Neurenteric cysts (NCs) are rare congenital lesions that are thought to result from the persistence of the neurenteric canal connecting primitive gut and neural tube. Despite the congenital nature, NCs can be diagnosed at any age and at a similar frequency in women and men. To our knowledge, 140 intracranial NCs, confirmed by histology, including the patient presented in this review, have been reported since 1952. Parenchymal NCs are extremely rare, and there are no publications describing the intra-axial NCs of the brainstem at the moment.A 19-year-old female presented to the clinic with the following complaints: moderate dysphagia (two to three times per day) for and liquids and solids, dysphonia, vertigo, spontaneous nystagmus, imbalance, and numbness in the left side of the body, including the face. The magnetic resonance imaging (MRI) of the brain showed a well-defined lesion centered in the medulla. The patient underwent a small right-sided keyhole retro-sigmoid craniotomy. Just under the sulcus, a cyst containing pathological amorphous gray-yellow liquid was evacuated. Accessible parts of the capsule were resected without brain injury. Residual particles of the capsule were coagulated.Two months after the operation, the patient presented with similar symptoms. We used the previous craniotomy during the second surgery. After the evacuation of the cyst, a silicone stent was set for connecting with the cerebellopontine cistern and preventing new synechiae formation. As surely as after the first surgery, all neurological symptoms gradually regressed. In two months after surgery, deglutition and sensations recovered, and hemiparesis and imbalance decreased. Postoperative MRI examination two months after surgery showed no evidence of cyst recurrence.Intra-axial NCs are a rare group of congenital pathological lesions with a favorable prognosis. There are no publications of brainstem NCs with intra-axial localization to date. The treatment of choice in this group of patients is complete microsurgical excision followed by long-term observation. Neurenteric cyst (NC) was first described in 1928 by Kubie [Neurenteric cysts (NCs) are rare congenital lesions that are thought to be the result of the persistence of the neurenteric canal connecting primitive gut and neural tube. As a result of separation failure, the NC cavity canal is lined with cuboidal or columnar epithelium and contains mucin-producing cells -5. NowadThe other existing non-comprehensive theory includes embryonal failure of separation between the notochord and the foregut leading to the incorporation of primitive endodermal cells in the notochord. However, as the most rostral extent of the endoderm terminates at the level of the clivus, this hypothesis does not explain the occurrence of spinal NCs .The most contemporary hypothesis suggests an anomalous migration of endodermal cells via the primitive neurenteric canal into the ectoderm, thus reaching far cranial and lateral locations (positions) -7. AccorDespite the congenital nature, NCs can be diagnosed at any age and at a similar frequency in women and men. Compared to intraspinal NCs, which usually occur in the pediatric age groups, intracranial NCs are more common in the adult population in the third and fourth decade. The average age of patients diagnosed with intracranial NC is 34 years old ,11.Overall, 140 intracranial NCs, confirmed by histology, including the patient presented in this review, have been reported since 1952. From 1952 to 2012, a total of 139 cases of NCs were reported in the literature ,9,12-16.The majority of neurenteric cysts occur in the spine; they are usually ventral to the spinal cord. Intracranial neurenteric cysts are far less common. The majority of cysts are located infratentorially in the pre-pontine region, in the cerebellopontine angle, and to a lesser extent within the cisterna magna and the fourth ventricle. Parenchymal NCs are extremely rare ,4,6,7,17A 19-year-old female with complaints of hoarseness and mild dysphagia for liquids presented to the clinic; her symptoms had gradually deteriorated in the past five months. On admittance, physical examination showed moderate dysphagia (two to three times per day) for liquids and solids, dysphonia, vertigo, spontaneous nystagmus, imbalance, and numbness of the left side of the body and face.Magnetic resonance imaging (MRI) of the brain showed a well-defined lesion located in the medulla oblongata. This lesion was homogeneously hypointense on T2-weighted images and heterogeneously hyperintense on T1-weighted images and demonstrated no solid enhancing components. It was also heterogeneously hypointense on diffusion-weighted imaging (DWI)  and clinical  features. Through a small craniotomy (2x1 cm) and a little C-shaped dura incision along the sigmoid sinus towards the skull base, the medulla surface was achieved. It was deformed and bulged into the сerebellopontine cistern. There were no signs of brain parenchyma destruction on the surface. So, the brainstem incision was made in a small region  along the retro-olivary sulcus. Just under the sulcus, the cyst containing pathological amorphous gray-yellow liquid was evacuated.The cyst walls were presented by a thin gray capsule, tightly attached to the surrounding brain parenchyma. Accessible parts of the capsule were resected without causing any brain injury. The residual capsule fragments were coagulated. We did not perform additional endoscopic revision of the cyst cavity due to its surgical accessibility. We used transcranial motor evoked potentials and direct caudal brainstem mapping during the operation.Numbness of the left side of the body and all clinical signs from posterior cranial fossa (PCF) increased after surgery while bulbar disturbances considerably decreased. Control computed tomography (CT) demonstrated decreased deformity of the caudal brain stem parts; no cyst remnants were evident. Almost all neurological symptoms regressed in one month after the operation, including numbness. Karnofsky Scale (KS) score was 90.In two months after surgery, the patient developed mild dysphagia and dysphonia, vertigo, spontaneous nystagmus, imbalance, and numbness of the left side of the body and the right limb, including face and mild left-sided hemiparesis before MRI was planned. MRI revealed recurrence of the cyst. As before, the lesion had well-defined, heterogeneously hyper- and isointense signal on T1-weighted images, demonstrated no solid enhancing components, but this time was homogeneously hyperintense on T2-weighted images. Sites of hyperintensity were less pronounced than on MRI before the first surgery  showed that the site of the brainstem incision was covered with tight arachnoidal synechias. It resulted in white viscous formless fluid accumulation Figure .After the evacuation of the cyst, a silicone stent was set to connect with the cerebellopontine cistern and to prevent new synechia formation. The stent was fixated to the arachnoidea with a single clip. After the repeat surgery (as after the first surgery), all neurological symptoms gradually regressed. In two months after surgery, swallowing and sensibility improved (recovered) and hemiparesis and imbalance decreased. Postoperative MRI examination done two months after surgery showed no evidence of cyst recurrence Figure .Histological material after the first and second surgery was characterized by yellow-white gelatinous liquid with small parts of epithelial lining seen microscopically. The morphological appearance intraoperatively and histological findings matched with features of NC.NC is a rare congenital abnormality of the CNS, most likely localized in the inferior cervical and superior thoracic parts of the spinal canal. Most intracranial NCs are localized in PCF in basal cisterns, craniocervical junction, or 4th ventricle. Parenchymal localization is extremely rare ,4,6,7,17MRI examination is a method of choice for diagnosing this type of pathology, but its characteristics can be variable. It shows well-demarcated lesions, which are iso- or tightly hypointense on T1 and hyperintense on T2-weighted sequences and fluid attenuation inversion recovery (FLAIR) sequence ,4,6,17. NCs are slow-growing benign lesions. An NC can compress surrounding neural structures during its enlargement. It leads to these clinical signs due to anatomical localization.The treatment of choice is complete surgical excision. Clinical signs most commonly regress after surgery. Although a radical resection prevents recurrence, considering the fact that a thin capsule may firmly adhere to the brainstem, it is not always possible to completely resect the capsule without any neurological deficit, especially in PCF -6,17.Kozak et al.  describeIn the case series of Wang et al. , seven cBesides problems with radical resections, many authors write about the necessity of relapse surgery in cases of early NC recurrence from capsule remnants. Nelson et al.  present Chen et al.  showed 1Opposed to the above described clinical case series, the reason for recurrence in our case was a firm adhesion of the capsule to the brainstem incision area, so we had to place a silicone stent in the cyst cavity for its drainage in the lateral cistern of the brain stem.According to a literature review, NC recurrence can occur in later periods after surgery. However, the incidence of these complications is rather difficult to determine due to the rare occurrence of NCs. Only Chavda et al. indicated that incidence of NC recurrence in their series of NC subtotal resections made up 37% within a 30-year follow-up . Today, Intra-axial NC is a rare group of congenital pathological lesions with a favorable prognosis. Today, there are no publications of brainstem NCs with an intra-axial localization. The treatment of choice in this group of patients is complete microsurgical excision followed by long-term observation.


Primary female genital system lymphoma (PFGSL) is an infrequent entity. All genital organs may be affected, and most PFGSLs are localized to the cervix, uterine body, and ovaries. The clinical manifestations are nonspecific, which complicates a timely diagnosis. We report an unexpected case of PFGSL and discuss the disease characteristics by reviewing the literature.A 48-year-old G3/P2 woman presented to the Department of Gynecology with a physical examination. Ultrasound examination and CT revealed pelvic masses. The woman underwent surgical treatment because of the pelvic masses and underwent a hysterectomy for a recurrent mucinous borderline ovarian tumor. However, the results of the postoperative pathological examination showed diffuse large B-cell lymphoma of the endometrium. After four courses of chemotherapy, the woman was in good condition. The clinical manifestations were nonspecific, which made a timely diagnosis complex.This case highlights the importance of the difficulty in detecting early PFGSL early and how easily nonspecific manifestations can be ignored. It may lead to missing the best time for early treatment. Primary female genital system lymphoma (PFGSL) is an infrequent entity and constitutes 0.2–1.1% of all extranodal lymphoma cases. In the U.S., there are an estimated 165 new cases of PFGSL annually [A 48-year-old G3/P2 woman presented to the Department of Gynecology with a physical examination. Ultrasonography Fig. A and enhPFGSL is a sporadic neoplastic disorder that accounts for 1.5% of all non-Hodgkin's lymphomas. PFGSL usually occurs in women older than 60 years of age . The mosPrevious case series have reported that DLBCL is the most common histological type of PFGTL , 6. Its There are currently no randomized clinical trials or specific guidelines addressing the treatment of PFLGT. The patients receive comprehensive treatment, which usually involves a combination of surgery, chemotherapy, and radiotherapy. Surgical treatment aims to define the pathology and stage of the tumor, reduce the tumor load, and improve the efficacy of postoperative chemotherapy or radiotherapy. At present, comprehensive treatment based on chemotherapy and surgery can improve the survival rate of patients. However, chemotherapy is mainly administered for lymphoma. Regarding rituximab, cyclophosphamide, doxorubicin, vincristine,and prednisone(R-CHOP) therapy, the combination of CHOP therapy, the standard treatment, and rituximab, a chimeric anti-CD20 monoclonal immunoglobulin G antibody, has been successfully used to treat CD20-positive B-cell non-Hodgkin's lymphoma . At pres


Mirizzi Syndrome is a rare complication of cholelithiasis.In this case report the Authors present an original surgical approach for the treatment of complicated gallbladders, based on open subtotal cholecystectomy, leaving in situ the stone. This is the first case showing safety and reliability of the present strategy at a four-year follow-up.A 68-year-old patient came to our emergency room with abdominal pain, leukocytosis and fever. At surgical exploration he presented a sclerotic retraction of the gallbladder together with an intrahepatic abscess, that forced us first to perform an open subtotal cholecystectomy, resecting the gallbladder cranially and leaving in situ the stone.The post-operative course was uneventful. The four-year clinical, US and CT scan follow-up was negative and the patient referred a normal quality of life. The present strategy could be considered an intraoperative rescue option in such a complex operative scenario in which is impossible to safely remove the stone.This case report demonstrates how in selected cases, when absolutely necessary and unavoidable without high risks, the stone can be left in situ as an eventual stone resection would be extremely risky. •Subtotal cholecystectomy is a well-known and established procedure in case of difficult gallbladders as in Mirizzi syndrome.•A traditionally accepted part of this technique is to remove the stone together with the gallbladder.•In selected cases the removal of the stone could be difficult and even dangerous for the patient.•Necessity of stone removal in difficult gallbladders should be carefully counterbalanced with possible local complications.•Four-year follow-up without complications is showing that in selected cases the stone can be left in situ. The operation was performed by the last Author of the present report as an open procedure. The intraoperative findings showed a complex retraction of the gallbladder hilar portion with duodenal retraction and rotation inside the liver hilar portion.A 67-year-old patient came to our clinical observation in emergency room: male patient, married, truck driver, affected by type II diabetes in good compensation by Metformin assumption, under oral anti-coagulation due to stent positioning for a previous heart attack. He came with a 40 °C intermittent fewer from 2 days, extreme leukocytosis (30.000 WBC) and acute abdominal pain at the right hypochondrium. Murphy's sign manually evocated was positive. No family history of biliary disease was reported. A CT scan of the abdomen revealed a giant hepatic abscess involving the entire right lobe till the falciform ligamentum A and a h3Given the sclerotic retraction of the gallbladder, we performed the subtotal cholecystectomy, opening the gallbladder: the digital exploration of the hilar part guided the gallbladder resection. Due to the incarceration of the stone inside the cystic stump  and the 4The Gold Standard treatment of non-complicated cholelithiasis is laparoscopic cholecystectomy . HoweverIn our case, not only the intense fibrosis and retraction of the gallbladder, but even the previous drainage of intrahepatic abscess due to intrahepatic gallbladder perforation, forced us to prefer an open approach ,11. Out 5To best of our knowledge this is the first reported case of successful leave-in-situ of the stone after a subtotal cholecystectomy as a definitive treatment of Mirizzi Syndrome with long uneventful follow-up out of recommendations or guidelines. Given that the prior goal of the treatment is to remove gallbladder and stones, we showed that in selected cases, when absolutely necessary and unavoidable without high risks, the stone can be left in situ as an eventual stone resection would be extremely risky.6Written 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.No sources of funding declared.No ethical approval needed for this study.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.MZ wrote the draft of the work, collected clinical data, made follow-up and literature search; GB1 collected images and wrote comments; GB2 made interpretation of data, FB made literature search and first review; MD made study design and final revision. MD and FB performed the operation. Each Author approved the submitted version.Not appliableProf. Marcello Donati.The Authors declare they have no conflict of interest.


Mixed adenoneuroendocrine carcinoma (MANEC) of the gastrointestinal (GI) tract is a rare subtype of mixed tumors, and it is scarcely described in the literature. MANEC tumors are composed of adenocarcinoma and neuroendocrine carcinoma components, each of which comprises at least 30% of the lesion. Diagnosing MANEC requires specific histological and immunohistochemistry (IHC) analysis. Typically, MANEC tumors carry a poor prognosis due to their very aggressive nature.We report the case of a 70-year-old female patient with no past medical history who presented with a three-week history of abdominal pain and one episode of hematemesis one week prior to presentation. Initial CT of the abdomen showed a large, 8 x 6 x 6-cm mass arising from the stomach and extending to the lesser sac as well as the central crus of the diaphragm with bilateral retroperitoneal lymphadenopathy. Upper endoscopy revealed an excavated, ulcerated, and partially necrotic mass on the lesser curvature of the proximal gastric body. Tissue biopsy of the lesion showed infiltrating mixed poorly differentiated adenocarcinoma and neuroendocrine carcinoma. On IHC, the adenocarcinoma component stained positively for CDX2 and pancytokeratin, and the neuroendocrine component stained positively for synaptophysin and chromogranin. Further workup included CT of the chest, which demonstrated extensive bilateral pulmonary emboli and new liver lesions with moderate ascites not seen on the initial abdominal CT. The latter was repeated and showed remarkable enlargement of the gastric mass (up to 12 cm) with extensive retroperitoneal adenopathy and mesenteric implants. Given the rapid clinical deterioration and progression of tumor burden, comfort measures were offered and the patient passed away soon after. MANEC tumors are highly aggressive subtypes of "collision" tumors, which are not well described in the medical literature due to their rarity. The etiology is poorly understood with various theories proposing different pathophysiological mechanisms. Standard therapy is not well developed at present; however, a few reports have demonstrated successful outcomes with surgery or combined chemotherapy (cisplatin with irinotecan or etoposide) if diagnosed at an early stage. Mixed adenoneuroendocrine carcinoma (MANEC) of the gastrointestinal (GI) tract is a rare subtype of mixed tumors, and there is scarce data on them in the medical literature . MANEC tThe patient was a 70-year-old female with no past medical history who presented with complaints of abdominal pain of three weeks' duration and one episode of hematemesis in the past week. At the emergency department, the patient underwent a CT scan of the abdomen, which exhibited a large, 8 x 6 x 6-cm abdominal mass arising from the stomach and extending to the lesser sac and central crus of the diaphragm with bilateral retroperitoneal lymphadenopathy Figure . AdmissiHistopathological analysis of tissue biopsied during EGD revealed gastric oxyntic mucosa with infiltrating mixed poorly differentiated adenocarcinoma Figure  and neurHelicobacter pylori were negative. Alcian blue and periodic acid-Schiff staining highlighted many goblet cells. CT scans of the chest and abdomen were performed two weeks later, which revealed bilateral pulmonary embolism, as well an interval increase in the size of the gastric mass now to 7 x 12 x 7 cm with new liver metastasis and moderate ascites  if diagnosed at an early stage.


Most primary esophageal adenocarcinomas arise from the Barrett epithelium of the distal esophagus. Thus, cancer developing from the ectopic gastric mucosa (EGM) of the proximal esophagus is extremely rare. Furthermore, recurrent adenocarcinoma at the EGM has not been reported. Here, we describe adenocarcinoma originating from the EGM at the boundary of the cervical and thoracic esophagus that recurred twice at the same site within 40 months. This adenocarcinoma was treated throughout its course by three endoscopic submucosal dissections and a subsequent thoracoscopic esophagectomy. This is the first description of recurrent adenocarcinoma originating from the EGM of the proximal esophagus. We describe adenocarcinoma originating from the ectopic gastric mucosa (EGM) at the boundary of the cervical and thoracic esophagus that recurred twice at the same site within 40 months. This adenocarcinoma was treated throughout its course by three endoscopic submucosal dissections and a subsequent thoracoscopic esophagectomy. This is the first description of recurrent adenocarcinoma originating from the EGM of the proximal esophagus. Ectopic gastric mucosa (EGM) in the esophagus is considered to persist when the esophageal mucosa, which is covered with columnar epithelium at the fetal stage, is replaced by squamous epithelium from the middle esophagus in upward and downward directions.Most primary esophageal adenocarcinomas are derived from the Barrett epithelium of the distal esophagus, and adenocarcinoma arising from the EGM of the proximal esophagus is extremely rare. Here, we describe recurrent esophageal adenocarcinoma arising from the original site in the EGM at the boundary of the cervical and thoracic esophagus in a male patient. He was treated by three endoscopic submucosal dissections (ESDs) and an eventual subtotal esophagectomy.A 52‐year‐old man was referred with an esophageal tumor. He had a 70‐pack year smoking history and a history of alcohol abuse, but his family history and medical records were negative for hereditary diseases. The physical and laboratory findings were unremarkable. Esophagography and esophagogastroduodenoscopy revealed an EGM with a stalked elevated lesion (20 mm in diameter) at the boundary of the cervical and thoracic esophagus that was diagnosed as mucosal cancer by endoscopic ultrasound (EUS) Figure . A biopsThe patient was followed up every 6 months thereafter and remained recurrence‐free for 21 months, when a 15‐mm stalked elevated lesion arising from the post‐ESD scar was pathologically diagnosed from a biopsy as adenocarcinoma Figure . The lesStalked elevated lesions (20 mm in diameter) developed twice from the ESD scar 19 months after the second ESD, and this was again pathologically diagnosed as adenocarcinoma by biopsy Figure . EsophagAn ESD scar was located at the boundary of the cervical and thoracic esophagus, indicating that the larynx could be preserved. The patient underwent thoracoscopic subtotal esophagectomy with cervical and mediastinal lymph node dissection, and the esophagus was reconstructed using a gastric tube. Postoperative complications did not develop. A postoperative pathological examination revealed no tumor remnants and no lymph node metastasis. The patient remains alive, without signs of cancer recurrence at 5 years after the last surgical procedure.The incidence of adenocarcinoma among patients with cervical EGM is 0–1.56%.Among the patients, 53 (91%) were male and 33 (57%) of 58 esophageal adenocarcinomas arising within the EGM were managed by surgical resection, whereas small carcinomas confined to the submucosal surface in 7 (12%) were managed more recently by endoscopic resection.The adenocarcinoma originating from EGM of the proximal esophagus in our patient recurred twice at the same site after ESDs. This might have been due to either multiple occurrences of cancer arising from residual EGM or residual tumor cells proliferating after ESD. Although the EGM was resected as widely as possible at the first ESD, some remained that was detected in a biopsy specimen at follow‐up after ESD. Furthermore, two resected margins after the first two ESDs were pathologically negative for cancer. Therefore, we considered that the repeated lesions might be metachronous esophageal adenocarcinomas that developed from the EGM.In contrast, one patient has been described with recurrence caused by tumor cells implanted in a mucosal laceration even after curative gastric ESD.We described an extremely rare recurrent adenocarcinoma originating from EGM of the proximal esophagus. Although the mechanism of repeated tumor development in our patient was difficult to confirm, this experience suggests that at least cancerization from EGM should be considered during periodic follow‐up, even if the risk for cancer is low. Furthermore, early adenocarcinoma originating from the EGM should be treated by complete endoscopic resection, including the entire EGM.None of the authors has any specific financial interests, relationships or affiliations relevant to the subject of this manuscript.


Desmoid tumor is a rare fibroblastic proliferation with a variable and often unpredictable clinical course that arises in the deep soft tissues and is characterized by infiltrative growth with tendency to local recurrence but not to metastasize. A 49-year-old man was referred for a second opinion regarding a pancreatic mass. With a personal neoplastic background of two different tumors, we considered as a high probability of being metastatic of his previous colorectal or renal cancers, in a peritoneal implant. Due to the unclear origin and nature of the mass, we opted for requesting a computed tomography (CT)-guided core needle biopsy that could eventually lead to a surgical and/or chemotherapy treatment. So far, this is the first case of pancreatic desmoid fibromatosis with splenic vein invasion diagnosed by CT scan-guided core needle biopsy. Surgery should be performed by an experienced surgeon as first-line therapy, provided expected surgical morbidity is limited. Desmoid tumor (DT) is a rare monoclonal, fibroblastic proliferation with a variable and often unpredictable clinical course . About 5Desmoids in FAP arise from adenomatous polyposis coli (APC) inactivation and subsequent accumulation of beta-catenin in cells , 5. In cCross-sectional imaging of the affected area with computed tomography (CT) or magnetic resonance imaging is needed to evaluate the involvement of the tumor, in order to assess resectability. There are no imaging patterns that clearly differentiate between DT and malignant soft tissue tumors.The diagnosis of a DT can only be established by histological findings of a biopsy specimen. However, for experienced pathologists, even tissue from a core biopsy may be sufficient to the correct diagnosis.DT involving the pancreas is very rare with only few cases previously reported in the English-language literature , and theIn this case, a CT scan-guided core needle biopsy gave an adequate cellular sample allowing accurate diagnosis by immunohistochemistry (IHC) staining and molecular testing.A 49-year-old man was referred for a second opinion regarding a pancreatic mass. The patient did not complain of abdominal pain, nausea, vomiting, chills, fever, bloating, diarrhea, anorexia, fatigue, hematochezia and cutaneous itching. There was no history of diabetes, without reference to using drugs, alcohol or tobacco.In 2019 the patient had the diagnosis of an ascendent colon cancer and underwent a laparoscopic right colectomy with an extended colon resection performed until close to the splenic angle. Histopathology showed a well-differentiated adenocarcinoma of the colon with the 73 resected lymph nodes (LNs) negative for metastasis, Stage IIA. No evidence of Gardner’s syndrome or FAP was found.Genetic screening did not show any pathogenic variants but identified one of uncertain significance in BMPR1A gene, which is associated with autosomal dominant juvenile polyposis syndrome.At the end of 2020, the patient had the diagnosis of a right renal tumor and underwent a robotic partial right nephrectomy in a zero-ischemia procedure. The pathologic results were a renal cell carcinoma (RCC) of clear cells, Stage I, Fuhrman grade II.The complete blood count, complete metabolic and coagulation panels, enzyme and tumor markers  were all normal.Abdominopelvic CT scan disclosed a 3.7-cm mass, between the tail of the pancreas and the splenic hilum, causing a narrowing of the splenic vein and splenomegaly –3.With that personal neoplastic background of two different tumors, these findings were considered as a high probability of being metastatic colorectal or renal lesion, in a peritoneal implant. Due to the unclear origin and nature of the mass, we opted for requesting a CT-guided core needle biopsy that could eventually lead to a surgical and/or chemotherapy treatment.Microscopically, the lesion presented as proliferation of spindle cells without atypia, a low mitotic index and a fibrous stroma rich in collagen  and 5. IThe patient underwent laparoscopic distal pancreatectomy with splenectomy  and 8 wiThe macroscopic anatomopathological study showed a 4.3 cm diameter nodular lesion, consisting of a firm and brownish tissue, ill-defined fibrous mass in the pancreas that was diffusely infiltrative on gross and microscopic examination . HistoloDTs  are benign, slow-growing fibroblastic neoplasms with no metastatic potential but a tendency for local recurrence 8–31%) [–31% [8],Fine needle aspiration (FNA) or core needle biopsy can be an important tool for preoperative diagnosis of intra-abdominal DT. Previous studies of DT in FNA specimens are relatively rare but do offer some guidance regarding helpful features and frequent pitfalls . ObtainiIn addition, colorectal cancer (CRC) is a leading cause of cancer-related deaths worldwide, and its incidence has been increasing . PeritonRegarding kidney cancers, a study  that incTherefore, DT involving the pancreas, because of its rarity and often nonspecific presentation, represents a distinct diagnostic challenge , 5. So fIn summary, when interventional treatment for DT is required, surgery should be performed by an experienced surgeon as first-line therapy, since undesirable consequences are unexpected.All the authors testified to the care of the patient and the writing of the manuscript. The authors have read and agreed with the contents of the manuscript.None declared.Written informed consent was obtained from the patient for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request.


Inferior mesenteric vein thrombosis (IMVT) is a rare entity that can lead to a potentially lethal event unless recognized early in the disease. Although its prevalence is low, IMVT presents mainly in certain conditions such as in inflammatory processes like diverticulitis, arrhythmias, hypercoagulable states, connective tissue disorders, malignancy, or hereditary thrombophilias. Mesenteric venous thrombophlebitis is a condition in which a blood clot in a vein causes inflammation and pain. It can appear in an acute or subacute manner that leads to acute mesenteric ischemia. The case of a 58-year-old male without a significant past medical history who presented with suprapubic abdominal pain secondary to a partial IMVT of unknown etiology with accompanying thrombophlebitis is discussed here. Acute mesenteric vein thrombosis (MVT) is a rare but an important cause of intestinal ischemia, and an early diagnosis requires a high index of suspicion. Diagnosing acute mesenteric ischemia (AMI) is challenging, and failure to recognize it prior to the onset of intestinal necrosis is associated with high mortality. AMI can be caused by various conditions such as arterial occlusion, venous occlusion, strangulating obstruction, and hypoperfusion associated with non-occlusive vascular disease.Early diagnosis and prompt treatment are goals of successful therapy but there are not any randomized control trials to guide treatment . The repAlthough there are not any specific clinical features of AMI, a high index of suspicion is necessary for the evaluation and diagnosis of MVT. Definitive diagnosis is made by imaging studies that reveal the presence of thrombosis within the mesenteric veins. It is recommended that the use of computed tomography (CT) with and without intravenous (IV) or oral contrast is used for initial screening of MVT. More reliable modalities like CT angiography (CTA) and magnetic resonance venography are also helpful; however, the ability of CT for diagnosing mesenteric ischemia has recently been reported to have a sensitivity of approximately 90%. The CTA has the added benefit of capturing delayed images in the venous phase, especially in the setting of non-diagnostic non-contrast CT, which leads to a high clinical suspicion of MVT .A 58-year-old male with no significant past medical history presented to our institution for progressively worsening suprapubic pain lasting one week and not associated with urination. One week earlier he had presented with similar symptoms and complaints including general myalgias, dark urine, and subjective fevers. He was sent home with a course of antibiotics without much improvement for presumptive urinary tract infection.He returned on this admission with persistent suprapubic pain described as sharp, non-radiating with a 10/10 severity. Pain was exacerbated by activity and was alleviated with rest and the use of non-steroidal anti-inflammatory drugs. He denied fevers, chills, night sweats, nausea, vomiting, or changes in bowel habits. At presentation the patient was hemodynamically stable. Physical examination was significant for abdominal tenderness out of proportion with the presence of voluntary guarding. The abdomen was soft, non-distended with normoactive bowel sounds. The rest of the examination was unremarkable.Initial blood count revealed a pertinent result of hemoglobin 15.5 grams/deciliter and leukocyte count of 13.2 cells/liter. A comprehensive chemistry panel revealed an elevated alanine aminotransferase of 66 units/liter but with otherwise unremarkable results including lactic acid of 0.9 millimoles/liter and severe acute respiratory syndrome coronavirus 2 polymerase chain reaction negative. The urinalysis was significant for urine specific gravity of 1.056. Imaging studies included a CT IV contrast of the abdomen and pelvis, which was significant for prominence of the IMV, with surrounding mesenteric inflammation, raising concerns for IMVT versus thrombophlebitis. As a result of these imaging findings, general and vascular surgery were consulted and recommendations to place the patient on full-dose anticoagulation with lovenox were given, in addition to obtaining a CTA with delayed imaging in order to capture the venous phase of the IMV. The CTA confirmed a partial occlusion of the IMV with surrounding inflammatory changes to both the portal vein and SMVs, which were patent  bowel infarction. IMVT is a relatively uncommon finding that has been reported to be responsible for only 4%-11% of cases of AMI and carries a 15%-23% risk of mortality [MVT and AMI are both associated with prothrombotic states ; however, the diagnosis has been made without these associated pathologies present . It is eTreatment of symptomatic patients with radiological signs of acute MVT will be determined by a few factors such as 1) the presence or absence of clinical signs of peritonitis or 2) overt signs of intestinal necrosis or perforation on imaging. Any positive findings of the aforementioned will determine the need for a surgical intervention versus non-surgical intervention . ConservOur case of a partial IMVT with associated thrombophlebitis is seldom reported in the literature. Relevant history, physical examination, and high clinical suspicion are crucial in these cases. When clinical suspicion of mesenteric thrombosis or thrombophlebitis is present, a CT scan with IV contrast is the recommended initial imaging study of choice. Early recognition of mesenteric thrombosis is essential as it can lead to AMI, which is associated with high morbidity and mortality rates. Given the vast array of clinical presentations, we believe further research is warranted to raise awareness of these pathologies.


Schizencephaly is a rare congenital brain structural abnormality that is not clearly understood and has no specific treatment yet. Therefore, cases related to it should be added to the literature. This report aims to introduce a rare case of severe schizencephaly co‐occurring with post‐traumatic intracranial epidural hematoma. Schizencephaly is a rare congenital developmental malformation, for which there is no specific treatment yet. Schizencephaly should be differentiated from lesions associated with gray matter abnormalities and cerebrospinal fluid‐containing defects. It is characterized by clefts in the cerebral tissue that are commonly located in the Sylvian region and can be unilateral or bilateral.2A 5‐year‐old boy was admitted to the hospital in a state of traumatic brain injury due to a fall and hit his right parietal head against the wall. His history was presented with motor and mental retardation accompanied by occasional seizures. Family history was unremarkable. Vital signs including pulse, temperature, blood pressure, and respiratory rate were all normal limits. Laboratory evaluations were nothing unremarkable. Physical examination revealed mild scalp swelling in the right parietal region. The patient presented with a headache with delayed mental and motor response. He underwent a computed tomography (CT) scan of the head, which showed skull fracture with epidural hematoma in the right parietal region Figure . Further3Schizencephaly was first described by WilmarthThe etiology is not well understood but those that cause destruction of brain tissue ; and disorders of nerve cell migration  lead to schizencephaly.Clinical severity depends on defect type, cleft size, cleft location, unilateral versus bilateral defect, the extent of the cerebral tissue damage, and the extent of anatomic abnormalities of other neural structures involved. Clinical manifestations of schizencephaly are variable and heterogeneous, such as neuro‐psychologic disorder, neurobehavioral abnormality, motor impairment, psychomotor developmental delay, intellectual dysfunction, language behavior disorder, seizure, epilepsy, microcephaly, muscle hypotonia, focal neurologic signs, spastic diparesis, hemiplegia, etc.Image methods give a demonstration of anatomic changes as well as in identifying other associated lesions. They delineate gray matter lining the defect and the communication with the ventricle. MRI is more sensitive than CT in detecting the clefts as well as additional abnormalities such as polymicrogyria, pachygyria, heterotopic gray matter, optic nerve hypoplasia, septo‐optic dysplasia, agenesis of the septum pellucidum and corpus callosum, etc.Differential diagnosis of schizencephaly includes gray matter abnormalities  and CSF‐containing defects .Head trauma in patients with schizencephaly may be more severe than in normal patients because of poor behavioral control. Care of epidural hematoma in patients with schizencephaly should be with an interdisciplinary approach. An interprofessional team is established in this situation including a pediatrician, psychiatrist, neurologist, neurosurgeon, nurse, and pharmacist. In these patients, conservative management should be attempted; surgical treatment is only performed in case the epidural hematoma causing severe symptoms.The authors declare no conflicts of interest.VTH involved in writing and conceptualization. THH involved in data curation and diagnosis confirmation. VC and DTD involved in review and revision. All authors read and approved the final manuscript.Ethics approval was not required for this study.Written informed consent was obtained for use of the clinical images.


Supernumerary extraocular muscles (EOMs) are relatively rare in humans compared to other species. Therefore, few cases are reported on pediatric patients with strabismus. We describe a case of an incidental intraoperative finding of a right eye accessory medial rectus (MR) muscle in a child with normal ocular motility. This supernumerary muscle was found inserted underneath the original MR muscle and was of a similar size. In this article, we discuss the anomaly and its clinical relevance. Deep knowledge of the anatomy of the ocular muscles, compartments, vessels, nerves, and fascias is essential for the diagnosis and surgical treatment of orbital diseases. Voluntary movements of the eyeball are executed by six extrinsic ocular muscles. Restrictions of movements and functional disturbances of the eyeball are caused by the variation in the origin, position, and insertion of these muscles. Reported variations of extraocular muscles (EOMs) include congenital absence, supernumerary EOMs, and bifurcation of the muscle tendon. These are diagnosed as incidental findings on orbital imaging, post-mortem examinations, or during strabismus surgery . AdditioAn otherwise healthy nine-year-old girl, with no significant past medical, surgical, or trauma history, presented with an inward deviation of both eyes. The deviation started intermittently nine months before and progressed to be constant. Her best-corrected visual acuity was 20/30 and 20/20 in the right and left eye, respectively. Cyclo-refraction results were +3.50 sphere in the right eye and +3.00 sphere in the left eye with -1.00 cylinder in both eyes at 90 degrees. On initial examination, the patient was noted to have an esotropia (ET) of approximately 60 prism diopters (PD) at a distance with full ocular motility. No abnormal head or chin position was noted. MRI of the brain and orbits showed normal brain and parenchymal structures. An initial trial of full-correction glasses for six months was given. On subsequent visits, the deviation was found to be around 45 PD on full-correction glasses. We planned for bimedial rectus muscle recession (BMR), targeting 45 PD correction. Under general anesthesia, the surgery was started on the right eye with an inferonasal fornix-based incision. During hooking of the MR muscle, another fibromuscular band was incidentally found inserting behind the original MR muscle Figure . The oriOn the first post-operative visit, six weeks after the operation, the patient was found to be orthotropic in near and distance. In addition, she maintained full extraocular motility in both eyes.Developmental anomalies of the EOM, apart from congenital fibrosis, are extremely rare in humans. Only a few case reports describe such anomalies . The exaThese anomalies, including accessory MR muscles, rarely affect the motility or the primary position of the globe . HoweverDespite accessory MR muscle being a rare entity, it could be a part of other associated ophthalmological or systemic diseases. For example, one case report stated that this entity might play a role in the pathogenesis of strabismus fixus convergence (a rare type of restricted strabismus) .We did not perform histological confirmation of the lesion, as only recession of the anomalous muscle was performed. No abnormalities were identified on MRI of the brain and orbits. According to a previously published case series, small bands connecting two original EOM were observed in 12 subjects on MRI . In our Accessory EOMs are infrequent incidental findings during strabismus surgery. This case of an accessory MR muscle provides an example of a rare anatomic anomaly. Awareness of such anomalies could assist ophthalmologists and radiologists in evaluating cases with unusual strabismus because this anomaly is manageable surgically.


For isthmic lumbar spondylolisthesis (ILS) associated with the removal of herniation, it remains challenging to perform less invasive and minimally disruptive procedures. Good results could potentially be obtained by further preserving the posterior elements in full-endoscopic lumbar discectomy (FESS), which is less invasive than microenscopic surgery (MES).One patient complained of left leg pain, and another patient complained of right leg pain and low back pain.Two patients with ILS and Meyerding Grade 1 lumbar spondylolisthesis.We performed a full-endoscopic lumbar discectomy via the interlaminar space (FESS-IL) for L5/S1 lumbar disc herniation (LDH) accompanied by isthmic lumbar spondylolisthesis. FESS-IL was performed in 2 patients with radiculopathy caused by different types of LDH using a full endoscopic system with a 4.1 mm working channel and 6.9 mm outer diameter. A 3.5-mm diameter high-speed drill was used in one patient for an upward-migrated LDH in the inner-rim of the infravertebral border. The other patient underwent minimal resection without bone resection.The one-year clinical outcome included confirmation of pain relief and evacuation of migrated LDH on magnetic resonance imaging in all patients. There was no progression of slippage on radiography. The mean operative time was 82 min, and no complication was observed. The one-year clinical outcome demonstrated sufficient pain relief.ear postoperative outcome showed improvement. We believe that FESS-IL is a viable alternative operative approach for LDH for ILS. Good results with microendoscopic discectomy (MED) have been reported for lumbar spondylolysis. We believe that in FESS, which is less invasive, good results could be obtained by further preserving the posterior elements. In this report, we performed FESS on cases with spondylolysis. We report two cases and present their clinical outcomes including the preoperative and 1-year postoperative Oswestry Disability Index (ODI) and Roland–Morris Disability Questionnaire (RDQ-24). This study was approved by ethics committee of the Iwai Medical Foundation, and informed consent was obtained from patients for the purpose of publication.Full-endoscopic lumbar discectomy (FESS) with a 4.1 mm working channel is one of the minimally invasive operative procedures for the treatment of lumbar disc herniation (LDH).2A 55-year-old man presented with left leg pain (L5 dermatomes) and low back pain that started 2 months before visiting our outpatient clinic. Although neurological examination revealed a positive straight-leg rising sign (SLR) at 50° on the left side, no apparent muscle weakness was observed. His symptoms were resistant to medical treatment . Radiographic imaging revealed ILS and Meyerding Grade 1 lumbar spondylolisthesis  that started 2 months before visiting our outpatient clinic. The patient did not complain of low back pain. Neurological examination revealed a positive SLR at 30° on both sides with no apparent muscle weakness. Her symptoms were resistant to medical treatment (celecoxib 200 mg). Radiographic imaging revealed ILS and Meyerding Grade 1 lumbar spondylolisthesis  at the L5S level is affected by the L5 being the longest intervertebral foramen and the high iliac crest, making the surgical exposure of the channel difficult to obtain freely. When approaching a severely displaced hernia, the superior articular process must be carved out in order to obtain an unrestricted working space.,9 In cases similar to Case 1, many reports in the literature have recommended the IL approach.,11 We also believe that a small amount of the medial border from the inferior border of the lamina could be removed with a drill to access the hernia; thus, the amount of osteotomy was smaller than that of TFA, and a sufficient degree of freedom could be obtained in terms of the working space. Based on the above, FESS-IL was selected as a surgical alternative. This is a short-term outcome at 1 year after surgery. Further clarification is needed for long-term clinical results. Treatment options tailored to various lifestyles are considered to be an important factor in a rapidly aging society. Since there are potential drawbacks for fusion surgery such as adjacent facet injury, we believe the addition of FESS-IL surgery as an alternative procedure is beneficial for broadening the choice of treatment.Some concerns remain on the progression of slippage when opting not to perform fusion surgery.5We reported a case of lumbar spondylolisthesis complicated by hernia. The 1-year postoperative outcome showed improvement. In terms of ILS, the FESS-IL approach was a useful alternative procedure. Even in spondylolisthesis, fusion surgery may not always be necessary.Conceptualization: Takeshi kaneko.Data curation: Takeshi kaneko.Formal analysis: Takeshi kaneko.Investigation: Takeshi kaneko.Methodology: Takeshi kaneko.Project administration: Takeshi kaneko.Resources: Takeshi kaneko.Software: Takeshi kaneko.Supervision: Hirohiko Inanami.Validation: Yuichi Takano.Writing – original draft: Takeshi kaneko.Writing – review & editing: Takeshi kaneko.


Lipomas are the most common type of soft tissue tumor, and 95% of them are benign. While lipomas can present anywhere on the body, 1% of them are found in the fingers. The ultimate goal of management is surgical excision of the mass with preservation of the neurovascular surroundings. Here, we present the case of a 24-year-old, morbidly obese Saudi female patient complaining of large non-tender lumps in the index and middle fingers involving the palmar and dorsal surfaces of the left non-dominant hand. The lumps were associated with paresthesia and tingling sensations. The article aims to report and highlight the satisfactory outcomes after total excision of such lipomas and restoring the function as well as the cosmetic results of the hand.  Lipomas are benign fat cell tumors that are primarily found in the head and neck, as well as the shoulder and back ,2. LipomA 24-year-old, morbidly obese Saudi female patient presented with large non-tender lumps in the index and middle fingers involving the palmar and dorsal surfaces of the left non-dominant hand. The patient reported a history of the initial appearance of the lumps at the age of eight and surgical excision four years before presentation, as well as the history of debulking procedure three years before the surgical excision. The lumps were asymptomatic until they started to be associated with paresthesia and tingling sensations of the involved digits, which affected her daily activities. She does not smoke and is not exposed to second-hand smoke. The rest of her history was unremarkable. The physical examination results were all within the normal limits, except she had a limited range of motion due to the mass in the affected digits. Soft-tissue hemangiomas, vascular malformation lipoma, and lipomas were all considered as differential diagnoses based on the history given.For further investigations, she underwent Magnetic Resonance Imaging (MRI), which showed an encapsulated multilocular mass in the proximal and distal sections of the index and the middle digits, extending to the palmar and dorsal aspects of the left hand until the carpal bone dorsally and from the first web space to the fourth web space with a volar extension of approximately 3 cm to proximal palmar crease Figures , 1B.The patient was booked and taken to the operating theatre under general anesthesia and full aseptic technique. Soft, mobile, raised, and fluctuant masses were felt over the second and third digits of the left hand with no overlying skin changes Figures , 2B.Two lipomatous tumors were felt within the ulnar border of the index finger and the radial border of the middle finger. The incision spanned from the superior border of the dorsal proximal interphalangeal (PIP) creases distally to the second web space’s dorsal center proximal to the index digit. The incision was kept dorsal to the glabrous line Figures -3D.The lipoma was found to encompass the zone of incision and was adherent to the extensor mechanism; it was also engulfing the neurovascular bundle. Thus, segmental excision rather than en-bloc resection was preferred due to the engulfment of the structures. Similarly, another incision was made over the middle digit in the radial border, and extensor tendons were repaired, respectively Figures -4D.The tumor on the middle digit had similar proportions, distribution, and attachments as the tumor on the index digit Figures , 5B. Intra-operative findings were summarized as two lipomatous tumors excised from the index and middle digits over the ulnar and radial borders, respectively. Histopathology revealed that the specimens consisted of several fragments of fibro-fatty tissue measuring 7.5 x 5.5 x 1 cm, and three ovoid pieces of yellow-tan tissue measuring 5.5 x 4 x 3 cm, and 2.5 x 2 x 1 cm, respectively, for both the left index and left middle digits. After the procedure, the patient was placed in a compressive dressing and volar splint. The patient tolerated the procedure very well and reported satisfactory outcomes with no complications at the one-week follow-up appointment at an outpatient clinic Figures , 6B.Lipomas are the most common form of benign soft tissue tumors with a rare incidence rate in the fingers -3. They While lipomas are common benign tumors, ones affecting the hand and digits are rare. This case presentation aims to contribute to the literature on lipomas, specifically articles addressing lipomas of the index and middle fingers, even if those types of lipomas are rare, to emphasize the importance of considering it as a differential diagnosis. Total excision of such lipomas is considered to be the surgical method that is preferred by most plastic and hand surgeons. This article aims to report and highlight the satisfactory outcomes after total excision of such lipomas and restoring the function as well as the cosmetic results of the hand.


To describe a case of diffuse unilateral subacute neuroretinitis (DUSN), a rare condition that causes progressive vision loss following infection by a nematode using enface vitreous imaging.We present the clinical findings of a 37-year-old female, clinically diagnosed with DUSN after a non-invasive multimodal imaging approach that included MultiColor scanning laser imaging and enface vitreous OCT, which revealed the nematode body and lacunae created by worm migration, respectively.To our knowledge, this is the first reported case of lacunae visualized using enface vitreous optical coherence tomography (OCT), potentially marking the migration path of the nematode. It primarily presents unilaterally, however bilateral cases have been previously reported.Previously termed unilateral wipeout syndrome, DUSN presents with: “(1) insidious, usually severe loss of peripheral and central vision; (2) vitritis; (3) diffuse and focal pigment epithelial derangement with relative sparing of the macula; (4) narrowing of the retinal vessels; (5) optic atrophy; (6) increased retinal circulation time; (7) subnormal electroretinographic findings.”In 60–75% of cases, the nematode is not visualized and thus surgical or laser intervention is not possible.2A 37-year-old female with sudden vision loss in the left eye was referred for possible MEWDS. The patient works as a social media manager and had no past medical or ocular history that was pertinent to this case. There was no family history of any ocular or genetic diseases. In November 2019, the patient travelled to Lahore, Pakistan where she consumed street food that contained beef, chicken and fish. The meat was either grilled or fried and no uncooked or raw meat was consumed. The patient returned home to Toronto in January 2020, asymptomatic from her travel. In May 2020, the patient was gardening and handled racoon feces, while wearing disposable gloves. Within one month, the patient noticed sudden decreased vision in the left eye. Her best-corrected visual acuity (BCVA) was 20/20 OD and CF OS. Anterior segment examination was unremarkable. Afferent pupillary defect was noted OS. The right eye was normal. Fundus examination revealed the presence of 1+ vitreous cells in the left eye with a normal appearing disc, the macular and posterior pole demonstrated diffuse non-specific retinal pigment epithelium (RPE) changes and normal appearing retinal vessels. OCT revealed nerve fibre layer (NFL) thinning in the affected eye. No obvious change in the choroid was noted.Initially, color fundus photography and OCT was performed, but the nematode was not visible. Fundus autofluorescence (FAF)  demonstrated both focal and pinpoint hyper-and hypo-autofluorescent dots in the posterior pole and along the arcade, but did not show a nematode body. MultiColor scanning laser imaging  revealed the nematode body A, which After her initial diagnosis of presumed MEWDS, further serological testing  was initiated, but halted once the nematode body was discovered. The patient subsequently received laser photocoagulation  in a circinate ring around the nematode with central spots delivered directly on the worm body. After treatment, the patient remained CF OS, but in post-laser imaging at one week, the worm carcass was visible in the inferotemporal quadrant of the fundus A&B. One 3Toxocara canis, Baylisascaris procyonis and larvae of Ancylostoma caninum.B. procyonis to be the etiological agent.B. procyonis, as larger worms (1500–2000 μm in length) are associated with northern midwestern United States. The majority of the western hemisphere is associated with smaller worms (400–700 μm in length), which makes them harder to visualize.,DUSN is an ocular infection caused by several nematodes, including B. procyonis rapidly moves in and out of the retina, adding to the difficulty in capturing its image. It exhibits random movement through all the retinal layers, not only the subretinal space and thus causes vast damage to the retina while minimally altering the choroid.Caenorhabditis elegans, are used in real-time survival bioassays that utilize blue LED light (450–490nm) to evaluate their survival. In these studies, nematodes that stopped moving under white light (360–760nm) responded rapidly to blue light.B. procyonis may exhibit similar properties to C. elegans, but this is purely speculation and would need to be further evaluated in future studies.As part of the imaging workup, we used the Heidelberg Spectralis HRA + OCT MultiColor system. MultiColor scanning laser imaging simultaneously scans 3 individual laser wavelengths, including blue light: 820 nm (NIR), 515 nm (GR) and 488 nm (BR).Enface OCT scans, provides a high resolution, confocal OCT image of the macular area combined with a transverse image of the same area.Following laser photocoagulation, the carcass of the nematode remained visible in the inferotemporal quadrant of the left eye A&B. Nate4This is the first report to show nematode visualization using a full non-invasive multimodal approach. Each of the imaging techniques involved revealed anatomic patterns that were pertinent to the case. The nematode was visualized during the image capture process; therefore, it may be worthwhile for ophthalmologists to use a multimodal approach that includes modalities that utilize a blue light laser to potentially stimulate the nematode enough to trigger motility. Enface vitreous OCT was also utilized to visualize lacunae and may provide an additional tool in assisting in the diagnosis of DUSN when the nematode body is not found. These lacunae should not be confused with age related lacunae, which occur in older patients.Consent to publish this case report has been obtained from the patient in writing.No funding or grant support.All authors attest that they meet the current ICMJE criteria for authorship.None.Netan Choudhry is a consultant and receives research equipment from Topcon, Optos and Carl Zeiss Meditec. None of the aforementioned companies had a role in the study design, collection, analysis and interpretation of data in this report. The following authors have no financial disclosures: SKS, JG, EDM.


Organized hematoma of the maxillary sinus (OHMS) is a rare benign disease that can be locally aggressive. The diagnosis of this condition is challenging. , There was no recurrence at 19 months’ and six months’ follow-up respectively.We report two cases of OHMS presented with recurrent nasal bleeding, nasal obstruction and anosmia. Radiological findings were suggestive of a vascularised lesion in the first case and a malignant tumor of the maxillary sinus in the second case. Both patients underwent an endonasal endoscopic surgeryOHMS should be included in the differential diagnosis if a patient presents with history of recurrent epistaxis and nasal obstruction and radiological findings reveal an expansible maxillary mass with or without bone erosion. Correct preoperative diagnosis is important to avoid unnecessary extensive surgery. The prognosis is very good and minimally invasive surgery such as endonasal endoscopic surgery can cure it completely. Sinonasal organized hematoma (OH) is a rare benign lesion. However, it can be locally aggressive and accompanied by bone destruction . It presCase 1A previously healthy 47-year-old woman presented to the emergency with abundant epistaxis. She had a prior history of recurrent nasal bleeding, rhinorrhea, right-sided nasal obstruction and anosmia for one month. She had no significant medical problem including bleeding diathesis, facial trauma, or sinus surgery. Epistaxis was treated with nasal packing, which was removed two days after. Anterior rhinoscopic evaluation demonstrated a reddish mass that bled easily occupying the right nasal cavity. The right lateral nasal wall was medially displaced towards the nasal septum, which was also deviated to the left side. Computed tomography (CT) of the paranasal sinuses revealed a 6,5×4,5 cm heterogeneous soft-tissue mass in the right maxillary sinus and the ethmoid with associated destruction of the medial wall of the sinus, extension to the nasal cavity and destruction of the nasal septum. Destruction of the right orbital floor and extension of the mass into the peri-orbita were also noted. Contrast enhanced scan revealed a nonhomogeneous mass with important contrast enhancement . Since the clinical and radiological findings raised the index of suspicion for a vascularised lesion and the risk of profuse bleeding an angiography was performed . It showed a strongly enhanced lesion and found that facial artery was the feeding artery. Embolization was successfully performed. The patient underwent EES. Although the mass was friable, complete resection was achieved .Bleeding was not serious during surgery. There were no postoperative complications. Histopathological finding was consistent with a fibrous encapsulated organized hematoma without neoplastic tissue. There was no recurrence of lesion at 19 months’ follow-up.Case 2An 80-year-old man presented with a three years’ history of recurrent epistaxis from right nasal cavity, right nasal obstruction and anosmia. He already had diabetes and dyslipidemia. This patient had no past history of nasal or paranasal sinus surgery or trauma and did not receive anticoagulant drugs. On physical examination, no facial deformity was detected. Endoscopic examination revealed a friable reddish mass at the right middle meatus and a polyp occupying the right nasal cavity. Nasal septum was deviated to the left side. CT showed a well-defined expansible mass of the right maxillary sinus, the frontal sinus, the ethmoid and the nasal cavity with bone destruction . On magnetic resonance imaging (MRI) , the masOHMS is a rare nonneoplastic but locally invasive lesion . The exaRegardless of the initial process of the hematoma, poor ventilation and drainage in the maxillary sinus impede resorption of the hematoma and results in neovascularization and fibrosis . It has The most common clinical manifestations, which were also present in our cases, are nasal obstruction and repeated epistaxis . Other sA correct preoperative diagnosis is important for determining a therapeutic strategy and avoid unnecessary extensive surgery. CT and MRI are strongly recommended however radiologic appearances are nonspecific and differential diagnosis from neoplastic pathology is problematic . CT findThe mucosa is well enhanced on T1-weighted images with contrast and has high intensity on T2-weighted images, which suggests the inflammatory change and differs from a malignant tumor that causes mucosal invasion . Park etTreatment strategy is based on complete surgical excision. Surgical approach and extent of the resection depend on size of the lesion and the involvement of adjacent compartments . PreviouPreoperative biopsy has no serious complication but does not provide helpful information in differentiating malignant processes . EmbolizThe prognosis of OH after complete surgical removal is usually very good and it rarely recurs.OHMS is a rare benign lesion that may mimic a neoplasm or other benign aggressive pathology. If a patient presents with a history of frequent epistaxis and nasal obstruction and radiological findings reveal an expansile maxillary mass with or without bone erosion, OHMS should be included in the differential diagnosis. The prognosis is very good and minimally invasive surgery such as endonasal endoscopic surgery can cure it completely.


We described a case of a pseudomonas aeruginosa subperiosteal abscess in a healthy adult, complicated by ophthalmic artery occlusion.Pseudomonas aeruginosa and laboratories studies did not find any cause of immunodeficiency. Although medical and surgical treatment, the retinal damage was irreversible with visual acuity limited to light perception.A 41-year-old woman presented with the chief complaint of a severe painful left eyelid. The visual acuity was limited to light perception. Fundus examiantion showed diffuse retinal edema, papillary swelling and whitened retinal vessels without cherry-red spot. Multimodal imaging confirmed the diagnosis of ophthalmic artery occlusion. Computed tomography study was performed and objectified a pansinusitis complicated by left orbital cellulitis and a 7.4mm × 29.8 mm subperiosteal abscess (SPA). In addition to intravenous antibiotics, surgical drainage of the SPA was performed. The bacterial culture of the abscess has shown growth of Pseudomonas aeruginosa is not common in healthy adults. An early diagnosis and an adequate treatment are important for the visual prognosis.The developing of a subperiosteal abscess (SPA) of the orbit is a serious complication that arises usually from bacterial sinusitis and can lead to sight threatening complications. Orbital cellulitis should be diagnosed and treated promptly, even in healthy people, to improve visual prognosis. •The developing of a subperiosteal abscess of the orbit is a serious complication of bacterial sinusitis.•Orbital cellulitis incriminating Pseudomonas species are very rare.•Nowadays, the severe cases resulting from orbital cellulitis have dropped significantly due to the general use of antibiotics.•Orbital cellulitis are sight threatening, even in immunocompetent people. It's anathogens . Althougathogens . It is iathogens .The developing of a subperiosteal abscess (SPA) of the orbit is a serious complication that arises usually from bacterial sinusitis and can lead to sight threatening complications . TherefoPseudomonas aeruginosa subperiosteal abscess in a healthy adult, complicated by ophthalmic artery occlusion.To the best of our knowledge, this is, conceivably, the first case reporting a 2A 41-year-old Arabic woman presented with the chief complaint of a severe painful left eyelid swelling without any prior systemic or ocular history, apart from an occasional use of nasal corticosteroid spray for allergic rhinitis.Our ophthalmological examination found in the left eye a visual acuity (VA) limited to light perception, the eyelid was markedly swol1en and erythematous, a severe hemorrhagic chemosis, a proptosis with an ophtalmoplegia  and a noThe intraocular pressure IOP was 12 mmHg in right eye and couldn't be evaluated in the left eye.Fluorescein angiography of the left eye showed an almost complete absence of retinal and choroidal flow and thus, confirmed the diagnosis of ophthalmic artery occlusion B. MaculaThen, a computed tomography study was performed and objectified a pansinusitis complicated by left orbital cellulitis and a 7.4mm × 29.8 mm subperiosteal abscess (SPA) .Fig. 3A Intravenous antibiotics were promptly delivered combining cefotaxime 1.5 g every 6 hours, vancomycin 1 g every 12 hours and metronidazole 500 mg every 8 hours and a surgical drainage of the SPA was planned in 6 h under general anesthesia because of the visual impairment.A sub-brown incision was made in the skin. The periosteum was identified at the orbital rim and incised with a 15 steel surgical blade. The subperiostal space was entered and a dissection was carried down posteriorly until the abscess cavity was objectified. The pus was aspired and sent for microbiological exam and culture. A drain was placed for 2 days and the wound was closed in layers.Oral and topical anti-glaucoma drugs including Timolol 1 drop every 12 hours and Acetazolamide 250mg 4 times per day, were also prescribed.Pseudomonas aeruginosa  sinusitis [Sinusitis are common in daily practice and frequently treated without complications. In some cases, it can cause serious orbital complications leading to blindness and even death . The subinusitis .Staphylococcus aureus (20.5%) [PA is implicated in only 7.2% of cases [PA sinusitis rates are increasing [In a recent study published in 2017 in Taiwan, the most implicated pathogens was coagulase-negative Staphylococcus spp. (25.3%) and  (20.5%) . PA is iof cases . In japacreasing . Moreovecreasing . It's noThe diagnosis of subperiostal abscess is clinically evident by the visual impairment, directional proptosis, eye pain and chemosis.CT scan with contrast infusion, including axial and coronal views, is essential to determine the extend of the abscess and to rule out peridural and parenchymal brain abscess.Complete Blood count show elevated white blood cells WBC. In cases of Pseudomonas cellulitis with eyelid necrosis, it is crucial to research neutropenia. Early recognition with reversal of neutropenia is crucial in the management of this infection.The possible pathophysiology mechanism of ophthalmic artery occlusion (OAO) noted in our case is the acute elevation of the intraorbital pressure (IOP) due to the rapid progression of SPA in the orbit which is a limited space and so it can hamper the ophthalmic artery circulation. Also, the cherry-red spot is absent because of both retinal and choroidal insufficiency.Proctor  describeStaphylococcus aureus OC after black fly bite leading to permanent visual loss.Okamoto  reportedThe OAO complicating OC is a rare condition and has a worse prognosis because of retinal and choroidal involvement. In 1998, a case of ophthalmic artery occlusion following orbital inflammation was reported . HatipogFor the ophtalmoplegia, in some studies  it was eThe treatment of orbital cellulitis include broad-spectrum antibiotic therapy for 14 days. In case of visual impairment, the surgical management of SPA is required because medical treatment alone is often ineffective . The aimA follow-up of the patient is crucial to evaluate response to medical and surgical treatment and to research any ophthalmological or cerebral complication. The visual and vital prognosis depends on the moment and on the quality of treatment.In our case, we ignore the exact onset time of SPA and OAO so despite the early surgical intervention, the retinal damage was irreversible.4Nowadays, the severe cases resulting from OC have dropped significantly due to the general use of antibiotics. However, an early diagnosis of orbital complications and a prompt treatment can improve visual prognosis. Our case demonstrated the retinal damage caused by the PA orbital cellulitis in a healthy adult, supporting by multimodal imaging.None.Not applicable.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.Mahjoub Ahmed and Mahjoub Anis collected data, Ben Abdesslem Nadia and Doukh Meriem analysed data and drafted the manuscript. Mahjoub Hechemi, Leila Knani, Ghorbel Mohamed and Krifa Fethi provided critical manuscript revisions.All authors read and approved the final manuscript.Not applicable.Dr Ben Abdesslem Nadia.Not commissioned, externally peer reviewed.None.


Actinomyces. The abdominopelvic localization of this pathology makes preoperative diagnosis extremely exceptional. The following report is the case of a patient treated for adenocarcinoma of the middle rectum associated with mesorectal actinomycosis. The diagnosis of actinomycosis was made postoperatively.Actinomycosis is a rare chronic infection caused by A 69-year-old Caucasian male patient was admitted for rectal bleeding. Clinical and paraclinical assessment revealed a middle rectum adenocarcinoma with local extension in the mesorectum. The patient underwent an anterior resection of the rectum by laparotomy after neoadjuvant chemoradiotherapy. Postoperative follow-up was simple. Pathological study of the specimen noted complete sterilization of the rectal adenocarcinoma and the presence of large foci of suppurative necrosis containing actinomycotic grains in the mesorectum.Abdominopelvic actinomycosis is a rare pathology and has therefore rarely been dealt with. This issue can lead to unnecessary and mutilating surgery. We report an exceptional coincidence of rectal adenocarcinoma and mesorectal actinomycosis mistaken for mesorectal extension of the cancer. Actinomyces, which are saprophytic bacteria in the oral cavity and the digestive tract. The abdominopelvic localization of actinomycosis, often overlooked because of its rarity, poses problems of differential diagnosis especially with neoplastic pathology. The rarity of this pathology is why its diagnosis has often been established on surgical resection pieces. These resections are often mutilating and unnecessary since the treatment is simply based on antibiotics [Actinomycosis is a rare chronic granulomatous infection caused by ibiotics .The following report is the case of a patient with “locally advanced” adenocarcinoma of the middle rectum through which the final histologic examination of the surgical specimen revealed a complete response of the adenocarcinoma to the neoadjuvant chemoradiotherapy associated with mesorectal actinomycosis. The local extension of the cancer in the mesorectum, suspected preoperatively, was nothing other than this synchronous mesorectal actinomycosis.A 69-year-old Caucasian male patient with well-balanced type 2 diabetes consulted for rectal bleeding and rectal syndrome. Rectal examination revealed a budding and circumferential tumor at 7 cm of the anal margin; the rest of the clinical examination was normal.Colonoscopy revealed ulcerative budding tumor 7 cm from the anal verge; exploration of the rest of the colon showed no other anomalies. Pathological examination of the biopsy revealed a well-differentiated and infiltrating lieberkuhnien adenocarcinoma. Magnetic resonance imaging (MRI) showed a circumferential and irregular parietal thickness of the middle rectum, associated with a heterogeneous mass with exophytic development, infiltrating the mesorectum and arriving at the contact of the mesorectal fascia on the right Figs. ,2. ThoraDue to the low location of the cancer and its “local extension,” chemoradiotherapy (CR) administered over a period of 5 weeks was established. An anterior resection of the rectum with low mechanical colorectal anastomosis protected by an ileostomy was performed 10 weeks after the end of the CR. The operation was carried out by laparotomy to minimize the risk of intrusion of the mesorectum. Postoperative follow-up was simple. Pathological study of the specimen noted the complete sterilization of the tumor after CR with the presence of large foci of suppurative necrosis containing actinomycotic grains in the mesorectum; lymph node dissection revealed ten negative nodes Figure . No adjuActinomyces, which is Gram-positive, strict anaerobic bacteria. Actinomyces israelii is the principal pathogenic species isolated in human infections [Actinomycosis is a slow and misleading granulomatous infection caused by fections .These bacteria are saprophytes of humans’ natural cavities, particularly the oral cavity, the digestive tract, and the genital mucosa –4. TheseActinomycosis evolves insidiously over months or years. It typically gives abscesses that evolve in the long term to the formation of pseudotumors that invade organs close by. The clinical presentation varies depending on the stage of the evolution of the disease; in the acute phase, it can take on the appearance of peritonitis or pelviperitonitis with an infectious syndrome. Later, in the pseudotumor phase, the tumor syndrome is in the foreground with a palpable, ill-defined, and sensitive mass, more or less indurated with a tendency to invade the abdominal wall and to fistulate on the skin , 9.Biology is not very contributory, and hyperleukocytosis with elevation of inflammatory markers can be noted in suppurative forms , 11.Imaging examinations are not specific. Ultrasonography and computed tomography (CT) scan can show a solid or cystic mass, with thick walls, multilocular or not, frequently evoking a neoplastic process , 12. In Bacteriological diagnosis is difficult and must meet a couple of requirements: sampling and seeding done in rigorous aseptic conditions, and anaerobic culture (7–20 days) in special environments .Differential diagnosis arises mainly with cancer, tuberculosis, Crohn’s disease, and amoebiasis or appendicitis .The treatment of actinomycosis is based on antibiotic therapy by high doses of penicillin G administered intravenously 10–20 MIU) for 4–6 weeks followed by oral relay with amoxicillin + clavulanic acid associated to metronidazole for 6–12 months. In the case of an allergy to penicillin, other antibiotics can be used: tetracyclines, macrolides, vancomycin, chloramphenicol, or rifampicin 0–20 MIU .The particularity of our observation is that the diagnosis of actinomycosis was a fortuitous discovery. Indeed, the extension of the rectal adenocarcinoma in the mesorectum, objectified on imaging tests, and which did not regress after the neoadjuvant CR, was only a mesorectal actinomycotic pseudotumor. This has often been mistaken as a locally advanced cancer with a bad prognosis and risk of incomplete resection. It also was why we opted straight away for a median laparotomy instead of a laparoscopy to minimize the risk of mesorectal break-in.The abdominopelvic actinomycosis is a rare pathology, with misleading clinical manifestations, which can often be the cause of differential diagnosis with several diseases including cancer. In our case, the occurrence of mesorectal actinomycosis is probably due to the development of the adenocarcinoma in the rectum and mistaken for a local extension of this cancer.


Sarcomatous change in ependymal tumors is rare and has been poorly described. We report on a cerebellopontine angle lesion that demonstrated rapid progression two years after radiosurgery in a 73-year-old female patient. Histopathological diagnosis at clinical progression showed an ependymoma with sarcomatous change (“ependymosarcoma”) that was believed to be due to radiation. The patient underwent a complex tumor resection without complications using an exhaustive multi-modal neuromonitoring paradigm throughout the dissection and resection of the tumor. Given the limited available data on these rare tumors, we review their presentation, imaging, and histopathology in the context of the previous literature, and also discuss the management of these lesions in the cerebellopontine angle. Gliosarcomas are rare central nervous system malignancies, and they account for approximately 2% of all glioblastomas (GBM) ,2. The tUniquely, gliosarcomas display a characteristic dimorphic tumor pattern of glial and mesenchymal elements. The glial component is most commonly malignant astrocytoma , while tWhile cytogenic studies have investigated the many possible molecular mechanisms of sarcomatous transformation , isolateWe report on a cerebellopontine angle lesion that demonstrated rapid progression two years after radiosurgery in a 73-year-old female patient. Histopathological diagnosis at clinical progression demonstrated an ependymoma with sarcomatous change believed to be due to radiation. We review the presentation, imaging, and histopathology in the context of previously published data on this rare condition.A 73-year-old female with a past medical history of hypertension, hyperlipidemia, and chronic obstructive pulmonary disease (COPD) presented to the hospital with progressive dizziness and gait instability, dysphagia, worsened bilateral hearing loss, and mild intermittent headache. The patient reported a previous syncopal episode and left-sided hearing loss three years prior, followed by tinnitus in the form of a “swish” sound. Workup in a local emergency department had demonstrated a previously treated 3.2 x 2.7 x 3.2-cm “salt and pepper” left cerebellopontine angle lesion arising from the medial aspect of the jugular bulb with compression of the brainstem and cerebellum, as well as fourth ventricle compression. Differential diagnoses had favored paraganglioma and included ependymoma and meningioma. Schwannoma and metastatic disease had been deemed less likely, and no abnormal nodularity or enhancement of the cranial nerve VII/VIII complexes had been seen. Bloodwork had shown no secretion of hormones. The patient had been recommended for stereotactic radiosurgery given her minimal symptoms at the time and her desire to avoid surgical intervention. She had elected to undergo linear-accelerator-based radiosurgery three years ago at an outside institution. She had been subsequently treated with fractionated stereotactic radiosurgery using 6 megavoltage photons to a prescription dose of 2500 cGy in five fractions over the course of seven days. She had been followed up with serial imaging for one year and then lost to follow-up.On this admission, contrast-enhanced MRI of the brain on admission demonstrated progressive growth of the known lesion with a change in its radiographic characteristics Figure . On physNeuromonitoringA multi-modal neuromonitoring paradigm included somatosensory evoked potentials (SSEP), transcranial motor evoked potentials with limb recordings (TCMEP-L), corticobulbar motor evoked potentials (co-bulb MEP), brainstem auditory evoked responses (BAER), spontaneous cranial nerve electromyography (s-CNEMG), and evoked CN EMG (e-CNEMG).SSEP and TCMEP-L were conducted in the standard fashion and were obtained prior to the incision and did not deviate from their established baseline. BAEPs were unreliable from the start due to the underlying binaural hearing loss. Co-bulb MEPs were only obtained from the trapezius muscles. All other muscles revealed compound muscle action potentials (CMAP) with single pulse stimulation, indicating that they were not being generated centrally but instead peripherally due to stimulus current spread.Cranial Nerve EMG (Spontaneous and Evoked)Cranial nerves V, VII, IX, X, XI, and XII were targeted for CNEMG. Using an electrified monopolar ring dissector, we conducted dynamic stimulation throughout the dissection and resection of the tumor. Using stimulus intensities between 0.05 mA and 0.5 mA, we were able to identify all motor cranial nerves targeted excluding CN V, which was visualized instead Figure . We werePostoperative resultsTumor resection proceeded without complication. Postoperatively, the patient developed worsening dysphasia and delayed gastric emptying requiring a percutaneous endoscopic gastrostomy due to decreased calorie intake. She was able to swallow and receive oral intake consistent with her preoperative baseline neurologic status. The patient also underwent laryngoplasty with a return of normal vocalization. She was eventually discharged to acute rehabilitation. Pathology was consistent with a WHO grade II ependymoma with a high-grade spindle cell neoplasm component with a TERT (C228T) promoter mutation. Postoperative MRI demonstrated an STR with an expected residual tumor located along the vertebral artery/brainstem interface Figure . There wPathologyThe resection specimen grossly consisted of multiple fragments of tan-pink hemorrhagic friable soft tissue measuring 12.0 x 3.0 x 0.5 cm in aggregate  that demonstrates a biphasic mixture of both malignant astrocytic and mesenchymal components . HoweverThe prevalence of ependymosarcomas will likely continue to increase as anaplastic ependymomas continue to be treated with radiation therapy. The limited descriptions of these tumors in the literature have prevented an effective understanding of their appropriate surgical and post-surgical treatment to date. Many have considered the sarcomatous transformation to be similar to the sarcomatoid changes seen in carcinomas occurring outside the CNS, such as the kidney  and prosIn this case, given the history of previous radiation, options for re-irradiation were limited. Safe brainstem dosing limits the ability to perform further radiotherapy to the residual tumor at the level of the brainstem. While the use of radiosurgery or proton therapy for re-irradiation was considered in this case, the patient's overall condition declined, leading to the patient and family deciding to cancel any plans for further tumor-directed therapies.This report discussed a rare case of an ependymosarcoma occurring in the cerebellopontine angle. Given the history of radiosurgery in our patient, it is presumed that radiation may have induced malignant changes within the lesion. In addition to high-grade astrocytomas, ependymal tumors must also be considered as possible sites of sarcomatous change following radiosurgery. This information may guide future indications for upfront surgical management of lesions with atypical imaging features on diagnosis.


Subarachnoid hemorrhage (SAH) with subdural hygroma (SH) was rarely reported after endovascular coiling. A 60-year-old male presented with impaired consciousness and convulsions due to SAH from a ruptured aneurysm. It was managed by endovascular coiling 20 h after the onset of symptoms. Serial brain imaging for 2 weeks revealed progressive bilateral SHs, more on contralateral side of leaking aneurysm. Management of SH was discussed in a multidisciplinary setting to be conservative as there was neither significant mass effect nor hydrocephalus. The patient recovered neurologically except for mild dysarthria. The SH persisted for 2 months and then cleared gradually. We concluded that SH may arise and become symptomatic as an unusual sequela of post-coiling of a ruptured intracranial aneurysm, in which the SH can complicate the clinical course of SAH. However, the symptomatic SH may resolve spontaneously and completely without any intervention, but needs meticulous neurological assessment and follow-up. Collection of cerebrospinal fluid (CSF) in the subdural space can be described as ‘subdural hygroma’ (SH), ‘external hydrocephalus’ and ‘subdural effusion’. SH represents a unique clinical entity .SH can complicate the course of subarachnoid hemorrhage (SAH), particularly if there is a history of head trauma, CSF diversion techniques, or craniotomy and clipping of aneurysms. However, SH is rarely reported after endovascular coiling for ruptured aneurysms.The patient was a 60-year-old male with a history of hypertension and tobacco smoking. He was admitted to the intensive care unit (ICU) with acute onset of headache and mild right-sided weakness. The patient had neither history of head trauma nor fever before the presentation. Nonenhanced computed tomography (CT) of brain revealed extensive SAH. CT cerebral angiography revealed a ruptured left posterior communicating artery aneurysm (PCA), 4.5 × 6 mm with neck 2–3 mm, and another internal carotid artery, para-ophthalmic, unruptured aneurysm on the right side. Hunt and Hess’s scale was 3, and Glasgow Coma Scale (GCS) was 14/15. The patient developed generalized tonic–clonic convulsion that was controlled by midazolam and kept on oral levetiracetam.Endovascular coiling was performed 20 h after the onset of symptoms, and it was an uncomplicated technique. ICU management followed the standard protocol of SAH [On the 5th day, GCS decreased to 11/15 and brain CT revealed the same degree of SAH and increased SH, but without any mass effect nor hydrocephalic changes. Transcranial Doppler to exclude cerebral vasospasm was requested but not done at that time due to technical problems.No improvement was observed in the consciousness level, which deteriorated further. On the 10th day, GCS was 9/15 with worsened right-sided weakness (grade 2). Brain magnetic resonance imaging revealed right-sided sizable SH exerting mild mass effect and left basal ganglia ischemic focus. Multidisciplinary meeting (MDM) concluded that the patient had delayed cerebral ischemia (DCI) and significant SH with mild mass effect and recommended no intervention for SH.At the end of the 2nd week, the consciousness level improved to GCS 11/15 and weakness was grade 3. Surprisingly, imaging revealed progressive right SH and new SH on the left side, but with no mass effect from either hygromas. Another MDM recommended continuing conservative management.By the end of 1st month, the consciousness level was regained and right-sided weakness improved to grade 4 with mild dysarthria. Brain imaging revealed that SH had decreased. The patient was discharged to a rehabilitation center (RC) after 1 month of ICU stay.Imaging after 2 months revealed that SAH was almost cleared, both SHs were still decreasing and a small left basal ganglia infarction. The patient was discharged home from RC without any residual weakness, fully conscious but with mild dysarthria.SAH is a serious medical condition with an increased fatality, an incidence of 9 per 100 000 and a fatality rate within 6 months of about 60%. In aneurysmal SAH, the three most important variables related to prognosis are the early neurological state, age and the degree of extravasation on imaging. Consciousness is the most important determinant for outcome after SAH .In 1932, Dandy described SH as a collection of nonblood fluid in the subdural space that can be encapsulated under a thin membrane . The patBoth external hydrocephalus and SH have unique clinical entities. External hydrocephalus is usually associated with disturbances in CSF flow caused by the imbalance between production and absorption . RadiogrOur case was managed by simple endovascular coiling through the femoral approach with the intervention of bleeding left PCA aneurysm (four coils were deployed), and the right one was postponed after complete patient recovery.The serial imaging of our case never showed any ventriculomegaly during the course. This made it a unique case of SH post-coiling. A previous study reported a case of external hydrocephalus as it was associated with ventriculomegaly, which also complicated the course of coiling for ruptured aneurysm. However, the case remained asymptomatic and the collection resolved spontaneously .Subdural collections may be seen after clipping of ruptured aneurysmal SAH but rarely seen after coiling. Ventriculoperitoneal shunting alone is an effective and accepted procedure in post-clipping states. However, patients with subdural effusion that is not accompanied by hydrocephalus do not require subdural peritoneal shunt. When selecting the treatment for subdural effusion, it is important to consider the presence of hydrocephalus .The management strategies for cases of SH following aneurysmal SAH patients are still undefined. Close neurological observation is indicated to follow the progression of any mass effect or conversion into a subdural hematoma.The management of our case regarding SH was challenging. The deteriorating consciousness level put more ambiguity on the clinical impact of SH due to the incidence of DCI at the same time of increasing size of SH and its mass effect. However, the absence of ventriculomegaly with a meticulous neurological assessment directed us to continue the conservative plan.The etiology of the SH in the presented case is unknown as there was no history of head trauma at presentation, CSF diversion technique, nor craniotomy, which represent the potential causes for SH after SAH. Whether it is related to CSF flow dynamics post-occurrence of SAH or from a direct effect of coiling  is still to be defined.SH may arise and become symptomatic as an unusual sequela of post-coiling of a ruptured intracranial aneurysm, in which the SH can complicate the clinical course of SAH. However, the symptomatic SH may resolve spontaneously and completely without any intervention, but needs meticulous neurological assessment and follow-up.


An adrenal incidentaloma is a mass found incidentally on radiological imaging performed for other reasons. The prevalence of these incidentalomas increases with age, and they all must be evaluated to determine if they are benign or malignant and if they are functioning or non-functioning.A 71-year-old female presented with sub-acute bilateral lower limb pitting edema and dyspnoea. Imaging showed an 8 cm smoothly defined heterogeneous right adrenal mass and a number of low attenuation lesions throughout the liver. This case report describes a rare presentation of adrenocortical carcinoma due to an adrenal incidentaloma identified on imaging in a patient presenting with bilateral lower limb edema. The laboratory and imaging evaluation of these incidentalomas are also discussed. An adrenal incidentaloma is defined as a mass greater than 1 cm found incidentally on radiological imaging performed for other reasons . The preIn this report, we present a case of adrenal incidentaloma in a patient presenting with bilateral lower limb edema. We also discuss the laboratory and radiological investigations of these incidentalomas and their management options.A 71-year-old Irish Caucasian female presented with sub-acute bilateral lower limb pitting edema and dyspnea. Her background history included obesity (BMI 45.5), atrial fibrillation, obstructive sleep apnea, subclinical hyperthyroidism, eosinophilic colitis, and diverticular disease. She was an ex-smoker with a 20 pack-year history. Furthermore, she was under surveillance for a 3 cm ovarian cyst with the local gynecology services.The patient had normal cardiac and respiratory examinations. Her transthoracic echocardiogram showed an ejection fraction of more than 50% with normal left and right ventricles and valves. Her chest radiograph was also unremarkable. An abdominal ultrasound was performed to assess for a pelvic mass that could impede pelvic venous return leading to peripheral edema. Ultrasound revealed an 8 cm hyperechoic mass lesion at the superior pole of the right kidney as well as a 2 cm hypoechoic liver lesion Figure . SubsequThe patient exhibited potential features of cortisol excess including weight gain of 11 kg over two months and depression. She also had a newly diagnosed type 2 diabetes mellitus prior to admission with glycated hemoglobin (HbA1c) of 50 mmol/mol. The hormonal evaluation was consistent with hypercortisolism with failure to suppress on overnight dexamethasone suppression test and elevated 24-hour urinary free cortisol  and repeat CT thorax, abdomen, and pelvis demonstrated a large necrotic adrenal mass consistent with a primary adrenocortical carcinoma with direct invasion into the intrahepatic inferior vena cava. Multiple lung nodules concerning pulmonary metastasis were also observed. A diagnosis of adrenocortical carcinoma with pulmonary and hepatic metastasis was made. Due to metastatic disease, she was deemed unsuitable for surgery and treated pharmacologically with mitotane and metyrapone to manage symptoms caused by excess cortisol production by the tumor. She subsequently progressed to palliative care and died three months after diagnosis.This case report describes a rare presentation of adrenocortical carcinoma due to an adrenal incidentaloma identified on radiological imaging in a patient presenting with bilateral lower limb edema. Multiple factors including technological advancements in imaging, availability of multiple imaging modalities in most hospitals, and increased prevalence of chronic diseases have led to a higher number of imaging tests being performed each year, which in turn have led to a higher detection rate of incidentalomas -8. The p2) but hormonal evaluation confirmed cortisol excess.Malignancy is an uncommon cause of incidentaloma in patients not known to have cancer . The majAssessment of the risk for malignancy is largely based on lesion size and imaging characteristics. On non-contrast CT imaging, a Hounsfield Unit (HU) value of <10 is indicative of a lipid-rich, benign adenoma. Contrast-enhanced washout CT is required if a HU value of >10 is obtained. A relative washout >40% and an absolute washout >60% suggests that an adrenal lesion is benign .Adrenal surgery is the treatment of choice for adrenocortical carcinoma. Open surgery is the standard procedure however for tumors <6 cm without local invasion laparoscopic surgery may be performed . The metIn conclusion, adrenal incidentalomas are not uncommon and require an approach combining clinical, laboratory, and radiological evaluation. It is vital to distinguish functioning from non-functioning masses and malignant from benign ones. Bilateral lower limb edema due to impedance of venous return via external compression or intravascular metastasis of the inferior vena cava can be a presenting complaint about primary adrenocortical carcinoma and should prompt clinicians for further investigations.