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A pregnant woman in her late 20s with a history of epilepsy since childhood presented with recurrent loss of consciousness and witnessed twitching and involuntary muscle contractions. She had hyperemesis during pregnancy reporting four previous miscarriages attributed to seizures. During evaluation in cardiac telemetry and while suffering from severe nausea, the patient experienced prolonged ventricular asystole resulting in convulsive syncope and was diagnosed with cardioinhibitory malignant vasovagal syncope (CMVS). Initiation of levetiracetam was recommended for 6 months, and after undergoing dual-chamber pacemaker placement, her neurological symptoms resolved despite persistent hyperemesis during the first trimester, leading to a successful vaginal delivery. 4 years later, the patient remains asymptomatic. This case emphasises the importance of conducting a thorough differential diagnosis in patients with atypical seizure presentations, the multidisciplinary approach required to assure optimal outcomes in cardio-obstetric cases and the role of selective pacemaker placement in patients with documented prolonged ventricular asystole associated with CMVS., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

A male patient in his 40s with a history of nephrolithiasis and found in the desert after 10 days without oral intake was admitted to the hospital for severe dehydration, acute kidney injury and rhabdomyolysis. He had acute-onset loss of consciousness during hospitalisation with new left-sided hemiparesis and hemineglect. After haemorrhage was excluded, prompt thrombolysis was given. He later had chest pain and became hypotensive. An echocardiogram revealed pericardial effusion and dilation of the ascending aorta with suspected dissection. Magnetic resonance angiography of the brain and neck reported bilateral parieto-occipital areas of stroke in a watershed distribution and dissection of the right internal carotid artery. CT angiography showed type A aortic dissection from the ascending aorta extending into the bilateral common iliac arteries. Thrombolysis was reversed and the patient underwent ascending aorta replacement, resuspension of the aortic valve and aortic arch debranching at outside facility with complete recovery., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2023. No commercial re-use. See rights and permissions. Published by BMJ.)

Purpose: This study aimed to review the cases of giant adenomas that were operated on from 2012 to 2020 and to analyze the epidemiological profile, complications, and resection rates using the transseptal/transnasal endoscopy technique. We also compared the results with data from revised literature., Methods: This is an observational, retrospective study includes a review of the medical records of 26 patients diagnosed with giant adenomas (diameter > 4 cm or volume >10 cm 3 ) who underwent 28 surgical procedures., Results: Of the 57 patients operated for pituitary adenoma, 26 (50.8%) had giant adenomas. The mean volume was 17.28 cm 3 (95% confidence interval [CI], 8.3359-26.2241). Moreover, 64.28% of the patients were graded Knosp 3 (p < 0.0001). Most cases were of nonsecretory adenomas (88.46%). Visual impairment was present in 89.2% of the patients and hormonal deficit and headache affected 53.5% of them. The visual impairment improved in 60% of the patients. The most common surgical complication was cerebrospinal fluid fistula (10.71%). Tumor resection > 90% was achieved in 53.56% of the cases, and the mean resection rate was 78.36% (95% CI, 71.316-87.956)., Conclusions: The endoscopic endonasal technique is a good treatment option for giant adenomas, showing satisfactory optic apparatus decompression rates and a low incidence of complications when performed by surgeons with expertise in this approach., (Copyright © 2022 Elsevier B.V. All rights reserved.)

The molecular evolution of medulloblastoma is more complex than previously imagined, as emerging evidence suggests that multiple interactions between the tumor cells and components of the tumor microenvironment (TME) are important for tumor promotion and progression. The identification of several molecular networks within the TME, which interact with tumoral cells, has provided new clues to understand the tumorigenic roles of many TME components as well as potential therapeutic targets. In this review, we discuss the most recent studies regarding the roles of astrocytes in supporting sonic hedgehog (SHH) subgroup medulloblastoma (MB) and provide an overview of MB progression through SHH expression and signal transduction mechanisms into the complex tumor microenvironment. In addition, we highlight the associations between tumor and stromal cells as possible prognostic markers that could be targeted with new therapeutic strategies.