A case of massive upper gastrointestinal bleeding in a 37-year-old female is presented showing a submucosal mass in the gastric body. At laparotomy a pedunculated submucosal mass was found located on the posterior wall at the junction of the body and antrum of the stomach, 8 cm from the pylorus. Pathology confirmed that it was a 4 cm benign gastric lipoma with a bleeding central ulcer. Gastric lipomas are rare, benign, typically submucosal tumors occurring in the gastric antrum. They are usually asymptomatic but can become symptomatic depending on size, location, and if there is ulceration of the lesion. These lesions may be mistaken as malignant tumors or present with upper GI bleeding or intussusception. The diagnosis can be made using a combination of upper endoscopy, endoscopic ultrasound, CT, and MRI with surgical excision being the definitive treatment of choice. We hope that this case highlights the fact that these lesions can present with massive upper GI haemorrhage and should be included in the diagnosis when appropriate.
Background
Plasmacytomas of the skull base are not commonly encountered in clinical practice, with few reported cases in the literature. They form part of the spectrum of plasma cell neoplasms and are classified as a solitary bone plasmacytoma if arising from the sphenoid bone. Its radiographic appearance can lead to misdiagnosis as one of the tumours that are more frequently seen in the skull base, especially meningiomas. Due to the risk of evolution into multiple myeloma, accurate diagnosis is essential.
Case presentation
A 56-year-old male presented to the emergency department with rapid proptosis and worsening vision in his right eye for one week’s duration. Imaging studies revealed an extra-axial right sphenoid bone tumour with invasion into the temporalis muscle and orbit, leading to significant proptosis. Tumour debulking was done, but there was no improvement in vision postoperatively. Final histology was consistent with a plasmacytoma. The patient was referred to the oncologist for radiation therapy, but subsequently developed further lesions consistent with multiple myeloma.
Conclusions
Plasmacytomas need to be considered in the differential diagnosis of skull base tumours. Due to their excellent response to radiation, these patients should have early oncology intervention to prevent irreversible neurological deficits.
The treatment paradigm for intracranial aneurysms has evolved with technological advancements, resulting in improved patient outcomes. In particular, the management of posterior circulation aneurysms has shifted to favor endovascular therapy (EVT). However, this modality is not always accessible in low-resource settings.
In our country (Trinidad and Tobago), neuroendovascular services are not readily available. We report a case of a patient with a ruptured left posterior inferior cerebellar artery (PICA) aneurysm (Fisher grade 4) who underwent a far-lateral craniotomy and clip ligation. It was done by a fellowship-trained vascular neurosurgeon in a public hospital and resulted in an excellent patient outcome. This highlights the need to maintain this surgical skill set in resource-poor countries, in spite of the increasing popularity of endovascular therapy.
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