Hypertension in young patients can mask rare conditions like paragangliomas, especially in the absence of conventional symptoms. A comprehensive diagnostic evaluation and multidisciplinary approach are crucial for optimal management and outcomes. Contrast‐enhanced computed tomography showcasing a distinct lesion near the aortic bifurcation, consistent with a paraganglioma arising from the Organ of Zuckerkandl. This report delves into the challenges in diagnosing and managing a rare presentation of a functional paraganglioma in a 28‐year‐old male with resistant hypertension. We present a unique case of a young male whose sole presentation was resistant hypertension, lacking classic symptoms of catecholamine excess, traced to a paraganglioma in the Organ of Zuckerkandl. Emphasizing the diagnostic and therapeutic challenges, particularly when conventional antihypertensive therapies prove ineffective, this report advocates for an integrative diagnostic strategy and multidisciplinary treatment approach. By shedding light on this diagnostic labyrinth, we aim to provide a nuanced understanding of paragangliomas and offer insights to clinicians navigating similar cases.22. Initial antihypertensive therapy using prazosin was ineffective, even after dosage adjustment.A 33‐year‐old male presented to his general practitioner (GP) with blurred vision and eye discomfort over 2 weeks. His visual acuity was found to be 6/6 bilaterally without additional ocular symptoms. A thorough physical examination showed persistently elevated blood pressure, ranging from 150/90 mmHg to 180/100 mmHg, in the absence of any other abnormal findings. The patient denied experiencing any characteristic hypertensive symptoms, such as palpitations, chest pain, dyspnoea, headaches, dizziness, nausea, vomiting, flushing, diaphoresis, insomnia, or anxiety. The patient had no notable personal, medical, or family history, led a healthy diet, and had a body mass index of 20.6 kg/m3Exhaustive investigations into the secondary causes of hypertension mostly yielded results within the normal range with one standout exception: markedly elevated serum normetanephrine levels, measured at 4550 pmol/L. Other indices, including metanephrine, 3‐Methoxytyramine, renal function, the renin‐angiotensin‐aldosterone system, endocrine studies, and thyroid function, were within standard thresholds Table .24‐h ambulatory blood pressure monitoring indicated average systolic readings of 136 mmHg (day) and 126 mmHg (night), with a peak of 171/96 mmHg (day) and 146/77 mmHg (night). Systolic dipping was significantly reduced, observed at just 7.4%. The electrocardiogram showed a sinus rhythm with intermittent episodes of 2nd degree Mobitz type I (Wenckebach) atrioventricular blocks, but otherwise normal electrical activity and intervals . Immunohistochemistry showed positive staining for synaptophysin  using oxycodone with bolus doses of 0.5–2 mg, a regimen that was maintained for 2 days. To mitigate thromboembolic risks, especially considering the partial resection of the iliac vein, prophylactic Enoxaparin was introduced and escalated to therapeutic doses by the next day.Given the patient's stable condition, he was transferred to a general ward on the first postoperative day. Pre‐admission antihypertensives were gradually tapered and eventually ceased. The patient progressed well initially, tolerating a full diet, mobilizing independently, and passing flatus by the second day, albeit without bowel movements.On Day 3 postoperatively, he began experiencing increased discomfort, marked by acute lower back pain, nausea, vomiting, extreme lethargy, and reduced appetite. These symptoms worsened over the following 2 days, prompting a reintroduction of PCA and starting IV hydration. By the fifth day, his pain intensified, accompanied by periodic fevers peaking at 38.5°C, with serum tests showing a drop in hemoglobin and rising inflammatory markers  enzyme complex.Paragangliomas are sub‐classified based on origin: parasympathetic paragangliomas, primarily non‐secretory, are found in the neck and skull base along the glossopharyngeal and vagus nerves, while sympathetic variants, often catecholamine‐secreting, arise anywhere along the sympathetic chain.Diagnosis is a two‐step process that involves biochemical analysis of urinary and plasma fractionated metanephrines and catecholamines, followed by radiological imaging through CT, angiography, MRI, and PET.8.2Paragangliomas, particularly those in the Organ of Zuckerkandl, present a formidable diagnostic challenge due to their rarity and often subtle manifestations. In younger patients without risk factors, treatment‐resistant hypertension can point towards atypical causes like paragangliomas, reinforcing the need for an exhaustive diagnostic workup.The diagnosis employed a multi‐modal approach, leveraging serum normetanephrine biochemical testing and various imaging techniques essential for differentiating conditions like lymphadenopathy, adrenal masses, or other abdominal neoplasms. While contrast‐enhanced CT and 68Ga DOTATATE PET findings suggested a paraganglioma in the Organ of Zuckerkandl, the subsequent MRI was initially misinterpreted. This exemplifies the diagnostic complexities of paragangliomas and the imperative for vigilant radiological evaluation to avoid misdiagnosis.The potential genetic implications of paragangliomas with inherited syndromes add another layer of complexity, even in the absence of a familial history. The immunohistochemical evidence of retained SDH B expression suggest that germline SDH mutations are not an aetiological risk factor in this case.8.3Emphasizing the significance of a multidisciplinary approach, this case involved collaboration among general practitioners, radiologists, endocrinologists, and vascular surgeons. Presented initially with blurred vision and discomfort without notable ocular anomalies, the patient was unexpectedly diagnosed with labile hypertension. Despite initial antihypertensive interventions, the underlying catecholamine‐producing tumor rendered them ineffective. Diagnostic clarity was achieved through a combination of radiological tools, including contrast‐enhanced CT, 68Ga DOTATATE PET/CT scan, and MRI.Upon biochemical and radiological validation, the focus shifted to surgical management. The tumor's size and strategic location at the aortic bifurcation necessitated meticulous preoperative planning. Moreover, the potential catecholamine surge during surgery posed a risk of hypertensive crisis. Although abdominal paragangliomas can be addressed through open or endoscopic methods, factors such as tumor size, surgical anatomy, and indicators of local invasion often dictate the choice.8.4Despite a <10% risk of local recurrence post‐total resection, it is crucial for healthcare practitioners to remain vigilant, especially in cases with multiple tumors, metastatic disease, familial paraganglioma, or extra‐adrenal tumors.Following resection of catecholamine‐secreting paragangliomas, the National Comprehensive Cancer Network suggests repeat biochemical evaluation and imaging within 3 months.9In reporting a young male with resistant hypertension and a subsequently diagnosed Organ of Zuckerkandl paraganglioma, this intricate case illuminates the diagnostic complexities and challenges inherent in managing such rare conditions. Emphasizing the crucial role of multi‐disciplinary collaboration, from GPs to vascular surgeons, the case report underscores the importance of comprehensive diagnostic evaluation, particularly when secondary hypertension arises in younger patients. Despite the successful intervention, postoperative complications highlighted areas for enhanced clinical decision‐making and the need for genetic considerations within paraganglioma management. Moving forward, refining diagnostic criteria, advancing surgical practices, and delving deeper into genetic predispositions are paramount in optimizing patient outcomes. Encouraging dedicated research on these fronts will not only bolster evidence‐based practices but also elevate the comprehensive care and management of paragangliomas.Reabal Najjar: Conceptualization; data curation; formal analysis; investigation; methodology; visualization; writing – original draft; writing – review and editing. Elizabeth Paver: Resources; supervision; visualization; writing – review and editing. Jonathan McGuane: Resources; visualization; writing – review and editing. Gert Frahm‐Jensen: Conceptualization; investigation; project administration; resources; supervision; writing – review and editing.The authors declare no financial support.The authors declare no conflicts of interest.Written informed consent for the publication of this case report was obtained from the patient. A copy of the written consent can be made available for review if requested.


Spindle cell hemangioma (SCH) is an exceptionally uncommon vascular neoplasm, primarily manifesting on the extremities. This article delves into a singular case of a 20-year-old female presenting with erythema and discomfort in the left palm, diagnosed with SCH. Post-consultation with a dermatologic neoplasm consortium, she underwent a comprehensive excision, followed by a bi-phasic skin graft. Despite non-clear surgical perimeters, the patient, five years post-procedure, has experienced neither re-emergence nor functional encumbrance. The discussion emphasizes the notable recurrence propensity of SCH, with a historical recurrence rate surpassing 50%, and underscores the importance of an interdisciplinary strategy, enduring surveillance, and bespoke therapeutic decisions for management. The paper concludes by advocating for augmented research and expansive case compilations to enhance therapeutic paradigms for such atypical vascular lesions. Spindle cell hemangioma (SCH) represents a very rare type of vascular tumor. It was initially described by Weiss and Enzinger in 1986, who presented the first 26 cases . SCH canThe patient was a 20-year-old female who had noticed redness in the palmar region for several years Figure . Due to MRI with fat-suppressed T1-weighted images showed a high-signal area at the index finger MP joint, and the axial view allowed visualization of its extent Figure .Histologically, there was an increase in spindle-shaped cells, which did not stain for CD34/CD31 (Figures The decision was made to perform wide local excision of the soft tissue tumor after consulting with the dermatology tumor team for margin determination Figure . During Although pathology results indicated positive margins, the area was near the nerve. After consultation with the patient and her family, no additional excision was done, opting instead for skin reconstruction Figure . Two weeFive years post-operatively, the patient shows no signs of recurrence, pain, or restriction in finger mobility Figure .SCH has been reported in roughly 200 cases, with about 20% involving the hand. Although it is primarily a benign tumor, there are suggestions that multifocal symptomatic cases can become malignant. The recurrence rate is greater than 50%, with wide excision being recommended ,4. HarriIn the present case, given its symptomatic nature and the patient’s family’s surgical preferences, wide excision was chosen to prevent recurrence. The margins were positive, suggesting that digital nerve excision might have been necessary. However, perhaps due to the removal of the nerve’s superficial membranous tissue, there was no recurrence or functional impairment even five years post-surgery. This was an instance in which the preservation of the digital nerve was successful. Continuous long-term follow-up will be necessary.SCH in the hand is a rare benign tumor with a high recurrence rate. Treatment typically involves wide excision. In this case of a 20-year-old female, surgical intervention successfully prevented recurrence for five years post-operatively, with nerve preservation. Continuous long-term monitoring remains crucial.


Sturge-Weber syndrome (SWS) is a rare neurocutaneous vascular disorder characterized by a facial birthmark known as a port-wine stain (PWS), eye abnormalities, and abnormal blood vessels in the brain. It is basically a multisystem disorder that can involve the nervous system, skin, and eyes (phakomatosis). We report a case of a 14-year-old female who presented to the outpatient department with a complaint of upper lip swelling. She had a visible PWS since birth on the left side of her face, which was extending onto the right side of the face as well. She had two episodes of paroxysmal hemiparesis that were four years apart. Moreover, she was diagnosed with epilepsy when she was three years old. She was treated for glaucoma as well when she was nine years old. She was diagnosed with SWS based on her medical history, grossly visible PWS, and neuroimaging findings. Treatment is mostly symptomatic, as no definitive treatment is yet available. GNAQ gene, on the long arm of chromosome 9 [Sturge-Weber syndrome (SWS), also known as encephalotrigeminal angiomatosis, belongs to a group of disorders known as phakomatosis. Phakomatoses, or neurocutaneous disorders, represent a group of disorders in which benign or malignant tumors develop in different parts of the body, mainly the skin, brain, spinal cord, and bones. Port-wine stain (PWS), also known as nevus flammeus, is commonly found in areas innervated by the trigeminal nerve. It extends rarely onto the trunk and upper and lower limbs. SWS is the third most common neurocutaneous disorder after neurofibromatosis and tuberous sclerosis. The most common neurological manifestation of SWS is seizures. SWS can present with variable phenotypes in different individuals . The incmosome 9 . This mumosome 9 . Differemosome 9 .SWS can be classified into three subtypes based on symptomatology. Type 1, which accounts for approximately 90% of cases, involves facial and leptomeningeal angiomas. Type 2 is characterized by the presence of a PWS birthmark on the face and may involve the neck and upper chest without intracranial lesions. Both types 1 and 2 may or may not have ocular manifestations, such as glaucoma. Type 3, the rarest subtype, exclusively involves the nervous system and is referred to as the isolated neurological variant. Unlike types 1 and 2, glaucoma is typically not present in type 3.A 14-year-old female presented to the outpatient department with a complaint of painless swelling of the upper lip. The swelling was non-pulsatile, non-compressible, and painless. The patient reported that this swelling had recurred in the past but had always resolved on its own. However, during the most recent episode, the swelling persisted for the entire month.The patient had a PWS on the left side of her face that extended onto the right side Figure . This diAfter taking a detailed medical history, the patient disclosed that she had a history of generalized tonic-clonic seizures and was diagnosed with epilepsy at the age of three years. She had been prescribed anticonvulsants to manage her seizures. The patient also reported that a high-grade fever was always associated with her seizures.The patient had experienced two episodes of right hemiparesis at the ages of five and nine years. Both episodes were completely motor in nature and lasted for a week. She received physical therapy, which helped improve her condition over a month. A neurologist prescribed aspirin for her.The patient also disclosed that she had been diagnosed with glaucoma in both eyes at the age of nine years due to decreased vision in both eyes. She received treatment for glaucoma at a local hospital and currently reports clear vision with no new episodes since the initial diagnosis.On physical examination, the presence of a PWS on the left side of the body, as previously described, was confirmed. A new lesion forming on the right side of the patient's back was also observed. There were no remarkable findings in other systems, including gastrointestinal, cardiovascular, respiratory, and genitourinary. Computed tomography (CT) of the brain revealed subcortical calcification in the left occipitoparietal region with the tram-track sign, which was associated with parenchymal volume loss and ipsilateral choroidal plexus enlargement Figure .MRI of the brain revealed a decrease in brain volume with mild atrophic changes, which were more pronounced on the left side than on the right. Additionally, there was a dilated lateral ventricle and prominent cortical sulci, ipsilaterally. Other features observed were as follows: (1) coarse cortical tram-track calcification in the parieto-occipital region, as confirmed by a CT scan of the brain; (2) significant leptomeningeal enhancement along the left cerebral hemisphere, particularly in the parieto-occipital region; and (3) thickened areas of the scalp over the left frontal and parietal regions, corresponding to the associated cutaneous lesion.Finally, based on the patient's medical history, physical examination, and the constellation of imaging findings, a diagnosis of SWS was established.Regarding the complaint of lip swelling, a lip debulking procedure was planned for the patient under the supervision of a plastic surgery team. Lip reduction surgeries have a better prognosis. After a thorough discussion with the patient and the surgeon's consideration, the Brazilian technique of lip reduction was selected. This procedure focuses on the shape of the lip, creating a more triangular shape at the bottom, resembling a bikini line, and a "bikini top" shape at the upper lip (two cups and a middle strap).A referral to a dermatologist was made for the extensive PWS, with a recommendation for dry laser photocoagulation. The patient was thoroughly counseled regarding the seizures, episodes of hemiparesis, and glaucoma. The patient was advised to have a continuous follow-up in the surgical outpatient department for the newly formed discolored lesion on the back.SWS is a group of disorders that can present as multisystem manifestations, mainly neurological, cutaneous, ocular, and oral. Pathologically, all these manifestations arise from vascular malformations, which cause the symptoms mentioned above. Based on the vascular malformation in different systems, the manifestation of SWS can be divided into four distinct parts.Cutaneous manifestationPWS is the most common clinical manifestation of SWS . It is aNeurological manifestationLeptomeningeal angiomatosis gives rise to neurological signs and symptoms, such as seizures, stroke-like episodes, contralateral hemiparesis, and vascular headache. Seizures are generally of the partial type and occur contralaterally to the cutaneous lesion , and areOcular manifestationsGlaucoma is the most common ocular manifestation. In most cases, the etiology is an anterior chamber angle abnormality . VasculaOther manifestationsIn some cases, oral signs and symptoms have been noted. These generally include soft tissue hypertrophy secondary to characteristic vascular malformations. Typically, unilateral vascular hyperplasia of the oral mucosa and gingiva is noted. This feature has been reported in about 60% of the cases in some studies . These cBased on various manifestations, SWS is classified into three main types by the Roach scale as follows : type 1:Some studies also add a fourth type that is marked by SWS combined with other disorders such as tuberous sclerosis .To diagnose SWS, the different vascular abnormalities in the skin, eyes, and brain are typically demonstrated. Investigations such as CT and MRI of the brain with gadolinium are most useful in addition to skin and eye examination. Brain MRI with gadolinium enhancement is considered the investigation of choice for diagnosing SWS . In our Differential diagnosis in a patient with features of SWS can include Klippel-Trenaunay-Weber syndrome, which is a rare congenital disorder involving malformation of blood vessels in soft tissues, bones, and the lymphatic system. Angio-osteodystrophy syndrome is characterized by a triad of cutaneous malformations, venous varicosities, and bony or soft tissue overgrowth. Rendu-Osler-Weber syndrome is an inherited disorder of the blood vessels that can cause excessive bleeding. Maffucci syndrome is characterized by benign overgrowth of cartilage, skeletal deformities, and cutaneous lesions composed of abnormal blood vessels. However, in the present case, all these possibilities were ruled out on the basis of a thorough history, clinical examination, and investigations.The treatment of SWS is generally symptomatic and supportive . HoweverThis case is unique and important in that it involves all the major signs and symptoms that are described in the literature. It includes left-sided facial PWS along the ophthalmic and maxillary divisions of the trigeminal nerve. Nevus flammeus extends onto the left side of the whole trunk, the left upper limb, and the left lower limb up to the knee. The patient has a positive history of glaucoma, episodes of paroxysmal paralysis, seizures, and soft tissue hypertrophy. As SWS is rare in nature, a case with all the common features in a single patient might prove to be of vital importance in having a better understanding of the pathology and presentation of this syndrome. Multidisciplinary treatment of SWS, including expert psychological evaluation and counseling of patients and their families, is essential for optimal management.


We report a rare case of a solitary paraganglioma arising from the small bowel mesentery, found in a 70-year-old female who presented with abdominal pain. Paragangliomas are rare neuroendocrine, neural crest-derived tumors, most commonly found in the adrenal medulla. While extra-adrenal paragangliomas arise from diverse locations, mesenteric origins are extremely rare. Our comprehensive review shows 35 previously documented cases and updates the epidemiology, clinical features, and outcomes of mesenteric paragangliomas. Paragangliomas (PGLs) are rare neuroendocrine neoplasms of neural crest origin that arise from autonomic paraganglia. There are two main types of extra-adrenal paragangliomas: head and neck, and abdominal. The head and neck PGLs are more common and often occur around the carotid artery, jugular vein, and along the base of the skull. Extra-adrenal abdominal PGLs can develop in various locations within the abdomen, including the abdomen's sympathetic and parasympathetic nerve chains.RET, NF1, SDHB, SDHC, SDHD, and SDHAF2).While a majority of PGLs occur sporadically, approximately 30-40% are associated with hereditary syndromes such as multiple endocrine neoplasia type 2 (MEN2), von Hippel-Lindau disease (VHL), and familial paraganglioma-pheochromocytomas syndrome (HPPS) with mutations identified in several genes  of the abdomen pelvis with intravenous (IV) contrast revealed a right para-midline enhancing mass measuring 2.7 x 2.8 x 3.1 cm in the pelvis. The mass appeared mobile as it was in a different position on prior CTs  showed a T2 hypointense, T1 isointense mesenteric mass measuring 2.4 x 2.9 x 3.0 cm associated with small bowel loops Figures -2C.Additionally, imaging with positron emission tomography (PET) with 2-deoxy-2-[fluorine-18] fluoro-D-glucose integrated with computed tomography (18F-FDG PET/CT) demonstrated low-grade neoplastic activity in the mass Figure .GATA-3 gene and showed rare cells positive for S100. Notably, tumor cells were negative for cytokeratin stains AE1/AE3 and CAM 5.2 . The most common presenting symptom was a palpable abdominal mass , but many patients presented with abdominal pain/discomfort  or were asymptomatic .The majority of these tumors are benign, but they can still cause significant health issues depending on their size and location. Sympathetic-associated PGLs can often produce hormones such as catecholamines , which can lead to symptoms such as high blood pressure, rapid heart rate, and other signs of excessive sympathetic nervous system activity. Malignant PGLs are less common but are often indistinguishable by imaging. Of the cases that reported metastases in our review, 5/28 (18%) found evidence of PGL in nearby lymph nodes.While a majority of extra-adrenal PGLs are nonfunctional and discovered incidentally during imaging evaluations for other reasons. CT features include a nonspecific soft-tissue density similar to other neoplasms. Therefore, preoperative diagnosis of extra-adrenal PGLs is usually difficult . MRI chaWhile only 25% of PGLs are functional and have the potential to secrete catecholamines, 131 I metaiodobenzylguanidine (MIBG) scintigraphy is a specific imaging study for preoperative diagnosis .The primary treatment choice for PGLs is surgical resection. There have been no reported cases of tumor recurrence, but median follow-up was relatively short. While chemotherapy and radiotherapy may be used for unresectable or metastatic cases, there is no current evidence of increased survival with these treatments .We report an extremely rare case of a solitary paraganglioma arising from the small bowel mesentery, found in a 70-year-old female who presented with abdominal pain. A comprehensive literature review found only 36 reported cases of mesenteric paragangliomas, including the current case. Although rare, these tumors should be among the preoperative differential diagnosis of abdominal masses of unknown etiology.


The diode laser, with a wavelength ranging from 810 to 980 nm, is a modern treatment modality that offers significant advantages in the management of benign oral soft tissue masses. Therefore, this report aimed to assess the efficacy of diode laser application for excisional biopsy of such masses.Three female patients, aged 9, 39, and 45 years, visited the Oral Medicine Clinic with complaints of painless masses in the oral cavity persisting for two to three months. Their intraoral examination showed the presence of pedunculated or sessile exophytic lesions with a smooth surface. The lesions appeared as single, pink to red protrusions located in various sites, including the left buccal mucosa, right lateral border of the tongue, and lower gingiva.Excisional biopsy of the masses was carried out in the patients using the diode laser. The surgical procedures ranged from 10 to 20 min, with minimal intraoperative bleeding and precise cutting, while no pain was reported. Postoperatively, at two weeks and four months follow-up, the intraoral wounds exhibited excellent healing without complications such as pain, bleeding, swelling, scarring, infection, or mass recurrence. The clinical diagnosis of irritational fibroma (two cases) and fibrous epulis were confirmed by histopathological examination.Diode laser emerges as a highly efficacious method for the excisional biopsy of benign oral soft tissue masses, providing intraoperative and postoperative advantages over scalpel surgery. •The diode laser with wavelengths ranging from 810 to 980 nm, is beneficial for managing benign oral soft tissue masses.•A diode laser used in oral mucosa surgery reduces swelling, bleeding, scarring, pain, and accelerates the healing process.•The diode laser's compact, portable, cost-effective design make it ideal for various surgical applications in dentistry. Several factors, including poor oral hygiene, removable dentures, smoking, malposition, bad habits, and mechanical irritation, influence the development of these masses. Oral lesions are often categorized into non-neoplastic, neoplastic, and potentially malignant groups. Meanwhile, the five groups provided by The International Classification of Diseases for Dentistry and Stomatology (ICD-DA) and the World Health Organization are reactive lesions, pre-cancerous/potentially malignant lesions, salivary gland pathology, benign masses, and malignant masses .Benign masses do not metastasize but may cause local damage. They exhibit slow growth, lack invasiveness, possess low mitosis and high cell differentiation rates, and tend to recur ,5. TheseA biopsy is suggested for oral lesions that cannot be diagnosed clinically or radiographically, but it should be avoided in cases of bleeding disorders. An excisional biopsy involves the complete removal of the lesion, which is then sent to the Anatomical Pathology department for histopathological examination. This technique is suitable for small clinically benign lesions. Either scalpel, punch, laser, or electrosurgical biopsy can be employed for oral lesion excision. Even though simple scalpel biopsy is routinely used due to being affordable, uncomplicated, accurate, and characterized by minimal damage to surrounding tissues, it does not provide good hemostasis in highly vascular or maxillofacial areas. Injection or diode laser as an adjunct to soft tissue surgical operation in the oral mucosa has been reported to minimize swelling, bleeding, scar tissue formation, and postoperative pain, along with the acceleration of wound healing .The diode laser is a modern treatment modality introduced in dentistry in 1999. Furthermore, it is a solid-state semiconductor, which primarily uses a combination of gallium (Ga), arsenide (Ar), and other elements such as aluminum (Al) and indium (In), with wavelengths ranging from 810 to 980 nm. Prior studies have indicated that this device effectively removes premalignant lesions during the management of oral mucosa and maxillofacial diseases . Both hiwww.processguideline.com) criteria [We performed a prospective single-center consecutive case series with the inclusion criteria involving patients with oral benign masses who underwent treatment using a diode laser. The study was conducted at Oral Medicine, Teaching General Hospital of Padjadjaran University. All patients were operated on by an experienced oral medicine specialist and oral surgeon. This case series has been reported in line with the PROCESS 2020  and erbium lasers [The diode device was characterized by a small size appearance, portability, and relatively lower cost compared to other laser equipment. These features make it an attractive choice for dentists and specialists in various surgical indications. The diode laser could be used at three wavelengths, namely 810, 940, and 980 nm. A prior study investigated the thermal tissue effects of diode lasers with wavelengths of 830 nm and 940 nm in contact applications, reporting low thermal effects at the carbonization zone on the surface of histological tissue examination . Specialm lasers ,13.In this report, a diode laser with a 976 nm wavelength, a 400 μm diameter tip, a pulse repetition rate of up to 50 kHz, a pulse duration of 2 milliseconds, and a power range of 2.0–10.0 W (Solase®) was used. This low-power wavelength was chosen to minimize postoperative complications such as burning and pain, as observed in our three cases . Our expThe postoperative pharmacological therapy following laser excision biopsy included 250 mg tablets of amoxicillin and paracetamol administered three times daily for five and three days, respectively, along with 0.1 % triamcinolone acetonide in an oral base applied to the surgical site. Amoxicillin was prescribed to ensure proper wound management, promote healing, and prevent local infection by the polymicrobial target microbiota that could arise from surgical contamination or infection by normal oral and saliva microbiota. Natarajan et al., reported that amoxicillin has been commonly used as the first-choice antibiotic by dental practitioners in post-surgical scenarios . ParacetDuring the follow-up for two weeks and four months after the last visit, all patients reported no complaints after the surgery. Moreover, they were educated about maintaining oral hygiene, caring for their removable dentures, avoiding smoking and bad habits, and preventing mechanical irritation to minimize the risk of mass recurrence in the future.4Diode laser emerges as a highly efficacious method for the excisional biopsy of benign oral soft tissue masses, providing intraoperative and postoperative advantages over scalpel surgery.For case 1, written informed consent was obtained from the patient's parents for publication and any accompanying images. For cases 2 and 3, written informed consent was obtained from the patient for publication and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request.This study is exempt from ethical approval in our institution for publishing anonymous case reports/case series.Universitas Padjadjaran for funding the publication.The authors thank Irna Sufiawati: Conception, design of the study, acquisition of the data, drafting and revising of the manuscript, final approval of the version to be submitted, and involved in direct management of the patient.Fitri Dona Siregar: Acquisition of the data, drafting and revising of the manuscript, final approval of the version to be submitted, and also as the assistant in management of the patients.Endang Syamsudin: Acquisition of the data, drafting the manuscript, final approval of the version to be submitted, and also involved in direct management of the patient.Indah Suasani Wahyuni: Acquisition of the data, final approval of the version to be submitted.All authors agreed to be accountable for all aspects of the manuscript.Irna Sufiawati.Not applicable.There are no conflicts of interest.


Symbrachydactyly is a complex and rare congenital hand deformity characterized by missing or underdeveloped fingers and rudimentary digit nubbins. This case report focuses on a newborn female with type 3A symbrachydactyly, highlighting the unique clinical presentation, diagnostic assessment, and initial management approach. The rarity of this condition underscores the need for sharing cases to enhance understanding and treatment strategies. Various classification systems exist, contributing to the challenge of accurately categorizing symbrachydactyly. Surgical interventions play a crucial role in restoring hand function and appearance, with treatment choices tailored to individual evaluation and goals. Early surgical intervention is often necessary to improve outcomes, and nonvascularized toe phalangeal transfers have shown promising results. Further research is required to uncover the underlying cause and pathogenesis of symbrachydactyly, enabling more targeted and effective treatment approaches. This case report contributes to the existing knowledge and management of this uncommon congenital anomaly, emphasizing the importance of sharing and studying such cases for improved patient care. Symbrachydactyly is a congenital abnormality of the embryonic limbs that affects the growth of the hand plate, nail plate, bone, and cartilage . With onIn this instance, we talk about a baby girl who has type 3A symbrachydactyly. By detailing our approach and discussing this case, we hope to improve other clinicians' understanding of this uncommon anomaly, its presentations, and the available treatments.A healthy newborn female was born at 38 weeks and 5 days to a 20-year-old G2 P1011 woman, who had a history of scant prenatal care and no significant medical or surgical history. The patient was born via spontaneous vaginal delivery with no complications. There is neither a family history of genetic syndromes nor congenital malformations. Obstetric ultrasound at 27 weeks and 4 days revealed that the left hand appeared to be missing digits, with the repeat ultrasound at 35 weeks and 1 day not clearly showing the left hand due to fetal crowding.Upon physical examination, the patient was noted to have a left-hand deformity, whereby she was missing the ulnar digit, there was an ulnar deviation of the left fourth digit, and there was decreased/absent webspace between the left first and second digits, as seen in Figure  and Figure The diagnostic assessment involved physical examination and imaging. The initial X-ray was performed shortly after birth. The findings included the absence of the ulnar digit and the fifth metacarpal bone. The second finger displayed a hypoplastic middle phalanx, indicating underdevelopment and foreshortening. Only three fingers were identified on the medial side of the thumb, as seen in Figure 2BThe patient has been evaluated outpatient by pediatric orthopedic surgery, who are planning for regular follow-up, with a repeat visit scheduled in six months, with repeat radiographs of the left hand at that time, and an aim for surgical reconstruction in the future.Symbrachydactyly is a complex congenital hand malformation that exhibits various manifestations and poses challenges in its management. The rarity of this condition further emphasizes the importance of sharing cases and discussing treatment strategies to enhance medical professionals' understanding and improve patient care.Different criteria can be used to categorize symbrachydactyly. Symbrachydactyly is classified by one classification scheme, the Oberg-Manske-Tonkin (OMT) classification, as a lack of axis development and differentiation of the hand plate or the entire upper limb . Based oBased on Foucher’s classification, the presence of a normal thumb differentiates our diagnosis of type 3A symbrachydactyly from other similarly presenting conditions that lack the presence of an ulnar digit . These iThe management of symbrachydactyly involves a surgical intervention to restore hand function and appearance . SurgicaThe prognosis of symbrachydactyly depends on the severity of the condition and the chosen surgical intervention. Nonvascularized toe phalangeal transfers can also be a viable treatment option for select cases of symbrachydactyly, resulting in a functional hand with mobile metacarpophalangeal joints . Long-teIt is worth noting that the underlying cause of symbrachydactyly remains largely unknown, and further research is needed to elucidate the etiology and pathogenesis of this condition, which would aid in developing more targeted and effective treatment approaches.Type 3A symbrachydactyly in a newborn female is rare, as represented by our case. Accurate diagnosis and subtype distinction are emphasized. Mild cases may not require surgical intervention. Surgical techniques, such as distraction lengthening, web-syndactyly release, and toe-phalanx transfer, are aimed at improving function and appearance. Sharing and studying such examples improves patient care and management by increasing knowledge of this rare congenital condition.


Invasive mole (IM) is a very uncommon subtype of gestational trophoblastic disease (GTD), which is the invasion of molar tissue into the uterine or myometrial vasculature. However, this report presents a rare case of a 41-year-old female multiparous P7 with five full-term normal vaginal deliveries and two preterm normal vaginal deliveries. As the patient was not using contraception, her urine pregnancy test (UPT) was done, which demonstrated positive results. A speculum examination revealed a healthy cervix with just mild bleeding, whereas a vaginal examination revealed a firm cervix and an anteverted and mobile eight-week-old uterus along with a free fornix. Pelvic ultrasound and magnetic resonance imaging (MRI) demonstrated the diagnosis of GTD, for which consultation from an oncology physician was taken and the treatment proceeded with a total abdominal hysterectomy. Histological examination of the uterus showed a circumscribed nodule showing a large area of hemorrhage with few chorionic villi lined with trophoblastic cells and occasional villi invading the myometrium and endometrial cavity suggesting hydatidiform mole showing early invasion that confirmed the diagnosis of IM. In conclusion, reproductive-age women who experience abnormal uterine bleeding (AUB) should suspect pregnancy with several possible complications, for which a pregnancy test should be done to rule out complications. Invasive moles (IMs), a rare subset of gestational trophoblastic disease (GTD), are molar tissue consisting of hydropic villi with hyperplasia of the trophoblastic elements and can invade the myometrium or uterine vessels in women of childbearing age ,2. The fLocalized invasive gestational trophoblastic neoplasia (GTN) develops in 15% of people after total mole excision and sporadically after partial mole removal. It becomes a metastatic condition in 4% of patients . Human c8 [The most frequent site for metastasis is the lungs (80%), followed by the vagina (30%), pelvis 20%), liver 10%), brain (10%), and bowel, kidney, and spleen (<5%) [0%, liver8 . Chemoth%, brain A 41-year-old multiparous female, married with P7L5D2, presented with chief complaints of continuous bleeding per vagina and occasional passage of clots since the last menstrual cycle 45 days ago, for which she had received symptomatic treatment in a private hospital with no further investigations or relief. Additionally, the patient complained of fatigue, dizziness, shortness of breath, anxiety or irritability, sleep problems, and unexplained weight loss. There was no significant past medical or surgical history, and she was not using any contraceptive method.On examination, the build of the patient was found to be average with a weight of 65 kg and a body mass index (BMI) of 22.5 kg/m². The patient was afebrile, and all vitals were within normal limits: heart rate, 78 beats per minute; respiratory rate, 19 breaths per minute; blood pressure, 150/90 mmHg; and peripheral capillary oxygen saturation (SpO2), 96%. The local genital examination was normal with no discoloration, swelling, or discharge. The cervix was healthy with minimal bleeding present per speculum examination, and the cervix was firm on vaginal examination, with a uterus of eight weeks that was anteverted and mobile along with a free fornix.3 and the platelet count was 1.87 lakhs/mm3 with reduced hemoglobin (Hb) percentage of 11.05 mg%. Considering the patient’s age and lack of contraception, a urine pregnancy test (UPT) was done, which was found to be positive. The patient was admitted with a provisional diagnosis of P7L5D2 with abnormal uterine bleeding (AUB) under evaluation.On investigations that included complete blood count and biochemical evaluation, the total leukocyte count was 6,820 cells/mmThe diagnostic assessment that involved ultrasonography (USG) revealed a bulky uterus of 9 × 6 × 5 cm, with a heterogenous lesion, predominantly hyperechoic, measuring 2.8 × 3.4 × 2 cm, with no evidence of calcification. Vascularity on color Doppler was present with vascular channels from the myometrium supplying the lesion noted. The USG impression was changes of adenomyosis with a heterogenous lesion in the fundus and heterogenous endometrial thickness (ET) Figure .With a confusing picture of USG and a positive UPT, beta-HCG was done to confirm pregnancy, which showed increased values , following which magnetic resonance imaging (MRI) was done that revealed a bulky uterus measuring 9.8 × 6.9 × 5.9 cm, which was heterogenous in intensity with normal ovaries along with an ill-defined altered enhancing lesion measuring 3.5 × 3.3 × 4.2 cm noted in the endometrium and in the fundal area extending into the anterior myometrium. The anterior myometrium measured 3.7 cm, and >50% anterior myometrium was replaced by multiple dilated vascular channels. Hence, the probable diagnosis based on the above findings, along with increased beta-HCG and UPT positive status, was suggestive of GTN with hydatidiform mole showing early invasion leading to IM.Following a discussion with the oncologist, the decision on total abdominal hysterectomy with bilateral salpingo-oophorectomy was taken. The purpose of this case report was explained to the patient, and written informed consent was obtained before commencing the surgical intervention. Intraoperatively, a bluish lesion of 3 × 3 × 2 cm was present on the anterior and fundal wall of the uterus, and the lesion from the endometrium was extending into the myometrium. There were areas of necrosis and hemorrhage. Figure Furthermore, the histopathology report of the uterus showed round to oval endometrial glands, cystically dilated and lined with tall columnar cells, a stroma composed of spindle-shaped cells, and a circumscribed nodule showing a large area of hemorrhage with few chorionic villi as demonstrated in Figure According to the modified World Health Organization (WHO) prognostic scoring for GTN, the final diagnosis of IM stage I with a prognostic score of 9 was confirmed. The postoperative course was uneventful, and on postoperative day 4, beta-HCG was repeated, which was <2 IU/mL. The patient was discharged with close follow-up and monitoring of beta-HCG.This case report highlights a rare case of invasive mole (IM) stage I with a prognostic score of 9 along with the effectiveness and adherence of the patient to surgical intervention that mainly involved total abdominal hysterectomy. IM belongs to the GTD histological subgroup. Choriocarcinoma, placental site trophoblastic tumor (PSTT), and epithelioid trophoblastic tumor are the other three varieties of GTD ,11. AlthPelvic USG and HCG dosage serum confirm the diagnosis. Histology, however, provides conclusive confirmation of an IM ,4,14. InIn cases of abdominal urgency caused by uterine bleeding, severe bleeding, sepsis, and the patient who had finished her parental project, a hysterectomy is recommended as a specialized form of treatment to manage difficulties and stabilize patients ,10,17,18This case report concludes that, as IM is a rare GTD that can be life-threatening, reproductive-age women who experience abnormal uterine bleeding (AUB) should suspect pregnancy with several possible complications, for which a pregnancy test should be done to rule out complications. A histological examination establishes the diagnosis of these uncommon pathologies, and interdisciplinary management aids in improving the prognosis. Early detection enables the commencement of CT, allowing for the prevention of consequences and the preservation of the obstetric prognosis. A hysterectomy may be an option when the essential prognosis is at risk.


Angioleiomyoma, a rare variant of leiomyoma, is a benign tumor of mesenchymal origin. Angioleiomyomas of the female urogenital tract are extremely rare, with only six cases of uterine cervical angioleiomyoma previously reported in the literature. In this case study, we report on a 49-year-old female patient who presented with menorrhagia whose initial magnetic resonance imaging (MRI) findings suggested cervical squamous cell carcinoma (SCC). However, following the hysterectomy, histological examination confirmed the lesion to be angioleiomyoma. To the best of our knowledge, there have been no previously reported cases of angioleiomyomas presenting with MRI findings that are suggestive of uterine SCC. Recognizing that angioleiomyomas can mimic uterine malignancies on MRI may prove beneficial for future diagnostic and treatment strategies.


Hernia is one of the most common clinically diagnosed cases seen in day-to-day practice. But some of them might pose a challenge in diagnosing the condition and, thus, their further management. Some types of hernias are rare and mimic the common presentation of the acute abdomen, thus requiring extra caution to keep hernias as a differential diagnosis in the acute abdomen. In this series, we report five cases of rare hernias presented to a tertiary care center in northern India over the course of one year. Two cases of paraduodenal hernias (PHs), a right and left, respectively, a male femoral hernia, an Amayand hernia, and an obturator hernia presented as acute abdomen in the emergency department, with challenges in their diagnosis, intraoperative findings, and their outcomes. Computed tomography is a useful diagnostic tool for arriving at the diagnosis pre-operatively in these situations. Hernia is the protrusion of the viscus or part of the viscus through the cavity containing it. Hernia is a common case scenario in the outpatient department (OPD) and emergency room. Hernias presenting in OPD are usually uncomplicated, whereas those presenting in an emergency room can be due to obstruction, incarceration, or strangulation. They usually present with vague symptoms of pain in the abdomen and non-passage of the flatus and stools. Sometimes they have similar symptoms that recur over time. In this case series, we review a few cases of rare hernias presented to a tertiary care center in northern India. Most hernias presenting as the acute abdomen are diagnosed perioperatively, but careful observation of symptoms and relevant investigations will help in the preoperative diagnosis and better-planned management of these hernias, which will improve the prognosis in the patients. Computed tomography is a useful diagnostic tool for arriving at the diagnosis pre-operatively in these situations.Case 1A 44-year-old farmer from the northern part of India, a known diabetic and hypertensive, presented to emergency with a history of pain in the abdomen, which was located diffusely all over the abdomen, intermittent in nature, insidious in onset, gradually progressive colicky type, non-radiating, non-aggravating, and relieving factors associated with a history of non-passage of flatus and stools. She also complains of vomiting that is nonprojectile, bilious, and non-blood-stained. The patient had multiple similar episodes of pain, obstipation, and vomiting over eight months. Physical examination reveals the abdomen is distended, with no guarding or rigidity and absent bowel sounds. A working diagnosis of internal hernia was made based on the symptomatology and clinical examination, with no previous history of surgeries. On contrast-enhanced computed tomography (CECT) of the whole abdomen, the patient was diagnosed with a right paraduodenal hernia (PDH; Figures Case 2A 38-year-old known hypertensive and diabetic male shopkeeper presented to emergency with pain in the abdomen, which was of the colicky type, non-radiating, aggravated by eating food and lying down, relieving on taking medication, and intermittent on and off episodes. Also, complaints of nausea and vomiting that were non-projectile, bilious in nature, and non-blood-stained contained ingested food particles. On physical examination, the abdomen is distended, tense, and mildly tender, with no guarding/rigidity noted and absent bowel sounds. The patient had multiple episodes of similar events, which subsided after Ryle's tube insertion. The patient also has multiple episodes of presentation to the ER with complaints of not passing flatus and stools, which were managed conservatively, and the symptoms were relieved after a day or two. Laparoscopic hernia repair was tried Figure , but theCase 3A 75-year-old male farmer from the northern part of India presented to the emergency room with symptoms of swelling in the right upper thigh close to the inguinal ligament for four months. Associated with pain described as colicky, intermittent, non-radiating, aggravated on eating food, and relieved on lying down. His previous medical history reveals hypertension, and he is on regular anti-hypertensive medications. Physical examination of the mass reveals a reducible swelling in the upper thigh below and lateral to the pubic tubercle with a positive cough impulse. A working diagnosis of femoral hernia was made based on the symptomatology and clinical examination. The patient underwent the Mcevedys procedure, where an incision was placed directly over the femoral canal, extending to the inguinal ligament directly upwards, and the sac was dissected from below. An intraoperatively strangulated bowel loop was seen through the femoral canal Figure , and resCase 4A 47-year-old farmer from the northern part of India presented to the emergency room with painful swelling in the right groin region. The patient has had swelling in the right groin region for two years but started developing pain in the last two days. Associated nausea, vomiting, and altered bowel movements are present. A history of smoking and lifting heavy weights is present. On physical examination, partially reducible swelling is noted in the right inguinal region, which is tender with reddish discoloration of the overlying skin. On exploration intraoperatively, a dilated and inflamed appendix was noted as the content of the hernial sac (Figure Case 5An 81-year-old female housewife from north India presented to the emergency room with not being able to pass flatus and stools, nausea, vomiting, and associated pain in the abdomen, which was located in the right lower quadrant, was insidious in onset, gradually progressive, radiating to the right buttock, aggravated the movement of the right leg, and relieved on taking medications. On palpation, tenderness was present, but no mass was palpable in the right iliac fossa. Blood parameters and an ultrasound examination were inconclusive. On MRI, a small bowel loop was seen herniating into the obturator foramen on the right side Figure , and aftListed below is the consolidated list of all cases Table .Hernia is defined as an abnormal protrusion of the viscus or part of the viscus through the cavity containing it. Hernias can be one of the differential diagnoses for patients presenting with acute abdominal pain. Obstruction, incarceration, or strangulation are the causes of hernias presenting as acute abdominal pain. Inguinal hernia and umbilical hernia are common causes of acute abdomen; careful monitoring is needed to prevent complications.Internal hernias are a well-known but rare cause of intestinal obstruction, accounting for 0.2% to 0.9% of cases . PDH is A femoral hernia occurs through the femoral canal. The femoral canal is an inverted cone-shaped, 1-2 cm-long fascial space present in the medial part of the thigh. Anteriorly made of the medial part of the inguinal ligament, posteriorly made of the pectineal ligament overlying the pectineus muscle and its fascia covering the superior pubic ramus, laterally made of the femoral vein within the intermediate compartment of the femoral sheath, and medially made of the lacunar ligament . AlthougProtrusion of the vermiform appendix in the inguinal hernia sac with or without appendicitis is known as Amayand's hernia . ClaudiuAmong abdominal hernias, the incidence of obturator hernias is less than 1% . PreoperThough hernias are very common cases seen in routine practise, we should be aware of some rare hernias presenting as acute abdomens requiring immediate action. When required, a thorough history and clinical examination adjunct with CECT abdomen should suffice. Internal hernias, along with the rare presentation of other hernias, should be a differential diagnosis in the acute abdomen. Early, timely intervention can curtail disease progression and increase survival.


Meningiomas are rare benign tumors during pregnancy. They can put both the mother and the fetus at risk because rapid changes in size may occur. The study reports a case of olfactory groove meningioma in a 34-year-old pregnant woman with visual impairment, anosmia, and dysgeusia that increased in severity during the 29th week of gestation. Magnetic resonance imaging showed an olfactory groove meningioma. The patient underwent a preterm cesarean section to avoid the worsening of the clinical condition due to intracranial compression phenomena. A computed tomography scan of the brain supported the diagnosis. The surgical intervention occurred on the third day after delivery. The clinical course was uneventful and the chiasmal syndrome improved in the following 2 months. Meningiomas in pregnancy may present unique challenges and have a wide array of clinical presentations. Management of maternal meningiomas can be complex and requires a multidisciplinary approach. The treatment decision largely depends on the size and location of the tumor, the presence of symptoms, gestational age, and fetal well-being. Further research is needed to enhance the understanding of the underlying mechanisms and improve management approaches for this rare condition. •Meningiomas are rare benign tumors during pregnancy.•Maternal meningiomas can put both the mother and the fetus at risk because rapid changes in size may occur.•Management of maternal meningiomas can be complex and requires a multidisciplinary approach.•The treatment decision largely depends on the tumor specifics, symptoms, gestational age, and fetal well-being. They originate from the arachnoid cap cells of the meninges, the protective layers that envelop the brain and spinal cord. They are usually benign and slow-growing but can become problematic due to their location and size . PregnanThe present study reports a case of an unrecognized olfactory groove meningioma in a pregnant woman. The report demonstrates how a meningioma can present unique characteristics and how early diagnosis is essential. In this case, pregnancy unmasked the symptoms, necessitating the performance of a preterm cesarean section due to the worsening of the maternal clinical condition.2A 34-year-old primigravid woman was admitted to the emergency gynecologic unit reporting anosmia and dysgeusia during the 29th week of pregnancy. She did not report headaches, nausea, or vomiting. Her family and personal history were negative for any significant disease. She affirmed being a former smoker and denied any alcohol or drug abuse.The symptoms started before pregnancy, and were initially mild. A test at the time for Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-COV-2) was negative and an ophthalmological examination excluded any ocular pathology. Routine first-trimester ultrasound showed no anomalies, and Toxoplasmosis, Other agents, Rubella, Cytomegalovirus, and Herpes simplex (TORCH) screening was negative. During the 22nd week of gestation, she reported blurred vision in both eyes, which became progressively worse, for which she underwent optical coherence tomography. It excluded retina and optic nerve disorders.On admission, the general physical examination was unremarkable, and the vital signs were within normal limits. A fetal ultrasound scan showed regular fetal growth, homogeneous placenta, regular amniotic fluid, and an umbilical artery Doppler pulsatility index in the 50th centile. The neurological examination did not reveal abnormalities in motor and mental state but her symptoms were an indication for urgent magnetic resonance imaging (MRI) of the brain. It showed a tumor involving the subfrontal middle line starting from the olfactory groove, which marked the anterior part of the corpus callosum, the optic chiasm, and compressed the overlying frontal convolutions, compatible with the diagnosis of an olfactory groove meningioma.After the administration of corticosteroid and magnesium sulfate for fetal lung maturation and neuroprotection, the patient underwent a cesarean section to avoid the worsening of clinical condition due to intracranial compression phenomena. A premature male infant was born, with one- and five-minute Apgar scores of 6 and 8, respectively. A brain computed tomography (CT) scan with contrast demonstrated a homogeneously subfrontal contrast-enhancing mass with well-defined borders and peritumoral brain edema, supporting the earlier diagnosis .Fig. 1BrOn the third day after delivery, the patient underwent surgical intervention. The lesion was approached by a frontal craniotomy and complete resection was achieved, with no intraoperative complications. The histopathological examination confirmed the diagnosis. Postoperatively, visual acuity improved, and the visual field returned to normal after 2 months. At the time of writing, the patient had had no relapse and was undergoing follow-up.3Meningiomas are estimated to constitute between 13% and 26% of all intracranial tumors. They show a rising incidence with age and are most common in the sixth and seventh decades of life. In adults, there is a 2:1 female-to-male ratio .The pathophysiology of meningioma in pregnancy is different from that of other meningiomas and is far from being understood. There are two possible mechanisms to consider: endocrine and vascular. The abundant expression of progesterone receptor (PR) in meningiomas is well established, but it is not known how PR expression is regulated and what function it exercises in tumor growth. It is uncertain if PR contributes to cell proliferation or not; the evidence that several meningiomas enlarge and become symptomatic in pregnancy and reduce their size after delivery suggests an important role of the sex steroid hormone . In a seMaternal meningiomas can present unique challenges during pregnancy. The clinical implications depend largely on the tumor size and location. Common symptoms include headaches, seizures, changes in vision, and neurological deficits like weakness or numbness on one side of the body. The patient complained of anosmia and dysgeusia, but she did not report headache, nausea, or vomiting, providing further evidence of the highly variable symptomatology of this condition.From the maternal perspective, untreated meningiomas can cause serious neurological complications, and even life-threatening conditions such as hydrocephalus and intracranial hypertension.From the fetal perspective, maternal meningiomas carry the risk of premature delivery, low birth weight, and, in some severe cases, intrauterine death. Additionally, certain medications for managing maternal symptoms or surgical interventions can have adverse effects on the fetus . In thisDiagnosing maternal meningiomas during pregnancy requires a comprehensive evaluation. Imaging studies are crucial in determining the size, location, and characteristics of the tumor. MRI is the preferred imaging technique as it provides a detailed view of the brain and meninges without exposing the mother or fetus to radiation. An early diagnosis can be important for the mother's and fetus's health, because untreated or complex cases can have significant complications, making careful management vital .A multidisciplinary approach was performed involving obstetricians, neonatologists, radiologists, neurosurgeons, and anesthesiologists, which is crucial to manage these cases effectively and ensure the best possible outcomes for both the mother and baby. A “wait and watch” approach with close monitoring might be taken for asymptomatic, small meningiomas . SymptomThe prognosis of maternal meningiomas depends on several factors, including tumor characteristics, treatment modalities, and the overall health of the mother. Most meningiomas are benign, and with timely diagnosis and appropriate management, the prognosis is generally favorable with a low recurrence rate after complete surgical resection . After tPostpartum regression of the tumor has been observed in some cases, presumably due to the normalization of hormone levels after pregnancy. However, certain factors, such as higher-grade tumors, larger tumor size, and certain histological subtypes, may influence long-term outcomes. Thus, long-term monitoring is essential as there is always a risk of recurrence.4Meningiomas during pregnancy present unique challenges and can have a wide array of clinical presentations. Pregnancy is considered risky and patients should be carefully monitored for possible neurological maternal manifestations and fetal well-being. Timely diagnosis, personalized treatment strategies, and close monitoring are essential for achieving favorable outcomes and the timing of delivery should be based on an accurate evaluation of the fetal and maternal outcomes. The presence of a multidisciplinary team is essential to improve maternal and fetal survival. Further research is needed to enhance the understanding of the underlying mechanisms and improve management approaches for this rare condition.


Needle arthroscopy has enjoyed a tremendous growth concerning the quality of intraoperative images due to technical innovation, resulting in innovative possibilities concerning concomitant minimally invasive procedures and treatment of osteochondral lesions of the talus (OLT). These lesions have increasingly been receiving scientific attention in the orthopaedic (sports) medicine field, and, as such, the quality of evidence-based treatment for them has developed substantially. Treatment of OLTs—and specifically subchondroplasty. OLTs may also be suitable for needle arthroscopic interventions. The purpose of the present technical note is, therefore, to present an all-arthroscopic needle arthroscopic technique, including subchondroplasty with adipose-derived stem cells augmentation for osteochondral lesions of the talus. The authors describe the technique for needle arthroscopic inspection and treatment of (osteo)chondral lesions of the ankle joint as a standardized approach. The osteochondral lesions of the ankle joint can be located at any talar location and are preferably nonfragmentous and of size <1.5 cm. It must be stated that the lesion should be of symptomatic nature and have already undergone a rigid and thorough conservative treatment approach prior to the surgery. In the video, the equipment is noted, including sterilization, the set of the needle arthroscopy, including a handpiece set, a portable console, 50 cc syringes, and a 3-way tap, as well as sterile sodium chloride 0.9%. Besides the needle arthroscopic set, a clear description of the harvesting of stem cells from the adipose tissue is given. After this harvesting, the aspirated tissue is centrifuged with a Hettich Rotofix 32A swing-out 220V centrifuge system. The procedure that is described is then continued by the application of subchondroplasty: a cannulated drill is used to drill the subchondral cyst, which is performed under fluoroscopic guidance and control. Five milliliters of subchondroplasty material are injected into the subchondral lesion area under both fluoroscopic guidance and control, as well using the needle-arthroscopic procedure to verify that there is no leakage of the subchondroplasty into the joint after full insertion. Thereafter, the video describes the injection of the concentrated adipose-derived stem cells in the ankle under nanoarthroscopic control. There is no superior treatment for primary OLTs.The study was conducted in agreement with the 1964 Helsinki Declaration and its later amendments. Ethical approval by the institution’s review board was not required.The procedure is demonstrated in The preoperative planning consists of a proper physical examination taking into account the patient’s wishes and will be followed by a shared-decision making process by the treating surgeon. The preoperative magnetic resonance imaging (MRI) reports are of importance to confirm the diagnosis and accurately study the anatomy of the subchondral cyst in order to determine the amount of subchondroplasty  to be injected.As equipment, we use the needle arthroscopic device , which consists of a sterile disposable handpiece set and the portable video console.The procedure is initiated by the adipose-derived stem cell augmentation process consisting of emulsification, harvesting, and processing . The abdAn arthroscopic system  is used consisting of a disposable handpiece and a control unit consisting of a screen. The details of the arthroscopic system are described in earlier publications by Stornebrink et al.All instruments are removed, and sterile wound closure strips or a simple band aid are sufficient for skin closure of the percutaneous camera portal. A wire suture is used for the working portal. Standard postoperative rehabilitation is started.,,,,The needle arthroscopic technique combined with a subchondroplasty technique, biologically augmented with adipose-derived stem cells, as presented in the present article provides a minimally invasive surgical approach to treat osteochondral lesions of the talus of cystic nature. The advantages of this procedure are the minimal invasiveness of the needle arthroscopy, the potentially improved postoperative recovery due to the decreased soft-tissue trauma and potentially improved patient experience, while the advantages of the biological augmentation through the adipose-derived stem cell therapy may stimulate a greater subchondral bone and cartilage recovery.As a conclusive remark, needle arthroscopy, combined with a subchondroplasty and a subsequent biological augmentation with adipose-derived stem cells, provides a minimally invasive, high-quality cartilage repair technique that can increase patient-reported outcome measures and improve the postoperative recovery due to decreased soft-tissue trauma and potentially improved patient experience.


Presence of pituitary metastases (PMs) is a relatively rare clinical situation, especially when originating from hepatocellular carcinoma (HCC). A 73-year-old man presented with headaches, diplopia, and soon impaired vision, as well as gastrointestinal symptoms. Computed tomography (CT) and magnetic resonance imaging (MRI) of the brain revealed a space-occupying mass in the sellar region. The patient had a history of hepatocellular carcinoma and recent abdominal ultrasound and positron emission tomography (PET) indicated recurrence and metastases. Endoscopic transnasal transsphenoidal tumor excision was performed, and postoperative pathological report confirmed the diagnosis of HCC PM. In the literature review, 17 published cases of HCC PMs were summarized. Both the diagnosis and management of HCC PMs are difficult. Patients who had HCC-related history and new-onset headaches or diplopia should be inspected with a suspicion of metastatic lesions. Surgical intervention with transnasal endoscope is only recommended to ameliorate the symptoms and improve the life quality. The reported incidence of metastatic lesions among all surgically removed pituitary tumors is approximately 1% , perhapsIt has been reported that the primary cancer can originate from multiple sites , 6. Amon22.1Pertinent literature was searched using Pubmed for English references and CNKI for Chinese references. Keywords “pituitary metastases” and “hepatocellular carcinoma” were searched in all fields. 23 English articles and 1 Chinese article were retrieved, of which 13 were unrelated and thus excluded. Careful reviews were executed in the rest of the articles, and 5 more references were identified from the bibliographies. Eventually, 17 reported cases of HCC PMs were included in this review.2.2A 73-year-old man with a history of severe headaches for 1 month, and diplopia for 2 weeks was admitted to the Department of Neurosurgery at Peking Union Medical College Hospital on May 10, 2022. Previously, local hospital made a diagnosis of left genyantritis and prescribed conservative analgesic medication. His headache attacks were mitigated after the medication. Two weeks later, with no precipitating factors, a sudden onset of diplopia and blurred vision on the right side was developed. He also had nausea, vomiting, and abdominal discomfort for six days.On admission, blood pressure was 140/90mmHg, and other vital signs were normal . Neurological examination identified abducens nerve palsy with binocular cohesion and limited abduction. Visual acuity was recorded as 0.5 for left eye and 0.6 for right eye (converted as 20/63 and 20/80 in Snellen eye chart). A further visual field test revealed temporal field defects. Other ocular movements were intact and pupillary light reflexes were normal. Further neurological tests found that he was unable to perform the finger-to-nose test and the Romberg sign was probable positive.A CT brain scan showed a soft-tissue density mass in the sellar region and the sphenoid sinus, and bone density was decreased in the clivus. Subsequent enhanced MRI of the brain depicted a homogeneously enhancing pituitary mass extending into the bilateral sphenoid sinus and invading the clivus, measuring approximately 3.1×3.4×2.7 cm in size  was 92.2 ng/ml . Other tumor markers were all within normal limits. Abdominal ultrasound detected a 7.6×7.0 cm hypersonic mass in the right posterior section of the liver. PET highlighted the possibility of recurrence and metastasis of hepatocellular carcinoma, with increased radiation uptake in multiple sites including the liver, vertebral bodies, and costal bones. However, no abnormally elevated uptake was detected within the brain parenchyma.In combination with this patient’s history, neurological examination, and imaging findings, an initial inference of HCC PM was made. The diagnosis was made mainly based on his malignancy history, despite the PET results being inconsistent. To mitigate symptoms and confirm the diagnosis, a surgical plan comprising endoscopic transnasal transsphenoidal sellar region exploration, tumor excision, and sellar base reconstruction was devised. At surgery, highly vascularized tumor tissue was encountered, with erosion of the clivus bone. The intraoperative frozen section indicated metastatic HCC, which was further confirmed in postoperative immunohistochemical reports Figure 23Their initial clinical manifestations and imaging findings were listed in The most commonly used imaging technique for diagnosis was MRI Table 2.Concerning the management of HCC PMs patients, surgery was mostly the first option, either by decompressive partial resection or radical resection Table 4.We further summarized the previous malignancy history of these HCC PMs patients Table 5.4PMs were relatively rare in pituitary tumors and other intrasellar lesions, with only 1% of all pituitary tumor surgeries reported by retrospective studies . HoweverSo far among all reported tumor origins, PMs from HCC were remarkably rare, of which only 16 cases were reported in English literature and 1 case in Chinese literature. Our case presented here became the eighteenth reported. Interestingly, there is a strong male predominance in all reported cases, with only 1 female patient. We interpreted this prevalence as a result of the disproportionate incidences of HCC between males and females . AccordiAs mentioned above, most PMs were asymptomatic. In some earlier reviews, the most common clinical presentation reported among symptomatic PMs was diabetes insipidus (DI) , 4. But Diagnosing PMs remains difficult, especially among patients with unknown malignant diseases . One obsSurgery is still the priority for the management of PMs, serving as a palliative treatment to improve life quality. Endocrinological replacement is necessary for pituitary insufficiency. Other available options include radiotherapy, chemotherapy, and other modalities . DecomprThe prognosis does not depend on the manifestation or the management of metastases . No stat5We presented a rare case of HCC PMs in a 73-year-old man presented with headaches and diplopia. He had hepatitis and HCC history, and recent imaging showed primary cancer recurrence and metastases. Endoscopic excision was performed to alleviate his symptoms and assist diagnosis. Literature review contains 17 documented cases. Consensus about the diagnosis and management is challenging due to the low incidence. Headaches and diplopia are typical initial symptoms. A majority of these patients have known history of HCC or hepatitis infection. Therefore, we recommended taking further examinations with patients who have sudden-onset headaches and previous HCC-related history. Surgical excision is recommended to ameliorate symptoms and improve life quality.Both authors have made substantial contributions to the conception of this work. YC drafted the first version of the manuscript. MF revised the manuscript and provide approval for publication. All authors contributed to the article and approved the submitted version.


Rectal atresia is a rare cause of bowel obstruction in neonates with a normal-appearing anus. We present two different types of rectal atresia requiring different surgical management. Case one was a one-day-old term male with web-type rectal atresia diagnosed preoperatively with bedside obliteration of the web. Subsequent transanal web resection was performed. Case two was a one-day-old male born at 28 weeks weighing 980 g with significant cardiac defects including aortic atresia. The patient underwent initial colostomy creation and delayed rectal anastomosis via posterior sagittal anorectoplasty. We review the published literature, discuss the surgical strategy, and highlight the decision-making of diverting ostomy creation and approach of definitive anorectal anastomosis. Rectal atresia is a rare but possible cause of large bowel obstruction in neonates with a normal-appearing anus. This anorectal malformation, in contrast to others, involves a patent anal orifice at the normal location and normal development of the internal and external anal sphincters ,2. Most Case oneA one-day-old male was born at term weighing 3.1 kg. His prenatal history was unremarkable, and delivery was uncomplicated. He had not passed stool since birth and had increased bilious emesis and abdominal distention. The anus appeared in the normal position with matured gluteal muscle and skin wrinkles, as seen in Figure His genital examination demonstrated well-formed, normal-appearing male genitalia without obvious evidence of a fistula. His urine was clean without contamination from meconium. No catheter traveled more than half an inch through the anal orifice. The echocardiogram, renal ultrasound, and vertebral X-ray were normal without evidence of VACTERL association. The abdominal X-ray depicted multiple dilated bowel loops with an S-shaped dilated loop of bowel traveling downward toward the pelvis representing the sigmoid colon, as depicted in Figure Lower gastrointestinal fluoroscopy showed no contrast passage through the rectum, and the catheter tip met resistance at half an inch from the anal orifice, as seen in Figure The physical examination and image findings were consistent with rectal atresia. After the diagnosis was confirmed, we gently inserted an 8-Fr Salem sump tube through the anal orifice. The tube was pushed through with some resistance, and the meconium started to pass. We suspected that we obliterated a mucosal web, which further solidified the decision to perform an examination under anesthesia in the operating room on the day of life (DOL) five. Operative findings showed that only a lacrimal probe was able to pass through the orifice initially. During a more detailed inspection, a posteriorly placed epithelial band that was partially obstructing the anal opening was identified. The diagnosis of rectal atresia type 1b with a mucosal web was confirmed. The band was divided using electrocautery. Then, the anal orifice was dilated using Hegar dilators, achieving a maximum dilation of up to size 10. Postoperatively, serial anal dilations were continued daily to prevent further adhesion. The patient has been stooling and micturating for one year postoperatively.Case twoA one-day-old male was born at 28 weeks and four days of gestation weighing 980 g by emergency C-section due to multiple gestations, breech presentation, and premature rupture of membranes at an outside hospital. The patient was prenatally diagnosed with congenital heart disease, including aortic atresia. Meconium had not passed since the birth, and abdominal distention was noted on DOL one. The anus was located in the normal position. A feeding tube inserted in the anal canal met resistance at approximately 1.5 cm from the anal opening without passage of the meconium. His abdominal X-ray was relevant for diffuse intestinal and colonic dilation. The patient was diagnosed with rectal atresia, and a sigmoid colostomy was created on DOL one. Postoperatively, the patient was transferred to our hospital for management of his comorbidities, including chronic bronchopulmonary dysplasia with a tracheostomy and congenital cardiac disease including ventricular septal defect, aortic atresia with aortic arch hypoplasia, and hypoplastic left heart syndrome status. After Rastelli’s surgery was completed, a definitive repair of rectal atresia was planned at the age of 10 months when the patient weighed 8.4 kg. His preoperative distal colostogram showed a blind-ended rectum without any evidence of a fistula, as seen in Figure We performed an intraoperative distal colostogram, which demonstrated that the length of the atretic part of the rectum could be approached via a posterior sagittal incision. The decision was made to proceed with PSARP. Operative findings showed an atretic chord measuring several centimeters between the blind end of the anal canal and the blind pouch of the rectum, as described in Figure No fistula was noted between the rectum and urethra. The diagnosis of rectal atresia type III with an intervening fibrous cord was confirmed. The proximal rectal pouch was dissected several centimeters proximally, and the rectal pouch was opened. The anal pouch was opened vertically at the posterior wall and anastomosed circumferentially with the rectum using 4-0 Vicryl interrupted stitches while reconstructing the anal canal, as shown in Figure Rectal atresia has a reported incidence of 0.3-1.2% of all anorectal malformations . It showMost rectal atresia cases have no associated fistula with the urogenital system ; howeverThe published literature was reviewed with a focus on surgical management. All cases underwent surgical intervention. In most case series, initial diverting colostomy creation was performed , and somThere was a notable variance in definitive surgery reported. Most selected procedures included anastomosis, such as PSARP, transanal pull-through, magnetic anastomosis , and traWith the exception of web-type rectal atresias, some procedures accompanied by anastomosis will be required for the other types. If a patient undergoes initial ostomy creation, a distal colostogram will tell us the distance between the proximal rectum and the distal rectal pouch and the existence of the fistula. Radiopaque material such as a Hegar dilator inserted from the anal canal is also helpful. In case two, the intraoperative colostogram showed that the proximal rectum pouch was considered amenable to be approached by PSARP. End-to-end anastomosis was achieved under minimum tension without abdominal dissection. If the colostogram had shown a significant distance between the pouches, we would have changed our approach to a laparoscopic intra-abdominal dissection combined with PSARP/transanal pull-through with resection as the more suitable option. No study has compared PSARP with transanal pull-through for rectal atresia. Shehata et al. reported the advantage of the transanal end-to-end rectoanal anastomosis approach over the PSARP as anatomical anorectal reconstruction under direct visual control is favorable rather than an extensive anorectal dissection or any division of the sphincter musculature with simultaneous closure of the ostomy. However, to achieve tension-free anastomosis, a previous sigmoid colostomy should be positioned properly low. In case two, the ostomy was created at a relatively high position in the sigmoid colon by an outside hospital; therefore, we were inclined to proceed with PSARP rather than the transanal approach. To compare each approach, a longer period of follow-up with a higher number of cases is essential.In this report, we describe two different types of rectal atresia requiring distinct operative approaches. Rectal atresia is a rare cause of bowel obstruction in neonates with a normal-looking anal opening. There is a wide range of surgical strategies, including primary repair versus initial ostomy creation, transanal approach versus PSARP, and delayed reconstruction, which can be tailored based on the distance of the rectal pouches and other comorbid conditions.


Craniopharyngiomas (CPs) are Rathke’s cleft-derived benign tumors originating most commonly in the dorsum sellae and representing 2% of intracranial neoplasms. CPs represent one of the more complex intracranial tumors due to their invasive nature, encasing neurovascular structures of the sellar and parasellar regions, making its resection a major challenge for the neurosurgeon with important postoperative morbidity. Nowadays, an endoscopic endonasal approach (EEA) provides an “easier” way for CPs resection allowing a direct route to the tumor with direct visualization of the surrounding structures, diminishing inadvertent injuries, and providing a better outcome for the patient. In this article, we include a comprehensive description of the EEA technique and nuances in CPs resection, including three illustrated clinical cases. Craniopharyngiomas (CPs) are benign intracranial extra-axial tumors (OMS grade I) that originate from remnants of the Rathke’s cleft, representing 2% of all intracranial neoplasms, with an estimated incidence of 0.17 to 0.2 and prevalence of 4.78 per 100,000 [Surgical management of CPs is challenging because of the vicinity to critical neurovascular structures, demanding a thorough understanding of the anatomy of the suprasellar region. The extension of the tumor in relation to the optic chiasm, pituitary gland and stalk, hypothalamus, carotid artery, and anterior cerebral artery complex is essential for surgical planning. Surgical options include transcranial and endonasal endoscopic approaches (EEA) .EEA provides a direct route to the sellar region, with improved midline exposure without retraction of brain parenchyma and neurovascular structures, obtaining a better visualization. This approach is ideal for lesions without significant lateral growth and retrosellar CPs with suprasellar third ventricular extension ,4.The aim of this study is to familiarize young neurosurgeons with the anatomy of the sellar and suprasellar region, as well as the advantages of EEA in the resection of craniopharyngiomas. This remains paramount as endoscopic resection techniques have become an accessible option for all neurosurgeons, making it necessary to master dissection techniques to preserve critical neurovascular structures when facing CPs.A comprehensive description of the surgical EEA in CPs is deeply analyzed by summarizing the technique and detailing a step-by-step approach based on the senior author’s experience in our hospital. For its comprehensive description, the technique was divided into nasal, sphenoidal, sellar, and closure phases. Three illustrative clinical cases are included.In the operative room, the patient is positioned supine with the head tilted 15 degrees away from the surgeon so the nasal fossae are facing the endoscope’s trajectory. The trunk is elevated 20 to 30 degrees in order to aid venous return. The patient’s head is in neutral position when our target is the sellar region, and extended 10 to 30 degrees or flexed 20 to 40 degrees when the target is located in the anterior fossa or the clival region, respectively. Perioperative steroids (100 mg hydrocortisone) are administered, as well as a single dose of broad-spectrum antibiotics. Topical nasal decongestant is employed in order to reduce nasal bleeding. It is important to consider preparing the abdominal wall and outer thigh in an antiseptic manner since abdominal fat and fascial graft may be used for reconstruction .The EEA is divided into four phases: nasal, sphenoidal, sellar/parasellar, and closure.A 0-degree endoscope is introduced into one nostril to identify the relevant anatomy  . The supThe anterior wall of the sphenoid sinus is enlarged circumferentially, preserving the sphenopalatine artery which is located inferolaterally . The sphA 4 mm diamond burr is preferred to make an initial opening of the pituitary fossa, as the sellar floor can be thin and partially dehiscent because of chronic remodeling by a large intrasellar mass. The durotomy is usually carried out with a sickle or retractable knife in a cruciate fashion, starting in the middle sector and extending it with angled microscissors in a cruciform fashion. After the dura is opened and hemostasis is achieved, exploration of the intrasellar mass depends on the nature of the pathologic process. For a large mass, as CPs, with a cystic and solid component, resection begins in the inferior and lateral portions of the tumor to allow the superior aspect to descend into the surgical field at last. If the superior portion is delivered first, diaphragmatic descent will obscure the operative field. If the tumor has a suprasellar component, the diaphragm can be sharply dissected and incised. Most CPs are soft in consistency and the resection is usually performed with a variety of microdissectors, ringed curettes, and suction cannulas. On the other hand, if the tumor has a harder consistency, it can be removed with the aid of an ultrasonic aspirator. After tumor removal, exploration of the surgical field with the 0-degree or 30-degree endoscope is mandatory to look for any residual tumor .In case of a CSF leak, there are two well-described techniques: the gasket seal and the multilayered technique. The gasket seal method consists in placing a piece of allograft dural substitute over the bony defect so that its dimensions exceed that of the defect by at least 1 cm circumferentially. A rigid implant cut to fit the opening is then placed over the dural substitute and counter-sunk within the bony defect ,13. The A 24-year-old man with a previous history of incomplete transcranial resection of a CP was admitted to the emergency department with a 3-month history of progressive visual loss, nausea, and vomiting. Neurological examination revealed a Glasgow Coma Scale of 14, pupils of 4 mm with poor light response, and no motor or peripheral sensory deficits. Endocrinological examination was relevant only for central hypothyroidism. An MRI was performed , revealiA 34-year-old woman with complaints of headache and bilateral loss of visual acuity in the last year, presented to our emergency department due to acute onset of gait disturbance and sleepiness. Upon arrival, an urgent CT scan was performed, revealing an isodense mass in the sellar and suprasellar region with calcifications, conditioning obstructive hydrocephalus. An emergent ventriculoperitoneal shunt was placed. Endocrinological testing revealed low levels of thyroid-stimulating hormone, cortisol, and free thyroxine, so hormonal replacement therapy was initiated before surgical treatment was deemed safe. Brain MRI revealed a hypo and hyper-intense lesion on T1 and T2-weighted MRI, respectively, compatible with a cystic lesion located in the sellar region and extending upward into the third ventricle with brainstem displacement . The patA 19-year-old man was referred to our hospital for endocrinological evaluation due to delayed pubertal development. Hormonal tests were performed revealing low testosterone, thyroxine, and cortisol levels. The patient reported a 2-month history of asthenia, polyuria, polydipsia, and blurred vision. Neurological examination was relevant for decreased bilateral visual acuity and bitemporal hemianopsia. Brain MRI revealed a sellar and suprasellar hypointense lesion on T1W, mixed iso and hyperintense lesion on T2W and FLAIR, and heterogeneous enhancement on postcontrast sequence, suggestive of a cystic lesion with a solid sellar component . The patCPs represent quite challenging lesions that require multidisciplinary management. What has been theorized and later proven to be the advantage of the extended endonasal endoscopic approach (EEEA) for resection of CPs is that gross total resection (GTR) is more achievable with this technique, having ranges of up to 70% in some series ,15,16. OOne of the key considerations for surgeons in their learning curve is to divide the invasion of the tumor into infra and supra diaphragmatic compartments. Originally, only tumors in the infradiaphragmatic compartment were removed with the EEA but, as more experience was obtained, the supradiaphragmatic lesions started to be treated this way . Doing aUnderstanding each stage during the endonasal approach is essential for the young neurosurgeon. The nasal stage is usually performed by an ENT surgeon in most centers, although the anatomical knowledge and technique mastering is a great ability to achieve as a neurosurgeon. CSF leak is one of the most prevalent complications of these approaches and, historically, the use of nasoseptal flap (NSF) had proven to reduce CSF leak rates in all kinds of endonasal approaches ,23.For lesions extending to the suprasellar compartment, we must try to harvest an NSF from the beginning of the nasal step. This NSF is usually harvested from the side which will undergo less manipulation depending on the lateral invasion of the tumor. As we mentioned, the NSF is a crucial step in the prevention of CSF leak and meningitis hence for its correct realization technique must be well understood and dominated by the surgeon ,24.During the sphenoidal phase, widening the opening on the sphenoid rostrum is an advisable behavior with the goal to attain freedom of movement in the field with the tools. This will strongly depend on the sinus pneumatization but should not be a limitation to accomplishing a sufficient opening and a comfortable setup. Anatomical knowledge plays a crucial role and landmark identification will consist the main goal of the sinus stage in which the visualization of the sella turcica, tuberculum sellae, planum sphenoidale, and other landmarks, gives the surgeon the confidence and safety needed to continue with the approach . Some leIn the sellar stage, opening the sella turcica is usually done with a high-speed drill to thin the bone and after making a small opening, the use of angled dissectors may constitute a safe way to continue with the already thinned bone removal. Approaching the lateral limits of the boney opening, rongeurs are usually used taking special care to remove these portions with small bites avoiding the use of excessive force, further drilling may be used to thin the bone and see through the structures behind these lateral portions of the bone removal. The visualization of the anterior compartment of the cavernous sinus should be the goal permitting early coagulation but this can be tailored for each specific tumor invasion .The goal is to find a safe and direct route to the tumor. Usually, the tumor is not adherent in its whole circumference and classical CPs show most adherent parts in the hypothalamus, which is to be expected when taking into consideration the origin of the lesion. Even when preoperative hypothalamic disfunction exists by tumor compression, this part of the lesion should be always evaluated with direct sight of the adherences, and should be dissected when possible, either bluntly or preferably sharply, since sharp dissection needs the least amount of traction to bring the lesion into the field. Sometimes, it is preferable to leave a small tumor capsule cuff when none of these techniques can be performed in a safe manner. This point can be debatable as some authors prefer to reach GTR if any preoperative sign of hypothalamic involvement exists .Retracting or manipulating the tumor is thought to be a risky maneuver but it is nonetheless unavoidable in some instances, when this situation is presented, it is advisable to never pull the tumor without pushing the tissue you are trying to separate it from. This creates a pivot point that is usually in the field and on sight, rather than a blind spot that can be an important structure . We usually call this maneuver traction–countertraction.It has been proposed in the literature a useful classification for endoscopic endonasal surgery according to the degree of technical complexity, taking into account two main factors: the affected compartment  and the pathology in question, as shown in Accordingly, young neurosurgeons must keep in mind that these approaches require a steep learning curve, which may be associated with an increase in complication rates as the surgeon obtains experience. Therefore, to minimize surgical morbidity, it is highly advised to acquire surgical experience and technical competency from less complex pathologies in a step-by-step fashion before proceeding to the most technically demanding ones ,28. As pA suggested strategy is to first acquire experience with intrasellar and intra-suprasellar lesions before moving to more complex procedures such as suprasellar craniopharyngiomas (Category C), often requiring an extended approach, intradural tumor dissection and exposure of neurovascular structures. Additionally, the importance of laboratory training with anatomical models and cadaveric dissections cannot be over-emphasized, as well as assisting/observing experienced surgeons before attempting these procedures. Finally, it is essential for young neurosurgeons to recognize their limitations and to not hesitate in performing a transcranial approach when the case complexity is beyond their endoscopic capabilities ,28.CPs continue to be a high-complexity intracranial pathology despite advances in neurosurgery, nevertheless as EEAs evolve this technique offers greater advantages over the conventional transcranial approaches, allowing a better visualization of the tumor and its relationships with neurovascular structures surrounding it, thus contributing to achieve a GTR whenever possible. A comprehensive knowledge of this technique and its nuances, in conjunction with intensive laboratory training, is fundamental for young neurosurgeons who aim to perform these approaches. Finally, it should be noted that these approaches require a long learning curve, hence, the acquisition of surgical skills and experience from less complex cases is imperative before moving to the most challenging ones, and should be recognized that some cases may be better managed transcranially if the surgeon feels more comfortable and experienced with this approach.