to a dislodgement of the mural thrombus through the fistula into the IVC . Even if infrequent, our case highlights the necessity to exclude pulmonary embolism in all patients with ACF, especially when AAA presents with a large thrombotic apposition.Therefore, in the immediate post-operative period, a major problem is represented by the management of anticoagulant therapy to prevent pulmonary embolism.After the intra-operative administration of 5000 IU Low Molecular Weight Heparin (LMWH), the patient was managed with 4000 IU LMWH twice a day for 7 days and then 6000 IU twice a day until his discharge with the indication to continue the treatment until the first post-operative follow-up.1,6 In these cases, during follow-up a risk of IVC stricture caused by fibrotic reaction should be considered.In the current literature, endovascular repair is considered to be preferable than open repair (OR) because of less surgical stress and shorter hospitalization. However, in the present case, OR was chosen as the treatment option due the lack of bilateral distal neck related to a bilateral aneurysmatic involvement of the iliac bifurcation. Operative treatment includes repair of the fistula with direct suture of the caval defect from inside the aortic lumen and surgical reconstruction of the aorto-iliac axis with a prosthetic graft.1,3,5In conclusion, spontaneous ACF caused by aneurysmal rupture is an uncommon condition; its presence can be fatal for potential congestive right heart failure. Since clinical symptoms may be nonspecific, a prompt diagnosis, ideally prior to surgery, is mandatory. In fact, as reported in the literature, intraoperative diagnosis, has a higher mortality rate.In most cases instability and severity of symptoms require prompt surgical or endovascular treatment carried out by a skilled team in a well-equipped center.Aortocaval fistula (ACF) is a rare complication of abdominal aortic aneurysm and its presence can be fatal for potential right heart failure.In presence of an ACF, the dislodgment of thrombotic material from the aorta in the inferior vena cava can lead to paradoxical pulmonary embolism.CT angiography can detect the ACF and the pulmonary embolism, leading to a prompt pre-operative diagnosis.


However, RFCA is associated with perioperative problems, such as systemic embolization, and asymptomatic brain infarction is frequently detected by magnetic resonance imaging immediately after RFCA for AF.An 81-year-old man with a history of myocardial infarction, diabetes mellitus, hypertension, and chronic kidney disease experienced multiple episodes of presyncope associated with paroxysmal AF. He underwent RFCA along with loop recorder implantation  to detect AF recurrence at another hospital.2 score, 3 points; CHA2DS2-VASc score, 5 points). In addition to aspirin (100 mg/day) for post–coronary stent implantation, an anticoagulant agent, rivaroxaban (10 mg/day), was prescribed in the perioperative period of RFCA. This is an appropriate dose for Japanese patients.2 score ≥ 2), continuation of anticoagulation for as long as possible is recommendedThe patient had a high risk of developing stroke owing to his advanced age, history of myocardial infarction, and the presence of comorbidities such as hypertension and diabetes mellitus (CHADS2). Large, abnormal structures with beaded appearance were detected in the left atrium  using warfarin, which was chosen because the thrombus in the left atrium had formed under anticoagulation by direct oral anticoagulants, and we believed that more aggressive and monitored anticoagulation was needed. Five months after surgical treatment, transesophageal echocardiography indicated no recurrence of the thrombosis in the left atrium. We continued anticoagulant treatment for 1 year until his malignant findings became apparent.This case highlights that RFCA carries a risk of thrombus formation, leading to a periprocedural complication of systemic embolization. To the best of our knowledge, there are few reported cases of giant thrombus in the left atrium associated with RFCA. In a case similar to ours, a giant left atrial mass was found in a 71-year-old man who had undergone RFCA for AF 3 months before.2 score, he was found to have essential thrombocythemia and carcinoma after the cardiac surgery. Even though these diseases were undiagnosed at the time of ablation, they may have promoted thrombus formation after the procedure. Thrombus formation in cancer patients is associated with proliferation and metastasis.In our case, the patient was at high risk of thromboembolism. In addition to the high CHADS•This report summarizes a rare case of brain infarction and amaurosis fugax due to a giant left atrial thrombus 3 months after radiofrequency catheter ablation (RFCA) for atrial fibrillation (AF) in an 81-year-old man.•Cardiac thrombectomy revealed that the thrombus was on the ablation line, suggesting that the endothelial damage with RFCA may have promoted thrombosis.•This patient had essential thrombocythemia and advanced malignant cancer, both of which are risk factors for thromboembolism. This case suggests the importance of evaluation for the risk of thromboembolism after RFCA, even in cases with adequate anticoagulation or nonrecurrence of AF.We report a rare case of brain infarction and amaurosis fugax due to a giant thrombus in the left atrium after RFCA for AF. In this case, essential thrombocythemia and cancer, as well as endothelial damage with RFCA, may have promoted thrombosis. It is important to recognize this complication when patients who undergo RFCA show signs of thromboembolism, particularly in cases at high risk of thrombosis.


We describe a unique case of bilateral acquired vitelliform lesions in a 67-year-old-female with pachychoroid associated with subretinal fluid in the right eye (OD) and a nonexudative choroidal neovascular membrane (CNVM) in the left eye (OS). Multimodal imaging performed at baseline and over the ensuing two years showed an increase in the OS vitelliform lesions with a concurrent transformation of quiescent CNVM to an exudative form. Further studies are warranted to gain better insight into the etiopathogenesis of these vitelliform lesions in pachychoroid and their potential role in instigating CNVM activation. Acquired vitelliform lesions (AVL) are a focal or multifocal subretinal accumulation of autofluorescent material reported in various dystrophic, degenerative, paraneoplastic, toxic, and vitreoretinal interface disorders involving the macula . The natA 67-year-old lady with a history of hypertension, dyslipidemia, and ischemic heart disease presented to us with complaints of diminution of vision in the right eye for 1.5 years. Her best-corrected visual acuity (BCVA) was 20/40 in the right eye (OD) and 20/20 in the left eye (OS). OU anterior segment was normal. Fundus examination showed patterned retinal pigment epithelial (RPE) alterations in OD and nonspecific RPE changes in OS, seen better on multicolor imaging Figures . VitelliSerial infrared reflectance IR;  and SD-OThe purpose of this case report was to highlight the conversion of quiescent PNV to an exudative network with progressive deposition of AVL. We also illustrate the role of OCTA in detecting quiescent networks that are likely to be missed on dye-based angiography and for their periodic noninvasive monitoring. Additionally, intravitreal ranibizumab monotherapy can be successfully used to treat PNV in the presence of AVL.In the current case, there was presence of bilateral pachychoroidopathy with AVL deposition. One eye showed spontaneous resolution of the deposits while the other eye having PNV demonstrated recurrent deposition with the onset of exudation. Freund et al. had reported features of AVL eyes demonstrating the natural history and imaging characteristics of these lesions . 2.2% ofWe believe that in pachychoroid eyes, the dilated outer choroidal vessels with a resultant choriocapillaris compression led to a primary RPE dysfunction. This can alter the physiological homeostasis of the RPE and neurosensory retina causing poor phagocytosis of the shed outer segments that can accumulate over time as the vitelliform lesions. Spontaneous resolution may occur when there has been sufficient photoreceptor loss to allow for the normal mechanisms of photoreceptor outer segment turnover to “catch up,” whereby RPE phagocytosis of the abnormal subretinal material may occur . This phAlthough many eyes having primary pattern dystrophy with vitelliform deposits are misdiagnosed as age-related macular degeneration (AMD), central serous chorioretinopathy (CSCR), or nonspecific RPE changes , the conIn conclusion, our case highlights the presence of vitelliform lesions in pachychoroid eyes. We noted the transformation of a subclinical PNV to an exudative one with progressive deposition of vitelliform lesions. To the best of our knowledge, this is the first case report to describe the simultaneous occurrence of these two pathologies, namely, PNV and AVL. More research is needed to ascertain whether the simultaneous occurrence of these two pathologies is linked to each other or is a mere coincidence.


Hydatidosis is a parasitic disease, endemic in various parts of the World. It frequently involves liver and lungs and, rarely, other organs as well. Isolated renal hydatidosis is a rare entity that accounts for less than 3% of all hydatid cases. Surgery remains the mainstay of treatment. We hereby report a case of isolated renal hydatid cyst involving left kidney that was managed by laparoscopic approach. Human hydatidosis is endemic in several parts of World including Indian subcontinent, parts of Africa and Middle-East Asia. The disease usually occurs in persons having close contact with dogs, sheep and cattle . In humaA 26 years old gentleman, presented to outpatient department with the complaints of pain in left hypochondrium for the last 5 to 6 months. The pain was initially mild, intermittent and dull in nature. However, since last one month the pain was constant, requiring daily oral analgesics. There was no history of fever, anorexia, weight loss or any urinary or bowel symptoms. There was no history of any abdominal trauma as well. He was non-vegetarian, teetotaler and did not smoke. On inquiry he revealed past contact with pet dogs till 5 years ago. On examination, his vitals were within normal limits. Abdominal palpation revealed a vague, non-tender lump in the left hypochondrium. The lump was immobile and there was no movement with the respiration either. Blood tests and urinalysis were normal. Patient was also evaluated elsewhere before reporting to us. Ultrasound abdomen done there showed a well-outlined complex cystic lesion, measuring 11 x 8cm containing echogenic fluid collection and arising from infero-medial aspect of left kidney. Computerized tomography (CT) scan reported similar findings .Once the diagnosis of renal hydatid cyst was made, patient was started on Albendazole therapy at a dose of 400mg BD. He was planned for laparoscopic surgery after 2 weeks. The surgery was performed in supine position under general anaesthesia. Laparoscopic transperitoneal approach was used to access the cyst. Two 5-mm working ports were placed in the epigastrium and right paraumbilical region in the mid-clavicular line. Descending colon was reflected medially by incising the lateral attachment and cyst was exposed . Gauze pHydatid cystic disease is a parasitic infection caused by the larval form of Echinococcus species. The parasite inhabits the small intestines of infected dogs that serve as the primary host. The infected dogs excrete a large number of parasite eggs in its stool. Lamb, cattle, goats, or sometimes humans swallow these eggs. Humans are dead-end hosts and get infected through contact with the infected definitive host or ingesting contaminated soil, water or vegetables. After ingestion, the eggs hatch and produce larva in the small intestine of the host. The larvae penetrate the jejunum and gains access to the venous and lymphatic system. Through these routes, they reach various organs and develop into hydatid cysts. Liver and lungs act as primary and secondary filters, whereas genitourinary involvement is very rare .Approximately 3% of the larvae that escape from these filters enter the systemic circulation and affect other systems. Kidneys are concomitantly affected as a part of secondary infection and isolated involvement is very rare , 2. MostThe differential diagnosis of renal hydatid cysts can be challenging even in endemic areas. The combination of clinical history, imaging studies and serological tests yields a reliable diagnosis in only 50% of cases . Renal hThe treatment modalities of renal hydatid cyst include medical management, percutaneous intervention and surgery by open or minimally invasive approach. Medical management in the form of Mebendazole or Albendazole has been the recommended for hepatic hydatid cyst . HoweverPercutaneous management of renal hydatidosis has also been described. PAIR  can be an alternative treatment for renal hydatid cysts that do not communicate with the urinary collecting system . SurgeryRecently, laparoscopic management of hydatid cyst has gained increasing popularity. Both transperitoneal and retroperitoneal laparoscopic approaches have been reported for renal hydatid cyst. The former approach has been considered superior in some studies as it allows more working space with less chances of cyst rupture . LaparosSurgery remains the mainstay of treatment of renal hydatid cyst. The growing evidence suggests that laparoscopic approach may be feasible and safe in treating this rare clinical entity.


In this work, we reported a young man complaining of asthenia and intermittent fever for 10 days, and an ultrasound showed an undefined lesion on his liver. Facing the patient's situation with severe agranulocytosis, anemia, and thrombocytopenia, we passed through a tough diagnostic process for choosing an appropriate treatment for him with an ambiguous result of pathological biopsy. The undefined liver lesion was successfully solved by withdrawing the androgen for observation, without lobectomy. The lesion gradually diminished over 2 years of follow-up. Androgen-related hepatic adenoma happens occasionally in people who take androgen for therapy , such as2. On deep palpation he had increased mild tenderness of the right upper abdominal quadrant. His admission test was significant for declined leukocytes level , declined erythrocytes level  and declined platelets level . Alpha fetoprotein (AFP) and carbohydrate antigen 19-9 were normal. His abdominal magnetic resonance imaging showed the lesion was markedly hyperintense at T2 with a range of 65.0 × 45.0 mm, and normal liver contour with no signs of liver cirrhosis. The mass was enhanced in the arterial phase and persisted in the portal venous and hepatobiliary phases  and immune inhibitor therapy. In this patient, liver biopsy revealed that the focal area of the liver plate was thickened with more pseudo-adenoid structures, slightly alien cells. Nevertheless, there was still divarication over the diagnosis of either benign or malignant as immunohistochemical stains for hepPar-1, glutamine synthetase, and heat shock protein 70 were positive, which are hepatocellular carcinoma markers . But cel obvious .The key to the correct diagnosis is recognizing that the presence of a liver mass in the background of normal liver parenchyma is unlikely to represent hepatocellular carcinoma, especially at a normal AFP level. Considering the patient's past medical history, negative blood tests, and the pathology of liver biopsy, the final diagnosis was identified as androgen-related hepatic adenoma. Then we withdrew the androgen for observation. Surprisingly, the lesion shrank significantly after 38 days. The patient was transferred to the department of hematology and completed hematopoietic stem cell transplantation. The lesion diminished gradually over a two-year follow-up .Gonadal hormones can induce adenoma described by Baum et al. first . HepaticAndrogen-related hepatic adenoma is not a malignant tumor. A rash choice of surgery will undoubtedly increase the incidence of intraoperative hemorrhage, postoperative infection, liver failure, and even death, and surgical intervention should be considered if there is sudden massive bleeding or malignant tendency . Non-negThe original contributions presented in the study are included in the article/supplementary material, further inquiries can be directed to the corresponding author/s.The study was approved by the ethics committee of the Second Affiliated Hospital of Dalian Medical University. Written informed consent was obtained from the patient to have the case details and any accompanying images published.JL, JS, ZG, JB, JY, and LW developed the main concept and designed the study. JL drafted the manuscript and JS edited it. DS literature search and data collection. KG assisted with the pathology part of the manuscript. LW supervised the whole process. All authors participated in the management of the patient in this case report.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


The Allurion Elipse™ device is a swallowable balloon in the form of a capsule placed without endoscopy that serves the same purpose as an intragastric balloon (IGB) used for weight loss. We report a case of a 43-year-old female who presented with a complete gastric outlet obstruction confirmed by computed tomography (CT) scan. The patient initially failed conservative management; therefore, the IGB was later removed endoscopically. This is a rare complication and one of the first cases described in the literature; therefore, further studies are needed before its widescale implementation. The Allurion Elipse™ device is a swallowable balloon in the form of a capsule that is placed without endoscopy. The scope is to function as a bariatric balloon for weight loss that gradually degrades over time so that four months after placement, it deflates and then is expelled safely through the gastrointestinal tract. The balloon is usually filled with 550 mL of saline solution through a thin catheter after being swallowed . AlthougA forty-three-year-old female with no significant medical history but status post abdominoplasty and breast enhancement surgery presents to the hospital with ongoing abdominal pain for three weeks. The patient reported to have had a bariatric surgical procedure in the Dominican Republic consisting of an Allurion Elipse™ balloon placed into her stomach Figure . The devAt the moment, the device Allurion Elipse™ is not yet FDA approved for use in the United States. While some health authorities outside of the US have a more liberal approach, it is paramount that more studies and research are performed on this device before its introduction into the North American market. While its way of being deployed and extracted without undergoing anesthesia or endoscopy seems appealing for many patients and providers, more studies are needed for definitive recommendations on the potential carcinogenic risk deriving from the device being in direct contact with the digestive tract lining even after deflation -6. FurthAlthough initial data showed that the Elipse™ intragastric balloon to be safe overall, serious complications can still occur. As medical providers, we are not able to release definitive recommendations on the safety of the Allurion Elipse™ balloon until further studies and trials are available in the literature.


Primary intracranial malignancies with extra-skeletal myxoid chondrosarcoma (EMC) features are extremely rare. EMC constitutes a distinct genomic entity characterised by reciprocal translocation of fusion genes, most commonly EWS RNA Binding Protein 1 (EWSR1) in 22q12 with Nuclear Receptor Subfamily 4 Group A Member 3 (NR4A3) in 9q2-q31.1. It is reported to have a high propensity for local recurrence and has potential for metastasis. So far in 28 years since its first description, only 17 cases of primary intracranial EMC were reported in literature. This would be the second case of intraventricular origin and first case from lateral ventricle.A 27-year-old male presenting with complaints of headache, seizures and pain in neck was diagnosed to have a mass lesion in right lateral ventricle in Magnetic Resonance Imaging of brain. He underwent right parieto-occipital craniotomy with total excision of the lesion. Initial histopathological examination was reported as Ependymoma, WHO grade II. However, blocks and slides review with immunohistochemistry (IHC) markers revealed neoplastic aetiology with extensive myxoid changes. Hence, fluorescent in-situ hybridisation (FISH) testing was done with EWSR1 break apart probe, which demonstrated EWSR1 break apart signals. Therefore, correlating the clinical findings with morphology, IHC and FISH, the diagnosis of primary intracranial EMC was rendered. Patient received adjuvant external beam radiation of 54 Gy in 30 fractions to the post-op region. At 29-month follow-up, there was no evidence of disease recurrence.Owing to the rarity of the condition, there are no standard treatment guidelines available for primary intracranial EMC. A combined treatment approach with surgery followed by adjuvant radiotherapy provides good local control with less morbidity. Cartilaginous tumours constitute about 0.16% of intracranial neoplasms . Myxoid A 27-year-old male evaluated elsewhere for complaints of headache, seizures and neck pain. Magnetic resonance imaging (MRI) of spine did not reveal any abnormality, whereas MRI brain showed a well-defined lobulated T1 hypointense, T2 heterogeneously hyperintense mass lesion of size 3.5×3.7×3.6 cm in atrium of the right lateral ventricle causing mass effect in form of dilated occipital and temporal horns of right lateral ventricle and midline shift of 11 mm towards left . ModeratThe postoperative blocks and slides were reviewed in our hospital. Histopathology revealed fragments of lesion with cells arranged in cords and focally in sheets in abundant myxoid stroma. The tumour cells were ovoid to spindle shaped with ovoid nuclei and specked chromatin and moderate bipolar cytoplasm. Focal perivascular arrangement of tumour cells was seen. No significant atypia, mitosis or necrosis identified. A provisional diagnosis of neoplastic aetiology with extensive myxoid change was rendered warranting immunohistochemistry (IHC) examination. IHC with vimentin, cluster of differentiation (CD99), revealed positive results, while Glial Fibrillary Acidic Protein (GFAP), pancytokeratin, CD34, S100 were negative and Ki67 proliferation index was low (1%–2%) . SubsequOwing to the extremely rare occurrence of the disease, case was discussed in multi-disciplinary tumour board and planned for post-operative radiation. Patient was immobilised with a thermoplastic head mask in a supine position and contrast-enhanced CT was taken at 3 mm thickness on a Philips Big bore CT Scan machine. Images were exported to ECLIPSE Treatment Planning system. Pre-op and post-op MRIs were fused with the Planning CT images. Contouring was done on fused images, post-operative bed along with organ at risk  was delineated. A planning target volume was generated around the clinical target volume. A dose of 54 Gy in 30 fractions at 1.8 Gy per fraction using 6 MV photons was delivered to the patient using Rapid-Arc image-guided radiotherapy technique. Patient tolerated treatment well with grade 1 skin reactions and alopecia at the treated site. At 29 months follow-up, patient had no neurological deficit and MRI brain showed no evidence of disease recurrence.Extra-skeletal cartilaginous tumours are thought to be derived from primitive mesenchymal cells or embryonal rests of cartilaginous matrix within the bone or a result of metaplasia of fibroblasts , 25. HisThe symptomatology of EMC is extremely non-specific. It is consistent with any brain lesion with headache, seizures, focal neurological deficit and symptoms due to mass effect/midline shift. MRI is the standard imaging modality of choice. In MRI, primary intracranial EMCs are seen as hypointense well-demarcated lesions in T1-weighted images with slightly higher signal intensity in T2-weighted images and generally lack surrounding oedema , 12–14. In the case discussed above, the patient presented with headache, seizures and neck pain. Both clinical and MRI findings were non-specific. A diagnosis of EMC was never considered at any stage of clinical evaluation. The morphologic diagnosis of ependymoma was rendered at a community centre presumably based on ovoid cells with few bland elongated nuclei and location of the tumour being lateral ventricle. However, when it was reviewed at our centre, the young age, bland appearance of tumour cells which were round to ovoid in a myxoid matrix associated with cord like arrangement, negativity for GFAP & epithelial markers, and strong vimentin & CD99 (membrane) positivity by IHC led us to consider this to be a sarcoma, particularly a myxoid sarcoma , intracranial myxoid sarcoma with EWSR1 translocations). Since we had the EWSR1 break apart probe, we were compelled to do FISH for EWSR1 which demonstrated EWSR1 break apart signals. The differential diagnosis at this juncture consisted of all intracranial myxoid lesions with EWSR1 translocation. The possibility of myxoid (AFH) was ruled out as there was no lymphocytic cuffing or prominence of vasculature. Myxoid liposarcoma was also ruled out due to morphology of cells that lack lipoblasts and no S100 staining. The possibility of myoepithelial carcinoma needs to be ruled out in this setting which was negated by cytokeratin AE1/AE3 and S100 expression by IHC. The other fusion partners of EWSR1 in intracranial myxoid sarcomas include cyclic-AMP response element-binding protein 1 (CREB1), cyclic-AMP response element modulating protein (CREM) and Activating Transcription Factor 1 (ATF1) of which CREB1 being the most common. The Proliferation index (Ki 67) also was substantially low which corroborated with the indolent behaviour of EMC, presumably a tumour with EWSR1-Nuclear Receptor Subfamily 4 Group A Member 3 (NR4A3) fusion. However, NR4A3 by FISH was not available at any centre in the country at that point in time. Therefore, correlating the clinical findings with morphology, IHC and FISH, the diagnosis of EMC was rendered.About two thirds of EMC show chromosomal reciprocal translocation t  q22: q12 resulting in the fusion of EWSR1 gene to NR4A3 –37. A smOn literature review, surgery has been the first treatment modality of choice for primary intracranial EMC. Either total or subtotal resection of tumour was done in all cases depending on site and extent of the tumour  7–23]. –23. 7–23Primary intracranial EMC is an extremely rare malignancy of central nervous system. It is always advisable to do a thorough histopathological examination with IHC markers in all intracranial neoplasms to identify the true histology. EMC should be considered as one of the differential diagnosis, especially when tumour cells appear bland in myxoid matrix with associated cord like arrangement and suggestive IHC markers. Combined modality of treatment with surgery followed by adjuvant radiotherapy results in good local control.Not applicable.Consent for publication was obtained from the patient.The authors declare that they have no competing interests.The authors declare that no specific grant was obtained for this research from any funding agency in the public, commercial or not-for-profit sectors in the design of the study and collection, analysis and interpretation of data and in writing the manuscript.Dr Deleep Kumar Gudipudi contributed to concept, design and proof reading of manuscript. Dr Vinodh Kumar Selvaraj contributed to data collection, review of literature and manuscript writing. Dr Rachna Khera and Dr Sudha Murthy contributed to preparing the histopathology images and in manuscript writing of the pathologic description of the case.


Uterine leiomyoma is a common benign uterine tumor of women in the reproductive age group. Although the common symptoms of leiomyoma are menorrhagia and dysmenorrhoea, this patient presenting as a near collapse is a rare finding. The patient presented with abdominal pain and worsening anemia within a span of hours and hypotension, tachycardia, and tachypnoea needing urgent surgical intervention and blood transfusion and intensive care support is relatively rare. Though every effort to know the exact cause of intraperitoneal hemorrhage in this patient was taken, the rarer diagnosis of capsular venous rupture was not identified prior to surgical intervention. Initially, laparoscopy was introduced first to identify the cause of massive hemorrhage; the approach was changed to open myomectomy keeping in mind the general condition of the patient. Hence, for any patient with a prior diagnosis of myoma with hemodynamic instability, the rarer diagnosis of leiomyomatous capsular venous erosion should be a differential diagnosis to aid in the appropriate management of the women. The team of interdisciplinary expertise will definitely improve the outcomes in such cases. Uterine leiomyomas are the most prevalent benign tumors of women in the reproductive age group arising from the proliferation of myometrial cells  The inciThis patient is aged 34 years, P2 L2 with previous 2 caesarean sections with last child birth 6 years back and had the last menstrual period 21 days back. Her cycles were regular and no prior history of dysmenorrhoea. Bowel and bladder habits were normal. The patient developed mild abdominal pain a day prior. She sought consultation with her primary consultant as her pain worsened since morning. On admission, the patient was evaluated for anemia and her hemoglobin was 8.0 gms%. She was administered pain reliever, and her abdominal palpation revealed a firm mass in the lower abdomen and mild tenderness in the lower abdomen. As then, an ultrasound was done. Ultrasound revealed echogenic free fluid suggestive of intraperitoneal hemorrhage in the abdomen. A myoma of size 15 × 10 cm, 5.9 × 4.7 cm, was seen with an endometrial thickness of 8 mm. Bilateral ovaries appeared polycystic (Figures β-HCG was 1.2 mIu/L. The patient was advised for CT as the cause of hemoperitoneum could not be established. The patient then complained of dyspnoea on lying down and severe abdominal discomfort. Hence, a preoperative diagnosis of intra-abdominal hemorrhage of unknown origin was established with the incidental finding of a uterine fibroid as what happened in 96% of similar cases reported in literature [Meanwhile, attempts were made to rule out other common causes of intraperitoneal hemorrhage such as ectopic pregnancy and corpus luteal rupture. Urinary terature .On examination, the patient was tachypnoeic and had tachycardia and blood pressure 90/60 mmHg. Meanwhile, packed cell transfusion started and the consent for surgical intervention was obtained. A team of gynecologist, general surgeon, and anesthetist formed as the definitive diagnosis was not established as outlined in this study . Under gFibroids subserous in location, about 15 cm and 5 cm, were seen. No evidence of torsion or evidence of degeneration was seen. The uterus was seen to be of normal size. As the collected blood was removed, a gush of blood in the cleft between the fibroids was seen. Venous rupture of the capsule between the two subserous myomas was found. However, as the bleeding from the venous end was profuse, we decided for open myomectomy Video .The base of the myoma was fundal in location, and myomectomy was done. Ovaries are found to be normal. The abdomen closed in layers. The patient was transfused with six units of packed cells and 4 units of fresh frozen plasma.Post-op period was uneventful, and the patient was discharged on the 4th postoperative day. The histopathological diagnosis was benign leiomyoma with no evidence of degeneration Figures  and 4.The causes of hemoperitoneum in connection with leiomyoma include bleeding from a subserosal artery , ruptureThe cause of hemorrhage in this case is venous in origin, and there are no predisposing factors identified for rupture. It has been postulated that a myoma larger than 10 cm can overstretch the covering vessel, resulting in the rupture of the feeding vessel, and two that the myomas can enlarge and split the feeding vessels between the uterine masses . CongestAbdominal pain was the most common symptom described on initial presentation with worsening pain since then. About 83.2% presented with sudden onset lower abdominal pain while 16% experienced a gradual onset over 3–5 days  have beeEstablishing a diagnosis in cases of large pelvic tumors with hemoperitoneum is difficult . In bothThe differential diagnoses are twisted adnexa, ruptured ectopic pregnancy, hemorrhagic corpus luteum, or follicular cyst, while that of the pelvic mass would be ovarian or endometrial carcinoma, uterine sarcoma or leiomyoma, and, rarely, ovarian fibroma . VariousThe definitive treatment of myoma is myomectomy or sometimes hysterectomy either by laparoscopy, hysteroscopy, or laparotomy in tumors of large size . LaparotThe clinicians should be aware of the complications to aid in timely diagnosis and management of such rare catastrophesThe interdisciplinary team of gynecologist, anesthetist, and surgeons would help to tackle cases of uncertain diagnosisFurther research regarding the cause and predisposing factors of such massive hemorrhage in subserous myoma would be life-saving as timely management is rewarding.


Eruption of tooth into place other than tooth-bearing region is defined as ectopic eruption. Although ectopic eruption of tooth is rare, there have been cases in the maxillary sinus, mandibular condyle, nasal cavity, chin, palate, and orbital floor. Due to ectopic teeth's rarity and lack of consensus for ıts treatment, incidence was entitled to be added to literature and discussed. It was reported that odontogenic tumors and cysts can develop around the ectopic tooth. Thus, ectopic teeth can be followed up regularly in case of no signs and symptoms. If the patient has unusual orofacial pain, undiagnosed nasal discharge, maxillary sinusitis, preauricular pain, preauricular fistula, trismus, and lip paresthesia, the patient should be evaluated in terms of ectopic tooth. Whether the patient has signs and symptoms related to ectopic tooth, early intervention for the removal of ectopic tooth along with accompanying lesion is the treatment of choice. Specialists choose intervention way based on their experience. When selecting the intervention, minimally invasive and less morbid way should be preferred. Intraoral approach rather than extraorally should be the first choice to prevent unesthetic scar and damage to facial nerve. Ectopic tooth is defined as the tooth is not located at dental arch. Some interactions which are not normal during the odontogenesis may cause ectopic eruption. Some factors  are asserted to cause ectopic eruption , 2. EctoIn this paper, we present 3 ectopic teeth located at mandibular canal, maxillary sinus, and condylar region.A 33-year-old male patient was referred to our clinic with recurred pain at right mandibular region. The patient also had referred pain to his right ear and had paresthesia at region innervated by right nervus alveolaris inferior. Root remnants of right second molar tooth were seen at orthopantomograph (OPG). Pathosis was shown neither OPG nor clinical examination. OPG showed that ectopic premolar tooth superimposed on mandibular canal . Cone beMucoperiosteal flap was raised, and simultaneously, root remnants of second molar tooth were extracted. Lingual nerve was dissected during the operation by using silk suture . OsteotoA 14-year-old male child was referred to dental clinic for orthodontic treatment. Clinical examination of the patient showed absence of upper left second bicuspid. Maxillary left first bicuspid in the nasal floor was planned to be erupted but ectopic tooth (maxillary left second bicuspid) located in the maxillary sinus was removed due to ıts accompanying lesion (radiolucent region surrounding the crown of an ectopic tooth) seen at OPG . EctopicOperation was performed under the local anesthesia, after the mucoperiosteal flap was raised . CaldwelA 28-year-old female patient was referred to dental clinic for dental rehabilitation. Routine OPG was taken . RadiogrOperation was performed under the local anesthesia intraorally to avoid postoperative extraoral scar and damage to facial nerve. Flap was raised to expose coronoid notch and subcondylar region. Osteoectomy was performed to expose ectopic tooth by using high-speed handpiece under the constant irrigation. Ectopic tooth was removed by dividing into 3 pieces to avoid condylar fracture. The soft tissue in the bony canal was completely enucleated. Operated area was rinsed with saline and povidone iodine. It was closed primarily. Soft tissue in the bony canal was sent to histopathological examination and confirmed our prediagnosis as dentigerous cyst. Postoperative period was uneventful. The patient was under the antibiotic coverage and anti-inflammatory analgesic. The patient was followed up regularly. Nerve function was preserved.Tooth development requires consecutive steps which occur between oral epithelium and mesenchymal tissue. Abnormal interactions during the odontogenesis result in ectopic tooth development. Lower jaw is affected more than upper jaw due to ectopic tooth . EctopicDentigerous cysts accompanied to ectopic teeth are reported in the literature , 11, 12.A symptomatic or cystic ectopic third molar tooth should be extracted by the intraoral way to avoid damage to facial nerve and scar. Ectopic teeth were associated with pathoses as in our cases (case 2 and case 3). Because of this, they were extracted intraorally. Long-term postoperative follow-up is required until the ossification of mandibular defect is filled with bone tissue when the ectopic tooth is removed from condylar and subcondylar region (case 3). Weakened bone region renders the condyle to pathologic fracture .Although many techniques  were developed for extracting ectopic tooth from maxillary sinus, Caldwell-Luc procedure is the most common technique while extracting ectopic tooth from maxillary sinus among the oral and maxillofacial specialists (case 2). Complications of Caldwell procedure are to damage of infraorbital nerve, fistula formation, and pain. But operation can be performed in less morbid, invasive way by using endoscope. Selecting the approach to ectopic tooth depends on clinician's experience. Ear, nose, and throat specialists choose mostly endoscope .Teeth can displace into mandible intraosseously. They could not be symptomatic. In those situations, these ectopic teeth can be followed up in a regular basis to rule out cystic or neoplastic changes , 17. TreEctopic teeth are rarely seen anomaly in oral and maxillofacial surgery practice. As the patients have unusual pain, swelling, and discharge in maxillofacial region, possibility of the ectopic should be taken into consideration. Asymptomatic ectopic teeth can be followed up regularly because lesions can be developed around such teeth. When extracting the ectopic teeth, minimally invasive and less morbid way should be preferred. Intraoral extraction rather than extraorally should be the first choice because of esthetic outcomes. Patients' life quality should be put in the foreground.


Gastric outlet obstruction (GOO) is a mechanical obstruction usually located in the gastric pylorus or duodenum. After the introduction of proton pump inhibitors (PPIs) in the late 1980s, most cases of gastric outlet obstruction are now caused by malignancy and peptic ulcer disease rarely leads to obstruction. We present a case of GOO caused by a large clot in the pylorus, preventing visualization of the source of bleeding. As the removal of the obstructing clot was deemed too high risk, the patient was treated with promotility agents that relieved the obstruction and allowed for the identification of the etiology of his upper gastrointestinal bleeding. Bleeding was definitively managed with embolization of the gastroduodenal artery. Gastric outlet obstruction (GOO) is a mechanical obstruction usually located in the gastric pylorus or duodenum that typically presents with abdominal pain and postprandial vomiting . Before A 72-year-old man with a past medical history of Hodgkin’s lymphoma, rectal adenocarcinoma in remission, and left total knee replacement six days prior to presentation was admitted with diffuse abdominal discomfort and no bowel movement for four days. He was initially thought to have opioid-induced constipation and was given magnesium citrate. He was found to have swelling of the left lower extremity and lower extremity doppler showed left common femoral vein deep vein thrombosis, for which he was started on Enoxaparin. However, the patient continued to have diffuse abdominal discomfort and developed vomiting. Physical exam was significant for a distended abdomen with tenderness to palpation in the epigastrium. Abdominal x-ray showed prominent gaseous distension of the stomach Figure . ComputeThis is a rare case of a large blood clot causing gastric outlet obstruction. On initial endoscopy, the scope was unable to traverse the duodenal sweep due to the obstructing clot. It is unlikely his symptoms were due to postoperative ileus as his symptoms were delayed in onset after his knee replacement and did not improve after constipation had resolved. The patient’s pyloric and duodenal ulcers were presumably caused by nonsteroidal anti-inflammatory drug use, which he was taking for knee pain, and significant bleeding was likely due to enoxaparin. Peptic ulcer disease typically affects the pyloric channel and duodenal bulb, as in the case we describe. Gastric outlet obstruction is an uncommon complication of peptic ulcer disease and may require surgical intervention ,7. DiagnGastric outlet obstruction is an uncommon complication of peptic ulcer disease. We present a case of GOO caused by a large clot attributed to peptic ulcer disease. The patient presented with abdominal pain and vomiting, and gastric distention was confirmed with imaging. A large clot was visualized in the pylorus, but the scope could not be advanced past the duodenal sweep. As the removal of the obstructing clot was deemed too high risk, the patient was treated with promotility agents that relieved the obstruction and allowed for the identification of the etiology of his upper gastrointestinal bleeding.