Fibrosarcoma is a rare malignant tumor comprising spindle-shaped fibroblasts exhibiting variable collagen production. Adult-type fibrosarcoma (AFS) mainly occurs in people aged between 30 and 80 years, primarily in the deep soft tissues of the trunk, neck, and extremities, especially in areas surrounding bones. Juvenile fibrosarcoma(JFS) is a type of AFS that occurs in adolescents and rarely develops in the abdominal cavity.A 13-year-old girl presented with right upper quadrant pain for 5 days. Abdomen and pelvis computed tomography showed a 12 × 6-cm, ill-defined, lobulated, solid, cystic mass in the abdominal cavity. On laparoscopy, there were two masses in the abdominal cavity. One abutted the stomach and severely adhered to the gallbladder. The second mass was located between the transverse colon and duodenum, and it was surrounded by the omentum. The tissues surrounding the masses were finely dissected, and the two masses were excised completely. The patient was discharged without complications on post-operative day 7.JFS, AFS in adolescents, is a rare malignant tumor. And there have been no reported cases of multiple JFS in abdominal cavity. Surgical excision is the gold standard of treatment for localized AFS, and the laparoscopic approach for minimal tumor handling is beneficial.We describe a rare case of multiple intra-abdominal juvenile fibrosarcoma, managed through laparoscopic surgery. •Fibrosarcoma is a rare malignant tumor composed of spindle-shaped fibroblasts with variable collagen production.•Juvenile fibrosarcoma(JFS) is a type of AFS occurring in adolescents, and it rarely develops in the abdominal cavity.•Curative surgical excision is the gold standard treatment for localized fibrosarcoma, and laparoscopic approach is benefitial. Her laboratory results were unremarkable. Contrast-enhanced abdomen and pelvis computed tomography showed a 12 × 6 cm, ill-defined, lobulated, solid, cystic mass in the abdominal cavity. The mass was located at the right side of the greater omentum, abutting the inferior aspect of the left liver, gallbladder, and the duodenal bulb and its second portion. The fat plane was preserved  of Chungbuk National University Hospital, South Korea (IRB No 2021–07-008).Written informed consent was obtained from a parent for the participant under 18 years old for publication of this article and any accompanying tables/images. A copy of the written consent is available for review by the Editor of this journal.Conceptualization: Hanlim Choi, Dong Hee Ryu.Data curation: Hanlim Choi, Chang Gok Woo, KangHe XU.Investigation: Hanlim Choi, Jin Young Lee.Supervision: Jae-Woon Choi, Dong Hee Ryu.Writing – original draft: Hanlim Choi.Writing – review & editing: Hanlim Choi, Jin Young Lee, Dong Hee Ryu.Not applicable.Dong Hee Ryu.Not commissioned, externally peer-reviewed.The authors declare that they have no competing interests.


Staphylococcus aureus (MRSA). The patient had no significant past history and presented to our clinic reporting a two-week history of lower abdominal pain, foul-smelling urethral discharge, a burning sensation during urination with pain in the tip of his penis, and itchiness around the anus. On examination, we noted lower abdominal tenderness, and on per rectal examination, we noted tenderness in the anterior wall of the rectum. A culture from the urethral discharge was positive for MRSA. The patient was diagnosed with a prostatic abscess and was started on antibiotics. We performed ultrasound-guided transrectal drainage, and afterward, the patient’s condition improved. He was doing well on the last follow-up. This case reminds physicians to consider prostatic abscesses in patients with lower urinary tract infections that do not respond to antibiotics.While prostatic abscesses infrequently occur in adults, they are extremely rare in children. We present a rare case of a prostatic abscess in a 13-year-old male patient caused by methicillin-resistant  Staphylococcus aureus (MRSA) have been documented in the literature. Staphylococcus aureus is a rare cause of prostatic abscess, and gonorrhea was the most common etiology prior to using antibiotic medications. However, with the advantages of antibiotic use, Gram-negative bacteria are the most common organisms causing prostatic abscesses and are responsible for 60%-80% of cases [A prostatic abscess is a rare condition, especially in the pediatric population. Very few cases of pediatric prostatic abscess attributed to methicillin-resistant of cases . Surgicaof cases .A 13-year-old male with no previous medical history presented to our clinic reporting a lower abdominal pain lasting two weeks. He also reported experiencing a foul-smelling urethral discharge and burning sensation on urination, with pain at the tip of his penis. He had no history of fever, sexual activity, hematuria, or back pain, and he mentioned itchiness around his anus. we noted he had visited the emergency department one week prior with the same reported concerns. On examination, the patient looked well, his vitals were stable, and he is afebrile, with normal activity and interactions. An examination of his lower abdomen revealed abdominal tenderness, and a rectal examination revealed tenderness in the anterior wall of the rectum. His scrotum examination revealed Tanner stage 5 anatomy with no other remarkable findings.His initial laboratory workup results were within the reference ranges, chlamydia and gonorrhea were negative, and his serology tests for human immunodeficiency virus, hepatitis B virus, and hepatitis C virus were nonreactive. The second and third urine cultures showed no growth, and his blood culture showed no growth. The urethral discharge sample culture was positive for MRSA. The patient was admitted to the pediatric department as a case of urinary tract infection, and we started him on ceftriaxone and clindamycin to rule out any sexually transmitted diseases.We conducted ultrasonography for the kidney and bladder and incidentally noted a small amount of free fluid in the pelvis. We also noted a well-defined, thick-walled hypoechoic lesion posterior to the urinary bladder measuring 5.3 × 3.7 cm Figure .A computed tomography (CT) showed evidence of a multilocular and septated prostatic cystic lesion measuring approximately 5 × 4 × 3 cm, which could be a cystadenoma or prostatic abscess to be confirmed by a histopathological examination (Figure We performed an ultrasound-guided aspiration that released bloody pus. A cytology investigation showed mostly neutrophils with no malignant cells. The prostatic abscess diagnosis was confirmed. The patient was kept on ceftriaxone and clindamycin antibiotics. He improved gradually but started to have bloody discharge from the urethra even with the improvement of other symptoms. Later, however, all his symptoms improved, and he was doing well as of this writing.The diagnosis of a prostatic abscess is often challenging, and persistent symptoms despite antibiotic treatment should raise suspicions for this condition .The symptoms overlap with symptoms of other lower urinary tract diseases, and prostatic abscesses are often diagnosed after patients’ conditions are unresponsive to initial medical treatment. Rectal examination is not routine for the pediatric age group, although rectal examinations can lead to a correct diagnosis. The presence of urethral discharge, common urinary symptoms, and unresponsiveness to antibiotic treatment should point clinicians to the possibility of a prostatic abscess .Escherichia coli and other Gram-negative bacteria - very rarely is it caused by Staphylococcus aureus [Fistulation to the surrounding pelvic structures may complicate prostatic abscesses. Abscesses located at the base of the prostate gland commonly fistulate to the bladder, prostatic urethra, or rectal or perianal spaces. Severe cases of a prostatic abscess may extend into the seminal vesicle and spermatic cord . Early ds aureus ,7. Repors aureus -10. PatiA prostatic abscess can be a diagnostic and therapeutic challenge. We discussed a rare case of prostatic abscess secondary to MRSA infection in a 13-year-old male. Our case highlights the importance of considering prostatic abscess as the cause of urinary tract symptoms and the importance of rectal examination in any patient with lower urinary tract symptoms - especially in patients with urethral discharge or those who do not respond to antibiotic treatment.


She was delivered for severe oligohydramnios. After delivery, she was found to have a left adrenal infarction on computed tomography scan. She was found to have two mutations of the gene MTHFR 677CC. Our presented case should remind physicians to consider the presence of thromboembolic state during pregnancy. The diagnosis of adrenal infarction should be among the differentials of an ambiguous flank pain that is resilient to medical therapy. Diagnosis in a pregnant patient can be easily confirmed with MRI, after which anticoagulation should be started and the workup for hypercoagulable state investigated.Abdominal pain is the most presenting complaint during pregnancy with multiple etiologies. The diagnosis could be unpredictable. We present a case of 36-year-old pregnant woman  MTHFR 677CC. The patient was started on anticoagulation therapy to prevent right adrenal thrombosis. She received treatment by anticoagulation for 1 week and was discharged on prophylactic dose for 6 months.A 36-year-old pregnant woman during her tenth pregnancy, known to have seven previous normal vaginal deliveries, presented at 36 weeks and 5 days of her gestational age with increasing left flank pain. She was found to have a left adrenal gland infarction on computed tomography scan after delivery. She has no previous medical history. There was no evidence of adrenal insufficiency during pregnancy. Evaluation for hypercoagulable state showed two mutations in  Abdominal pain is the most common chief complaint during pregnancy. It is a routine priority to rule out uterine contractions by nonstress test in pregnant women complaining of flank pain, low back pain or pelvic pain. However, if labor pain is excluded, what else can be added to the differentials of flank pain during pregnancy and what are the best testing modalities?During pregnancy, identifying the cause of pain seems to be more challenging due to the physiologic changes that can affect some laboratory results and due to some restrictions in testing and even interventions. Eventually, the goal is to exclude serious or even life-threatening etiologies by reaching a prompt diagnosis and treatment, otherwise unnecessary delay will risk increasing maternal, fetal or newborn morbidity and mortality.In this article, we will present a very rare cause of pain with an atypical presentation during the late weeks of pregnancy. The diagnosis was only made in the postpartum period when the symptom did not improve but even worsened. The challenging diagnosis was a nonhemorrhagic left adrenal infarction.gravida 10 para 7 abortus 2 at 36 + 5 weeks of gestational age, presented for two consecutive days complaining of an increasing new onset of acute left upper quadrant pain. The pain was constant with intermittent worsening in her left upper quadrant and radiating to her left flank. During this gestation, she reported a previous presentation for abdominal pain with nausea lasting for 1 week. Those symptoms were associated with gastritis because no other cause was found.A 36-year-old woman The patient initially presented to the hospital for an increasing pain that was believed to be due to fetal movements or uterine contractions. She was given antispasmodics. However, the pain intensified which was the reason for her to seek medical advice again. She did not complain of any nausea or vomiting, nor decrease in appetite but she had 2 days of constipation. The patient’s medical history was unremarkable. Her obstetrical history included two spontaneous pregnancy losses that needed dilation and curettage at first trimester. She also had previous seven uncomplicated vaginal deliveries.2 was 100%, respiratory rate was 20.On presentation to the hospital, her blood pressure was 110/70 mmHg, her pulse was 84 beats per min, temperature was 36.9°C, saturation of OOn physical examination, the patient appeared uncomfortable and agitated.Her abdomen was soft; the uterus was gravid with no fundal tenderness. Bowel sounds were present and normal. There was moderate tenderness on the left upper quadrant under the rib cage with mild rebound. She also had costovertebral angle tenderness on the left side. The patient was admitted to the delivery suite and initially was started on intravenous fluid hydration, proton pump inhibitor and analgesia. This provided minimal relief to the patient. Nonstress test monitoring was done at this time also showing reassuring reactivity of the fetal heart rate with no contractions.Several differential diagnoses are to be noted: renal colic, mesenteric infarction, splenic vein thrombosis, pregnancy associated pain, pancreatitis and spleen associated pain.A complete set of laboratory tests were done and were unremarkable except for microcytic anemia hemoglobin was 8.9 g/dl and hematocrit was 29%. She had normal liver enzymes, pancreatic enzymes and creatinine.An abdominopelvic ultrasound was performed which showed oligohydramnios and sludge in the gallbladder. The appendix was not visualized, no gallstones, no biliary ducts dilation, no hydronephrosis. Doppler of the splenic vessels was not done, although splenic vein thrombosis was one of the differential diagnoses.At this time induction of labor was decided due to oligohydramnios. The patient delivered a live born boy APGAR score 9 and 10 at 1 and 5 min weighing 3040 grams.In postpartum period, the pain persisted and; therefore, surgical consultation recommended CT scan of the abdomen with contrast to rule out pancreatitis and splenic vein thrombosis. Subsequently the CT scan revealed left adrenal gland with decreased enhancement and adjacent inflammatory changes suggestive of an infarct. Right adrenal gland was normal. Normal appearing appendix, no anomalous vasculature was seen and MRI study was unlikely to add any more information; therefore, was not done.Cortisol level and adrenocoticotropic hormone level were obtained to assess for adrenal insufficiency. The hemato-oncologist was consulted to workup the thrombophilia disorders that included testing for factor V Leiden, prothrombin mutation and MTHFR as well as antiphospholipid panel, protein C and S, antithrombin 3, factor II, factor XIII, plasminogen activator inhibitor-1 mutation and annexin A5 antibodies.There was no adrenal insufficiency and thrombophilia workup showed MTHFR C677T homozygous mutation and HPA1 1a/1b heterozygous mutation. The results of workup of coagulopathies, adrenal insufficiency as well as thrombophilia disorders are shown in  & 2, resAnticoagulation with low molecular weight heparin (LMWH) 40 mg subcutaneously (sc.) once daily was initiated to reduce the risk of another infarct in the contralateral adrenal gland. After 2 days, she was started on therapeutic dose LMWH 60 mg sc. for 1 week.After 4 days the patient was discharged home for outpatient postpartum care on prophylactic LMWH for 6 months.  & 2.During the 6 months follow-up, the patient did not have any complaints and was clinically and hemodynamically stable. She had to continue iron supplements because of her iron deficiency anemia. A timeline can be seen in Nonhemorrhagic adrenal infarction (NHAI) is a very rare diagnosis with only a few reported cases during pregnancy . We haveAdrenal infarction can present with abdominal pain, nausea and vomiting as well as electrolytes disturbances. The adrenal glands are endocrine glands located in the retroperitoneum just above the kidneys and are responsible for secreting hormones in response to stress and releasing androgens.The adrenal gland has rich blood supply via three main arteries: the superior adrenal artery arising from the inferior phrenic artery, the middle artery from the abdominal aorta and the inferior adrenal from the renal artery. However, the venous blood draining the glands by the right and left adrenal veins only. The right adrenal vein drains into the inferior vena cava whereas the left adrenal vein drains into the left renal vein.Therefore, altered venous drainage with increased arterial blood flow can lead to adrenal blood stasis and infarction. The localization of the thrombi in adrenal vein might result in local stasis of blood leading to edema and necrosis of the gland in hypercoagulable states.The case we are presenting in this article highlights two important issues. First, despite that adrenal infarction is a very rare diagnosis, it should be taken into consideration as one of the differential diagnoses when a pregnant woman presents for acute severe abdominal pain. Second, once a diagnosis of NHAI is established clinically and radiologically, we should search for a thrombophilic and hypercoagulable state.A small number of cases of NHAI has been reported. Nine cases of unilateral NHAI during pregnancy have been published in the literature. All cases have similar presentation: severe unremitting acute abdominal pain, resisting usual analgesia with other clinical signs that are mild and not specific. Ultrasound imaging is usually not conclusive and diagnosis was definitive by CT scan or MRI. Most of these patients received anticoagulation as therapy and prophylaxis from the contralateral gland thrombosis. As of now, the role of therapeutic dose of anticoagulation has not been proven to be efficient and; therefore, prophylactic dose is usually given in this situation to prevent any further events.et al. and Sormunen-Harju et al. [In two cases of Green u et al. ,5, both u et al.  was assou et al. .The interesting part is that all nine cases involved the right adrenal gland while in our case, the left adrenal gland was the infarcted one. We also know that the main involvement of the right adrenal vein could be explained by its anatomical location with respect to that of the vena cava taking into account that the return of venous blood can be impaired by dextroverted gravid uterus leading to adrenal blood stasis. In other rare cases, when the ischemia is bilateral, adrenal insufficiency can occur.Literature supports evaluation with CT or MRI to make a diagnosis of suspected adrenal infarction or hemorrhage . The golOnce the diagnosis is made, prophylactic anticoagulation should be initiated as by the recommendations to prevent contralateral adrenal gland infarction.The risk of anticoagulation should be considered especially in the presence of hemorrhage or if the infarct occurred before delivery; we should take into consideration the potential complications with regional anesthesia or bleeding related to vaginal or cesarean delivery.The mechanism of spontaneous adrenal infarction is different from that of hemorrhage due to trauma, underlying tumor or systemic infection as seen in Waterhouse–Friderichsen syndrome associated with meningococcemia.The features described on MRI  also correlate with previous literature describing the CT appearance of adrenal infarction .In our patient, the presumed diagnosis of nonhemorrhagic adrenal infarction was supported by clinical presentation, laterality of symptoms matching the abnormal adrenal appearance on CT scan and absence of another pathological entity explaining the presentation.Therefore, the diagnosis of adrenal infarction should be suspected clinically in pregnant patients with unilateral abdominal or flank pain which is often severe, associated with nausea and vomiting like in our patient. Upon physical examination, presence of tenderness localized to the symptomatic area is noted but without peritoneal signs although sometimes it may be unremarkable.Our patient did not have adrenal insufficiency signs or symptoms. Therefore, a diagnosis of adrenal infarct during pregnancy is challenging. To diagnose an adrenal infarction, a great degree of clinical suspicion is required.During normal pregnancy, maternal adrenal glands will undergo changes. The cortisol physiology results in both total and free cortisol concentrations rising throughout the gestation. The increased estrogen in pregnancy stimulates corticosteroid-binding globulin level and; therefore, decreases free cortisol levels. As pregnancy progresses, an increase in pituitary adrenocorticotropic hormone production and an increase in free cortisol levels will result in an equal and striking rise into the third trimester.Treatment of adrenal infarction in pregnancy is based on narcotics for pain control, hematologic evaluation and anticoagulation therapy; however, some physicians have advocated conservative management without anticoagulation. There are insufficient long-term outcomes or understandings of the pathophysiology of the necrosis; therefore, it is difficult to favor either management approach.The foremost limitation of our case is that the etiology of infarction was not very well established because the only finding was homozygous C677T mutation of the MTHFR gene. On the other hand, optimal treatment of patients with NHAI with or without anticoagulation remains to be determined and should be decided on patient-by-patient basis by means of hematologic evaluation .During pregnancy, one of the most common chief complaints are abdominal and pelvic pain. Multiple differential diagnoses could be related to these complaints. One of the very rare ones is adrenal infarction. We report a case of NHAI in a multigravida patient during the beginning of her term and the approach for the diagnosis and the management; although, it is still not very well known what the best management is for long-term outcomes and what the real etiology of this disease is. Further cases should be recognized and more investigations should be done in order not to miss diagnosis as it might be life-threatening.The case has been reported with the CARE guidelines for case reporting.The diagnosis of adrenal infarction should be considered in pregnant patients presenting for acute unilateral abdominal or flank pain. This pain is often severe and accompanied by other symptoms such as nausea and vomiting and even labor pain. Pregnancy alone is a risk factor for thromboembolism. The diagnosis should also be under more suspicion in patients with known risk factors for thrombosis. If not known, more investigations should be done for the patient for coagulopathies and thrombophilias and adrenal insufficiency should be ruled out. An MRI should be the gold standard imaging during pregnancy and should be ordered when the cause of pain is not well established. Treatment with a therapeutic dose of anticoagulation might lead to better outcomes and might heal the infarcted adrenal gland. Meanwhile prophylactic anticoagulation should be given if there is still no evidence of the therapeutic effect of anticoagulation on long-term outcomes and recovery of the infarcted gland.Abdominal pain during pregnancy has multiple etiologies and it is sometimes difficult to predict the diagnosis.Nonhemorrhagic adrenal infarction is one of the very rare diagnosis causing abdominal and flank pain during pregnancy.The etiology of nonhemorrhagic adrenal infarction is not very well established. Most of the cases reported suggests that it is a due to coagulopathy. Therefore, a workup of coagulopathy and thrombophilic disorders should be done.Treatment, although not very clear, is with anticoagulation to avoid infarct of the contralateral adrenal gland.


Subependymomas are rare yet benign tumors that are commonly found within the ventricular system. We describe the case of a 51-year-old male presenting with hydrocephalus and progressive headaches found to have a right cerebellopontine angle (CPA) lesion encasing multiple blood vessels and cranial nerves (CN). The lesion was resected subtotally via a retrosigmoid approach and was found to be a subependymoma. CPA subependymomas are extremely rare lesions. The neuroimaging and histopathological findings as well as a comprehensive literature review of similar cases are discussed. Intracranial subependymomas are rare, slow-growing tumors that are typically found in the fourth ventricle, followed by the lateral ventricles . Many arMicroscopically, subependymomas consist of clusters of nuclei with coarse fibrillar matrices and lobular architecture, with microcysts being a defining MR feature ,7. In soA review of the literature suggests that extraventricular subependymomas are extremely rare . Here, wClinical history and examinationA 51-year-old male presented with a history of several months of progressively worsening headaches, visual disturbances, and gait imbalance. Physical examination revealed papilledema and poor tandem gait. A CT scan was obtained Figure , which sNeuroimaging findingsAs previously discussed, preoperatively, a coronal and axial CT were obtained, which revealed obstructive hydrocephalus in the lateral ventricles Figure . Brain MSurgical procedureThe operation was performed via a right retrosigmoid approach. During debulking, it was noted that the tumor had a slightly unusual consistency, not typical for a schwannoma. A quick frozen section pathology was requested and revealed some ependymal-type cells not consistent with a schwannoma or a meningioma. After further debulking, multiple blood vessels were seen to be exiting the tumor, which was also quite unusual. Moreover, the tumor was found to encase CN VII, X, and XII. Due to this anatomy, a decision was made to perform a subtotal resection; the tumor between the vertebral artery, basilar artery, posterior inferior cerebellar artery, and brainstem, where perforators would be penetrating the tumor to get to the brainstem, was left behind.CN VII motor evoked potentials changed slightly in morphology but maintained good amplitudes. The brainstem auditory evoked responses decreased during the procedure but recovered close to baseline by the end. The monitoring for the other nerves and brainstem remained unchanged throughout the procedure.Histopathological findingsThe tumor was received fresh from the operating room and subsequently fixed in formalin and embedded in paraffin. Routine hematoxylin and eosin (H&E)-stained sections revealed classic features of a subependymoma. The sections show a paucicellular tumor composed of small clusters of glial cells embedded in a dense fibrillar network Figure . The tumMethodsA thorough search of the literature available on PubMed, Ovid MEDLINE, and EMBASE databases was conducted for case reports of CPA subependymomas. This was completed by including a combination of the following MeSH terms: “Brain Neoplasms/,” “Cerebellopontine Angle/,” “Glioma, Subependymal/,” and “Neuroma, Acoustic/.” The search resulted in a total of 22 case reports. After removing duplicates and several other reports for either not being reported in English, being pediatric cases, or lacking information, four case reports of CPA subependymomas were reviewed and summarized in Table Subependymomas are rare, benign tumors that are typically detected at 39-59 years of age in adults and males in 72% ,10,12. DAfter a thorough review of the literature found on PubMed, Ovid MEDLINE, and EMBASE, four adult case reports were included and summarized, including the one we presently report, a 51-year-old male with a significant right low CPA subependymoma (Table According to the literature, the histogenesis of subependymomas remains unclear. Different authors have proposed their origin to be from the development of subependymal glial precursor cells, astrocytes of the subependymal plate, ependymal cells, or a mixed type of astrocytic and ependymal cells ,10,12. TSurgical treatment is typically indicated for cases of symptomatic subependymomas. In fact, complete resection, when possible, is often curative and favored as subependymomas are benign, indolent, and non-infiltrative . HoweverIn conclusion, we report a relatively rare case of a right CPA subependymoma encasing multiple cranial nerves and blood vessels that was resected subtotally via a right retrosigmoid approach. Although very unlikely, a lesion exclusive to the CPA without ventricular involvement should not exclude subependymoma from the differential diagnosis. In fact, it is vital for the purposes of planning the operation to have a preoperative suspicion of subependymoma. Furthermore, to resect the mass in a subtotal fashion may be an appropriate choice, as prognosis seems to be independent of the extent of resection.


Osteosarcoma is a malignant tumor in which the cancerous cells produce an osteoid matrix or mineralized bone. Jaw bones are affected in 6% of all osteosarcomas and are the fourth most common site of origin. Surgical treatment of osteosarcoma in elderly patients is rarely reported. Here, we report successful treatment of osteosarcoma arising in the mandible of a 90-year-old man. The patient was referred to our institution for diagnosis and treatment of an oral lesion. Intraoral examination revealed that a hard mass measuring 35 × 27 mm was located on the floor of the oral cavity, attached to the bone, and its growth displaced the tongue posteriorly. Therefore, he experienced difficulty in speech and swallowing. Biopsy of the mandibular mass was suspicious for chondrosarcoma. Preoperative examination did not detect critical risks for general anesthesia or surgery. Based on a clinical diagnosis of a malignant bone tumor of the mandible, segmental mandibular resection with reconstruction using a titanium plate was performed. Surgical site infection occurred on postoperative day 12, which was resolved by drainage, local irrigation, and administration of antibiotics. There was no delirium or cardiovascular or pulmonary complications. Surgery resolved the patient's difficulties in speech and swallowing. There was no evidence of tumor recurrence or metastasis 4 years after surgery. This case showed that it was not necessary to exclude surgical treatment merely because the patient was 90 years old. Indications for surgery should be determined individually to improve the patient's quality of life. Osteosarcoma is a malignant tumor in which the cancerous cells produce an osteoid matrix or mineralized bone . Jaw bonA 90-year-old man was referred to our institution in May 2017 for diagnosis and treatment of an oral lesion. He had first noticed the lesion approximately 1 year earlier. The lesion grew gradually and showed rapid enlargement in the last 6 months. The patient's medical history included atrial fibrillation treated with warfarin, hyperlipidemia, resected rectal cancer, and internal carotid artery stenosis treated by carotid endarterectomy. All of these conditions were followed up and controlled by the patient's physicians. He had smoked cigarettes from age 23 to 48 years, resulting in a Brinkman index of 3,000. His family history was unremarkable. Intraoral examination revealed that a hard mass measuring 35 × 27 mm was located on the floor of the oral cavity and attached to the bone. The overlying oral mucosa was partially ulcerated. The growth of the mass displaced the tongue posteriorly, resulting in a Mallampati score of IV ; therefoSurgery in the oldest patients has various complications, including cardiovascular and pulmonary complications, surgical site infection, and delirium. The cardiovascular risk index is a newly proposed method for preoperative cardiovascular evaluation . The indOsteosarcoma is also a common secondary malignancy following radiotherapy of a primary malignant tumor . In the


Racemose and intraventricular neurocysticercosis are uncommon types of neurocysticercosis, resulting in a multiloculated, grape-like cluster appearance in the cerebrospinal fluid (CSF) spaces. A male patient presented with symptoms of raised intracranial pressure and demonstrated racemose neurocysticercosis at an atypical location involving the region of the crus of the fornix at the level of the body of lateral ventricles on magnetic resonance imaging. Associated intraventricular neurocysticercosis was seen in the atrium of the left lateral ventricle and fourth ventricle. It is more prevalent in Latin America, Asia and Africa. It can affect the brain parenchyma, subarachnoid spaces and ventricles. In racemose neurocysticercosis, cysticerci are located in basal cisterns, subarachnoid spaces and ventricles producing multiloculated cystic lesions with mass effect and a surrounding inflammatory reaction.A 34-year male presented with a history of gradually progressive headache, nausea, vomiting and dizziness for 15 days. There was no history of seizures or visual symptoms and neurological examination did not reveal any focal neurological deficits or signs of meningitis.Initially, a non-contrast CT scan was performed, which revealed moderate dilatation of both lateral ventricles, as well as the third and fourth ventricles with a few cystic lesions in the forniceal region. No calcified lesions were appreciated at CT imaging.For further evaluation, MRI with contrast was acquired using a 3 tesla (T) magnetic resonance (MR) scanner at our institute. Magnetic resonance imaging revealed multiple small clustered thin-walled cystic lesions in the region of crus of fornix at the level of the body of lateral ventricles. The lesions were hypointense on T1 weighted imaging (WI), hyperintense on T2WI and revealed suppression on fluid attenuated inversion recovery (FLAIR) sequence images. No post-contrast enhancement of the cyst wall was seen. Surrounding parenchymal T2 and FLAIR hyperintensity was observed . MultiplBased on these MRI findings, a presumptive diagnosis of racemose and intraventricular neurocysticercosis with obstructive hydrocephalus was made. Differentials considered were ependymal cyst, choroid plexus cyst and colloid cyst. The possibility of an intraventricular neurocysticercosis cyst or post-inflammatory membrane was considered for the fourth ventricle lesion causing upstream obstruction. The patient underwent right ventriculoperitoneal shunting. Cerebrospinal fluid (CSF) was evaluated with enzyme-linked immunoassay (ELISA) was positive for neurocysticercosis. The patient was treated with albendazole and steroids and follow-up imaging was advised.6Neurocysticercosis is endemic in many developing countries, especially in Latin America, South-east Asia, the Indian subcontinent and sub-Saharan Africa. With increasing immigration and travel, the incidence of neurocysticercosis is also growing in developed countries. True disease prevalence is not well known because of the scarcity of case notification systems, systematic population studies and the absence of a gold standard test for screening and detection of asymptomatic disease. Data from different studies have shown that the prevalence of human taeniasis varies from 2.5% to 8.0% in India and the disease burden of neurocysticercosis causing active epilepsy is about one per 1000 population.8 Neurocysticercosis is classified based on its location, namely subarachnoid-cisternal space, parenchymal, ventricles, spinal and mixed form.8 These different forms may also co-exist. Parenchymal is the most common location where it can be seen in any of the four stages, namely vesicular, colloid vesicular, granular nodular and nodular calcified.8Neurocysticercosis is a parasitic disease caused by Taenia solium. Humans are the only known definitive host for the organism and neurocysticercosis occurs when the human acts as an intermediate host after ingestion of its egg present in food contaminated with faeces of the tapeworm carrier. No inflammatory response is elicited when the cyst wall is intact, but when the parasite dies, then cyst contents are released, causing oedema and surrounding inflammatory changes.9 Racemose neurocysticercosis is a type of extra-parenchymal neurocysticercosis characterised by the rapid growth of cyst walls forming grape-like clusters associated with degenerating scolices.Cysticerci can reach the ventricles through the choroid plexus, moving freely within the ventricles or attaching to the ependyma. From the ventricles, it can travel to the basal cisterns, cerebral and spinal subarachnoid spaces and become lodged in these regions. The most common site of intraventricular neurocysticercosis is the fourth ventricle, followed by the third ventricle, lateral ventricle and cerebral aqueduct, respectively.10 In different studies, the presence of the racemose variant is reported in 15.0% – 54.0% of patients.1 A study by Sierra et al., evaluated 125 extra parenchymal neurocysticercosis cases in which 51.6% were in basal subarachnoid cisterns, 33.7% in the ventricular system, 12.5% in Sylvian fissure and 2.2% in subarachnoid space of the medulla.11 Spinal neurocysticercosis is the rarest type of neurocysticercosis, which is most commonly associated with concomitant intracranial neurocysticercosis. Clinical symptoms depend on the stage of the lesions, their location and the host immune response.Bickerstaff et al. suggested that in cisterns, there is no limiting host response of encapsulation leading to uncontrolled proliferation.12 In the extra parenchymal form, degeneration elicits an inflammatory response, causing arachnoiditis and ventriculitis.13 Hydrocephalus may also develop because of mass effect of the cyst, arachnoiditis (in subarachnoid neurocysticercosis) and ventriculitis (intraventricular neurocysticercosis), leading to adhesions and obstruction.13 An intraventricular cyst may be freely mobile, or it can attach to the ependymal wall of the ventricle. If a cyst is freely mobile in the ventricular cavities, it can cause Bruns syndrome characterised by episodes of sudden headaches, papilloedema and loss of consciousness, developing upon cephalic movement and followed by rapid clinical recovery.14 It develops as a result of intermittent obstructive hydrocephalus caused by a freely mobile intraventricular cyst that acts as a ball-valve mechanism.14 Ependymitis following cyst degeneration may also lead to intraventricular loculation, which is often challenging to treat. Inflammatory response surrounding subarachnoid neurocysticercosis may progress to vasculitis resulting in cerebrovascular accidents.15 Spinal neurocysticercosis can present with paresis, paralysis and polyradiculopathy.Neurocysticercosis is one of the most common causes of recurrent seizures in both the parenchymal and subarachnoid forms because of oedema and encephalitis.8 Magnetic resonance imaging can show the pathological evolution of the disease, namely the vesicular, colloidal, granular nodular and calcified nodular stages. Typical neurocysticercosis lesions are smooth ring enhancing cystic lesions with an eccentric enhancing dot representing the scolex.The diagnosis is confirmed by neuroimaging and serological tests. Computed tomography (CT) is the initial imaging study that can identify active neurocysticercosis and the calcified stage of the disease. However, identifying racemose and intraventricular neurocysticercosis is difficult on CT because the cysts are iso-dense to CSF and usually non-enhancing. Magnetic resonance imaging with contrast is the imaging modality of choice for neurocysticercosis.1 Asymmetrically widened subarachnoid spaces and ventricles in a known case of cysticerci or neurocysticercosis can be a clue to the presence of racemose neurocysticercosis. T2 weighted imaging and FLAIR sequences in the racemose variant show multiloculated clustered cystic lesions in the subarachnoid spaces that follow CSF signal intensity and exert mass effect on surrounding structures.8 Surrounding wall enhancement may occasionally be seen in racemose neurocysticercosis because of associated arachnoiditis.1 In this report, similar clustered cysts without any scolices or post-contrast enhancement was observed but at an atypical location. The differential diagnosis for racemose variant includes tubercular meningitis; however, basilar exudates of tuberculosis (TB) are solid and are not entirely suppressed on FLAIR. Carcinomatous meningitis and neuro-sarcoid are also differentials for racemose neurocysticercosis but they are rarely cystic.Racemose neurocysticercosis is mainly seen around the rostral brainstem or Sylvian fissure and usually lacks a scolex with mild or no surrounding oedema.16Intraventricular neurocysticercosis is usually appreciated on FLAIR imaging when CSF is suppressed. On post-contrast T1W images, intraventricular neurocysticercosis appears as an enhancing lobulated cystic lesion with or without adjoining ventriculitis. Obstructive membranes and adhesions can also develop in ventricles because of ependymitis. Additionally, complications such as ventricular dilatation and vasculitis can be seen on MRI. In this case, similar intraventricular cysts were illustrated in the atrium of the left lateral ventricle associated with an obstructive membrane in the fourth ventricle. Differential diagnosis includes ependymal cyst, choroid plexus cyst, choroid plexus papilloma, colloid cyst, arachnoid cyst and cystic metastasis. An ependymal cyst is usually unilocular, non-enhancing, behaves like CSF and displaces the choroid plexus. Choroid plexus cysts are generally bilateral and most commonly seen in the atrium of lateral ventricles within the choroid plexus glomus. The colloid cyst contains mucin and is not completely suppressed on FLAIR. Choroid plexus papilloma is usually seen below five years of age and has a solid enhancing component. Arachnoid cysts and cystic metastasis are very rarely seen in the ventricles.17 Intraventricular neurocysticercosis, which is not well visualised on conventional MR sequences is better delineated with this sequence. Another advanced MR sequence is the 3-D spoiled gradient recalled echo sequence (SPGR), where both pre- and post-contrast T1W images are obtained. Both these sequences can identify missed obstructive membranes in intraventricular neurocysticercosis.18 In this report an obstructive membrane was only visualised on the 3-D SPGR sequence.Newer MR sequences are now being utilised for demonstrating intraventricular and subarachnoid space neurocysticercosis. Three-dimensional CISS is a fully refocussed steady-state gradient-echo MRI sequence. This is a heavy T2W sequence that increases lesion visibility in ventricles, cisterns and subarachnoid spaces.7Amongst the serological tests available for neurocysticercosis, enzyme linked electro-immuno transfer blot (EITB) using lentil lectin glycoproteins (LLGPs) has a sensitivity of >90% and a specificity of 100% for detection of NCC. This assay can be performed on both serum and CSF samples and it has outperformed the classic ELISA test.20 However, intraventricular cysts that are tightly adherent to the ependyma because of chronic ependymitis are difficult to remove endoscopically and can lead to injury.20Medical management of neurocysticercosis includes cysticidal drugs such as albendazole and praziquantel, steroids and antiepileptic drugs. Medical management is highly effective in the parenchymal and subarachnoid forms. Surgical management in the form of a ventriculoperitoneal shunt is required in cases of symptomatic hydrocephalus. As a result of recurrent blockage of a ventriculoperitoneal shunt, the endoscopic approach for removal of an intraventricular cyst is nowadays the preferred method of treatment.Racemose neurocysticercosis and intraventricular neurocysticercosis are both rare types of neurocysticercosis. The presence of these cysts in the region of the crus of the fornix, anterior to the splenium of the corpus callosum, is very rare. For intraventricular neurocysticercosis, the atrium of the lateral ventricle is also quite an unusual location. Knowledge of the imaging appearance of racemose neurocysticercosis and the different locations where it can develop will prevent overlooking the diagnosis and excluding other differentials. Moreover, newer MR sequences like CISS and 3-D SPGR should also be acquired, in addition to conventional MR sequences, for better delineation of any cyst or membrane obstructing the ventricles and CSF spaces.


Sigmoid volvulus (SV) is a rare complication of Hirschsprung's disease (HD) with only 31 cases have been reported in the English literature. Although its diagnosis is challenging, unrecognized SV is a life-threatening condition requiring early recognition to decrease morbidity and mortality.A 14-year-old male presented to our emergency department with massive abdominal distention. Plain erect abdominal X-ray showed massive colonic distention with multiple fluid levels. Colonoscopy failed to pass beyond 15 cm after entering dilated sigmoid loop. Open surgical exploration was done through a lower midline incision and revealed SV with massive distention of the entire colon. After detorsion, we found a markedly dilated sigmoid colon with an evident discrepancy at the lower sigmoid. Due to massive colonic dilatation, the decision was made for terminal ileostomy. Histopathological examination of biopsy from the narrow segment demonstrated aganglionosis and hypertrophic submucosal neural fibers confirming the diagnosis of HD.SV is a rare serious complication of HD. Unrecognized SV is a serious life-threatening condition, so it should be considered in children with acute or recurrent abdominal pain, distension, constipation and vomiting as early recognition and management of volvulus is essential to decrease morbidity.The presented case highlights the possibility of SV as a rare complication of HD should be considered especially in children with a history of chronic constipation and abdominal distension who present with acute colonic distension and failure to decompress despite rectal washes. •Sigmoid volvulus is a rare complication of Hirschsprung’s disease with a reported prevalence of 0.66%.•Prompt diagnosis of the acute of volvulus decreases morbidity and increases survival.•Sigmoid volvulus should be considered in children presenting with acute intestinal obstruction.•In children with sigmoid volvulus, Hirschsprung’s disease should be suspected, and proper evaluation is required. In later childhood, HD usually present as chronic constipation may be complicated by enterocolitis, and usually associated with growth retardation Sigmoid volvulus (SV) is a rare complication of HD with a reported prevalence of 0.66% To the best of our knowledge, there are only 31 cases have been reported in the English literature 2A 14-year-old male presented to our emergency department with respiratory distress due to massive abdominal distention. He reported non- bilious vomiting and decreased oral intake for the past 3 days. His last bowel movement was 5 days prior to the admission. Parents reported that the child had chronic constipation since birth with bowel movement every 2–3 days. He was not on any regular medications but occasionally, he takes oral laxatives, glycerin suppositories and sometimes he may require enema for colonic evacuation. The parents cannot remember when the child passed his first meconium. His growth and development are average for his age. There was no family history of similar illnesses.On general examination, vital signs were all in normal range except for tachycardia. All anthropometric measurements were in the normal range. Clinical examination of the abdomen showed massive universal distention, tympanic on percussion with diminished bowel sounds. Digital rectal examination revealed empty rectum. Plain erect abdominal X-ray showed massive colonic distention occupying most of the abdomen with multiple fluid levels and ground-glass appearance suggesting fecal impaction at the distal part of the sigmoid colon .Fig. 1PlAfter stabilization of the general condition with intravenous fluids, intravenous antibiotics, and correction of hypokalemia, the patient underwent a trial of surgical disimpaction with rectal tube for deflation, which failed to evacuate the colon or decompress the abdomen. Colonoscopy failed to pass beyond 15 cm after entering dilated sigmoid loop. So, the decision was made for surgical exploration. The time between presentation and surgery was about 6 h. The patient was not eligible for laparoscopy due to the massive abdominal distention causing respiratory distress. Open surgical exploration was done by the authors through a lower midline incision and revealed sigmoid volvulus 270 degree clockwise with massive distention of the entire colon .Fig. 2InAfter detorsion of the volvulus, we found a markedly dilated sigmoid colon (length ∼50 cm and diameter ∼15 cm) with an evident classical discrepancy at the lower sigmoid suggestive of HD .Fig. 3InDue to massive colonic dilatation and ectasia, the decision was made for terminal ileostomy. Evacuation of the colon was made from the ileostomy and by milking toward the anus. Full thickness biopsies were taken from the distal narrow segment, the dilated proximal segment and from the ileostomy. The site of the discrepancy was marked with two 3/0 sutures to help in the future pull through operation. The patient started oral feeding on the 2nd postoperative day and was discharged on the 6th postoperative day.Histopathological examination with immunohistochemical staining demonstrated aganglionosis and hypertrophic submucosal neural fibers in the biopsy from the distal narrow segment confirming the diagnosis of HD.After confirmation of Hirschsprung's disease, Duhamel pull through procedure was done after 3 months when the general condition of the patient was optimized. Frozen section was used intraoperatively for identification of ganglionic margins. The patient started oral feeding on the 2nd postoperative day and was discharged on the 5th postoperative day. The excisional biopsy showed aganglionic distal colon and ganglionic proximal bowel. Closure of the ileostomy was 2 months later.The patient experienced passage of loose frequent motions for the first 2 weeks after the operation which improved gradually. Currently, after 6 months from the operation, the patient is having regular bowel movement.3HD is a common gastrointestinal disorder characterized by absence of ganglion cells in the submucosal and myenteric plexuses leading to persistent spasm and narrowing of the affected bowel segment, causing functional intestinal obstruction SV is a rare serious complication of HD. A recent review of the literature found only 31 cases of colonic volvulus in patients with HD Clinical symptoms of intestinal obstruction predominate as abdominal pain, abdominal distension, constipation and vomiting. Careful interpretation of the plain abdominal radiographs recognizing a hugely dilated, twisted sigmoid loop filling the entire pelvis and abdomen with impacted stool giving a ground- glass appearance is diagnostic Management options of SV in children remain controversial but generally, non-operative reduction with enema, sigmoidoscopy or rectal tube is a possible option in clinically stable patients. However, if bowel gangrene or peritonitis is suspected, this requires immediate surgical exploration after initial resus-citation Although non-operative reduction of the SV is feasible in 30–70% it has a high recurrence rate (35%), so it should not be considered as the definitive treatment, but as temporary intervention allowing stabilization of the patient and preparation of the colon for the definitive surgery which necessitates resection of the both the aganglionic and the redundant ectatic segments and then restoring bowel continuity by anastomosis. This can be done as one stage procedure or in a staged manner In children with sigmoid volvulus, Hirschsprung's disease should be suspected, and proper evaluation is required to avoid missing the diagnosis.An algorithm was suggested for evaluation of these patients. Rectal tube can be used in acute sigmoid volvulus without sings of peritonitis for deflation. If deflation is successful, the tube should be kept in place for 1–2 days and rectal biopsy should be taken in the same admission. According to the biopsy result pull though or sigmoidectomy should be done urgently to protect from the high risk of early recurrence. When tube deflation is not successful or the patient develops signs of peritonitis emergency exploration is required. The options are sigmoidectomy, with either primary anastomosis or colostomy with pull through or colostomy reversal after 6–8 weeks based on the result of biopsy which is safer especially when the general condition of the patient is suboptimal In our case, there was massive colonic dilatation and ectasia till the level of the caecum with a diameter reaching 15 cm, so the decision was made for staged manner with initial diverting terminal ileostomy.To conclude, the possibility of SV as a rare complication of HD should be considered especially in children with a history of chronic constipation and abdominal distension who present with acute colonic distension and failure to decompress despite rectal washes.Not commissioned, externally peer-reviewed.The authors received no financial support for the research, authorship, and/or publication of this article.This case report has been approved by local ethics committee at our institute according to the declaration of Helsinki.Written informed consent was obtained from the parents on behalf of the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request.Concept – Zain; Design – Zain; Supervision – Abouheba; Materials – Zain; Data Collection And Processing – Zain; Analysis And Interpretation – Abouheba; Writer – Zain.; Critical Review – Abouheba.Not applicable.Mostafa Zain.The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.


A purely endoscopic management approach for Type V Mirizzi syndrome. When it coexists with any type of Mirizzi syndrome (MS), this is referred to as Type V MS.A 94-year-old female with a history of type 2 diabetes mellitus, hypertension, and hypothyroidism was admitted to an outside hospital with a mechanical fall and acute kidney injury. On day 5 of admission, she developed acute cholangitis. MRCP revealed a large calcified gallstone in the cystic duct (CD) with common hepatic duct and intrahepatic duct dilation. The next day, she underwent urgent ERCP for hemodynamic instability. Cholangiogram revealed intrahepatic duct dilation with many large stones in the CD and GB. A plastic biliary stent was placed. Sphincterotomy was not performed because of a prolonged international normalized ratio of 1:9. Several days later, she was transferred to our hospital for further management.www.giejournal.org). Cholangiogram revealed a dilated CD with multiple large CD stones. The common bile duct was compressed externally from the stones, and there was evidence of common hepatic duct and intrahepatic duct dilation, consistent with Type I MS. Because of the large stone burden, cholangioscopy was performed, which revealed a large impacted stone at the CD takeoff.Repeat ERCP was performed (Electrohydraulic lithotripsy (EHL) was performed to fragment the stone. Occlusion cholangiogram revealed residual stone in the CD, which had significantly decreased in size, and revealed extravasation of contrast from the GB into the colon, suggestive of a CCF A. This wColonoscopy was performed 1 week later to evaluate the fistula. Several small gallstones were seen in the colon, and a small mucosal defect with intermittent extrusion of microvilli was seen at the hepatic flexure B. ContraA 14-mm/6-mm type t over-the-scope clip was deployed over the fistula D. ContraThe patient returned 5 months later to undergo her final ERCP. Cholangioscopy revealed a residual stone at the CD takeoff, which was treated with EHL. Occlusion cholangiogram showed no further filling defects in the biliary tree, confirming complete stone clearance. At 6-month follow-up, the patient was doing well with normal liver chemistries and no symptoms.This case demonstrates the use of ERCP and EHL for successful management of a large impacted CD stone resulting in biliary obstruction and acute cholangitis. Endoscopic management of a concomitant CCF using an over-the-scope clip was also successful. This suggests the safety and efficacy of endoscopic management as a minimally invasive option for Type V MS.Dr Khashab is a consultant for Boston Scientific, Olympus, Triton, Medtronic, and GI Supply. All other authors disclosed no financial relationships.


Myelolipomas are rare benign tumors made up of adipose and hematopoietic tissue that commonly occur in the adrenal glands unilaterally. Spontaneous hemorrhage occurs in < 5% of these tumors, and often present as large masses. A 50-year-old male presented with right flank pain that had been growing increasingly worse over a two-week period. Contrast-enhanced Computed Tomography (CT) revealed a large suprarenal 15-cm mass exerting mass effect on the kidney and liver along with possible hemorrhage. T1 fat saturated and T2 non-fat saturated magnetic resonance imaging (MRI) confirmed the diagnosis of a myelolipoma with hemorrhage. The patient was treated with surgical resection of the mass and the follow-up pathology report confirmed a giant hemorrhagic adrenal myelolipoma. Spontaneous hemorrhage of a large myelolipoma measuring 15 cm is a rare entity and the correct imaging needs to be done in order to carry out the appropriate treatment. A myelolipoma is a rare benign tumor consisting of lipomatous and hematopoietic tissue . These t3. Myelolipomas are usually asymptomatic, however patients may feel pain if they are large or have hemorrhage [Adrenal myelolipomas are diagnosed around the age of 51 on average, with no difference reported between male and female [morrhage . These bmorrhage . We descA 50-year-old male with a history of hypertension and diabetes presented with complaints of right flank pain that had been growing increasingly worse over the prior two-week period. The patient was found to be diaphoretic and tachycardic in the emergency room. No other significant findings were noted on physical exam. Emergent multiphasic CT demonstrated a large fatty suprarenal ovoid mass measuring at least 15 cm with areas of high attenuation Figures . The masAdrenal myelolipomas are considered a rare finding in radiological imaging, composed of mature lipomatous and hematopoietic tissue. Most of these tumors are < 4 cm when first discovered and many either do not grow or demonstrate slow growth . One stuSpontaneous myelolipoma rupture is rare, being reported in 4.5% of myelolipomas . Most ruIn this case, a 15-cm tumor was measured with contrast-enhanced CT. US, CT, and MRI are all effective in helping diagnose adrenal myelolipomas, with CT being the most sensitive . Due to No malignant potential, regardless of size, has been reported in a myelolipoma so surgical intervention is not required for asymptomatic and non-hemorrhagic myelolipomas. Conservative management with follow-up over one to two years with imaging to ensure size stability has been recommended. Patients with myelolipomas > 10 cm, and in some studies > 7 cm, are strongly encouraged to undergo surgery due to the increased risk of hemorrhage . In thesA giant hemorrhagic adrenal myelolipoma is a rare entity. Hemorrhagic myelolipomas are mostly large and often cause symptomatic flank pain. Imaging modalities such as CT and MRI can yield an accurate diagnosis. With the correct diagnosis the proper treatment can be administered based on the size of the mass and the extent that it bleeds. We submit one more case to the world literature demonstrating excellent radiographic and pathologic correlation.


The most common cause of congenital torticollis is sternocleidomastoid contracture. Torticollis due to a unilateral absence of sternocleidomastoid is very rare. Association of an ipsilateral absence of sternocleidomastoid and trapezius with cerebellar hypoplasia is even rarer. We describe a combination of these rarities in an 11-year-old patient with congenital torticollis. Congenital absence of skeletal muscle is rare and has an incidence of one in 11,000 births , with onDifferentiation of the commoner causes of congenital muscular torticollis (CMT) apart from muscular agenesis is essential as the treatment offered is different. SCM agenesis can be associated with lung herniation into the neck, a sinister condition requiring surgical correction. We report a case of an 11-year-old patient who had a combination of rare associations, i.e., agenesis of right sternocleidomastoid and trapezius with ipsilateral cerebellar hypoplasia presenting with torticollis.An 11-year-old boy had presented to the orthopedic department with the complaint of head tilt to the left along with facial deformity in the form of a small left side of the face and skull. He had a full-term normal vaginal delivery in hospital and was apparently normal at birth. The parents noticed a head tilt to the left when the boy was six months of age but they did not seek any medical help at that time. The condition progressed mildly over the years, however, no physical discomfort was experienced by the patient. The child had adjusted well to this tilt. There was no history of similar complaints in other family members.On inspection, we noticed an asymmetry in the contour of the neck, the shoulder, and the bilateral scapula. Anterior neck muscles were prominent on the left with the the head turned to the left side Figure . The lefDue to asymmetry in the shoulder position, a radiograph of the neck Figure  was acquTorticollis describes an abnormal neck posture with the lateral translation of head on trunk, variable degrees of lateral head tilt, and neck rotation. It can be either congenital or acquired in nature . DependiThe association of unilateral congenital agenesis of sternocleidomastoid with trapezius muscles is known and was earlier reported usually via cadaver dissections  and now In our case, the agenesis of sternocleidomastoid and trapezius was associated with ipsilateral cerebellar hypoplasia. There is only one case report on the association of sternocleidomastoid agenesis with ipsilateral cerebellar hypoplasia . HoweverIn any case of pediatric torticollis, one of the most important conditions that needs to be ruled out before considering the diagnosis of sternocleidomastoid agenesis is CMT. It is characterized by fibrosis of the sternocleidomastoid muscle due to an insult in the prenatal life or during birth . US is oDespite its rarity, the unilateral absence of the SCM should be considered as a cause of torticollis in infants and in young patients with facial deformity and with congenital torticollis. The associated conditions such as ipsilateral absent trapezius, cerebellar hypoplasia, and lung herniation should also be sought for keeping in mind the other differentials and imaging pitfalls.


Tailgut cysts are rare developmental cysts arising from remnants of the embryological postnatal gut. Despite being frequently located in the presacral space, isolated cases of aberrant locations have been reported, including, perirenal, perianal, and subcutaneous sites, with only two cases of subdural tailgut cysts reported to date. The clinical course is often marked by linear growth, causing compression of the adjacent structures, however malignant transformation with carcinomatous features has been previously described. Hereby the authors describe a case of an intradural extramedullary tailgut cyst in a 33-year-old man presenting with progressive low back pain and signs of autonomic dysfunction, including urinary retention and bowel incontinence. Whole-spine MRI revealed an intrathecal cystic lesion located at L2-L3 level exhibiting hyperintensity on T2-weighted images not enhancing when contrast was administered. Laminectomy followed by tumor excision was performed and pathological analysis confirmed the diagnosis of tailgut cyst. Tailgut cyst, Spinal tumor, Developmental abnormality, Spinal cyst, Case report. T2The authors present a case of a 33-year-old man with progressive worsening of low back pain, unresponsive to symptomatic pharmacotherapy without any other relevant past medical history. At admission, the patient referred reduced touch sensation in the lower limbs, more pronounced in the right leg, associated with diffuse paresthesia of the L2-L3 corresponding dermatomal area. Neurological examination showed marked weakness , with a slight but present response to deep tendon reflexes stimulation. Anal sphincter insufficiency and urinary retention were also detected. No other neurological deficits were noticed, therefore, a whole-spine magnetic resonance imaging was performed . The sca3th day of gestation and involutes by the eighth week of embryonic development [The tailgut or postanal gut is the distalmost part of the embryonic gut, caudal to future anus. It normally reaches its largest diameter on the 35elopment , 3. Giveelopment , 9. Deveelopment , 6, 7. Delopment . In geneelopment , 14. Howelopment . Hjermstelopment , 9. For Grossly, tailgut cysts are soft, multiloculated, and usually well-circumscribed, exhibiting surrounding adherent fibroadipose tissue. Microscopically, these lesions are usually multicystic and lined by a variety of epithelial types, including transitional, squamous, ciliated columnar, and mucinsecreting epithelium; the latter was also apparent in the present case. Disorganized bundles of smooth muscle cells could be seen interposed within the multilocular cysts along with dense mucoid fluid . AlthougThe differential diagnosis includes a wide variety of conditions occurring in the presacral space, including cystic sacrococcygeal teratoma, duct and gland cyst, pyogenic abscess, neurogenic cyst, and necrotic sacral chordoma. When intradural, spinal cord compression is also noticed, and the additional differential diagnosis must include intervertebral disk herniation with radicular compression, lumbar stenosis, and intra-axial tumors. Magnetic resonance imaging with contrast administration represents the gold standard to define the relation of the tumor with adjacent structures and to initially differentiate benign from malignant lesions . General4In the present report, a rare case of intradural extramedullary tailgut cyst is described. As a result of its intra-axial location, the lesion caused atypical clinical manifestations secondary to spinal cord and nerve root compression. The patient presented with marked hyposthenia and diffuse paresthesia and was unresponsive to symptomatic pharmacotherapy for low back pain. Furthermore, autonomic dysfunction was noticed during examination with signs of urinary retention and anal sphincter insufficiency, therefore prompting urgent decompressive surgery followed by tumor excision. The pathological analysis confirmed the diagnosis of tailgut cyst with mucin secreting epithelial cells.The patient's written informed consent was collected prior to data collection and available on reasonable request.All authors listed have significantly contributed to the investigation, development and writing of this article.This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.Data will be made available on request.The authors declare no conflict of interest.No additional information is available for this paper.


A subtype of malignant melanomas, nodular melanoma often carries a poor prognosis because of local invasion and frequent distant metastasis. Here, we report a case of progressive dyspnea due to one of the largest primary melanomas in the literature to date along with management strategies and elucidate some of the reasons why patients delay seeking care. Cutaneous melanoma is a tumor produced by the malignant transformation of melanocytes that derive from the neural crest. Consequently, the disease usually occurs on the skin and occasionally in other areas where neural crest cells are found such as the GI tract or brain . It accoA 69-year-old Caucasian male was admitted to our hospital with complaints of progressively worsening fatigue and dyspnea for two months that were aggravated on exertion. His medical history was significant for chronic emphysema poorly controlled with intermittent inhaler usage, and his social history was notable for an 80-pack-year history of tobacco use, although he discontinued using tobacco products one month ago. The patient had not been to a physician in years. In addition to his dyspnea, the patient noted a large bleeding posterior back mass that began as a small erythematous papule five years ago which had progressively enlarged. On general physical examination, his vitals were within normal limits. He appeared in respiratory distress with increased work of breathing and scattered rhonchi and wheezes throughout. He looked older than his stated age, and prominent anterior kyphosis was noted. His Patient Health Questionnaire-9 score was zero. The dermatological examination showed Fitzpatrick type 2 skin, uneven skin coloring with yellowish predominance, and a posterior left scapular 17.0 × 17.0 × 6.0 cm exophytic, ulcerating, fungating mass with erythema. In addition, there was evidence of infarction and necrosis with fibrinolysis and purulence throughout , mild normocytic anemia (hemoglobin 9.6 g/dL), and mild thrombocytosis  and prothrombin time/international normalized ratio (14.0/2.0). Contrast-enhanced CT of the thorax showed a low-density large subcutaneous mass of the left posterior chest wall with superficial muscle involvement, multiple pulmonary nodules measuring up to 2 cm, moderate emphysema, pleural effusions, and left axillary lymphadenopathy findings, consistent with the presence of extensive metastases Figure .2, and was positive for S100, HMB-45, MelanA, SOX-10, and PRAME, but negative for BRAFV600 with 0% expression of PD-L1 on immunohistochemistry (Figure On biopsy and immunohistochemical stain of the mass, nodular melanoma was confirmed with a Breslow thickness of 10.1 mm, Clark level IV, stage pT4b, mitotic rate of 3 mitoses/mmAfter palliative care consultation, the patient elected to pursue all possible treatments. At the time of writing this report, wide resection of the mass was limited by its highly vascular nature. Radiation Oncology initiated radiation therapy using Cyberknife with a cumulative dose of 1,800 cGy directed at the occipital lobe metastasis, and the oncology team evaluated him for enrollment into a clinical trial.V600 mutation in the BRAF gene [There continues to be an increase in new chemotherapeutics for malignant melanoma . DespiteGiant primary cutaneous melanomas have been rarely reported as increased access to primary healthcare and screening measures continue to improve and reduce their incidence -11. AfteEarly diagnosis of melanomas is closely related to improved outcomes across all health-related metrics. The reasons for delayed diagnosis are multifactorial and include a lack of knowledge of the disease among the population, as well as a failure of patients and physicians to conduct annual skin examinations. Prior research has shown that 50% of melanomas are found by the patients . DespiteGiant malignant melanomas are extremely rare entities and pose a surgical and medical challenge due to their destructive nature and poor prognostication. Even though they have significant metastatic potential, a subset of these tumors could have a more benign course. Additionally, this case highlights the need for developing more therapeutic options in stage four metastatic melanoma and the current management options of primary giant melanomas with distant metastasis. It re-emphasizes the continued need for public health campaigns to recommend annual skin screens by both primary care and dermatologists, dispersing knowledge on how to reduce their risk factors, incentivizing patients to seek diagnosis and treatment as soon as a skin lesion begins to appear atypical, and the possible devastating consequences if not adequately followed promptly.


The confirmation of the improvement of endobronchial lesions in addition to that of vascular lesions after bronchial artery embolization of primary racemose hemangioma could be important. The confirmation of the improvement of endobronchial lesions in addition to that of vascular lesions after bronchial artery embolization of primary racemose hemangioma could be important. The case report suggested that the confirmation of the improvement of endobronchial lesions in addition to that of vascular lesions after treatment could be important.Racemose hemangioma is a rare disease in which the bronchial arteries are markedly bent, meandering, and dilated, which sometimes causes abnormal anastomosis with the pulmonary arteries and veins and the formation of a polypoid lesion in the bronchial lumen. In this paper, we report the case in which the effect of bronchial artery embolization (BAE) on racemose hemangioma was confirmed by the findings of bronchoscopy.2On 07 February 20xx, a 27‐year‐old man visited a general physician because of a small amount of hemosputum without particular inducement and was prescribed a hemostatic agent. He repeatedly expectorated a small amount of hemosputum, and therefore visited an otolaryngology clinic on 9 February, where blood adhesion was observed under the vocal cords by nasopharyngolaryngoscopy. It was suspected that the bleeding came from the lower respiratory tract, thus, he was introduced to our hospital on 12 February. Chest X‐ray showed no obvious abnormal findings . After BAE, the disappearance of abnormal deep staining of the blood vessels was confirmed (Figure While receiving a hemostatic agent by intravenous injection, he was transferred to the Department of Radiology, Wakayama Medical University Hospital on 18 February. He was treated with BAE on the same day. Before BAE, abnormal dark staining and bronchial artery‐pulmonary artery shunt were observed on right bronchial arteriography Figure . The midd Figure .He was transferred to our hospital on 22 February and received bronchoscopy on the same day. The polypoid lesion at the entrance to the right B6 bronchus had disappeared, and only mild redness of the mucosa remained Figure . He was 3Racemose hemangioma is a very rare disease first reported by Babo et alThis disease is classified as primary due to congenital angiogenesis without bronchial or pulmonary lesions, and secondary due to inflammation such as bronchiectasis and tuberculosis or neoplastic disease.Most cases of racemose hemangioma are found due to symptoms such as hemosputum, hemoptysis, or dyspnea,In the 1980s, most cases of racemose hemangioma were surgically treated,The efficacy of BAE has been evaluated by the improvement of symptoms or the findings of bronchial arteriography but has not been evaluated based on endobronchial findings. We confirmed the disappearance of the polypoid lesion on the bronchial mucosa at 4 days after or 10 months after BAE treatment. The confirmation of the disappearance of the polypoid lesion that was considered to be a dilated and meandering bronchial artery was direct evidence of the control of the arterial abnormality and risk of re‐bleeding. We, therefore, recommend the observation of endobronchial findings patients with racemose hemangioma who are treated with BAE.4We experienced a case of primary racemose hemangioma in which an endobronchial lesion was successfully treated by BAE. The present case suggested that the confirmation of the improvement of endobronchial lesions in addition to that of vascular lesions after treatment could be important.The authors declare no conflicts of interest.KK: engaged in the treatment of the patient. KK and YM: were major contributor in writing the manuscript. KK, SS, YA, HO, TS, and YM: read, revised, and approved the final manuscript.Written consent from the patient has been obtained.


To illustrate the regression of a metastatic lesion through ophthalmic imaging and correlating findings with standard chest imaging and treatment with osimertinib, an oral chemotherapy agent specific to Epidermal Growth Factor Receptor + Non-small Cell Lung Cancer (EGFR+ NSCLC).A 63-year-old Asian male presented to ophthalmology with a complaint of left blurry vision. Initial ophthalmic exam revealed a choroidal lesion and imaging results highlighted a spiculated lung mass with brain and bony metastases. Osimertinib was chosen for its specificity and ability to cross the blood–brain barrier. Follow-up ophthalmic and radiographic imaging were repeated over the course of treatment.After the initiation of osimertinib, ophthalmic and computed tomography imaging highlighted the regression of the ocular metastatic disease and primary malignancy, respectively.Osimertinib is an effective first-line treatment of EGFR+ NSCLC and corresponding metastatic sites. Additionally, ophthalmic imaging can be used to monitor general response to chemotherapy agents when ocular metastasis is identified. Visual disturbances may sometimes be the first presenting sign of metastatic disease to the eye. The most common malignancies to metastasize to the choroid are breast, lung, and gastrointestinal tract. Once malignancy is suspected in the eye, prompt characterization is needed to determine therapy targeting the primary lesion and its dissemination. Osimertinib is an irreversible third-generation Epidermal Growth Factor Receptor Tyrosine Kinase Inhibitor (EGFR-TKI) that targets EGFR-TKI sensitizing and T790M resistance mutations and is the standard of care as first-line treatment of Epidermal Growth Factor Receptor + Non-small Cell Lung Cancer (EGFR+ NSCLC).,3,4 We present a case of choroidal metastasis from a primary pulmonary malignancy with full characterization and follow-up using ophthalmic imaging as a clinical endpoint for treatment response to osimertinib.The choroidal vasculature underlying the retina is the most common site for intraocular metastasis.A 63-year-old Asian male presented to ophthalmology clinic with complaint of central blurry vision of the left eye. Past medical history revealed well-controlled type II diabetes mellitus and no past ocular history. Best-corrected visual acuity in both eyes was 20/20, however, the patient reported blurry vision in the left eye. Pupillary responses, confrontational visual field testing, and intraocular pressure were normal.Initial slit-lamp examination was unremarkable. On detailed funduscopy of the left eye, a non-pigmented choroidal lesion was noted superior to the macula [Figure 1a] with subretinal fluid extending from the tumor into the subfoveal space [Figures 1b & 2a]. Fundus examination of the right eye was normal. Autofluorescence imaging of the left eye showed hyperfluorescence with a mixed or speckled pattern overlying the subretinal lesion [Figure 1b]. Optical coherence tomography (OCT) highlighted an abnormal foveal contour with subretinal fluid in the affected eye [Figure 2a]. B-scan ultrasound on the same visit demonstrated a 6.6 Histological examination from fine needle aspiration of the lung mass and right lower paratracheal lymph node highlighted atypical cells and adenocarcinoma, respectively. Subsequent positive immunohistochemical staining with NapsinA, TTF- 1, BER-EP4, CK7, and Ki67 confirmed a malignancy of pulmonary origin. Positron emission tomography with Fluorodeoxyglucose (PET-FDG) revealed a right upper lobe pulmonary mass with extension into the right suprahilar region [Figure 3a], right paratracheal and mediastinal lymph node metastases, a 14-mm adrenal nodule, as well as T1 vertebral body, posterior iliac, and left acetabular bony metastases. MRI findings demonstrated a 4-mm enhancement in the left superior frontal gyrus suspect of brain metastases without significant mass effect. Due to the patient's “never- smoking” status, chances of finding a targetable driver mutation were high, and therefore, initiation of chemotherapy was withheld until sequencing was complete. Patient was then started on denosumab 120 mg every four weeks.Two months after presentation, further ophthalmic work-up revealed gravitated subretinal fluid and decreased acuity of the affected eye (20/60). B-scan ultrasound highlighted an enlarged growth at 10.5 One month later, the patient's pin-hole acuity improved to 20/40, with color fundus photography showing an amelanotic choroidal lesion with subretinal fluid that had not grown, B-scan ultrasound showed a smaller mass  has a yellow–white discoloration and is highly associated with subretinal fluid. Furthermore, the association of subretinal fluid and CM occurs in approximately 28.4% of patients. If these features are identified, it should initiate prompt investigation for a primary source. In the past, uveal metastasis in lung cancer generally carried a poor prognosis with mean time to death after discovery of 18.4 months in older patients (age 61–80). However, molecular profiling has recently led to improved treatment regimens, where osimertinib has shown increased median overall survival (38.6 months) compared to other EGFR-TKIs gefitinib and erlotinib (31.8 months) in treatment naïve NSCLC. Combinations of both systemic and external beam radiotherapies for CM previously showed lower regrowth rates,,11 but therapies targeting driver mutations spare patients from ophthalmic adverse reactions to therapy, including radiation keratopathy, iris neovascularization and glaucoma, accelerated cataract formation, and optic neuropathy.Although ocular metastases are infrequent in lung cancer patients, ocular metastasis of pulmonary adenocarcinoma is less common, as adenocarcinoma spreads to the liver and adrenal glands more commonly.,4 This case adds to the growing body of evidence highlighting the utilization of molecular profiling to optimally treat choroidal metastasis of EGFR + NSCLC.,14,15 However, in comparison to the some cases of ocular metastases treated with osimertinib, first- or second-generation TKIs were not attempted as first-line, as sequencing led to a more advantageous treatment plan that would spare adverse reactions to intravenous chemotherapy and targeted radiation.,15 Additionally, we comprehensively correlate ophthalmic and systemic radiographic imaging over the time course of treatment to highlight visual symptomatic improvement alongside mass regression that was not described in earlier cases. However, our case also confirms prior experience in the field, where ophthalmic imaging offered a real-time, low-cost, and noninvasive monitoring of ocular metastasis and therapeutic response to newer agents like osimertinib.,14,15Here, we present an informative depiction of the regression of ocular metastasis, where biopsy and next-generation sequencing directed the selection of osimertinib treatment due to its efficacy with EGFR-variant pulmonary adenocarcinoma and ability to penetrate the blood–brain barrier.This case report was conducted in accordance with the Declaration of Helsinki, data collection and evaluation were conducted in accordance with the Health Insurance Portability and Accountability Act (HIPAA).Informed consent was obtained from all individual participants included in the study. Consent for publication was obtained according to the ICMJE Recommendations for Protection of Research Participants. The participant has consented to the submission of the case report to the journal.Nil.There are no conflicts of interest.


Lhermitte–Duclos disease (LDD) is a rare tumor of the nervous system with a typical “tiger striped’” sign, but its features on functional magnetic resonance imaging (fMRI) are still inconclusive.To explore the characteristics of LDDs using fMRI.We report 3 cases of pathologically confirmed LDDs.Three patients underwent brain tumor surgery.All the patients had a good prognosis.Magnetic resonance spectroscopy and susceptibility-weighted imaging combined with conventional MRI can be used to better diagnose LDDs. Perfusion-weighted imaging is not specific for distinguishing cerebellar tumors. The combined application of fMRI and conventional MRI can improve the accuracy of LDD diagnoses. Loss of the phosphatase and tension homologue (PTEN) gene, located on chromosome ten, is also associated with Cowden syndrome in LDD patients. Some scholars classify LDD as part of Cowden syndrome (multiple hamartoma syndrome).Dysplastic cerebellar gangliocytoma  is a rare cerebellar tumor composed of dysplastic ganglion cells. Owing to its insidious onset, slow progression, and good prognosis, it is classified as a mixed neuron-glial tumor of WHO class I in the 2016 version of the central nervous system classification. Imaging analysis usually reveals that the normal granular layer cells in the cerebellar lobe are replaced by dysplastic cortical neurones (ganglion cells), resulting in enlargement of the cerebellar lobe. The molecular layer of the brain lobe thickens and produces excessive myelination changes, which lead to layered changes on imaging  is required. Therefore, imaging is of great significance for confirming a disease diagnosis.Currently, the disease is easily pathologically diagnosed as ganglion cell glioma or neuron-glioma.ing Fig. .[4] TherLDD is a rare type of tumor, and most previous studies were case reports. As functional imaging  has been widely used in the clinic, the understanding of the disease has gradually deepened. This article will combine the cases from our center and summaries previous studies to discuss the imaging characteristics of LDDs in different ways.2A total of 3 LDD patients were admitted to our centre between 2017 and 2021. All patients were aged between 37 and 44 years. In addition to plain MRI and enhanced MRI, some patients underwent related functional imaging examinations, including PWI, SWI, and MRS.2.1The patient was a 40-year-old female. One year prior, she presented with intermittent headaches and neck discomfort of no obvious cause. Assuming cervical spondylosis, rehabilitation physiotherapy was administered, but no obvious improvement was observed. Subsequently, the patient's headache symptoms worsened, accompanied by unstable walking. Physical examination and brain CT suggested the presence of tumorous lesions in the right cerebellum, hydrocephalus, and foramen magnum herniation, and the patient was referred to our hospital. The right fingernose test on the right side of our hospital was positive, and the stance with closed eyes test was positive.MRI examination in our hospital Fig.  showed aThe patient underwent resection of the right cerebellar space-occupying lesion under general anesthesia, and the operation progressed smoothly.Pathological results, light microscopy: glial cell proliferation mixed with a large number of ganglion cell-like cells, edema, formation of microcapsules, and a large number of irregular blood vessels. Immunohistochemical results: GFAP(+), IDH1 R132H(−), Ki67 approximately 1%(+), NeuN(+), Olig-2 part(+), P53(−), Syn(+), CD34(−), CgA(+), NF(+). Final pathological result: “LDD” in the right cerebellar hemisphere.Anti-inflammatory, intracranial pressure-lowering, and other drugs were administered postoperatively, and the patient's discomfort was treated symptomatically. The patient was regularly reviewed after discharge, and she had a good prognosis within 2 years2.212/L↓, hemoglobin 58.0 g/L↓, average red blood cell volume 82.2 fL, average red blood cell hemoglobin content 21.6 pg↓, average red blood cell hemoglobin concentration 262.0 g/L↓. Clinical considerations of iron-deficiency anemia red blood cell transfusion was performed to improve anemia and platelets were administered to improve blood coagulation function.This patient was a 44-year-old woman. Chronic course, unstable walking for 3 years PET-CT in another hospital showed slight low-density occupancy in the right cerebellar area. PET revealed increased radioactive uptake, suggesting the possibility of malignant tumors. On admission to our hospital, physical examination yielded a limb muscle strength of grade 5, muscle tension, and difficulty in establishing a positive sign with closed eyes; the remaining results were unremarkable. Routine blood test + nucleated red blood cells: red blood cell count 2.69 × 10MRI at our hospital Fig.  revealedThe patient underwent resection of the right cerebellar space-occupying lesion under general anesthesia, and the operation progressed smoothly.Pathological results and light microscopy showed that the granular layer of the cerebellum was absent, large and irregular ganglion cell-like nerve cells were seen in a layered distribution, nuclear divisions were difficult to observe, no necrosis was observed, and the molecular layer was thickened. Immunohistochemistry: GFAP , IDH1 R132H (−), Ki67 (<1% +), CD34 , NeuN (ganglion cell-like nerve cell +). The pathological results were consistent with the LDD-like manifestations.The prognosis of the patient was good, and the patient has been regularly reviewed for more than 2 years after the operation. The patient's condition was stable, and there was no recurrence.2.3The patient, male, 37 years old, had dizziness and headache for more than 10 days. Activated partial thromboplastin time 44.4 second↑; blood biochemistry: total calcium 2.03 mmol/L↓. The remaining test results showed no clear abnormalities.MRI at our hospital Fig.  showed sThe patient underwent total resection of the left cerebellum under general anesthesia. The surgery proceeded smoothly.Pathological results and light microscopy: The cerebellar tissue structure was disordered, with scattered mature ganglion cells of different sizes. Immunohistochemical results: NF +/−, Syn +, S-100 −, CgA +, GFAP +/−, Ki67 1%, EMA −. Pathological results: LDD.The patient had a good prognosis within ten months and was followed up regularly.3 Generally, patients are admitted to the hospital because of obstructive hydrocephalus and a sub-tonsillar hernia caused by the excessive size of the lesion, but resection can offer a cure. However, with the gradual application of imaging technology, some reports have advanced the age of onset of this disease to 24 weeks, and the number of reports of disease onset in elderly patients has gradually increased.,8 According to a report by Wang et al of West China Hospital in China, 1 patient had tumor recurrence, indicating that LDD may also evolve into a malignant lesion. The gradual application of MRS, SWI, and other technologies in the diagnosis and prognosis of LDD provides valuable information from imaging.LDD is a rare benign neoplastic lesion. It is generally believed that the highest prevalence is among individuals aged approximately 30 to 50 years, but its pathogenesis and possible genetic associations remain unclear.3.1 Moreover, on T2WI and FLAIR, this tumor has very unique features. The high-signal areas on T2WI and FLAIR are equivalent to the center of the diseased cerebellar lobe, including the atrophic white matter, a hyperplastic granular cell layer, and a thickened inner molecular layer. The iso-signal area on the MRI was equivalent to that of the brain lobe. On the surface layer, including the outer molecular layer and the pia mater layer .rts Fig. .[14] Therefore, to improve the diagnostic accuracy, functional imaging other than conventional MRI is necessary.Although almost all images of LDD patients showed the “tiger striped” sign, some studies reported the appearance of a false “tiger pattern” sign, as reported by Annette C. Douglas-Akinwandea et al, who misdiagnosed medulloblastoma as LDD.3.2–20 We divided the degree of perfusion into high perfusion (+++), local high perfusion (+), and low perfusion (−) , it can still cause high perfusion on PWI. Based on the analysis of the above cases, we initially believed that, in addition to the local hyperperfusion caused by the blood vessels around the lesion Fig. , the tum3.3,20,23–28 We divided patients according to the presence or absence of the Lac peak (presented as ∗) and the Cho/NAA ratio as follows: <1, 1 <ratio <2, and > 2. In total, 7 patients (70.0%) had a ratio <1, 3 (30.0%) had a ratio between 1 and 2, and 0 (0%) had a ratio>2 . However, in some new MRI technologies, such as amide proton transfer (APT) and myelin water imaging, there are no relevant reports on LDDs.,32LDD usually appears large on conventional MRI and has a typical “tiger striped” sign. Pathology also showed the corresponding components. The diagnosis is usually clear. However, some diseases can also show a false trigger pattern, which requires auxiliary diagnosis with functional imaging. According to existing studies, MRS exhibits a characteristic Lac peak. When the Cho/NAA ratio is low, SWI can reveal thickening of the interlobular veins in the tumor. LDD can be more clearly diagnosed when combined with the unk tiger pattern’ sign. PWI of cerebellar tumors is usually sensitive, but its specificity is low. For PWI to distinguish between these tumors and determine whether the level of LDD perfusion affects the prognosis and recurrence of patients, more patients need to be followed up and analyzed. In non-MR PET, there is a moderate increase in LDD metabolism.We found that MRS and SWI are more sensitive for the diagnosis of LDD, while PWI technology requires more cases and literature reports to confirm.In conclusion, LDD has the characteristics of both conventional and functional imaging. With a more complete examination, we will learn more about this disease, develop more targeted treatments, and provide a better prognosis.We thank Ms. Siling Gu for her help with this research.Project administration: Yi Lei.Resources: Yuan-qing Zhang.Software: Fan Lin, Xiao-lei Liu.Supervision: Xiao-lei liu, Yong-qian Mo.Writing – original draft: Hanwen Zhang.Writing – review & editing: Yu-ning Feng.


Panthera leo) with a history of vomiting, lethargy, and anorexia was referred to our institution. On physical examination, the lion weighed 180 kg and had a rectal temperature of 40 °C. Blood analysis showed mild neutrophilic leukocytosis, and abdominal ultrasonography revealed an enlarged uterus with echogenic fluid. Based on the clinical signs and hematologic and ultrasonographic findings, the lion was tentatively diagnosed with pyometra. Ovariohysterectomy was performed using the lateral flank approach to avoid complications that can occur with ventral celiotomy. Surgery was performed successfully despite unexpected rupture of the uterus which had occurred before the surgery. The lion recovered uneventfully and continued to do well at the 1 year follow up after surgery. To the best of our knowledge, this is the first reported case of ovariohysterectomy with the lateral flank approach in a lion with pyometra. Our report suggests that ovariohysterectomy with the lateral flank approach could be considered as an alternative method for pyometra in wild big cats with risk of complications at the surgical site.An 8.5-year-old intact female lion ( Pyometra is an acute or chronic clinical disease characterized by purulent exudate caused by secondary bacterial infection in the uterine lumen . The exaOvariohysterectomy is the most effective treatment option because the entire source of the infection is removed. It is commonly performed through either a ventral midline or lateral flank approach ,6,7,8. EPanthera leo); ovariohysterectomy using the ventral midline approach was performed in three cases, necropsy in one case, and the type of surgery was not mentioned for two cases [Pyometra is a common disorder in small animals, such as dogs and cats ,10. Howewo cases ,14,15,16In the present case, we show that ovariohysterectomy with the lateral flank approach could be considered in wild big cats with a risk of evisceration at the surgical site.Panthera leo) with a history of vomiting, lethargy, and anorexia was referred to our institution. On physical examination under anesthesia using medetomidine  and ketamine , the lion weighed 180 kg and showed a rectal temperature of 40 °C. Blood analysis showed mild neutrophilic leukocytosis . Abdominal ultrasonography revealed a distended uterus with echogenic fluid  and ketamine  by darting using a blowgun. Anesthesia induction was deemed complete by examining the lion for lack of response to stimulation upon lifting the front limbs or head after the darting. After anesthesia induction, the lion was blindfolded and transported in a car to the surgical room for surgical treatment. The lion was restrained on the operating table in the left lateral recumbent position. General anesthesia was maintained by inhalation of 3.5–4.0% sevoflurane  in 100% oxygen. Ketoprofen , tramadol , and enrofloxacin  were administered preoperatively.A right lateral flank laparotomy was performed via an approximately 20 cm incision from 5 cm below the 3rd lumbar transverse process towards the knee joint to facilitate uterine accessibility . To brieCytologic analysis of a sample from the pus revealed bacterial infection with predominantly rod-shaped bacteria and numerous degenerative neutrophils . Two dayPanthera leo) to avoid complications that may be caused by ventral midline celiotomy.Ovariohysterectomy for pyometra in lions is generally performed by ventral midline celiotomy. However, the ovariohysterectomy with the lateral flank approach could be used for the treatment of pyometra in a lion  [Pyometra is a common disease in small animals, but there are only limited reports in lions ,14,15,16%, 0/11) . In part%, 0/11) . TherefoThe ventral midline approach is a more common method than the lateral flank approach for ovariohysterectomy. However, in a study of complications following ovariohysterectomy in shelter-housed cats, the risk of wound complications was higher with the ventral midline approach than with the lateral flank approach . TherefoThe transdermal fentanyl patch is primarily used for relief from postoperative pain and severe pain caused by tumors, aortic thromboembolism, pancreatitis, etc. . They arIn conclusion, ovariohysterectomy with the lateral flank approach was performed successfully despite a ruptured pyometra which had occurred before the surgery. The lion recovered uneventfully and continued to do well at more than one year after surgery. Even though this is a single case, our results suggest that ovariohysterectomy with the lateral flank approach could be considered as an alternative method for pyometra in wild big cats with risk of complications at the surgical site.