MR imaging features of benign retroperitoneal paragangliomas and schwannomas

Ketamine for Critically Ill Patients with Severe Acute Brain Injury: A Systematic Review with Meta-analysis and Trial Sequential Analysis of Randomized Clinical Trials

BACKGROUND

Patients with severe acute brain injury have a high risk of a poor clinical outcome due to primary and secondary brain injury. Ketamine reportedly inhibits cortical spreading depolarization, an electrophysiological phenomenon that has been associated with secondary brain injury, making ketamine potentially attractive for patients with severe acute brain injury. The aim of this systematic review is to explore the current literature regarding ketamine for patients with severe acute brain injury.

METHODS

We systematically searched international databases for randomized clinical trials comparing ketamine by any regimen versus placebo, no intervention, or any control drug for patients with severe acute brain injury. Two authors independently reviewed and selected trials for inclusion, extracted data, assessed risk of bias, and performed analysis using Review Manager and Trial Sequential Analysis. Evidence certainty was assessed using Grading of Recommendations Assessment, Development and Evaluation. The primary outcomes were the proportion of participants with an unfavorable functional outcome, the proportion of participants with one or more serious adverse events, and quality of life.

RESULTS

We identified five randomized trials comparing ketamine versus sufentanil, fentanyl, other sedatives, or saline (total N = 149 participants). All outcomes were at overall high risk of bias. The proportions of participants with one or more serious adverse events did not differ between ketamine and sufentanil or fentanyl (relative risk 1.45, 95% confidence interval 0.81-2.58; very low certainty). Trial sequential analysis showed that further trials are needed.

CONCLUSIONS

The level of evidence regarding the effects of ketamine on functional outcome and serious adverse events in patients with severe acute brain injury is very low. Ketamine may markedly, modestly, or not at all affect these outcomes. Large randomized clinical trials at low risk of bias are needed.

Computed tomography angiography features of a retroperitoneal extra-adrenal paraganglioma in a cat

A 7-year-old spayed female domestic shorthair cat was presented for evaluation of a large-volume abdominal space-occupying lesion. A computed tomography angiography examination detected a round retroperitoneal mass, in contact with the large abdominal vessels, characterized by an external hyperattenuating capsule and a larger hypoattenuating center. The capsule was soft-tissue attenuating with marked heterogenous contrast enhancement. The center was hypoattenuating pre- and post-contrast administration. The mass displaced both kidneys laterally and the descendent colon ventrally. The mesenteric veins and both phrenicoabdominal veins were markedly increased in diameter. However, the adrenals were not involved. On the excretory phase, no contrast enhancement was observed in either ureter, except for the proximal tract of the right ureter. At laparotomy, both ureters entered the mass that was adherent to the great abdominal vessels. The cytological diagnosis was retroperitoneal extra-adrenal paraganglioma. In cats, retroperitoneal extra-adrenal paragangliomas are very rare. This is the first computed tomography angiography report of a retroperitoneal extra-adrenal paraganglioma in a domestic cat. Key clinical message: This report describes the computed tomography angiography features of a rare case of a retroperitoneal extra-adrenal paraganglioma in a cat. These features could be taken into consideration to direct the diagnosis of a possible neuroendocrine origin for a retroperitoneal mass in a cat.

Correlation between imaging and histology in benign solitary retroperitoneal nerve sheath tumors: a pictorial review

BACKGROUND

Benign nerve sheath tumors presenting as solitary retroperitoneal masses (RBNSTs) pose a complex diagnostic challenge for multidisciplinary teams regarding differential diagnosis, staging, and treatment planning. This article reviews the role played by different imaging techniques in assessing RBNSTs and elucidates their typical pathological features with a particular emphasis on the correlation between imaging and histological findings. Furthermore, some examples of retroperitoneal tumors that merit consideration in the process of differential diagnosis based on cross-sectional investigations (CSIs) are reported. The correlation between tissue architecture and appearance on imaging can help increase the accuracy of differential diagnosis with other retroperitoneal neoplasms at CSIs.

CRITICAL RELEVANCE STATEMENT

This educational review critically examines the correlation between imaging and histological features in solitary retroperitoneal benign nerve sheath tumors, offering valuable insights for improving the accuracy of differential diagnosis in clinical radiology.

KEY POINTS

RBNSTs are challenging to diagnose because they lack specific radiological features. Differential diagnosis of RBNSTs from other retroperitoneal neoplasms on imaging is complex. Surgical removal of RBNSTs is recommended for an accurate diagnosis.

Preoperative differentiation of mediastinum and retroperitoneum ganglioneuroma from schwannoma with clinical data and enhanced CT: developing a multivariable prediction model

AIM

To develop a multivariable prediction model for preoperative differentiation of ganglioneuroma (GN) from schwannoma in mediastinum and retroperitoneum based on clinical data and enhanced computed tomography (CT).

MATERIALS AND METHODS

This was a retrospective diagnostic study. Patients diagnosed with mediastinum or retroperitoneal GN or schwannoma at Zhongshan Hospital between July 2006 and March 2022 were divided into a training cohort and a validation cohort at a ratio of 7:3. Clinical information and CT features were collected. Histopathology was the reference standard for diagnosis. The model was developed using binary logistic regression. The predictive performance of the model was assessed using receiver operating characteristic (ROC) curves, calibration curves, and decision curve analysis (DCA).

RESULTS

A total of 105 patients (47 men and 58 women; mean age of 41 ± 15 years) were enrolled. There were significant differences in symptoms (p=0.006), location (p=0.008), ratio of the craniocaudal diameter (CC) to the major axis on axial images (CC/M; p=0.025), ratio of the CC to the diameter on axial images (CC/D; p<0.001), density homogeneity (p=0.001), enhancement homogeneity (p<0.001), enhancement degree (p<0.001), venous phase CT attenuation value (V; p=0.011), and blood vessels changes (p=0.045) between GN and schwannoma. The area under the ROC curve (AUC) and accuracy in the validation cohort were 0.841 (95% confidence interval [CI] 0.672, 1.000) and 0.839 (95% CI: 0.674, 0.929), respectively. Calibration curves and DCA showed that the model was beneficial for patients.

CONCLUSION

The multivariable prediction model exhibited good predictive performance and may facilitate preoperative planning.

Effect of tibial nerve mobilization on balance & gait functions in subjects with subclinical diabetic neuropathy: A randomized clinical trial

Introduction

With advancing age, balance control diminishes as a result of cognitive impairment, decreased muscle strength, and impairment in visual, vestibular, and somatosensory systems. Besides aforesaid factors, the addition of diabetes to all these leads to balance and gait-related issues such as falls and fall-related injuries. Impaired balance and gait performance in diabetics are primarily attributed to the diminished sensory function of the foot and ankle region owing to diabetic neuropathy. The purpose of this study was to explicitly examine the impact of neural mobilization on the balance & gait functions of subjects having subclinical diabetic neuropathy.

Methods

40 individuals with subclinical diabetic neuropathy, ranging in age from 50 to 75 years, were assigned to two groups at random: Group 1 received the concurrent application of Tibial nerve mobilization and Balance-Gait training whereas Group 2 received only Balance-Gait training. The therapy was administered five times each week, for four weeks. On the first and last day of treatment, measurements of VPT, BBS, TUG, and DGI were taken from each subject.

Results

The results of the study found that post neural mobilization and Balance-Gait training, scores of VPT, BBS, DGI, and TUG showed improvement but it was not significant. As it is evident that diabetic neuropathy is progressive in nature, even small changes can be helpful.

Conclusion

Neural mobilization integrated with balance-gait training of subclinical diabetic neuropathic individuals resulted in improved sensory functions along with enhanced balance-gait functions.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40200-023-01246-w.

Usefulness of optic nerve sheath diameter measurement in hypertensive patients during pregnancy and the puerperium

Pre-eclampsia/eclampsia during pregnancy and the puerperium are major risk factors for maternal and perinatal morbidity and mortality worldwide. Early diagnosis followed by appropriate treatment can prevent neurological disorders, considered one of the most serious sequelae of the disease. The detection of increased intracerebral pressure through the use of ocular ultrasonography could be considered an effective method for its diagnosis, since it has the advantage of being a noninvasive technique, easy to perform at the patient's bedside and with a high sensitivity and specificity for the detection of intracranial hypertension.

[Report of two cases of anti-LGI1 autoimmune encephalitis in Mexico]

Background: Anti-LGI1 encephalitis is characterized by a pattern of inflammation that predominantly affects the limbic system It is part of the autoimmune encephalitis that attack neuronal surface antigens. It is characterized by the triad of subacute dementia, faciobrachial dystonic crises, and hyponatremia, presenting an excellent response to immunotherapy. The aim of this article is to describe the clinical evolution and functional outcome at 6 months of two patients with anti-LGI1 encephalitis using clinical cases.

Clinical cases

Case 1: 62-year-old man with 8-week symptoms manifested by changes in mood, disorientation, and focal motor seizures. Case 2 A 72-year-old woman with a 5-month evolution of rapidly progressive dementia, hyponatremia and bitemporal hyperintensities on MRI. In both, due to clinical suspicion, acute dual immunotherapy with steroid and immunoglobulin was given with substantial improvement. Subsequently, the existence of anti-LGI1 antibodies in cerebrospinal fluid was confirmed. Although both patients received a dose of rituximab during their hospitalization, only the patient in the first case continued biannual doses of rituximab. The second patient was not initially considered to continue long-term immunomodulatory treatment and experienced a relapse.

Conclusions

These clinical vignettes present the reader with the classic characteristics of this disease. This can facilitate its recognition and timely initiation of treatment, improving the functional prognosis of patients.

Mapping physical activity patterns in hospitalised patients with moderate to severe acquired brain injury - MAP-ABI: Protocol for an observational study

Introduction

The physical activity level in patients hospitalised for rehabilitation across multiple diagnoses is low. Moderate to severe acquired brain injury further reduces activity levels as impaired physical and cognitive functioning affect mobility independence. Therefore, supervised out-of-bed mobilisation and physical activity training are essential rehabilitation strategies. Few studies have measured the physical activity patterns in the early phases of rehabilitation after moderate to severe brain injury.

Objectives

To map and quantify physical activity patterns in patients admitted to brain injury rehabilitation. Further, to investigate which factors are associated with activity and if the early physical activity level is associated with functional outcome at discharge.

Methods

This observational study includes patients admitted to rehabilitation after moderate to severe acquired brain injury. Mobility and physical activity patterns are measured continuously during rehabilitation at two separate seven-day periods using a wearable activity tracker. Activity will be categorised into four levels and presented descriptively. Linear and logistic regression models will analyse associations between descriptive variables and activity levels.

Discussion

This protocol describes an observational study investigating patients' mobility and physical activity patterns with moderate to severe acquired brain injury during in-hospital rehabilitation. The ability to increase the amount of mobilisation and physical activity in subgroups may have profound consequences on the rehabilitation outcome. Furthermore, data from this study may be used to inform a large variety of trials investigating physical rehabilitation interventions. (NCT05571462).

Association of white matter hyperintensities with migraine phenotypes and response to treatment

INTRODUCTION

White matter hyperintensities (WMHs) are frequently found in migraineurs. However, their clinical significance and correlation to different migraine phenotypes and treatment responses are not well defined. The study aimed to examine the association of WMHs with migraine clinical patterns and treatment response.

AIM OF WORK

We aimed to evaluate the association between WMHs and migraine phenotypes and explore the relationship of WMHs to treatment response.

METHODS

Our cross-sectional study formed of 500 migraineurs who sought treatment in Kafr el-sheik university hospital and underwent (3 T) MRI to evaluate WMHs. Different migraine phenotypes were compared between patients with and without WMHs. According to reduced headache pain intensity and frequency, these patients were divided into treatment responder and non-responder groups.

RESULTS

A total of 145 patients (29%) had WMHs. Patients with WMHs were significantly older, had a longer disease duration, and higher attack frequency. Patients who did not respond to acute and maintenance medications had a higher frequency of WMHs and high WMHs Scheltens score. Migraine with Aura and the presence of vomiting and dizziness were predictors for the development of WMHs.

CONCLUSION

WMHs are more common in migraine with aura. It is more frequent in migraine associated with vomiting and dizziness. WMHs increased with advancing age and more severe disease burden. Poorer response to acute and prophylactic medications was found in patients with WMHs.

Integrated Neurosurgical Management of Retroperitoneal Benign Nerve Sheath Tumors

Peripheral nerve sheath tumors (PNST) of the retroperitoneum are rare and are often treated by general surgeons dealing with retroperitoneal cancers. However, resection without the correct microsurgical technique can cause permanent neurological deficits and pain. Here, we discuss our interdisciplinary approach based on the integration of expertise from neurosurgery and abdominal surgery, allowing for both safe exposure and nerve-sparing microsurgical resection of these lesions. We present a series of 15 patients who underwent resection of benign retroperitoneal or pelvic PNST at our institution. The mean age of patients was 48.4 years; 67% were female. Tumors were 14 schwannomas and 1 neurofibroma. Eight patients (53%) reported neurologic symptoms preoperatively. The rate of complete resection was 87% (n = 13); all symptomatic patients showed improvement of their preoperative symptoms. There were no postoperative motor deficits; one patient (7%) developed a permanent sensory deficit. At a mean postoperative follow-up of 31 months, we observed no recurrences. To our best knowledge, this is the second-largest series of benign retroperitoneal PNST consistently managed with microsurgical techniques. Our experience confirms that interdisciplinary management allows for safe treatment of these tumors with good neurological and oncological outcomes.

Differentiation of retroperitoneal paragangliomas and schwannomas based on computed tomography radiomics

The purpose of this study was to differentiate the retroperitoneal paragangliomas and schwannomas using computed tomography (CT) radiomics. This study included 112 patients from two centers who pathologically confirmed retroperitoneal pheochromocytomas and schwannomas and underwent preoperative CT examinations. Radiomics features of the entire primary tumor were extracted from non-contrast enhancement (NC), arterial phase (AP) and venous phase (VP) CT images. The least absolute shrinkage and selection operator method was used to screen out key radiomics signatures. Radiomics, clinical and clinical-radiomics combined models were built to differentiate the retroperitoneal paragangliomas and schwannomas. Model performance and clinical usefulness were evaluated by receiver operating characteristic curve, calibration curve and decision curve. In addition, we compared the diagnostic accuracy of radiomics, clinical and clinical-radiomics combined models with radiologists for pheochromocytomas and schwannomas in the same set of data. Three NC, 4 AP, and 3 VP radiomics features were retained as the final radiomics signatures for differentiating the paragangliomas and schwannomas. The CT characteristics CT attenuation value of NC and the enhancement magnitude at AP and VP were found to be significantly different statistically (P < 0.05). The NC, AP, VP, Radiomics and clinical models had encouraging discriminative performance. The clinical-radiomics combined model that combined radiomics signatures and clinical characteristics showed excellent performance, with an area under curve (AUC) values were 0.984 (95% CI 0.952-1.000) in the training cohort, 0.955 (95% CI 0.864-1.000) in the internal validation cohort and 0.871 (95% CI 0.710-1.000) in the external validation cohort. The accuracy, sensitivity and specificity were 0.984, 0.970 and 1.000 in the training cohort, 0.960, 1.000 and 0.917 in the internal validation cohort and 0.917, 0.923 and 0.818 in the external validation cohort, respectively. Additionally, AP, VP, Radiomics, clinical and clinical-radiomics combined models had a higher diagnostic accuracy for pheochromocytomas and schwannomas than the two radiologists. Our study demonstrated the CT-based radiomics models has promising performance in differentiating the paragangliomas and schwannomas.

Traumatic Brain Injury in Select Low- and Middle-Income Countries: A Narrative Review of the Literature

Low- and middle-income countries (LMICs) experience the majority of traumatic brain injuries (TBIs), yet few studies have examined the epidemiology and management strategies of TBI in LMICs. The objective of this narrative review is to discuss the epidemiology of TBI within LMICs, describe the adherence to Brain Trauma Foundation (BTF) guidelines for the management of severe TBI in LMICs, and document TBI management strategies currently used in LMICs. Articles from January 1, 2009 to September 30, 2021 that included patients with TBI greater than 18 years of age in low-, low middle-, and high middle-income countries were queried in PubMed. Search results demonstrated that TBI in LMICs mostly impacts young males involved in road traffic accidents. Within LMICs there are a myriad of approaches to managing TBI with few randomized controlled trials performed within LMICs to evaluate those interventions. More studies are needed in LMICs to establish the effectiveness and appropriateness of BTF guidelines for managing TBI and to help identify methods for managing TBI that are appropriate in low-resource settings. The problem of limited pre- and post-hospital care is a bigger challenge that needs to be considered while addressing management of TBI in LMICs.

The Use of Tele-Occupational Therapy for Children and Adolescents with Different Disabilities: Systematic Review of RCT Articles

Background

Due to the limited access of clients in non-urban areas to rehabilitation and the difficulty of specialized counseling in such conditions, the need for telehealth services has increased. The purpose of this study is to evaluate the effectiveness of Tele occupational therapy in common disorders of children and adolescents.

Methods

In this systematic review study, a research method published from 2010 to 2022 focusing on the effectiveness of tele-rehabilitation and its impact on children and adolescents with different physical disabilities was done in Google Scholar, PubMed, Scopus and EMBASE databases. 467 articles were obtained in the review, and finally, 18 articles were reviewed.

Results

In children with CP, Tele occupational therapy will be effective on gross motor function and balance skills, but the impact on the executive function needs more studies. In children with ASD, it will be effective on behavioral problems, but the effect on pro-social behavior needs further studies. In children and adolescents with other movement disorders, it will have an impact on the progress of their physical activity and in children and adolescents with Traumatic Brain Injury (TBI), it will be effective, but the effectiveness of MitiiTM programs needs further studies.

Conclusion

The findings of this study showed that tele-occupational therapy could be performed in line with face-to-face occupational therapy, and it can lead to the satisfaction of families, but there is still a need to assess the effectiveness of various interventions and tools on different disorders, outcomes and settings.

Huge adrenal schwannoma: a rare type of adrenal tumor, misconceived as adrenocortical carcinoma

Schwannoma is a benign and uncommon neoplasm arising from the neural crest cells. The most common tumor sites are the skin and subcutaneous tissue of the head and neck. Retroperitoneal schwannomas account for 1–3% of all schwannomas and are predominantly female. In particular, adrenal schwannoma is very rare, and due to its large size at the time of diagnosis, adrenal schwannoma is frequently misdiagnosed as adrenocortical carcinoma or pheochromocytoma. Adrenal schwannoma is difficult to distinguish it from other adrenal diseases based on imaging findings alone. In this report, we introduce the case of a huge left adrenal schwannoma.

Which motor-cognitive abilities underlie the digital Trail-Making Test? Decomposing various test scores to detect cognitive impairment in Parkinson's disease-Pilot study

Since Parkinson's disease (PD) is a heterogeneous disorder with symptoms, such as tremors, gait and speech disturbances, or memory loss, individualized diagnostics are needed to optimize treatment. In their current form, the typical paper-pencil methods traditionally used to track disease progression are too coarse to capture the subtleties of clinical phenomena. For this reason, digital biomarkers that capture, for example, motor function, cognition, and behavior using apps, wearables, and tracking systems are becoming increasingly established. However, given the high prevalence of cognitive impairment in PD, digital cognitive biomarkers to predict mental progression are important in clinical practice. This pilot study aimed to identify those components of our digital version of the TMT (dTMT) that allow discrimination between PD patients with and without cognitive deficits. A total of 30 healthy control (age 66.3 ± 8.61) and 30 participants with PD (age 68.3 ± 9.66) performed the dTMT using a touch-sensitive tablet to capture enhanced performance metrics, such as the speed between and inside circles. The decomposition of cognitive abilities based on integrating additional variables in the dTMT revealed that the Parkinson's disease group was significantly more sensitive to parameters of inhibitory control. In contrast, the mild cognitive impairment group was sensitive to parameters of cognitive flexibility and working memory. The dTMT allows objective, ecologically valid, and long-term cognitive and fine-motor performance tracking, suggesting its potential as a digital biomarker in neurodegenerative disorders.

Caregiver Burden in Caregivers of Stroke Survivors: A Hospital-Based Study

Background

A principal caregiver (CG) is directly affected by the patient's health problems leading to CG strain. In the present study, we evaluated the different factors related to increased CG burden in stroke survivors and assessed the relationship between patient's personal and clinical characteristics and CG's stress.

Material and Methods

In this prospective, follow-up study, a total of 141 principle CGs of 164 First-ever stroke (FES) survivors were subjected to the Caregivers Strain Index (CSI) and Oberst Caregiving Burden Scale (OCBS) at 30 days (n = 141), 90 days (n = 129), and 6 months (n = 119) after informed consent. Patients were subjected to modified Rankin Scale (mRS) and Barthel index score assessment at the end of 30 days.

Results

The mean age of CG was 49.8 ± 21.0 years, approximately 20 years lesser than that of the patients. 102 (72.34%) CGs were females. Urinary incontinence (p < 0.006) morbidity at 30 days, mRS (p = 0.004), and moderate to the severe neurological deficit on admission (p = 0.003) were the patient factors in FES cases leading to significant CGs stress. CG factors responsible for major stress were long caregiving hours (P < 0.001), anxiety (P < 0.001), disturbed night sleep (P < 0.001), financial stress (P < 0.001), younger age (P = 0.002), and CGs being daughters-in-law (P = 0.039).

Conclusion

CG burden increases with increased severity of stroke. Integrated stroke rehabilitation services should also address CGs issues along with patients.

Does complete regression of intraneural ganglion cysts occur without surgery?

PURPOSE

The dynamic nature of intraneural ganglion cysts, including spontaneous expansion and regression, has been described. However, whether these cysts can regress completely in the absence of surgical management has important therapeutic implications. Therefore, we aim to review the literature for cyst regression without surgical intervention.

METHODS

We reviewed our database of 970 intraneural ganglion cysts in the literature to search for evidence of complete regression based on strict radiologic confirmation, either spontaneously, or after percutaneous cyst aspiration or steroid injection.

RESULTS

We did not find any examples of complete regression without surgical treatment that met inclusion criteria. Spontaneous regression was reported in four cases; however, only two cases had follow-up imaging, both of which demonstrated residual cysts. Nineteen cases of percutaneous intervention were found in the literature, 13 of which reported clinical improvement following aspiration/steroid injection; however, only seven cases had available imaging. Only two cases reported complete resolution of cyst on MR imaging at follow-up, but reinterpretation found residual intraneural cyst in both cases.

CONCLUSION

We believe that pathology (structural abnormalities and/or increased joint fluid) always exists at the joint origin of intraneural ganglion cysts which persist even with regression of the cyst. The persistence of a capsular abnormality or defect can lead to recurrence of the cyst in the future, and while imaging may show dramatic decreases in cyst size, truly focused assessment of images will show a tiny focus of persistent intraneural cyst at the joint origin. Thus, expectant management or percutaneous intervention may lead to regression, but not complete resolution, of intraneural ganglion cysts.

An incidental finding of retroperitoneal paraganglioma during the coronavirus disease 2019 pandemic: a case report

Background

Extra-adrenal paraganglioma of the retroperitoneum is a very rare neoplasm arising from cells of the primitive neural crest. Although paragangliomas are considered benign and are often found incidentally, they have the potential to metastasize.

Case presentation

We report the case of a 68-year-old Caucasian woman with an incidental diagnosis of retroperitoneal paraganglioma that was discovered on chest computed tomography performed for high suspicion of coronavirus disease 2019 pneumonia. The patient showed no metastasis and was successfully treated by complete surgical removal of the tumor.

Conclusion

As the diagnosis of paragangliomas is often delayed because of absent clinical symptoms, they represent a significant diagnostic challenge. Although surgery may exacerbate coronavirus disease 2019 infection, surgical resection of this tumor is prioritized, given its malignancy potential, and it must be performed as soon as no infection is detected.

A rationally identified panel of microRNAs targets multiple oncogenic pathways to enhance chemotherapeutic effects in glioblastoma models

Glioblastoma (GBM) is the most common malignant brain tumor. Available treatments have limited success because most patients develop chemoresistance. Alternative strategies are required to improve anticancer effects of current chemotherapeutics while limiting resistance. Successful targeting of microRNAs (miRNAs) as regulators of gene expression can help reprogram GBM cells to better respond to chemotherapy. We aimed to identify a panel of miRNAs that target multiple oncogenic pathways to improve GBM therapy. We first identified differentially expressed miRNAs and tested if their target genes play central roles in GBM signaling pathways by analyzing data in the Gene Expression Omnibus and The Cancer Genome Atlas databases. We then studied the effects of different combinations of these miRNAs in GBM cells by delivering synthetic miRNAs using clinically compatible PLGA-PEG nanoparticles prior to treatment with temozolomide (TMZ) or doxorubicin (DOX). The successful miRNA panel was tested in mice bearing U87-MG cells co-treated with TMZ. We identified a panel of five miRNAs (miRNA-138, miRNA-139, miRNA-218, miRNA-490, and miRNA-21) and their oncogenic targets (CDK6, ZEB1, STAT3, TGIF2, and SMAD7) that cover four different signaling pathways (cell proliferation and apoptotic signaling, invasion and metastasis, cytokine signaling, and stemness) in GBM. We observed significant in vitro and in vivo enhancement of therapeutic efficiency of TMZ and DOX in GBM models. The proposed combination therapy using rationally selected miRNAs and chemotherapeutic drugs is effective owing to the ability of this specific miRNA panel to better target multiple genes associated with the hallmarks of cancer.

Solid Primary Retroperitoneal Masses in Adults: An Imaging Approach

Mass lesions in the retroperitoneal space may be primary or secondary. Primary retroperitoneal mass lesions are relatively uncommon as compared to pathology that arises secondarily from retroperitoneal organs. These may be solid or cystic lesions. The overlapping imaging features of various solid primary retroperitoneal tumors make the diagnosis difficult, and hence, histopathology remains the mainstay of diagnosis. This paper provides a brief review of the anatomy of the retroperitoneal space and provides an algorithmic approach based on cross-sectional imaging techniques to narrow down the differential diagnosis of solid primary retroperitoneal masses encountered in the adult population.

Empirical evidence for biometal dysregulation in Parkinson's disease from a systematic review and Bradford Hill analysis

The Bradford Hill model evaluates the causal inference of one variable on another by assessing whether evidence of the suspected causal variable aligns with a set of nine criteria proposed by Bradford Hill, each representing fundamental tenets of a causal relationship. The aim of this study was to use the Bradford Hill model of causation to assess the level of empirical evidence supporting our hypotheses that alterations to iron and copper levels, and iron- and copper-associated proteins and genes, contribute to Parkinson’s disease etiology. We conducted a systematic review of all available articles published to September 2019 in four online databases. 8437 articles matching search criteria were screened for pre-defined inclusion and exclusion criteria. 181 studies met study criteria and were subsequently evaluated for study quality using established quality assessment tools. Studies meeting criteria for moderate to high quality of study design (n = 155) were analyzed according to the Bradford Hill model of causation. Evidence from studies considered of high quality (n = 73) supported a causal role for iron dysregulation in Parkinson’s disease. A causal role for copper dysregulation in Parkinson’s disease was also supported by high quality studies, although substantially fewer studies investigated copper in this disorder (n = 25) compared with iron. The available evidence supports an etiological role for iron and copper dysregulation in Parkinson’s disease, substantiating current clinical trials of therapeutic interventions targeting alterations in brain levels of these metals in Parkinson’s disease.

Schwannoma in and around the porta hepatis: radiological features in eight cases and literature review

PURPOSE

Schwannomas in and around the porta hepatis (porta hepatic schwannomas) are rare benign tumors easily misdiagnosed as other pathologies, including malignancies. We aimed to evaluate their imaging features on ultrasonography, computed tomography (CT), magnetic resonance imaging (MRI), and ¹⁸F-fluorodeoxyglucose-positron emission tomography/CT (FDG-PET/CT).

METHODS

We performed a multi-institutional retrospective study by reviewing the clinical and imaging findings of pathologically proven eight porta hepatic schwannomas (mean age, 55 years; range, 38-80 years; one male and seven females). Preoperative imaging included three ultrasonography, eight CT, eight MRI, and two FDG-PET/CT.

RESULTS

All patients were asymptomatic. The mean tumor size was 61.9 mm (range, 30-180 mm), and all tumors demonstrated well-defined lesions on ultrasonography and their solid components showed soft tissue attenuation on non-contrast CT. MRI showed two distinct components in all cases: the component with T1-weighted hypointensities and T2-weighted hyperintensities with poor enhancement (suggestive of Antoni B histology); the component with T2-weighted hypointensities with gradually increasing enhancement (suggestive of Antoni A histology), resulting in a heterogeneous pattern on post-contrast CT or MRI (8/8, 100%). The separated deviation of surrounding bile ducts and vessels without obstruction allowed the recognition of extrahepatic localization and their benign nature. A ginger root-like morphology (2/8, 25%) seemed to be suggestive of extension along the Glisson's sheath, although this finding was not seen frequently.

CONCLUSION

Recognizing imaging features such as extrahepatic location, benign nature with internal structures suggestive of Antoni A/B histology, and characteristic tumor extension may provide key diagnostic clues for porta hepatic schwannomas.

Imaging findings of retroperitoneal anastomosing hemangioma: a case report and literature review

Background

Anastomosing hemangioma is an uncommon benign vascular tumor that may be mistaken for a malignancy. The imaging findings of anastomosing hemangioma are not well provided from the previous reports. Herein, in the study, we discuss the imaging findings for one case of retroperitoneal anastomosing hemangioma.

Case presentation

One 64-year-old female patient had a left retroperitoneal mass that was incidentally detected upon physical examination. A hypoechoic mass with abundant blood flow signals was found by US in the perirenal space. CT and MRI detected a large cystic and solid lesion in the left retroperitoneal space. Plain CT indicated that the internal density was uneven, and the pattern of enhancement was obvious and progressive. MRI-T2WI showed high intensity, DWI showed isointensity, and the mass also showed obvious progressive enhancement. Finally, anastomosing hemangioma was diagnosed via histopathological studies.

Conclusion

As a rare and benign tumour, anastomosing hemangioma is easily misinterpreted. We suggest that the observation of “genitourinary tract related, well defined, hyperintensity or isointensity on T2WI, isointensity on DWI, and obvious progressive enhancement patterns likely to the vascular enhancement” may consider the diagnosis of AH.

Vaccines and myasthenia gravis: a comprehensive review and retrospective study of SARS-CoV-2 vaccination in a large cohort of myasthenic patients

Introduction

Myasthenia gravis (MG) is an autoimmune disease, for which the risk of exacerbation after vaccines is debated. The aim of this study is to review the available literature concerning safety and efficacy of vaccines in MG. In addition, we also conducted a retrospective research of MG exacerbations and new onset MG after anti-SARS-CoV-2 vaccination in a large cohort of patients.

Methods

A study of the available literature regarding vaccines and MG was carried out through research in the online database “Pubmed”. We also retrospectively collected data from 80 MG patients, who were followed at the Treviso Hospital and completed an anti-SARS-CoV-2 vaccination cycle. For each patient, we recorded MG exacerbations between first and second doses and within a window period of 1 day – 6 weeks after the second dose.

Results

We found 26 relevant articles about influenza, SARS-CoV-2 and other vaccines. No clear associations between most vaccines and MG exacerbations were found. Moreover, cases of new onset post-vaccine MG are mostly anecdotal, except for Japanese encephalitis virus vaccine. Concerning our cohort, 4/80 (5%) MG patients experienced an exacerbation within the post-vaccine window period. In addition, we report a case of new onset post-vaccine MG.

Discussion

Inactivated and subunit vaccines are safe and effective in MG. Although some of them, such as anti-SARS-CoV-2 vaccine, might uncommonly cause MG exacerbations, data from our review suggest that benefits still outweigh by far the potential risks, thus they should be recommended to these patients. Nevertheless, large prospective studies are needed for further investigations.

Risk factors of white matter hyperintensities in migraine patients

Background

Migraine frequently is associated with White Matter Hyperintensities (WMHs). We aimed to assess the frequency of WMHs in migraine and to assess their risk factors.

Methods

This is cross-sectional study included 60 migraine patients of both genders, aged between 18 and 55 years. Patients with vascular risk factors were excluded. We also included a matched healthy control group with no migraine. Demographic, clinical data, and serum level of homocysteine were recorded. All subjects underwent brain MRI (3 Tesla).

Results

The mean age was 38.65 years and most of our cohort were female (83.3). A total of 24 migraine patients (40%) had WMHs versus (10%) in the control group, (P < 0.013). Patients with WMHs were significantly older (43.50 + 8.71 versus. 35.92+ 8.55 years, P < 0.001), have a longer disease duration (14.54+ 7.76versus 8.58+ 6.89 years, P < 0.002), higher monthly migraine attacks (9.27+ 4. 31 versus 7.78 + 2.41 P < 0.020) and high serum homocysteine level (11.05+ 5.63 versus 6.36 + 6.27, P < 0.006) compared to those without WMHs. WMHs were more frequent in chronic migraine compared to episodic migraine (75% versus 34.6%; P < 0.030) and migraine with aura compared to those without aura (38.3% versus 29,2; P < 0.001). WMHs were mostly situated in the frontal lobes (83.4%), both hemispheres (70.8%), and mainly subcortically (83.3%).

Conclusion

Older age, longer disease duration, frequent attacks, and high serum homocysteine level are main the risk factors for WMHs in this cohort. The severity or duration of migraine attacks did not increase the frequency of WMHs. The number of WMHs was significantly higher in chronic compared to episodic migraineurs.

Seeking healthcare services post-stroke: a qualitative descriptive study exploring family caregiver and stroke survivor perspectives in an asian setting

Aim

Exploration of the healthcare journey post-stroke is incomplete without acknowledging the crucial role of family caregivers. With limited literature documenting the role of caregivers in the healthcare journey post-stroke, we aimed to describe the healthcare experiences of family caregivers and stroke survivors across different caregiver identities in Singapore.

Methods

We conducted a qualitative descriptive study involving semi-structured interviews with transcripts analysed using thematic analysis. 26 stroke survivors and 35 family caregivers purposively sampled from multiple settings.

Results

Findings were summarized into seeking care and experience of healthcare encounters. Seeking care comprised of the following themes: factors influencing seeking care, decision to seek care and role of caregiver in seeking care. Experience of healthcare encounters comprised of the following themes: service around the patient, service with care and role of caregiver in healthcare encounters.

Conclusion

Multi-dimensional role of caregivers in healthcare experience emerged as a major finding. Unique to our Asian context, as per the participants’ accounts, family caregivers seemed to be central in healthcare decision-making for stroke survivors, with adult-child caregivers commonly reported being engaged in collaborative decision-making. While spousal caregivers preferred a relational healthcare experience, adult-child caregivers preferred a transactional one. Practical implications include equipping caregivers with skillset to make healthcare decisions, provision of supportive decision-making environment for caregivers and reinforcing communication aspects in the medical, nursing and allied healthcare curriculum to improve healthcare experience.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12883-021-02463-7.

Adrenal Schwannoma: A Case Report

Schwannoma of the adrenal gland is very rare, comprising 0.2% of adrenal tumors, presenting usually as non-specific abdominal pain. We report such a rare case in a 50-year-old female. Her only complaint was right lumbar pain. Ultrasonography (USG) and computed tomography (CT) both showed a supra renal cystic mass most likely of adrenal origin. Excision of mass was performed. Post-operative course was uneventful. Histopathology showed a benign tumor of Schwann cell origin. Usually, pre-operative imaging including CT and magnetic resonance imaging (MRI) are inconclusive and diagnosis has to be confirmed on histopathology.

Neuroimaging Features and Associated Factors in Multiple Sclerosis Patients: A Perspective from a Private Care Center in Addis Ababa, Ethiopia

BACKGROUND

Brain and spine magnetic resonance image (MRI) have an invaluable importance in diagnosing multiple sclerosis (MS) in low prevalence countries such as Ethiopia. The objective of our study was to characterize the neuroimaging features and associated factors in Multiple sclerosis patients in Addis Ababa, Ethiopia.

METHOD

A cross-sectional observational study was conducted in 30 multiple sclerosis patients at Yehuleshet Specialty Clinic, Addis Ababa, Ethiopia. Both descriptive and analytical statistics were used to analyze the data.

RESULTS

We have enrolled 30 patients with confirmed multiple sclerosis and clinically isolate syndrome. The mean age was 34.7 years (1SD=8.9). Female accounted 86.7%. The mean duration of illness was 3.4 years (1SD=3.1) (range: 1 - 11 years). Relapsing and remitting variant was the commonest sub type (66.7%). Alcohol use and head injury were the commonest identified risk factors reported by the patients. Classical radiological features of MS such as white matter lesions involving juxtacortical, U-fiber, corpus callosum (CC), and Dawson's finger projections pattern were observed in 46.7%, 23.3%, 70%, and 40% respectively. Cervical and thoracic cords were affected in 40% and 6.7% respectively. Global cortical and CC atrophy was observed in 16.7% and 6.7% respectively. Advanced age was associated with lesions of corpus callosum when adjusted for duration of illness and history of head injury (AOR 1.13, 95% CI 1.01-1.28, p=0.04).

CONCLUSION

Typical neuroimaging features of MS were prevalent among Ethiopian MS patients. Age was an independent predictor of lesions involving corpus callosum. Global cortical atrophy was common among Ethiopian MS patients.

Diagnostic Dilemma of Retroperitoneal Schwannomas Encountered in a Specialized Gynecology Hospital

BACKGROUND

This study analyzed the potential diagnosis and therapeutic challenges of retroperitoneal schwannoma (RSs) in a specialized gynecology hospital.

METHODS AND MATERIALS

A retrospective review was performed in our hospital from 2000 to 2018. A literature search of RSs was conducted using PubMed database.

RESULTS

45 patients were identified (22 from our hospital and 23 from the literature review). The majority of patients presented asymptomatic (22/45). Among them, 25 cases were misdiagnosed as adnexal cysts, 13 uterine fibroids, 1 ovarian malignancy and 6 pelvic masses. Intraoperative exploration revealed that the masses were located in the retroperitoneal space. The median diameter was 6.2 cm (range 3.0-9.8 cm) in our hospital compared with 9.3 cm (6-15 cm) in literature review. Complete resection was performed in 37 patients and subtotal resection in 8 patients. The pathological results confirmed the diagnosis of benign schwannoma and no recurrence was found in the follow-up data.

CONCLUSION

The preoperative diagnosis of RSs is difficult to make because of its nonspecific characteristics. In a specialized gynecology hospital, it is more important to differentiate the benign and malignant of mass before surgery. Surgical complete resection of tumor is recommended and recurrence is unusual after complete resection.

Adrenal schwannoma: A case report of an unusual incidentaloma

Introduction and importance

Adrenal schwannomas are extremely rare tumors often misdiagnosed. The patients are usually asymptomatic while some present with non-specific abdominal pain. Only a few cases are reported to date.

Case presentation

We here present a case of a 55-year-old Nepalese man presented with nonspecific abdominal pain at our Outpatient Department (OPD) found to have mass on ultrasonography of abdomen. On further investigation with Contrast Enhanced Computerized Tomography (CECT) of the abdomen and pelvis, a well-defined heterogeneous adrenal mass of size (7.8 ∗ 8.3 ∗ 6) cm with foci of calcification was seen in the left retroperitoneum. The intraoperative finding of adrenal mass and histopathology of resected mass was suggestive of schwannoma arising from the adrenal gland which was further confirmed by immunohistochemistry.

Clinical discussion

Adrenal schwannoma can mimic tumors like pheochromocytoma, adrenal adenoma, cortical carcinoma, neuroblastoma, and other masses. Only 1–3% of schwannomas are retroperitoneal. Radiological findings of this tumor are non-suggestive. The histological section shows spindle cells with Antoni A and Antoni B regions while positive staining of S-100 protein in Immunohistochemistry.

Conclusion

The diagnosis of adrenal schwannoma in the retroperitoneum is often challenging. The treatment of choice is surgical resection with a good prognosis.

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Adrenal schwannomas are extremely rare tumors.

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These tumors are mostly found incidentally and often asymptomatic.

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Complete surgical resection of the tumor is a must for good prognosis.

Update on MR Imaging of cystic retroperitoneal masses

OBJECTIVE

This article reviews the MRI appearance of cystic retroperitoneal (RP) masses.

CONCLUSION

Lymphangiomas are the most common RP cystic masses and typically appear simple; microscopic fat is a specific but insensitive finding. Location, internal complexity, and enhancement pattern suggest alternative diagnoses which range from normal anatomic variants to congenital abnormalities and importantly include benign, neurogenic, and malignant neoplasms. An approach to the MR imaging of cystic RP masses is presented.

The value of multiparameter 18F-FDG PET/CT imaging in differentiating retroperitoneal paragangliomas from unicentric Castleman disease

The aim of this study was to investigate the value of multiple parameters retrieved from the FDG PET/CT studies, including SUVmax, SUVmean, SUVpeak, MTV, TLG, tumour size in differentiating retroperitoneal paragangliomas from UCD. 28 patients with solitary retroperitoneal masses who had undergone preoperative ¹⁸F-FDG PET/CT were retrospectively evaluated. Histopathology by surgical resection confirmed 17 paragangliomas and 11 UCDs. SUVmax, SUVmean, SUVpeak, MTV, TLG, and tumour size of ¹⁸F-FDG PET/CT were measured for each patient. Mann–Whitney U-test was used to assess differences in multiple parameters between paragangliomas and UCDs. The ROC curve analysis was performed to determine the differential diagnostic value of these parameters. Paragangliomas presented significantly higher SUVmax (P < 0.001), SUVmean (P = 0.001), SUVpeak (P < 0.001), and TLG (P = 0.024) than UCDs, whereas no significant difference was observed in MTV. The AUCs for differentiating paragangliomas and UCDs were 0.920, 0.888, 0.909, and 0.765 for SUVmax, SUVmean, SUVpeak, and TLG, respectively. The SUVmax cut-off of 7.75 yielded 82.4% sensitivity and 100% specificity for predicting paragangliomas. This study indicated that ¹⁸F FDG PET/CT-derived multiple metabolic parameters are useful in distinguishing between paragangliomas and UCDs. SUVmax showed the best result for the differential diagnosis of these two diseases among multiple metabolic parameters.

Retroperitoneal schwannoma sandwiched between abdominal aorta and inferior vena cava. A case report

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Retroperitoneal schwannomas in the abdominal cavity are rare and pose difficulty in preoperative diagnosis and management.

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Imaging modalities are usually not sufficient to conclude a diagnosis.

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EUS-FNA is useful to confirm preoperative diagnosis.

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In EUS-FNA, diagnosis can be accurate if the tumor size is small and tumor is devoid of intratumoral degenerations.

Introduction

Schwannomas are tumors that originate from the Schwann cells present in the nerve sheath of peripheral nerves. They are commonly seen in cephalocervical areas. Schwannomas in the abdominal cavity are rare. Here, we discuss a case of retroperitoneal schwannoma lying dorsal to pancreas with critical relations to surrounding vessels.

Presentation of case

A 74 years old asymptomatic male was found with elevated amylase level on his routine blood examination. MR imaging revealed retroperitoneal mass of size 21*18*24 mm. EUS-FNA confirmed retroperitoneal schwannoma. The patient had co-morbid renal disease and was on hemodialysis. During the latest follow up, the tumor was 41*37*41 mm in size located dorsal to the confluence of right renal vein and inferior vena cava. The tumor was in contact with inferior vena cava, horizontal part of duodenum, right renal artery, right kidney, and adrenal gland. The patient underwent laparotomy and the tumor was extract with intact capsule. There were no post-operative complications.

Discussion

Pre-operative diagnosis in retroperitoneal schwannomas is challenging because imaging features are usually non-specific, and biopsy is the only diagnostic technique. EUS-FNA, which has low diagnostic accuracy, is useful in pre-operative diagnosis of small tumors devoid of intra-tumoral degeneration.

Conclusion

Retroperitoneal schwannoma is a rare entity. Preoperative diagnosis and curative resection are technically difficult. Care should be given during preoperative investigations and surgical resection of the tumor. EUS-FNA can be a useful diagnostic tool.

Assessing emergence from a prolonged disorder of consciousness: Current opinion and practice in the UK

BACKGROUND

A patient in PDOC must demonstrate functional object use or functional communication to confirm they have emerged from this state. A range of tasks and stimuli are used and patients must achieve 100% accuracy. As consciousness occurs along a continuum, determining emergence is not straightforward.

OBJECTIVE

To establish the opinions of expert clinicians on how emergence is determined in practice.

METHODS

An online survey was completed by clinicians working in specialist rehabilitation settings across the UK. Questions were asked about diagnosis and confidence, informal assessment, formal assessment, and family involvement. Descriptive statistics were used to analyse responses to closed questions. Responses to open questions were analysed using thematic analysis.

RESULTS

Seventy-five surveys were analysed. Approximately a third (30.4 %) used tasks other than those recommended to determine emergence. A lack of confidence in tasks to detect the return of functional communication was reported by 46.4%. The majority (78.6%) reported they worked with patients who they felt had emerged, but could not demonstrate it based on the current criteria. A range of stimuli were employed, but 30.6% of respondents were not confident they could choose stimuli appropriately. Respondents reported a range of benefits and challenges when involving family in assessment.

Adrenal schwannoma: a case report

Retroperitoneum is an uncommon site for Schwannoma tumors and among adrenal incidentaloma the Schwannoma is rare. This condition lacks of a specific clinical and radiological features, but correct diagnosis before pathological examination should be very important for clinical management and surgical decision. We describe a case of voluminous retroperitoneal incidental mass, that was proved to be an adrenal Schwannoma.

Schwannoma Misdiagnosed as Adrenal Adenoma: A Case Report and Review of the Literature

Schwannoma is a benign neurogenic tumor originating from the neural sheath of Schwann cells. It is an extremely rare cause of adrenal adenoma which is very difficult to diagnose preoperatively. We report the case of a right adrenal schwannoma discovered incidentally in a 62-year-old woman during evaluation of right flank pain. The biochemical and hormonal evaluations were unremarkable. Radiological examination revealed a 4.8 cm lesion keeping with right adrenal adenoma. Surgical intervention was done due to the large size of the tumor, and laparoscopic right adrenalectomy was performed. The postoperative course was uneventful. Histological examination established the diagnosis of schwannoma, which was further confirmed by immunohistochemical staining. In conclusion, adrenal schwannoma is extremely rare and can be misdiagnosed as nonsecreting adrenal adenoma. Complete surgical excision is the treatment of choice which is associated with favorable outcome and also helps in clarifying its histopathological nature.

A laparoscopic treatment of a suspicious adrenal mass revealing an unsual cause of adrenal incidentaloma

Schwannomas are rare tumors, usually benign, originating from the Schwann sheath of the peripheral or cranial nerves. They are an extremely uncommon cause of adrenal incidentaloma. It is difficult to diagnose adrenal schwannoma preoperatively by imaging alone due of their aspect suspect on it. We report a case of adrenal mass discovered incidentally in a 41 years old patient who presented an atypical abdominal pain. Biological assessment was unremarkable, and imaging studies did not show strict imaging criteria for a typical adenoma. A surgical excision of the adrenal incidentaloma was decided. Histopathological examination and immunohistochemical staining of the excised specimen revealed a benign schwannoma.

Primary adrenal schwannoma: a series of 31 cases emphasizing their clinicopathologic features and favorable prognosis

PURPOSE

Primary adrenal schwannoma (PAS) is a very rare benign tumor, and most of them have been described in case reports. This study aimed to analyze their distinct clinicopathologic features and follow-up data through the largest series yet.

METHODS

Clinicopathologic features of 31 primary adrenal schwannomas were retrospectively studied. Imaging and histologic features were re-evaluated and summarized. Immunohistochemical markers were measured, including S100, SOX10, AE1/AE3, EMA, SMA, Desmin, HMB45, GLUT1, and Ki67. Follow-up of all cases was performed.

RESULTS

All the tumors were clinically misdiagnosed as nonfunctioning adrenal adenoma (NAA; 23/31), aldosterone-producing adenoma/aldosteronoma (APA; 3/31), cortisol-producing adenoma (CPA; 3/31), or pheochromocytoma (PCC; 2/31). Some 87% (27/31) presented with adrenal incidentaloma, and 13% (4/31) had a clinical symptom or unregulated hormone levels. They comprised conventional (19/31), cellular (7/31), plexiform (2/31), ancient (1/31), epithelioid (1/31) and microcystic/reticular variants (1/31) and had various histologic features. Immunohistochemically, all tumors (31/31) were positive for S100 and Sox10, with a low Ki-67 proliferative index. In the long-term follow-up (mean, 53 mo.; median, 56 mo.), none had evidence of recurrence and metastasis. Univariate analysis showed that OS and DFS were not associated with age; sex; tumor side, size, or number; adrenal-related symptoms; gross feature (solid vs. cystic); or any histologic feature (P > 0.9999).

CONCLUSION

PAS is an extremely rare tumor and mostly appears as an incidentaloma. Clinically, it tends to be misdiagnosed as other common adrenal tumors. This tumor has a benign biologic behavior and prognosis, without correlations with clinical or histologic parameters.

Schwannoma masquerading as adrenocortical tumor: A case report and review of literature

Schwannomas arises from retroperitoneal space are rare tumors. Adrenal Schwannomas are often misdiagnosed due to deficient of distinctive radiological findings. We report a case of adrenal schwannoma presented with vague abdominal pain. Initially, the patient was diagnosed as adrenocortical tumor that was treated with robotic adrenalectomy. Histopathological and immuno-histochemical examination revealed schwannoma. We will report the case and review the literature regarding this rare tumor.

Retroperitoneal paraganglioma: a chameleon masquerading as an adrenal pheochromocytoma

Retroperitoneal paragangliomas are rare tumours arising from neural crest cells located near or in the autonomic nervous system; right from the skull bass to the pelvic floor. Often called the great masqueraders, their diagnosis and treatment is often difficult and fraught with danger, considering the close proximity of these tumours to important retroperitoneal organs. A 29-year-old woman presented to the outpatient department with complaints of paroxysms of headache, sweating and palpitations for one year. She was found to have elevated urinary metadrenalines (metanephrines) and a suprarenal mass on contrast-enhanced computed tomography of the abdomen, which demonstrated increased tracer activity on I-131 iodine-123 meta-iodobenzylguanidine scintigraphy. Adrenal pheochromocytoma was diagnosed and she underwent laparoscopic adrenalectomy after stabilisation of her blood pressure. Laparoscopy revealed a large suprarenal mass with dense adhesions to the inferior vena cava that was carefully separated from the vein and surrounding structures. The cut section revealed a heterogeneous mass encasing a normal adrenal gland and histopathology confirmed the same, confirming the final diagnosis of retroperitoneal paraganglioma.