N = 113 patients were included. A total of 53 histopathological specimens were available, with 52.8% malignant and 50.9% benign findings. Related to the histopathology, imaging was true negative, false negative, false positive and true positive in 4.1%, 2.1%, 25.0% and 37.5% for standard ultrasound (US) and 9.1%, 1.8%, 25.5% and 43.6% for MRI. Sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) were 94.7%, 20.0%, 36.0% and 88.9% for US and 85.7%, 72.8%, 52.1% and 93.7% for MRI, respectively. Benign lesions were significantly smaller than malignant ones on standard US, MRI and histopathology .This retrospective multi-center study analyzes the diagnostic accuracy of magnetic resonance imaging (MRI) of the scrotum in comparison with standard ultrasound (US) and histopathological specimens. A total of n = 113 patients were included. A total of 53 histopathologies were available, with 52.8% malignant and 50.9% benign findings. Related to histopathology, imaging was true negative, false negative, false positive, and true positive in 4.1%, 2.1%, 25.0% and 37.5% for standard ultrasound (US) and 9.1%, 1.8%, 25.5% and 43.6% for MRI. Sensitivity, specificity, positive predictive value and negative predictive value were 94.7%, 20.0%, 36.0% and 88.9% for US and 85.7%, 72.8%, 52.1% and 93.7% for MRI, respectively. Benign lesions were significantly smaller than malignant ones in standard US (p = 0.001), histopathology (p = 0.001) and MRI (p = 0.004). The size of malignant tumors did not differ significantly between histopathology and standard US (0.72) and between histopathology and MRI (p = 0.88). Conclusions: MRI shows good sensitivity and specificity for the estimation of testicular tumors in this collective. Benign lesions are significantly smaller than malignant ones. Both MRI and US can estimate the size of malignant tumors adequately.Background: The purpose of this study was to retrospectively analyze the diagnostic accuracy of magnetic resonance imaging (MRI) examinations of the scrotum in comparison with standard ultrasound (US) and histopathology. Methods: A retrospective multi-center analysis of MRI examinations of the scrotum performed between 06/2008 and 04/2021 was conducted. Results: A total of  Testicular tumors account for 25% of malignant tumors in men between 20 and 40 years of age and present the most common malignancies in this age group. Overall, these tumors are rare, accounting for 1–2% of all adult neoplasms. The lifetime risk is approximately 0.4% . The mosSome of the testicular lesions are palpable, and others are detected incidentally, e.g., during urological or andrological examinations. Up to 80% of non-palpable testicular lesions are benign ,6, whereParticularly in the case of small lesions, a reliable classification by US alone can be difficult. Until histopathology is obtained via surgery, the final diagnosis usually remains indeterminate. According to the EAU guideline, organ-preserving surgery with an intraoperative fresh frozen section (FFS) procedure is an option for indeterminate masses in singular testes, bilateral lesions or small, non-palpable lesions . HoweverThe role of complementary MRI in the primary diagnosis remains that of a problem-solving tool, e.g., the EAU guideline only recommends MRI for the differentiation of intra- and extratesticular lesions ,10,11,12However, MRI has not yet been able to develop its full competence in testicular tumor diagnosis. The aim of the study is a retrospective assessment of the performance of conventional ultrasound (US) and MRI examinations of the testis in six major urological departments. Subsequently, histopathological correlation of the surgical specimen was used to determine the sensitivity and specificity of US and MRI in the diagnosis of testicular lesions, focusing specially on the potential benefit of adding MRI of the scrotum.The consent of the ethics committee of the Province of Salzburg was obtained (registration number 1194/2020), and the study was conducted in accordance with the Declaration of Helsinki. A retrospective analysis of the data of patients who received an MRI examination of the scrotum at six major urological departments in Austria and Germany  between June 2008 and April 2021 was conducted.The following inclusion criteria were applied: complete patient and diagnostic data available, MRI of the scrotum performed in the predefined period at one of the study centers with the indication “indeterminate findings of an US of the testis” and aged between 18 and 99 years at the time of the MRI.The following patient characteristics were collected using the respective clinic’s internal data programs: age, medical history , the type of diagnosis, findings by physical examination , data on the surgery if performed  and on the final histopathology  and the following therapy of the patient.The following imaging parameters and findings were analyzed based on the original reports: US findings , MRI data and findings . A repeated analysis of the images was not performed.The MRI criteria used to characterize malignant testicular tumors were based on previously published studies ,14,15.The presence of a multinodular/lobulated intratesticular lesion of mainly low signal intensity on T2-weighted images or an inhomogeneous lesion with heterogeneous signal intensity on T2-weighted images was considered suggestive of malignancy. Contrast enhancement, especially if heterogeneous, also was considered indicative of malignancy. The presence of a haemorrhage and/or the presence of necrosis and the extension of the neoplasm to the testicular tunicae, epididymis or spermatic cord was considered highly indicative of malignancy.2) and hypointensity on ADC maps according to Bakir et al. [DWI images and apparent diffusion coefficient (ADC) maps were (when available) visually evaluated in order to assess the signal intensity of the lesions. Diffusion was considered restricted in the case of hyperintensity on high b-value DWI sequences  and with normal distribution also for heteroscedasticity . In the case of normality and variance homogeneity, an independent two-sample t-test was used for group comparisons. In the case of normality but with no variance homogeneity, Welch’s Comparisons of continuous variables with normally distributed data and variance homogeneity were performed by a parametric analysis of variance . For comparisons of all other continuous variables and of variables measured on ordinal scales, a non-parametric analysis of variance  was used. Data of categorical variables were compared by the chi-squared test .The influence of patient age, history of testicular tumors, presence of symptoms, US findings and correct diagnosis on MRI was investigated by logistic regression analyses. Another logistic regression analysis was used to investigate the predictability of a malignant tumor on MRI plus the covariates mentioned above.Two-sided 95% confidence intervals (CI) were calculated according to the nature of the data .The type I error was not adjusted for multiple testing. Therefore, the results of inferential statistics are descriptive only. Statistical analyses were performed using the open-source R statistical software package, version 4.0.5 . The detailed statistical analysis can be obtained on request from the authors.n = 3 were excluded . Therefore, finally n = 113 patients could be included in the statistical analysis. The following study centers participated and included the following number of patients: University Clinic of Urology and Andrology Salzburg (n = 58), University Clinic of Urology Nürnberg (n = 23), Department of Urology, University Hospital Carl Gustav Carus Dresden (n = 10), University Clinic of Urology and Andrology Linz (n = 11), Department of Urology and Andrology, Barmherzige Brüder Hospital Wien (n = 6) and University Clinic of Urology Tübingen (n = 5).A total of 116 MRI examinations in the predefined time period were identified, but n = 19 patients, the medical history was positive for testicular tumors. In these cases, no previous systemic therapy had been required in n = 8, whereas n = 9 had received previous platinum containing chemotherapy and n = 2 radiotherapy. A total of 6 patients had a history of undescended testis. A total of 68 patients reported symptoms at initial presentation, including a palpable scrotal mass in n = 31, pain in n = 30 and infection in n = 5. The suspicious scrotal finding was incidental in n = 45, and the finding was detected during self-examination in n = 34 or during follow-up in n = 25. The tumor was located on the left side in n = 53, on the right side in n= 48 and on both sides in n = 5. The median volume of the affected testis in MRI or US was 14.0 mL (range 2.0–45.0 mL). The median tumor size in US was 0.6 cm (range 0–3.0 cm) for benign and 1.4 cm (range 0.5–15.0 cm) for malignant tumors.The median age of the patients was 39.0 years (range 16–89 years). A total of 10 patients were active smokers. In n = 3 showed testosterone deficiency.A total of 8 patients had positive tumor markers, and n = 98), the elevation of tumor markers or the exclusion of testicular primaries (n = 5) and pain (n = 3). As a result of the retrospective and multicentric study design, MR protocols were not standardized regarding field strength and sequences. All examinations were performed on either a 1.5 (n = 24) or 3 T (n = 82) Phillips  or Siemens  scanners. Most examinations (n = 57) included, in addition to standard T1 and T2 weighted sequences, contrast-enhanced sequences and diffusion-weighted sequences (DWI), and some included contrast-enhanced sequences but no DWI sequences (n = 40). Moreover, n = 2 examinations were performed without contrast but with DWI sequences. The median tumor size in MRI was 0.8 cm (range 0.1–14.0 cm) for benign and 1.7 cm (range 0.5–15.0 cm) for malignant tumors. MRI revealed benign, malignant and indeterminate findings in n = 60, n = 38 and n = 11 cases, respectively.Indications for MRI were indeterminate sonographic findings , and n = 20 partial testicular resections or biopsies . In n = 24 patients, a fresh frozen section (FFS) was performed during surgery. Due to the definite exclusion of malignant dignity in MRI , n = 58 patients did not undergo surgical intervention. A total of 28 cases showed benign findings in histopathology, whereas n = 27 were malignant. However, n = 2 histopathologies were not primary testicular or epididymal tumors and were only located intrascrotally, which is why they were excluded from statistical analyses. The distribution of histopathologies for the n = 53 specimens can be found in n = 23 cases, FFS and the final histopathology were concordant.A surgical intervention was performed in n = 48 (for US) and n = 55 (for MRI) histopathological specimens with concurrent preoperative imaging findings were available for this analysis. The rate of true negative, false negative, false positive, true positive and indeterminate US/MRI findings regarding final histopathology results can be found in A total number of In reference to final histopathology sensitivity, the specificity, PPV and NPV for the detection of benign and malignant tumors for US and MRI were calculated and are summarized in n = 8 cases with positive tumor markers. The individual cases can be found in Among study participants, there were p < 0.05, there was no significant correlation between the parameter “positive tumor marker” and the correctness of MRI findings in our collective. The statistical analysis revealed a p-value of 0.086.At a significance level of The clinical and diagnostic parameters were compared between the subgroups of patients with benign and malignant histopathology, and the results are given in p = 0.7214) and between MRI and histopathology (p = 0.8822) (unpaired t-test with Welch’s correction).The median tumor sizes for benign and malignant tumors in US, MRI and histopathology are listed in n = 24 FFS examinations were performed in a total number of n = 53 available final testicular or epididymal histopathological specimens. The FFS correlated with the final histopathology in 92.0% of cases. FFS was false positive in 0%, true positive in 40.0%, false negative in 4.0%, true negative in 48.0% and indeterminate in 8.0%. Overall, FFS was correct in 88.0% of cases and incorrect in 4.0% of cases.In addition, the performance of the FFS and the consistency with the final histology regarding benign/malignant findings were analyzed. A total number of For decades, US has been the standard diagnostic tool in the diagnosis and workup of testicular tumors, mostly due to low costs and wide availability in outpatient urological care . HoweverThe data for US is quite heterogeneous, and the expectation is for MRI to provide additional information, especially in indeterminate testicular lesions. MRI of the scrotum demonstrates generally high sensitivity up to 100%) and specificity (up to 88%) in the differentiation of benign and malignant lesions . In our 0% and spDue to the heterogeneous data situation, with different MRI protocols, it was not possible within the framework of our study to determine the ideal MRI protocol for lesion characterization. To address this question, and to perform a high-quality comparison of gray scale US, CM-enhanced US, real-time elastography and MRI with a histopathological correlation, our research group is currently conducting a prospective study of patients with testicular tumors who are already scheduled for surgery.p = 0.001), histopathology (p = 0.001) and MRI (p = 0.004). Our findings are correlated with the literature. Shilo et al. showed in 2012 that, in their study cohort of 131 patients with testicular tumors, benign lesions were 63.4% smaller than malignant ones (1.5 vs. 4.1 cm). It is interesting to note that the study group calculated a cut-off value of 1.9 cm, above which the percentage of benign findings was only 2%, below the percentage was 38.5% (p < 0.05) [An interesting result of our study is that benign tumors are significantly smaller than malignant tumors in all three techniques (US ( < 0.05) . In our As the lesion becomes larger, it becomes more likely to be palpable, and according to previous data, 90–95% of all palpable tumors of the testis are malignant . At primn = 18 underwent histopathological confirmation, and n = 6 were found to have a malignancy. However, these cases showed no significant differences in size and vascularity on preoperative US examination compared with the benign lesions [Nevertheless, the size of a lesion cannot provide reliable information of its dignity, and with smaller sizes, US and MRI assessment is more challenging. Bieniek et al. showed in 2018 a rate of indeterminate testicular lesions diagnosed by US smaller than 1 cm of 2.9% in a population of >4000 men undergoing urological treatment for fertility evaluation. Of these patients,  lesions .As a testicular lesion becomes smaller, it becomes more likely that organ-preserving surgery (testis-preserving surgery (TSS)) can be performed. The German Testicular Cancer Study Group (GTCSG) proposed in 2006 the option of TSS in the case of the following parameters: a tumor in a solitary testis or bilateral tumors, diameter < 2 cm, no invasion of the rete testis, biopsies of the surgical bed, normal preoperative LH and testosterone levels and good patient compliance .Especially in the planning of TSS, the preoperative estimation of the size of the lesion is crucial. In the standard preoperative preparation, this is performed with US. Assuming that the tumor size from histopathology is the one most likely to be correct, we could not reveal any significant difference in the histopathologic correlation between the sizes of malignant lesions in US and in MRI. This means that both examination methods can already estimate the size of a lesion very well. Other research demonstrated a tendency to underestimate the size of a testicular lesion by US examination , which cn = 8 patients with positive tumor markers. At first glance, one may think that this would speak against the intended question of this manuscript concerning the use of MRI in the diagnosis of unclear testicular lesions. However, the indication for MRI in these patients was partly to search for tumors with unclearly elevated tumor markers or to search for possible primaries in extratesticular  germ cell tumors. Other manuscripts with similar research questions do not mention specific tumor markers [p > 0.05) in our cohort.Among our study participants, there were  markers . For theAnother important point in the planning, particularly of a one-step TSS, is the application of FFS. The intraoperative diagnosis of a benign tumor in the FFS, which was subsequently revealed to be a malignant tumor in the final histopathology , would be a disadvantage for any patient because of the more restrained resection with a benign preliminary finding. In our study, the FFS showed a convincing concordance of 88.0% with the final histopathology, with only 4.0% of false negative findings. The literature also shows concordance rates of up to 100% between FFS and final histopathology . It is in = 53/55. Due to the partially small amount of data, statistical differentiation between tumors of testis, epididymis and spermatic cord was also omitted, which certainly favors inaccuracy in the evaluation. The heterogeneity of the examinations at six different clinics because of the lack of established protocols for the examination of the testis (US and MRI) limits the accessibility of the overall cohort. To our knowledge, this study represents one of the largest investigations of MRI examinations of the scrotum. Due to the low incidence of testicular tumors in the general population  in MRI were often not surgically explored. Therefore, a reliable histological diagnosis is missing. Even if a benign dignity can be assumed, malignancy cannot be excluded with certainty in every case. In addition, the number of histopathologies is relatively low, with  n = 438 ), the co in 2021 , and Pat in 2021  publisheIn our study, benign testicular lesions were significantly smaller than malignant tumors. This would allow for TSS in many cases. MRI shows good performance of sensitivity and specificity in the differentiation between malignant and benign lesions and good prediction of the size of the tumors. US is more sensitive but much less specific in detecting tumors of the testis. MRI of the testis could, therefore, be suitable in special cases for decision making and better counseling of the patient. Prospective trials must address optimal indications, as well as technical details for MRI examinations, to further improve the diagnosis of indeterminate testicular lesions. The long-term goal would be to dispense surgical exposure and histopathological confirmation in unequivocally benign findings in the future.


Appendiceal mucoceles occur when there is an abnormal accumulation of mucin causing abnormal distention of the vermiform appendix due to various neoplastic or non-neoplastic causes. The prevalence at appendectomy is 0.2-0.3%. They affect the middle-aged individuals, considering the epidemiology of the mucinous neoplasms. Though carcinoid tumor is the most common primary appendiceal neoplasm in surgical pathology series, mucoceles due to neoplasms are the most common appendiceal tumors detected on imaging. We report the case of a 54-year-old patient with no pathological history, who arrived at the emergency department presenting an appendicular syndrome evolving for a week with fever and vomiting, without transit disorders or urinary signs. Physical examination found tenderness of the right iliac fossa. An ultrasound was performed urgently and showed an appearance of a superinfected appendicular mucocele. The patient was admitted to surgery room 2 hours later. Surgical exploration objectived the presence of a very long appendix measuring 15cm x 2cm with an unthickened ceaco appendicular junction. The rest of the peritoneal cavity was unremarkable. An appendicectomy was performed. The anatomopathological examination objectived a ruptured chronic appendicular mucocele low grade mucinous neoplasia (LAMN).


Portal vein aneurysms are rare abnormal dilations of the portal vein and represent less than 3% of all visceral aneurysms. They may be congenital or acquired, symptomatic or asymptomatic, complicated or uncomplicated. Portal vein aneurysms may be fusiform or saccular and this last one has a low prevalence. Due to the small number of cases reported in the medical literature and the lack of specific guidelines, the management and treatment of this condition is still undefined. In this review, we report a case of saccular portal vein aneurysm in a 73-year old man with liver cirrhosis and discuss all cases of portal vein aneurysms reported in literature. Portal vein aneurysm is the abnormal dilation of the portal vein and is defined as a portal vein diameter exceeding the 19 mm in cirrhotic patients and 15 mm in normal livers [It was firstly described in 1956 by Barzilai and Kleckner, and since then, only less than 200 cases have been reported [It represents less than 3% of all visceral aneurysms and etiology is still unknown, even if two forms are generally considered: congenital and acquired .The main cause of the acquired form is liver cirrhosis complicated by portal hypertension . In thesPortal vein aneurysms may be fusiform or saccular; fusiform aneurysms are more common than saccular aneurysms, however these last ones are more likely to have complications .We report a case of saccular portal vein aneurysm in a 73-year old male with alcohol-related cirrhosis. Portal vein aneurysm was acquired, uncomplicated and, moreover, the patient was asymptomatic.We also performed a systematic literature search in PubMed and Scopus databases and discussed all case reports dealing with portal vein aneurysms.A 73-year old male patient presented to the outpatient clinic of our Liver Unit. Patient’s medical history included excessive alcohol intake (at least 10 drinks in a day for more than 10 years), moderate splenomegaly and thrombocytopenia 112.000/µL). Abdominal ultrasonographic examination revealed a hepatic coarse echo pattern, narrowed hepatic veins and increased portal vein diameter (14 mm). An hypoechoic area with a maximal diameter of 40 mm was detected next to the main trunk of the portal vein. A definite communication between this lesion and the main branch of the portal vein was observed. Color Doppler evaluation showed bidirectional, swirling, non-pulsatile and monophasic flow (“Korean flag” or “Yin-Yang” sign) within the hypoechoic area  or paucisymptomatic in 50% of cases and associated with mild and nonspecific abdominal pain 0% or pau.Literature data have shown that only less than 10% of patients present with gastrointestinal bleeding, jaundice due to biliary tract compression, duodenal compression or inferior vena cava obstruction, whereas about 20% may be complicated by thrombosis [Only one case reported by Khairallah et al. described the presence of wall calcifications within the intima and media of portal vein aneurysm due to mechanical stress . In patiIntrahepatic portal vein aneurysms are generally smaller than extrahepatic aneurysms and no correlations have been demonstrated with age or sex .In 2015 Laurenzi et al. reported, in their overview of the international literature, only 96 case reports including 190 patients with portal vein thrombosis [In the medical literature, only a few cases reported spontaneous rupture or regression of the portal vein aneurysms. Priadko et al. recently described 3 cases of asymptomatic portal vein aneurysms with no progression in dimension during a long-term follow-up [Treatment options, conservative management or surgery, should be considered case by case.Currently, in asymptomatic patients with small portal vein aneurysms, conservative management with regular ultrasound follow-up (every 6 months) is acceptable. The management of patients with large but asymptomatic aneurysms is questionable because a surgical approach should be considered taking into account the coexistence of portal hypertension and, if any, other liver-related clinical issues such as decompensation or kidney failure .Surgical treatment is the recommended strategy in cases of symptomatic patients without portal hypertension showing abdominal pain, biliary tract compression, enlarging aneurysms with risk of spontaneous rupture or in case of rupture .In these patients, aneurysmorrhaphy or aneurysmectomy, according to the type of aneurysm (saccular or fusiform), are the treatments of choice. In patients without portal hypertension, these procedures may be considered a definitive treatment because portal vein aneurysm is generally congenital and no liver disease or portal hypertension coexist .In patients with liver cirrhosis complicated by portal hypertension and criteria for surgical management, shunting and liver transplantation are considered as treatment options due to the high risk of surgical mortality. In this case, the aim is to decompress the portal system to prevent the dilation of the aneurysm , 17.Recently, some authors have proposed the use of transjugular porto-systemic shunt (TIPS) or embolization as new treatment approaches.. described a case of 70-mm aneurysmal dilation of the distal portal vein involving the left and right branches in a 48-year old man with hepatitis B-related cirrhosis. The patient had undergone a splenectomy because of upper gastrointestinal hemorrhage and, after portal aneurysm diagnosis, he was treated with a TIPS to prevent its progressive dilation. At the 6-month follow-up the aneurysm was decreased and, after 2 years, disappeared [Ding et alappeared .. reported the case of a rapidly growing saccular intrahepatic portal vein aneurysm (3 cm) in a 55-year-old man. Percutaneous embolization successfully occluded the aneurysm and prevented further growth and complication [Shukla et allication .Finally, Tsuo et al. observed a saccular aneurysm at the extrahepatic portal vein main trunk (3 cm) in a 65-year-old woman with Budd–Chiari syndrome and abdominal pain. TIPS was created with a significant decrease in the aneurysm size (1.9 cm after 1 year) .Portal vein aneurysms are rarely observed in clinical practice, therefore, no definite data are available on natural history, risk of complications and treatment. In all cases reported in literature, abdominal ultrasound played a pivotal role being the first diagnostic approach for the identification, evaluation of size and complications, and long-term follow-up. The use of Color Doppler US with the typical “Korean flag” or “Yin-Yang” flow pattern may provide crucial information and help the identification of portal vein aneurysms and thrombosis. Undoubtedly, ultrasonography and Color Doppler US are excellent tolls for the diagnosis and follow-up of portal vein aneurysms.


There is currently no information on the anatomical risk factors for splenic artery aneurysm rupture, specifically the location or size of the lesion; therefore, reporting this entity to obtain data and ultimately reduce morbidity and mortality is essential. Here we report a case of a male patient with spontaneous rupture of a large splenic artery aneurysm presenting with abdominal pain.A 59-year middle-eastern male, with known pemphigus vulgaris presented with a chief complaint of headache and syncope, followed by abdominal pain along with severe metabolic acidosis. A contrast-enhanced computed tomography scan of the abdomen and pelvic showed a splenic artery aneurysm of 33 × 30 mm with a 150 × 90 mm hematoma formation around the aneurysm site. The patient underwent an operation and splenectomy, with confirmation of the diagnosis of ruptured splenic artery aneurysm.It is essential to consider splenic aneurysm rupture as a second-line differential diagnosis, especially among patients with comorbid diseases, as this can lead to timely and appropriate lifesaving intervention. Splenic artery aneurysms (SAA) are the third most common type of arterial aneurysm, with diameters ranging from 0.6 to 30 cm. The majority of patients show no signs or symptoms . The exaA 59-year middle-eastern male, with known pemphigus vulgaris treated with a daily dose of 5 mg prednisolone, presented to the emergency department with a chief complaint of headache and syncope 3 days before presentation, with subsequent onset of severe abdominal pain. On admission, the patient’s Glasgow Coma Scale level was 13, he was tachycardic (rate: 130) and had severe epigastric pain, along with left upper quadrant pain and tenderness, without radiation or association with nausea and vomiting. Arterial blood gas evaluation demonstrated severe metabolic acidosis. Electrocardiography only showed premature ventricular complexes. Abdominal pelvic sonography demonstrated free fluid in the upper pole of the left kidney and around the spleen, without stasis.3/μL, creatinine of 1.9 µmol/L, and blood urease nitrate (BUN) of 30 mmol/L. Initial arterial blood gas had a pH of 7.19 with PaCO2 of 44.4 mmHg, PaO2 of 22.6 mmHg, HCO3 of 16.6 mmol/L, and base excess of −11.1, which then improved to PpH 7.36, PaCO2 31.7 mmHg, PaO2 57 mmHg, HCO3 17.7 mmol/L, and base excess −6.4 after fluid resuscitation.Initial laboratory data demonstrated white blood cell levels of 18.8 (neutrophil 81.4% and lymphocyte of 9.2%), hemoglobin of 7.7 g/dL, platelet count of 179 × 10Brain computed tomography (CT) and echocardiography were requested for the patient, which were unremarkable. A contrast-enhanced computed tomography scan of the abdomen and pelvis showed a splenic artery aneurysm of 33 × 30 mm with 150 × 90 mm hematoma formation around the aneurysm site  , making et al.  proposedet al. , it is vThe condition is largely diagnosed on contrast CT performed for abdominal pain, and is seen as free fluid around the spleen or other viscera and as leaked contrast media or contrast-enhanced hematoma. As part of the workup for abdominal pain, a ruptured SAA with intra-abdominal hemorrhage may be discovered. Free fluid around the spleen and other viscera is usually detected by CT, and contrast media leakage or contrast-enhanced hematoma may also be present. Because the majority of aneurysms develop late in pregnancy, placental abruption is the most common misdiagnosis, and it is usually only corrected during exploration, and complex diagnostic facilities are not readily available. Due to the double rupture phenomenon, aneurysm rupture can be difficult to diagnose at first. Rupture into the lesser omental can temporarily tamponade bleeding and cause acute abdominal pain and hypotension. As the bleeding continues, the lesser sac ruptures, releasing the tamponade and resulting in massive abdominal bleeding and cardiovascular collapse .The treatment of a ruptured SAA necessitates knowledge and an aggressive surgical approach. There are no well-established guidelines because this is a rare condition. Regardless of symptoms or size, elective repair is preferred during pregnancy, while planning for pregnancy, and in liver transplant candidates. Regardless of the size, intervention is recommended in symptomatic aneurysms. Other SAAs without symptoms can be effectively monitored with serial imaging , and allIn general, the use of endovascular interventions in the form of coil embolization or stent grafting has its place in SAA repair, and in many centers, this is considered the primary approach , 22. Howet al. also reported the rupture of a splenic aneurysm in a male patient with sarcoidosis [et al. [The current case is even more intriguing because the patient had pemphigus vulgaris and was on steroid therapy. Although vessels are rarely involved in pemphigus vulgaris, rheumatologic disorders have been linked to vasculitis, and several cases have been reported in which aneurysms in the splenic artery have developed as a result of vasculitis involvement , 24. Aydcoidosis . The moscoidosis . Akiyama [et al.  also proAneurysms of the splenic artery are a rare type of aneurysm that are often asymptomatic. It is essential to consider splenic aneurysm rupture as a second-line differential diagnosis, as this can lead to timely and appropriate lifesaving intervention.


Condyloma acuminata and anogenital warts are protruding papillomatous lesions caused by human papillomavirus. In pregnant women, condyloma acuminata over the cervical region may grow rapidly, mimicking cervical cancer.A pregnant woman at 14 weeks of gestation with condyloma acuminatum mimicking cervical cancer was referred to our hospital for further management.Condyloma acuminata.Tumor biopsy was performed twice, and the pathology confirmed condyloma acuminatum. Immunohistochemistry revealed focal positivity for p16 and Ki-67. Cryotherapy was performed and regular follow-up was performed at 2-week intervals. A small residual condyloma acuminata was found and treated with cryotherapy.During the follow-up period, no recurrence of condyloma acuminata was noted. She delivered a baby at 37 weeks of gestation via cesarean section, without complications.st-line treatment in all trimesters because of its safety, convenience, and cost-effectiveness. Serial follow-up at 2-week intervals to observe post-cryotherapy conditions is recommended.Condyloma acuminata of the cervix may grow faster during pregnancy, mimicking cervical cancer. Multiple factors must be considered when treating condyloma acuminata during pregnancy. Cryotherapy is proposed as a 1 HPV infection is mainly transmitted through sexual behavior. The development of condyloma acuminata can be affected by lifestyle, age, and sexual activity.Condyloma acuminata is an anogenital wart caused by human papillomavirus (HPV) infection. High-risk HPV (types 16 and 18) can cause cervical cancer in women.More than 100 HPV serotypes have been identified to date. Low-risk HPV serotypes 6 and 11 are the most common types that cause condyloma acuminata. Adults aged between 20 and 39 years of age are mostly infected. The risk factors for HPV infection include multiple sexual partners, a history of gonorrhea or chlamydia infections, human immunodeficiency virus infection, and smoking. The incidence of anogenital warts is 1.1 to 1.2 per 1000 person-years.The prevalence of HPV infection ranges from 9% to 13% globally. It is also the most common sexually transmitted infection worldwide. Condyloma acuminata may be discovered for the 1st time during regular perinatal examinations during pregnancy. Pregnant women with condyloma acuminata have a higher chance of vertical mother-to-child transmission. Therefore, it is important to treat condyloma acuminata in pregnant women to decrease the possibility of vertical transmission.Condyloma acuminata may be asymptomatic or present with symptoms such as itching, pain, and vaginal bleeding. Owing to the downregulation of cell-mediated immunity in pregnancy, pregnant women are prone to have large condyloma acuminata lesions. Apart from the symptoms caused by condyloma acuminata, obstetric complications may include hemorrhage-related impaired wound repair and increased neonatal HPV infection.Condyloma acuminata in pregnant women tends to proliferate significantly, possibly due to physiological changes in the external genitalia and the partially immunocompromised status of pregnancy, which allows for the rapid replication of HPV. Cryotherapy is inexpensive, less painful, and safe; thus, it is recommended as 1st-line therapy in pregnancy.,11Multiple treatment options are available for condyloma acuminata. Topical agents, surgical excision, electrocauterization, and cryotherapy are treatment options for condyloma.We report the case of a pregnant woman with cervical condyloma mimicking cervical cancer, which was discovered at 14 weeks of gestation and treated with cryotherapy. The baby was delivered via cesarean section because of a previous surgical scar.A 34-years-old pregnant woman presented to our outpatient clinic at 14 weeks of gestation with a chief complaint of a small amount of vaginal bleeding for 2 weeks. The patient was admitted to another hospital where cervical malignancy was suspected, and further evaluation at our medical center was suggested.Upon examination, she denied having trauma or engaging in recent sexual activity. She denied any known systemic disease, uterine or vaginal structural abnormalities, or medication use. She denied alcohol, betel nut, and cigarette consumption. She was a social worker in a nearby town and denied travel or contact history of respiratory disease. She had had a pregnancy 3 years before this evaluation, which was accompanied with uncomplicated hypertension. The previous delivery was performed at 37 weeks at a hospital due to a premature membrane rupture noted during a routine examination. The planned normal spontaneous delivery was switched to cesarean section because of prolonged labor and breech presentation.Vaginal examination showed a protruding cauliflower-like cervical tumor measuring 2.5 centimeters, with easy contact bleeding Fig. A. PelvicBecause of the suspected SCC of the cervix, we performed a repeat cervical biopsy. Pathological examination showed condyloma acuminatum Fig. A and B.  Surgical excision of large lesions before delivery is seldom considered reasonable management because the fetus may be affected during anesthesia.,13Various clinical conditions and management strategies for condylomas during pregnancy have been reported in the literature. Condyloma may be large and undiagnosed until the patient presents for delivery. The neonate may be delivered through a normal vaginal delivery or cesarean section if insufficient vaginal stretching with possible obstruction is suspected.st visited another hospital, where the lesion was highly likely to be malignant. The lesion showed risky features, including rapid outgrowth and contact bleeding, during her 1st visit to our outpatient clinic. A diagnosis of cervical SCC was considered until the pathology report confirmed that the lesion was a condyloma acuminata. To the best of our knowledge, this is the 1st case report of a condyloma mimicking cancer.In the present case, the patient 1 The former indicates the use of topical imiquimod, and the latter mainly includes laser therapy, cryotherapy, photodynamic therapy, and local hyperthermia. Cryotherapy is recommended as the 1st-line therapy because it does not require anesthesia; thus, management in an outpatient setting is possible. Moreover, the risks of local complications and danger to the fetus are low. Laser therapy is recommended as second-line therapy because all lesions can be treated in 1 session, especially extensive lesions.The treatment options for condyloma acuminatum can be divided into patient-applied and provider-applied methods. If no other indications for cesarean delivery are present, prophylactic cesarean section may have limited benefits. However, treating maternal condyloma lesions is important to decrease the overall HPV viral load.Vertical mother-to-child transmission of HPV can occur in children born via a cesarean section. The p16 and Ki-67 staining intensities gradually increase as lesions progress from low-grade to high-grade SIL. Diffuse staining for p16 is a marker of high-grade SIL and is not associated with HPV infections. p16 and Ki-67 positivity is associated with histologic severity. Our case showed focal positivity for p16 and Ki-67, and no SIL was found.p16 and Ki-67 double immunostaining is used to detect high-grade squamous intraepithelial lesions (SIL).A limitation of this report was that it included only 1 case, which may not be representative of other cases. Our case report indicates that condyloma can mimic cervical cancer, but the possibility of cervical cancer even in the presence of condyloma should still be considered.Our case showed a large cervical condyloma that mimicked cervical cancer. After pathological confirmation, the condyloma was diagnosed and treated with cryotherapy. Finally, the patient delivered a healthy baby. Our case suggests that pathological confirmation is essential for a condyloma diagnosis. A reasonable treatment plan can be determined if the correct diagnosis is made. We chose cryotherapy for condyloma owing to its convenience and the non-requirement for anesthesia. Serial follow-up after cryotherapy is important for determining treatment efficacy and the need for further treatment sessions. In our case, follow-up every 2 weeks was arranged to monitor for recurrence. The second cryotherapy session was conducted because of a small lesion during regular follow-up. The delivery was through cesarean section due to a previous scar; however, if no other factors exist, vaginal delivery may also be reasonable in a completely treated case of condyloma.Conceptualization: Dah-Ching Ding.Data curation: Kai-Chieh Chang, Yen-Chang Chen, Dah-Ching Ding.Formal analysis: Kai-Chieh Chang, Dah-Ching Ding.Investigation: Yen-Chang Chen.Supervision: Dah-Ching Ding.Writing – original draft: Kai-Chieh Chang, Dah-Ching Ding.Writing - review & editing: Dah-Ching Ding.


Esophageal schwannoma is a rare tumor and is classified as one of the esophageal subepithelial lesions (SELs). Endoscopic ultrasound (EUS) evaluation is the gold standard for evaluating subepithelial lesions. Differentiation through EUS-guided fine needle aspiration is sometimes important to exclude lesions with malignant potential. Immunohistochemistry differentiates schwannoma from other subepithelial lesions. Strong and diffuse positivity for S100 is characteristic. The decision for conservative management versus endoscopic or thoracoscopic intervention is made based on the tumor size, location, and symptoms. Schwannomas are slow-growing, mostly benign tumors that arise from the Schwann cells of the nerve sheath . They ocA 72-year-old female presented to our gastroenterology clinic for a complaint of dysphagia to solid food that had been progressing over a few months. She stated these symptoms started after her first COVID-19 vaccination around a year ago. We obtained an esophagogastroduodenoscopy (EGD) that showed a bulging lesion in the esophageal wall around 30 cm from the incisors, causing some luminal narrowing. We evaluated the mass using endoscopic ultrasound (EUS) and it revealed a subepithelial hypoechoic heterogeneous mass originating at the third or fourth layers of the esophagus. EUS-guided fine-needle aspiration biopsy (FNAB) was obtained, showing bland spindle cell proliferation with no atypia or mitosis. Cells showed S100 positivity, negative desmin, and smooth muscle actin (SMA), discovered on gastrointestinal stromal tumors 1 (GIST 1 (DOG-1)) and CD117 which suggests schwannoma. We obtained a chest MRI with contrast to further evaluate the mass. It confirmed a well-circumscribed 2.2 x 2.8 x 3.2 cm ovoid T2-hyperintense enhancing mass in the mid to distal esophagus that appeared to be submucosal.The patient continued to have dysphagia. After a discussion with the patient regarding her options, she elected to proceed with another EGD for resecting the mass using the submucosal tunnel endoscopic resection (STER) technique. A 10 mm mucosal incision was made 5 cm proximal to the mass. Dissection of the submucosal tissues was done and a tunnel was created. We dissected the mass from surrounding tissue till it was released from its attachments. The mass was captured and delivered and multiple endo clips were used to close the mucosal incision  and hypocellular areas Figure . ImmunohWe obtained an esophagogram one day after the resection which was negative for any leakage; a liquid diet was introduced on Day 1 after the procedure then advanced to a soft diet, and the patient was discharged home after resolution of dysphagia. A follow-up EGD was done after two months, with a normal appearance of mucosa and improvement of the patient’s symptoms.Subepithelial lesions of the gastrointestinal tract are increasingly discovered with the advancement in endoscopy. They are mostly benign at the time of diagnosis, however many of these lesions have malignant potential .Endoscopic ultrasound (EUS) is of great value and is currently recommended as a gold standard to describe subepithelial lesions including size, location, originating layer, echogenicity, and shape however, it's not enough to absolutely identify the lesion . CurrentEsophageal schwannoma is very rare and few cases are reported in the literature. The most common presenting symptom is dysphagia. On EUS, the schwannoma has sharp borders, hypoechoic, homogeneous, and sometimes with a marginal halo . In our Diagnosis is through tissue biopsy using immunohistochemical staining. Positivity for S100 protein and negativity for actin and desmin, support a nerve sheath origin of the tumor . In our Management is usually based on the presence or absence of symptoms. If obstructive symptoms are present, endoscopic full-thickness resection should be compared with thoracoscopic enucleation. The upper limit for the endoscopic approach is 35 mm to allow en bloc removal. Submucosal tunneling endoscopic approach is recommended . In our Esophageal schwannoma is a rare gastrointestinal tract tumor. It is an important differential diagnosis of subepithelial tumors of the gastrointestinal tract. There is not enough evidence in the literature to suggest that EUS tissue acquisition is required from all SELs or only from those > 20 mm or with high-risk stigmata. However, multiple gastroenterology societies recommend obtaining tissue biopsy for SELs with a size > 20 mm, or have high-risk stigmata since definite differentiation from other SELs is not feasible through EUS characterization alone.


Pneumatosis intestinalis (PI) and aeroportia have been rarely described in hemodialysis patients. We present a case of a 64-year-old woman on regular hemodialysis who presented with abdominal pain, vomiting, and diarrhea. Abdominal CT showed pneumatosis intestinalis and aeroportia suggestive of ischemic abnormalities. In this case, given the absence of transmural necrosis or bowel perforation, aeroportia seemed to be caused by nonocclusive mesenteric ischemia (NOMI), an increasingly recognized complication in hemodialysis patients. The patient was proposed for emergent exploratory laparotomy; however, she had a fatal outcome. Hemodialysis-dependent patients should be considered at risk of the “low-flow syndrome” of mesenteric arterial circulation. Prevention is crucial, and early detection of these entities is important for prompt diagnosis and management of mesenteric ischemia. Pneumatosis intestinalis (PI) and aeroportia are rare radiologic features that refer to the presence of gas within the intestinal wall and in portomesenteric vessels, respectively. Both are typical findings of mesenteric ischemia, the leading cause accounting for 70% of the cases . Other cWe present the case of a 64-year-old hypertensive woman on regular hemodialysis due to chronic kidney disease of unknown etiology, with no other significant past medical history. There was no history of previous surgery or recent endoscopic examination. She was admitted to the hospital due to abdominal pain, vomiting, and diarrhea with a three-day course. At hospital admission, she was apyretic, prostrate, hypotensive, with mild abdominal pain. Initial laboratory tests revealed a slight increase in inflammatory parameters , with no other findings. She was started on intravenous fluid replacement, bowel rest, and antibiotic therapy. Contrast-enhanced CT was performed showing pneumatosis intestinalis suggestive of ischemic abnormalities, and aeroportia Figures . No otheThe patient was proposed for emergent exploratory laparotomy. However, she developed shock with rapidly worsening general condition and died within a few hours.Aeroportia has rarely been described in chronic hemodialysis patients. To the best of our knowledge, only three cases have been described in the literature, and all of them presented with abdominal pain. Two cases reported no evidence of bowel necrosis or perforation, so aeroportia seemed to be caused by nonocclusive mesenteric ischemia (NOMI) and had a favorable outcome ,6. The tAs mentioned earlier, mortality is high among patients with aeroportia and even higher if related to mesenteric ischemia. Our patient was a case of PI and aeroportia with hemodialysis dependence, presenting with abdominal pain, vomiting, and diarrhea with a three-day course. Although rarely observed, these radiological findings are characteristic of mesenteric ischemia. Our patient presented a rapid and progressive worsening of her clinical condition and she died soon afterwards. Although she never underwent an exploratory laparotomy, the contrast-enhanced CT scan showed no evidence of transmural necrosis or bowel perforation. In this case, since mesenteric ischemia was the main cause of intestinal pneumatosis and aeroportia, these findings seemed to be caused by NOMI, an increasingly recognized complication in hemodialysis patients. In addition, CT allowed the exclusion of other possibly associated causes, such as intra-abdominal abscesses, diverticulitis, and pancreatitis, among others. As a predictor of poor prognosis, the presence of aeroportia should be noted given the patient's unfavorable evolution and fatal outcome . This caHemodialysis-dependent patients should be considered at risk of the “low-flow syndrome” of mesenteric arterial circulation. However, it should not be overlooked that atherosclerotic disease with the involvement of the mesenteric vasculature is prevalent in this patient population. When pneumatosis intestinalis is present on CT, it is important to rule out potentially life-threatening complications, such as aeroportia that carries a worse prognosis and increased mortality. However, whether surgical intervention is indicated must be determined according to the clinical features of the individual patient. Early detection of these entities is crucial for the prompt diagnosis and management of mesenteric ischemia.


Diffusion-weighted whole-body imaging with background body signal suppression (DWIBS) is an emerging extended modality of diffusion-weighted imaging for screening malignant lesions in the body. A 70-year-old male was diagnosed with advanced-stage prostate adenocarcinoma with distant metastasis. After hormone therapy, the disease progressed to castration-resistant prostate cancer (CRPC). Serum prostate-specific antigen (PSA) levels increased during androgen deprivation therapy with low serum testosterone levels. 18F-Fluorodeoxyglucose positron emission tomography (FDG-PET) and technetium-99m methylene bone scintigraphy (BS) did not reveal obvious distant metastases; however, we were able to identify distant metastases by DWIBS. We herein report a case in which stereotactic body radiotherapy (SBRT) was performed on target lesions detected by DWIBS and successfully suppressed disease progression. Discerning distant metastases is essential to determine recent cancer treatment strategies. Since the presence of distant metastases limits the efficacy of surgery and irradiation, it should always be located before initiating local treatment. Bone scintigraphy (BS) is often used for prostate cancer because of its tendency to metastasize to the bone. 18F-Fluorodeoxyglucose positron emission tomography (FDG-PET) is a powerful diagnostic imaging platform for the diagnosis of osseous and non-osseous metastases [Diffusion-weighted whole-body imaging with background body signal suppression (DWIBS) is an emerging, extended modality of diffusion-weighted imaging for screening malignant lesions in the whole body. DWIBS was first reported by Takahara et al. in 2004 to detect systemic metastatic lesions throughout the body without irradiation [A 70-year-old male was diagnosed with prostate adenocarcinoma with a Gleason score of 4+4 and a serum prostate-specific antigen (PSA) level of 63.44 ng/mL. He had a medical history of hepatitis C and duodenal ulcers treated surgically. Contrast-enhanced computed tomography (CT) revealed local invasion of the rectum and seminal vesicle, left internal iliac lymph node metastasis, and left femoral head bone metastasis. The clinical stage was T4N1M1b, stage IVB, according to the eighth edition of the TNM classification produced by the American Joint Committee on Cancer. He was started on androgen deprivation therapy, and his PSA level decreased to 0.24 ng/mL. However, the PSA serum level increased again to 3.27 ng/mL after 2.5 years from the initial diagnosis. Therefore, the patient was diagnosed with castration-resistant prostate cancer (CRPC). After 13 cycles of cytotoxic chemotherapy consisting of cisplatin and docetaxel, the PSA level decreased to 0.029 ng/mL; however, chemotherapy could not be continued owing to severe adverse events of dyspnea and right pleural effusion. He was then started on leuprolide with prednisone, but PSA gradually increased to 4.45 ng/mL. Technetium-99m methylene diphosphonate BS revealed no evidence of bone metastases. FDG-PET showed no evident distant metastasis except for slight fluorodeoxyglucose (FDG) accumulation at the standardized maximum uptake value (SUVmax) of 2.4 in the right sacral bone. This sacral lesion was not considered a metastasis from CRPC, and the patient decided to receive salvage stereotactic body radiotherapy (SBRT) to the primary prostate site, which was performed 6.5 years after the initial diagnosis. However, PSA still increased up to 11.8 ng/mL with suppression of serum testosterone < 0.04 ng/dL after five months from prostate bed SBRT. Where PET still exhibited weak FDG accumulation (SUVmax: 3.2), DWIBS clearly detected the right sacral bone, which demonstrated a high-signal intensity on diffusion-weighted imaging (Figure He was 77 years old at this time, and SBRT for solitary right sacral bone metastasis with 35 Gy in 5 Gy fractions was performed. Then, his PSA levels decreased to 0.60 ng/mL four months after SBRT Figure .The five-year survival rate for prostate cancer with distant metastasis is approximately 30%, which is extremely low compared to locoregional cases . Tamada DWIBS is an emerging extended modality of diffusion-weighted imaging for screening malignant lesions . There iIn our case, DWIBS was useful for detecting solitary bone metastases, which were rarely detected by FDG-PET-CT and BS imaging. There is no uniform method for detecting bone metastases in prostate cancer. Unlike other imaging modalities that use radiation, DWIBS can be performed without being exposed to such. Evidence for the utilization of DWIBS is still accumulating; therefore, further clinical applications are expected in the future.


A 60-year-old female sustained a distal radius fracture and underwent open reduction internal fixation with a volar locking plate. The patient had an uneventful recovery until four months postoperatively when the patient clinically regressed, and an expansile, radiolucent metaepiphyseal lesion was found. Further workup revealed this was a giant cell tumor of bone (GCTB). Definitive management consisted of extensive curettage, cryoablation, and cementation of the lesion, and the hardware was left intact. The current case presents an uncommon presentation of GCTB. The case illuminates the importance of thorough scrutiny of postoperative radiographs when clinical improvement plateaus or regresses and the need to pursue additional workup when the clinical course is atypical. The authors query the possibility of a sub-radiological presentation of GCTB. Giant cell tumor of bone (GCTB) is an osteolytic, often benign, but locally aggressive lesion, accounting for approximately 4-6% of primary bone tumors and 20% of benign skeletal tumors . It is oOnly two prior cases in the literature presented the development of distal radius GCTB lesions after patients undergoing ORIF for distal radius fractures with the apparent absence of inciting pathological lesions at the time of index injury ,7.This article briefly reviews the epidemiology, diagnosis, treatment options, and recurrence rate for GCTB. More notably, in the setting of a case report of a GCTB lesion presenting at four months postoperatively from a distal radius fracture ORIF in a 60-year-old female patient. The patient was informed that data concerning the case would be submitted for publication, and she provided consent.A 60-year-old female presented to an outpatient orthopaedic clinic in September 2021 with a one-week history of acute, traumatic right wrist pain after a mechanical ground-level fall while walking her dog. A distal radius fracture had been identified at an urgent care facility on the date of injury at which time the patient was provisionally splinted. The patient is an otherwise healthy, right-hand dominant female, non-smoker with noncontributory past medical/surgical history. The patient reported no prior history of trauma to the right wrist. On a focused musculoskeletal exam, she presented with a closed injury associated with significant swelling, but no visible deformity over the dorsum of the wrist. She was neurovascularly intact. Radiographs demonstrated a right, comminuted distal radius volar Barton fracture  to better evaluate the flexor and extensor tendons, given the concern for tendon irritation due to the plate. This showed no signs of tenosynovitis. As for the cyst, the US was concerning for a possible giant cell tumor and revealed progression of the expansive lesion with cortical thinning.Upon interdisciplinary team discussion with Orthopaedic Oncology, the decision was made to proceed with a biopsy for pathology and culture. A biopsy was performed through a small open dorsal approach, radial to Lister’s tubercle. When incising the retinaculum overlying the second extensor compartment a non-purulent, brown fluid was encountered. The dorsal cortical aspect of the metaphyseal radius was found thinned and insignificant. Sharp excisional debridement was performed in the metaphysis through the dorsal cortical window. Several samples, including soft tissue, bone, and fluid were sent for pathology and culture. The hardware was not revised and was found to be stable.She was seen thereafter by the Orthopaedic Oncology team. On exam, she had an unremarkable healing incision with swelling over the dorsal and volar aspect of the wrist. Shortly after the biopsy, the pathology report was conclusive for GCTB. Cultures remained negative throughout the postoperative course. A chest X-ray was ordered which was indicative of no lung metastasis. A new MRI was obtained for re-evaluation prior to definitive surgery and showed a T1 hypointense and T2 hyperintense expansile lesion with cortical destruction, measuring 3 x 2.4 x 4.2 cm , carpal tunnel release, neurolysis (median and ulnar nerve), and extensive curettage of the radial metaphyseal tumor. Soft tissue and deep bone biopsy were sent for cultures and pathology. These were again positive for GCTB (CD 68+) with no signs of malignancy. Cytogenetic testing showed no chromosomal aberrations. While protecting soft tissue structures, stepwise cryoablation  and cementation with tobramycin of the cavity followed. The hardware was found stable and in a good position, and thus the decision was made to leave it in place. Postoperatively at four weeks, May 2022, she had an uneventful recovery. She was found neurovascularly intact throughout. The dorsal incision was well-healed, and the volar incision had no signs of dehiscence or infection but showed delayed healing , and minimal swelling Figure . At thatMost GCTB occur in the 20-40-year-old age range with a slight female predominance as described previously . The thiRadiologically, the common presentation is an eccentric, lytic lesion extending into the subchondral bone. Other features are cortical thinning, expansile remodeling, periosteal reaction, extension from the metaphysis, fluid levels, or cystic spaces ,9. BasedThe goals of management are eradication with limb preservation, maintenance of function, and prevention of recurrence. Historically, curettage alone has been reported to have a recurrence rate of 21-65%, yet this has been substantially, but variably, reduced with co-adjuvant therapies , which often combine options  , en-blocFor the purpose of this case report, we found two unusual prior unique cases that presented as distal radius GCTB after ORIF ,7. MarshTo conclude, given the scarce literature in case reports regarding GCTB after fracture, it raises the concern or question if there is a sub-radiological presentation for a pathological fracture. In other words, whether a possible precipitating lesion would be structurally sufficient to weaken the bone in a way that would not initially be captured radiologically on plain X-rays and or on CT scans, which upon injury and fixation would trigger a progressive and expansile lesion. On the contrary, there is no known association between GCTB arising after a fracture.


The most common causes of hemobilia are iatrogenic, trauma related and neoplastic Gallbladder adenocarcinoma is a rare gastrointestinal malignancy and is the most common histologic subtype, making up 76 % of all gallbladder neoplasms. These malignancies are most often discovered incidentally, in 1 % of all cholecystectomy procedures and it is associated with a poor prognosis, with a mean survival of 6 months and a 5 year survival of 5–20 %.In the United States, the incidence of gallbladder adenocarcinoma is one to two cases per 100,000 people. It is more prevalent in women than men. Risk factors include cholelithiasis, porcelain gallbladder, gallbladder polyps, primary sclerosing cholangitis, chronic infection, congenital biliary cysts, abnormal pancreaticobiliary duct junction, obesity and medications.Hemobilia is a (1–7 %) rare presenting sign of biliary neoplasm This patient was managed in a public healthcare system setting. This case report has been reported in line with the SCARE 2020 criteria 2A 71-year-old female patient was admitted to the emergency department in a wheelchair with her family member, referred by her family doctor due to the presence of intense abdominal pain in the epigastrium, nausea and vomiting. On admission, a drowsy patient, with uncontrolled blood pressure, scleral jaundice, tachycardia and intense abdominal pain in the epigastrium, it is important to mention that the patient never presented lower gastrointestinal bleeding. Her past medical and surgical history included obesity, diabetes and long-standing arterial hypertension treated with insulin and nifedipine, chronic kidney disease on peritoneal dialysis for a year.An ultrasound is performed that reports an enlarged gallbladder of 113 × 35 × 39 mm, with the presence of a 13-mm stone inside the neck and echogenic material suggestive of acute cholecystitis ; laboratory tests revealed a white blood cell (WBC) count of 17,000/μL and biliary tract obstruction with total bilirrubin (TB) 3.8 mg/dL, direct bilirrubin (DB) 2.63 mg/dL, indirect bilirrubin (IB) 0.75 mg/dL, alkaline phosphatase (ALP) 639 U/L, alanine transaminase (ALT) 185 U/L, aspartate transaminase (AST) 311 U/L, gamma-glutamyl transferase (GGT) 425 U/L. There were signs of peritoneal irritation and patient was unstable.It is decided to perform an emergency open cholecystectomy, which is performed by the general surgeon in charge of the patient. During surgery there are abundant clots and a stone inside the gallbladder , Image 3On the follow-up, WBC and liver function tests were within the normal range. During her post-surgical stay, extension studies were requested, however the patient requested her voluntary discharge without accepting more treatments or interventions. The pathology report determined a tumor in the gallbladder fundus of 3 × 2 × 2 cm with the type and histological grade of poorly differentiated adenocarcinoma of the gallbladder without the presence of extension to the liver, it was classified as pT2b pNx pMx.The final outcome was the death of patient at 2 months.3The first reported case of hemobilia dates to 1654, when Francis Glisson wrote of a nobleman whom, while dueling, suffered a blow to the right upper abdomen leading to massive gastrointestinal bleeding and ultimately death. Literature from the early 1900s began to contain various case reports of biliary tract bleeding, but it was notuntil 1948 that the specific term ‘hemobilia’ was coined The most common spontaneous cause of hemobilia is primary or metastatic hepatobiliary malignancy. This is thought to be due to more friable tissue and vasculature, leading to an increased propensity for spontaneous hemorrhage. Hepatobiliary malignancies, including cholangiocarcinoma, pancreatic cancer, gallbladder cancer, liver metastasis, and hepatocellular carcinoma (HCC) have all been associated with hemobilia. All cause malignancies account for 10 % of total hemobilia cases Many authors have different presentations of GC, including empyema, cholecystitis, benign biliary stricture, liver abscess, gastric outlet obstruction, and carcinoma of the head of the páncreas The classic presentation of hemobilia is described by Quinke's triad: RUQ pain, jaundice and gastrointestinal bleeding, with all three present in only 25–33 % of cases The best imaging modalities for diagnosing these tumors are ultrasonography (US) and computed tomography (CT) scans US has the advantage of availability at emergency departments, portability, the absence of ionizing radiation, and its high sensitivity and specificity for biliary pathology. However, it has limitations, such as the patient habitus, uncooperative patients, and being operator dependent. CT carries high sensitivity and specificity in the identification of a gallbladder mass, but lower sensitivity in identifying nodal spread, and is therefore not considered ideal for staging. Angiography has also been used in some centers with questionable efficacy. More recently, magnetic resonance (MR) and cholangiopancreatography has evolved into a very sensitive and specific technique that can also help in the staging process. However, in the presence of a hemocholecyst all these imaging modalities become less sensitive. Given the rarity of gallbladder cancer, and the even rarer association with a hemocholecyst, prompt diagnosis still eludes the average radiologist, surgeon, and clinician Complete resection of the tumor provides the only chance of cure, but an early preoperative diagnosis is essential. In fact, the 5-year survival rate after resection with curative intent has been reported at less than 17 %. 4Hemobilia and hemocholecyst secondary to gallbladder cancer are infrequent, however, they should be considered in the differential diagnosis of pain in the right hypochondrium and symptoms of biliary tract obstruction to evaluate a complete preoperative surgical plan.This work has no funding sources.This manuscript is a case report retrospectively and also is not a clinical study. The ethical approval is not necessary. the institution is exempt from ethical approval.Not commissioned, externally peer-reviewed.Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request.Writing the paper & assisting in the procedure: Deysi Laura Navarrete Espinosa; Carlos de Jesús Cocom Quijano; Carlos Daniel Torres García.Performing the procedure & assisted in Literature search: Deysi Laura Navarrete Espinosa; Orson Raziel Juan Hernández; Aron cervantes Sánchez; Otoniel Escobar Flores.Assisted in writing manuscript: Deysi Laura Navarrete Espinosa; Carlos de Jesús Cocom Quijano.Data/evidence collection: Carlos Daniel Torres García; Otoniel Escobar Flores; Jonathan Esaú Ceseña Barrientos.Designed the study: Deysi Laura Navarrete Espinosa; Carlos de Jesus Cocom Quijano.Review of the manuscript: Carlos Daniel Torres García; Rashid Israel Arjona Bojórquez.Literature Review and guarantor: Carlos de Jesús Cocom Quijano; Deysi Laura Navarrete Espinosa.Carlos de Jesús Cocom Quijano; Deysi Laura Navarrete Espinosa.Does not apply.There are no conflicts of interests.


A 21-day-old female presented to the pediatric emergency department with swelling of the left groin. Physical examination revealed a soft, nontender abdomen and a two-centimeter firm and fixed mass on the left aspect of her mons pubis. Point-of-care ultrasound revealed a left inguinal hernia with incarcerated ovary.Inguinal hernias are common in the pediatric population. In female patients, particularly those less than one year old, inguinal hernias most frequently contain an ovary rather than bowel; so they require careful evaluation to protect future reproductive function. A 21-day-old female presented to the pediatric emergency department with swelling of the left groin, which was first noticed while her family changed her diaper the morning of presentation. They denied any redness or warmth over the site but felt that she was fussier than normal overnight. They reported that she fed normally that morning and had her normal number of wet diapers. The patient was otherwise healthy and born at 37 weeks gestation without complications. On physical examination, the patient was well appearing with a soft, nontender abdomen and an irreducible two-centimeter (cm) firm and fixed mass on the left aspect of her mons pubis that was tender to palpation.A point-of-care ultrasound was performed and showed a two-cm mass with follicles. A confirmatory formal ultrasound was subsequently obtained, which showed a 2.1 × 1.1 × 2.1 cm mass in the left perineal region with subcentimeter follicles and flow demonstration, which confirmed the diagnosis of an inguinal hernia with incarcerated ovary –3. PediaInguinal hernias in the pediatric population are more commonly seen in premature infants, in male infants, and in those less than one year old.5What do we already know about this clinical entity?Inguinal masses are a common chief complaint in infants presenting for emergency care. Majority of these are inguinal hernias and may contain bowel.What is the major impact of the image(s)?These images demonstrate an inguinal hernia in a female containing an ovary rather than bowel.How might this improve emergency medicine practice?Point-of-care ultrasound to identify the contents of an inguinal mass will improve and expedite patient care and management.


Peripheral facial paralysis is a relative common condition; it is mostly idiopathic, when it receives the name Bell's palsy. However, we should be aware of the differential diagnosis with less common severe or potentially lethal diseases.Thus, there are cases in which facial paralysis is a manifestation of a temporal bone metastasis. This is a rare situation, although its incidence has apparently increased in recent years; its diagnosis may be delayed by lack of appropriate and prompt investigation by a specialist.In this article we report a case of a patient with peripheral facial paralysis as the first manifestation of a metastasis originating from a hidden tumor; we also review the literature on the case. We highlight this case due to the difficulty in making the diagnosis and its unfavorable outcome.SMS, a female white patient aged 40 years, arrived at an emergency otorhinolaryngology clinic with a complaint of right peripheral facial paralysis that had started 15 days ago; there had been no previous otorrhea or otalgia. The personal and family history added no further information.The physical examination showed that the patient was in good general health; there was grade IV facial paralysis.Computed tomography of the temporal bones and audiometry  were donOne week later the patient complained of hypoacusis; the facial paralysis had worsened to grade V . A seconThe patient was admitted into hospital to search for the primary site. Breast, lung, gastrointestinal or skin tumors were discarded. Before locating the primary tumor, the patient died of intracranial hypertension notwithstanding therapy, two months after facial paralysis had started.Necropsy  did not Our review of the literature brought up 148 published cases of temporal bone lesions as the first manifestation of metastases. The main primary sites were, in decreasing order, breast, lung, kidney, stomach, and prostate cancers.Cases of facial paralysis secondary to malignances generally have a poor prognosis; the paralysis progresses and does not regress with any therapy, which is uncommon in Bell's palsy cases.We should always be watchful in all cases of facial paralysis, especially those with an atypical progression, so that the true diagnosis is not delayed. We also concluded that whenever the presentation is atypical, or if any of the initial exams are not aligned with the clinical history, image exams become of great use and should not be postponed.


There are several types of internal hernia. Herniation through the defect in the lesser omentum is extremely rare. Symptoms of this type of hernias may vary a lot and diagnosis is difficult. In this case report a young adult with nonspecific symptoms is diagnosed with an intestinal herniation through the defect in the lesser omentum.A 35-year-old man with the history of laparoscopic colectomy presented with abdominal pain but no symptoms of peritonitis or acute bowel obstruction. Abdominal computed tomography (CT) revealed displacement of mesenteric vessels, small intestine and stomach. Intestinal herniation through the lesser omentum was suspected. Laparoscopic reposition of small intestine was performed. The greater curvature of the stomach was sutured to the transverse mesocolon to prevent recurrence of hernia.Previous surgery, low body mass index (BMI), absence of adhesions may predispose the lesser omental hernia. Herniating of intestines through the large openings may occur without presence of acute obstruction or gangrene. CT is helpful in making a correct diagnosis.When evaluating the patient with abdominal pain, internal hernia should be considered. CT modalities may aid in the detection of these rare hernias and ensure timely treatment. Perioperative inspection and repair of the hepatogastric ligament may help to prevent lesser omental hernias. •Lesser omental hernia is a rare type of internal hernias with variety of symptoms.•The diagnosis of lesser omental herniation is challenging.•Perioperative closure of lesser omental defects may prevent herniation. We report this case to enrich a clinical thinking on abdominal pain.The case-presentation is made in full accordance with the current guidelines for surgical case reports (SCARE) 2A 35-year-old male presented to the emergency department, suffering from postprandial pain in the upper left abdominal quadrant, vomiting and belching for two days. Nine months prior to admission a laparoscopic total colectomy with terminal ileostomy was performed due to refractory ulcerative colitis. The patient had lost four kilograms of body weight over the past week, was dehydrated. He had the body mass index (BMI) of 21. There was no abdominal tenderness or symptoms of peritonitis and acute bowel obstruction was not suspected. The patient had an ileostomy which produced between 2000 and 3000 mL per day.Laboratory tests revealed a white blood cell count of 20,000/mL, C-reactive protein of 17.0 mg/L, creatinine 181 μmol/L, lactic acid level of 1.2 mmol/L.A normal upper GI endoscopy was performed, the patient was rehydrated with intravenous fluid and discharged from hospital on day four. Dehydration due to high stoma output was suspected.The patient was readmitted two weeks later with recurrent symptoms.Abdominal computed tomography (CT) showed periduodenal edema but otherwise normal small intestine without signs of mechanical obstruction, intestinal ischemia or intraabdominal liquid accumulation. Common manifestations of internal hernia like swirl sign appearance of the mesenteric vessels or mushroom shape sign was not observed Postoperative course was uneventful and the patient was discharged on postoperative day three. He was free of symptoms at one-year follow-up.3Lesser omental hernia is an extremely rare type of internal hernias. Although congenital factors, such as defects of gastrocolic and hepatogastric ligaments can cause this type of internal hernia, lesser omental hernias are most likely to occur in patients with history of abdominal surgery. Roux-en-Y surgery We have described a retrogastric herniation of the small intestine. The lack of the inferior and partially anterior wall of the lesser sac  enabled small intestine to freely prolapse from the retrogastric space through the opening in the hepatogastric ligament . In the The diagnosis of lesser omental herniation is challenging as symptoms may mimic other gastrointestinal diseases Contrast enhanced CT may aid in the diagnosis of intraabdominal hernias Lesser omental hernias are most likely to occur in patients with a history of abdominal surgery. In our case the defect in the hepatogastric ligament was most likely caused by previous laparoscopic colectomy. Postoperative lesser omental hernias may be prevented by paying careful attention when dissecting the posterior attachments of the stomach to the transverse mesocolon and by avoiding injury to the hepatogastric ligament. Prophylactic perioperative closure of lesser omental defects may prevent future herniation.4Although the incidence of the lesser omental hernia is rare, the attention should be paid on the symptoms in the patient with the history of previous surgery. Contrast enhanced abdominal CT may reveal signs of internal hernias, prevent the delay in surgical treatment and avoid complications. Perioperative inspection of the lesser omentum may be effective to avoid iatrogenic intraperitoneal gaps.Not commissioned, externally peer-reviewed.Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request.The project is notified and approved by The North Denmark Region Committee on Health Research Ethics.10.13039/501100006304Aalborg University Hospital funded the study. There were no other sources of funding.The Department of Gastrointestinal Surgery, M.D. Arnas Ugianskis, Aalborg University Hospital.N/A.AU was the surgeon who performed the laparoscopic colectomy, made clinical case description, compiled literature search and drafted the manuscript.The author has none to declare.


We described the case of a 42-year-old man who presented with left index finger mass persisting for 6 months. The mass was small and, painless and had gradually increased in size with limited finger flexion. Physical examination showed a firm mass over the volar surface of the left index finger. There was no tenderness, redness, warmth or punctum. The overlying skin was normal, and the mass did not transilluminate. Further examination of the head and neck, chest, upper limbs and neurovascular system revealed normal findings. No similar masses were found elsewhere in the body. Bedside ultrasound with further investigation and management confirmed the suspected diagnosis. A 42-year-old man presented with left index finger mass persisting for 6 months. The mass was small and painless and had gradually increased in size with limited finger flexion. No skin changes or neurological symptoms were noted. The mass was not preceded by trauma or fever. There was no other joint swelling, lymph node enlargement, cough, dysphagia or neck swelling. He had a medical history of hypertension managed with telmisartan 40 mg and felodipine 5 mg daily.Figure 1). There was no tenderness, redness, warmth or punctum. The overlying skin was normal, and the mass did not transilluminate. The range of movement of both interphalangeal joints especially upon flexion was limited owing to the mass. No effusions were felt. Further examination of the head and neck, chest, upper limbs and neurovascular system revealed normal findings. No similar masses were found elsewhere in the body. Haematological findings, including the full blood count, renal profile, liver function, serum uric acid level, fasting sugar level and lipid level, were within the normal ranges. Plain hand radiography showed a soft tissue shadow with no bony involvement .Physical examination showed a firm, non-fluctuance, non-mobile mass measuring around 0.5×1.0 cm over the volar surface of the left index finger . This is supported by the non-fluctuance, non-mobile nature of the mass. Further, the mass did not transilluminate, which would make the diagnosis of a cyst unlikely. The differential diagnosis for a finger mass includes ganglion cysts, lipomas, accessory muscles, venous or arteriovenous malformations and foreign body granulomas.1 On ultrasound, GCT usually presents as a nodular tumour-like structure arising against a flexor or extensor tendon. A cyst is typically anechogenic with posterior echo enhancement and no Doppler flow within. Chest radiography can also be performed to identify any lung metastasis.2Bedside ultrasound can be conducted for characterisation of the lesion and demonstration of the relationship with the adjacent tendon.3The patient should be referred for crosssectional imaging, such as magnetic resonance imaging (MRI), and further workup to confirm the diagnosis of GCT. Once diagnosis is confirmed, surgical excision is the standard of care for the treatment of GCT.3The potential complications include tumour recurrence, neuropathy or limited range of motion and skin necrosis of the finger.Figure 3). The diagnosis of GCT of the flexor tendon sheath was highly suspected. Excision of the mass was performed under local anaesthesia. The histopathology examination showed a well-circumscribed lesion composed of mononuclear cells with scattered osteoclast like multinucleated giant cells. Mitotic activity was rare. This confirmed the diagnosis of GCT of the tendon sheath and its benign nature.The patient was referred to a hand surgeon. Bedside ultrasound of the left index finger mass showed a mixed fluid and solid lesion. Subsequent MRI of the left hand revealed a solid soft tissue lesion sized 0.6×1.2×2.6 cm (3 GCT accounts for 5% of all primary bone tumours and mostly occurs in women and at the age of 20–40 years.3 It mainly affects the meta-epiphyseal area of long bones, although it can also affect the tibia, radius and humerus.2 GCTs are usually benign but can be aggressive locally. Bone disruption, especially around the joints, can affect the joint function and mobility.GCT of the tendon sheath is the most common form of GCTs. It is also the second most common soft tissue tumour of the hand after ganglion cysts.3 Ultrasound can be used to differentiate it from common causes, such as ganglion cysts.1 It also offers better spatial resolution than does MRI and is able to identify adhesions and analyse interactions with surrounding tissues using dynamic information about tendon motions and probe pressures. However, MRI is recognised as the most useful diagnostic tool, as it would help with further classification and surgical planning. The treatment of choice for GCT of the tendon sheath is simple excision. However, local benign recurrence of GCT has been reported to occur in 15%–45% of patients.3Diagnostic workup includes a detailed history-taking and physical examination. Plain radiography is beneficial, since GCT can cause erosions in the cortical bone and even invade the medullary space.


Epidermoid tumors (ET) are congenital and benign tumors that develop from de ectoderm during neurogenesis. In the skull base, these lesions can insinuate themselves into several intracranial compartments by filling the subarachnoid space, and possibly affecting some important structures, like the brainstem, cerebellopontine angle, the pituitary in the middle fossa, and others. In the pediatrics skull base tumors, the ET represents 7-9%, being very rare. The surgical perspective of these cases is dependent on the extension of the resection. We presented two cases of total and near-total resection of ETs in the pediatric skull base, with successful outcomes. Epidermoid tumors (ET) are congenital and benign tumors that develop from de ectoderm during the neurogenesis between the third and fifth weeks of gestation. Its cysts consist in encapsulated forms of epidermoid and connective tissue that grow independently at the expense of its peripheral structures, especially bones . The sacThese tumors, especially the base skull ones, have many potential cellular origins . BesidesET represents a small part of the central nervous system (CNS) tumors, approximately 1%. However, in pediatric skull base tumors, the ET represents 7-9%, being very rare in the skull base. The surgical perspective of these cases is dependent on the extension of the resection . Thus, dThe objective of this article is to report two cases of base skull ETs in the pediatric population and review the literature on these cases.Illustrative case 1A boy, 9 years old, came to our clinic complaining of blurred vision. The cranial MRI showed a tumoral lesion in the suprasellar cistern. The patient was submitted to a right frontotemporal approach, transsylvian with tumor resection Figures -2, improPathology showed a cystic lesion occupied by keratin lamellae, showing a thin wall consisting of loose connective tissue and lined by keratinized squamous epithelium with keratohyalin granules. The epithelial lining showed positive immunoexpression for cytokeratin (AE1/AE3).Case 2A 12-year-old girl came to the emergency department complaining of blurred vision and mild headache for 3 days. Eyes fundoscopy exam showed bilateral papillary edema. Other neurological exams were normal. The hearing was preserved bilaterally. CT showed a hypodense tumoral image in the prepontine and cerebellopontine cisterns plus obstructive hydrocephalus.MRI axial T2-weighted image showed a cerebrospinal fluid intensity, extra-axial cystic lesion in the right CPA, and prepontine cistern Figure . DiffusiThe patient was operated on with intraoperative monitoring of the lower cranial nerves, facial nerve, Brainstem Evoked Response Audiometry (BERA), SPSS, and motor-evoked potential. A retrosigmoid approach was performed just after an external drainage catheter was inserted in the right frontal horn of the lateral ventricles and CSF was sent for study. The tumor was resected through the window between the lower cranial nerves and the VII/VIII nerves Figure . There wETs originate from ectoderm cells between the third and fifth weeks of gestation, due to the incomplete cleavage of the neural ectoderm. These tumors grow slowly via a physiologic division of epidermoid cells. Thus, symptoms appear when the tumor has already reached a significant size .ET has some specific characteristics in neuroimage. The CT shows a low-density lesion without enhancement. The MRI presents hypointense cists in T1-weighted and hyperintense in T2-weighted -10. ThisThe most common clinical presentation of base skull ETs in pediatric patients is the involvement of cranial nerves (CN) and cerebellar dysfunction . Some inMeningitis can be present, especially linked to spontaneous rupture of the cyst releasing irritative fluid -2. The rThe ideal treatment for skull base ETs is total resection. Nonetheless, the possible proximity and enhancement with import structures and eloquent areas can hinder this gold standard treatment . Some inSmall ET can be resected with the translabyrinthine approach, but in the attempt to audition and facial CN preservation, the retrolabyrinthine approach can be done. Also, mastoidectomy can be performed -10. SomeUnderstanding the possible results that a large-size ET in the skull base of pediatric patients, the early detection of this kind of lesion is highly recommended. In small-size tumors, total resection is more likely to be achieved, and the clinical features of the patient are preserved -3,10.The presented cases show the total and/or near-total resection of a skull base ET in the pediatric population.


Central nervous system involvement related to decompression sickness (DCS) is a very rare complication of breath-hold diving. So far, it has been postulated that repeated dives with short surface intervals represent a key factor in the development of breath-holding-related DCS. We report the case of a breath-hold diver who, after repeated immersion, developed DCS with brain involvement. After treatment in a hyperbaric chamber, there was a clinical improvement in the symptoms. Magnetic resonance imaging of the brain showed hyperintense lesions in long-time repetition sequences  in the left frontal and right temporal lobes. Diffusion-weighted imaging (DWI) sequences and the apparent diffusion coefficient (ADC) map were characteristic of vasogenic edema, allowing us to exclude the ischemic nature of the process. These findings, together with the acute clinical presentation, the resolution of lesions in evolutionary radiological controls and the possible involvement of blood–brain barrier/endothelial dysfunction in DCS, could suggest a new form of posterior reversible encephalopathy syndrome (PRES)-like presentation of DCS. This would represent a novel mechanism to explain the pathophysiology of this entity. We conducted a literature review, analyzing the pathophysiological and neuroimaging characteristics of DCS in breath-hold diving based on a case of this rare disease. Diving has become a widespread practice in the world today, encompassing a wide range of activities from scuba diving  and snorkeling to breath-hold diving. Breath-hold diving is mostly practiced at shallow depths and for short periods of time by the general public; in contrast, spearfishermen or competitive breath-hold divers may make repeated dives to depths of more than 30 m and for longer periods of time >1 min) [ min 1,22. One ofDespite this, advances in modern neuroimaging techniques in recent years have allowed us to gain a deeper understanding of numerous neurological pathologies. This improvement has been partly due to the development of diffusion-weighted imaging (DWI) sequences and apparent diffusion coefficient (ADC) maps, which are very useful for a differential diagnosis between vasogenic and cytotoxic cerebral edema.We report the case of a spearfishing breath-hold diver with brain DCS and conducted a review of the literature, analyzing the pathophysiological and neuroimaging features of DCS in breath-hold diving.A 31-year-old male came to the emergency department with symptoms of paresthesia and difficulty writing. There was no medical or surgical history of note, and he currently worked as an underwater fisherman.The day before admission, while he was spearfishing, he began to have fatigue, as well as headache, paresthesia and weakness in the right hemibody. He also reported feeling “confused” and “disoriented”, even having difficulty getting out of the water. Finally, he managed to reach a dock and call for help. The summary of the patient’s dive profile consisted of a 3 h dive at a maximum depth of 30 m, with inter-immersion periods of less than 2 min on the surface and breath-hold times longer than two minutes. Two days earlier he had made another dive of approximately 4–5 h at a similar maximum depth (30 m) and with a similar dive profile.After consulting the emergency room for these symptoms, he was discharged due to “muscle weakness after physical exercise”. As the hours passed, he reported an improvement in the weakness, although with persistent right brachiocrural paresthesia, as well as manipulative clumsiness of the right hand and a feeling of dullness in the head. Finally, given the persistence of symptoms, he decided to return to the emergency department and was then assessed by the on-call neurologist. The vital signs were blood pressure 128/68 mmHg, heart rate 82 bpm, oxygen saturation 100% and temperature 36.0 °C. Neurological examination showed the following: alert and oriented; language, speech and voice were preserved; normal cranial nerves; motor balance preserved; right Babinski’s sign; preserved exteroceptive sensitivity; coordination without dysmetria; and cautious gait, not ataxic. A computed tomography (CT) scan of the brain was urgently requested , showingGiven the history of breath-hold diving with a risk profile for DCS, as well as the clinical-exploratory and neuroimaging findings, the patient was transferred to the reference hyperbaric chamber. Recompression was carried out in the hyperbaric chamber at 2.8 atmospheres absolute (ATA), and the patient presented progressive recovery of symptoms, for which treatment was completed using US Navy Table 6 . AbundanDuring admission, the following complementary examinations were performed: brain magnetic resonance imaging MRI;  showed rAfter the extension study, given the lesions in the cerebral MRI suggestive of brain involvement due to DCS, the patient being asymptomatic from the clinical point of view and the absence of findings in the extension study that could explain the clinical picture, the patient was discharged from hospital with planned follow-up neurology consultations.During follow-up, the patient did not present any new neurological symptoms, and radiological improvement was observed in successive neuroimaging tests , with onNowadays, the neurological involvement of DCS continues to be a serious problem related to diving. It predominantly affects the spinal cord, with brain involvement being less common , and evecritical supersaturation may be reached in which the inert gas cannot remain dissolved and bubbles appear in different locations. These bubbles may remain in the tissues or enter the venous system and may cause mechanical, biochemical or embolic damage, with a wide spectrum of manifestations [Firstly, what we know about the pathophysiology of DCS could be summarized as follows: according to Henry’s law, at a constant temperature, the amount of gas that dissolves in a liquid depends on the solubility constant of each gas/liquid and the partial pressure of the gas. During diving, the ambient pressure increases with depth at a rate of 1 ATA 1013.25 hPa) every 10 m of the water column; therefore, during the dive, the partial pressure of the gases in the pulmonary alveolus increases, and an absorption gradient of these gases is established towards the pulmonary capillary, and from there to the rest of the organism; the oxygen is consumed in cellular metabolism, but this is not the case for the inert gas (nitrogen when diving with pressurized air), which accumulates in the diver. The amount of inert gas absorbed will depend on the depth and duration of the dive, and its distribution in the various organs and tissues will depend on their vascularization and composition (nitrogen dissolves more rapidly in fat tissues). On returning to the surface, the ambient pressure decreases and the inert gas gradient from the tissues to the lungs is reversed. If the ascent is too rapid, if the diver fails to make the needed decompression stops (decompression is omitted) or if there are several predisposing factors , a state called .25 hPa estations . A partiSecondly, among the imaging techniques available for the study of neurological DCS, MRI represents the most accurate technique for the detection of pathological lesions in the spinal cord and brain . To date2), followed as soon as possible by recompression therapy in a hyperbaric chamber. The objective is to achieve an immediate reduction of the size of the inert gas bubbles formed (Boyle’s law), as well as to accelerate their redissolution (Henry’s law). In the case presented, US Navy Table 6  and was clinically asymptomatic. Neuroimaging findings showed hyperintensity in long-TR sequences , as well as in ADC mapping, and no hyperintensity in DWI sequences, compatible with the presence of vasogenic edema in the left frontal and right temporal lobes . RegardiThus, in our case, the brain lesions found had the typical radiological features of vasogenic edema. This allows us to exclude, in this case, the ischemic nature of the process , which would show radiological characteristics of acute ischemic injury (cytotoxic edema) in one or more cerebral vascular territories, as well as a reduction in CBV in MRI perfusion maps. The findings of the radiological evolution contributed to this. Follow-up MRI demonstrated complete resolution of the FLAIR/T2WI signal abnormalities, confirming reversible vasogenic edema, since cytotoxic edema formation and infarction lead to gliotic lesions in the brain and consequently result in permanent signal alterations  . DiffusiThese findings have opened the door to new etiological possibilities for DCS. At this point, in recent years, some cases of breath-hold diving-related DCS have been reported in which, based on neuroimaging findings, an alteration in the permeability of the blood–brain barrier (BBB) has been proposed as a possible underlying pathophysiological mechanism ,7. Likew2 or hypoxia, among others [These approaches involving endothelial and BBB dysfunction are of recent interest, having been proposed as a key element in the pathophysiology of other clinico-radiological entities such as PRES . Traditig others ,41,42,43Finally, in our case, control MRI (1 and 4 months after DCS) demonstrated resolution of the hyperintense bihemispheric vasogenic edema lesions on T2WI/FLAIR sequences and the ADC map, with only minimal areas of cerebral malacia persisting.The pathophysiology of DCS in breath-hold diving remains currently unknown. Here, we report a case of DCS in a breath-hold diver. The radiological findings observed in our case, with bihemispheric lesions, hyperintensity in long-TR sequences  and no restriction in diffusion sequences (vasogenic edema), suggest an alteration of the BBB. These findings, together with the acute clinical presentation, the resolution of lesions in evolutionary radiological controls and the potential involvement of BBB/endothelial dysfunction reported in recent research studies, could suggest a new form of PRES-like presentation of DCS. Despite this and because of the low prevalence of this pathology, a greater number of cases, studied with adequate neuroimaging protocols, are necessary to deepen our understanding of the pathophysiological mechanisms of neurological breath-hold diving-related DCS.