Ganglioneuroma (GN) may be misdiagnosed as neurofibroma when core needle biopsy samples only contain Schwannian stroma without mature ganglion cells. Even giant cervicothoracic GNs may be resectable through a transcervical approach alone. Recurrent laryngeal nerve palsy and Horner syndrome are foreseeable, anatomically predictable risks requiring dedicated preoperative counseling.

Schwannomas arising from the thoracic sympathetic trunk can cause Horner's syndrome, and surgical resection carries a risk of further nerve injury. We describe a technique for robotic nerve-sparing enucleation of a thoracic sympathetic trunk schwannoma presenting with Horner's syndrome. After exposure of the epineurium and perineurium, careful dissection of these neural sheath structures revealed a smooth tumor surface, along which enucleation was performed. Narrow-band imaging enhanced microvascular structures within the epineurium and perineurium and improved visual contrast with the relatively avascular tumor surface. The narrow-band imaging view was simultaneously displayed with the robotic view on the surgeon console using the TilePro function, allowing real-time comparison during dissection. Selective use of narrow-band imaging may provide supplementary information for identifying the dissection plane during robotic nerve-sparing enucleation.

Moderate-risk gene variants represent an increasingly recognized component of hereditary breast and ovarian cancer (HBOC) predisposition, yet their clinical interpretation and management remain less standardized than those of high-penetrance genes. This study provides a seven-year real-world evaluation of genetic variants in ATM, BARD1, CHEK2, RAD51C, and RAD51D in individuals undergoing germline testing at a specialized HBOC center, with a particular focus on variant distribution and associated clinical management. We retrospectively analyzed germline testing data from 3416 individuals evaluated at the HBOC center Erlangen between 2018 and 2024. Testing indications included predictive as well as diagnostic and therapeutic testing in the context of breast and gynecologic neoplasms. Variant classifications followed ACMG/IARC (American College of Medical Genetics and Genomics/ International Agency for Research on Cancer) criteria. Clinical recommendations, including participation in the intensified breast cancer surveillance (IBCS) program and risk-reducing surgery, were extracted from structured counseling documentation. (Likely) Pathogenic variants in moderate-risk genes were identified across all clinical subgroups. CHEK2 represented the most frequently altered moderate-risk gene, followed by ATM. In contrast, (likely) pathogenic variants in BARD1, RAD51C, and RAD51D were observed solely among individuals undergoing predictive testing or presenting with breast malignancies. A small subset of individuals carried more than one (likely) pathogenic variant in HBOC susceptibility genes. Most women with moderate-risk variants were enrolled in the IBCS program, although in justified cases participation was withheld based on patient-specific risk factors. An isolated moderate-risk variant generally did not warrant a recommendation for risk-reducing breast surgery. Risk-reducing salpingo-oophorectomy (RRSO) was primarily discussed with individuals harboring RAD51C or RAD51D variants. Individualized modifications to the recommendations were applied especially in cases with complex genotypes comprising multiple (likely) pathogenic variants. In conclusion, this study demonstrates considerable heterogeneity in germline variants among individuals evaluated for HBOC susceptibility and highlights the particular challenges associated with interpreting moderate-risk gene alterations. The findings underscore the importance of individualized clinical assessment and support the use of real-world data to inform evidence-based surveillance and prevention strategies in hereditary cancer care.

Primary hyperhidrosis substantially impairs quality of life. Conventional sympathectomy risks compensatory hyperhidrosis through trunk disruption, whilst selective sympathectomy preserves the trunk while dividing preganglionic and postganglionic fibres. We describe a technique refinement and a previously undescribed anatomical variant. A 23-year-old man had severe refractory palmar, axillary, plantar and gustatory hyperhidrosis (SSDS 4) profoundly affecting his confidence, social functioning and mental wellbeing, despite conservative management. He underwent staged bilateral robotic selective dorsal thoracic sympathectomy. Preganglionic and postganglionic fibres were divided from the top of T2 to T4 with trunk preservation. Refinements included resection from the top of the second rib, minimal diathermy with sharp dissection and non-touch technique using Maryland bipolar forceps. On the right, a postganglionic ramus ascending retrogradely from a displaced T3 ganglion into the third intercostal space was identified, previously undescribed in the literature, requiring dissection across the fourth rib to prevent hypothesized residual axillary hyperhidrosis. Both stages were completed 1 month apart, drain-free, with next-day discharge. There was complete symptom resolution, no Horner's syndrome and no compensatory hyperhidrosis at follow-up.

BACKGROUND Proximal humerus open reduction and internal fixation (ORIF) is usually performed under interscalene brachial plexus block (ISB) or general anesthesia (GA). ISB causes ipsilateral phrenic nerve paresis in nearly all patients, and GA may raise the risk of postoperative neurocognitive disorders in elderly patients with cognitive impairment. We report the feasibility of a low-volume regional technique, used as the sole regional anesthetic with sedation, in a patient in whom GA avoidance was desirable. CASE REPORT A 68-year-old woman (American Society of Anesthesiologists physical status II) with Alzheimer's disease underwent ORIF of a closed right proximal humerus fracture via a deltopectoral approach under superior trunk block (STB) with 5 mL of 0.5% bupivacaine, combined with superficial cervical plexus block (SCPB) with 3 mL of 0.5% bupivacaine, totaling 8 mL, with propofol and dexmedetomidine sedation. Surgery lasted 174 minutes without intraoperative rescue analgesia. Heart rate ranged from 48 to 68 beats/min during dexmedetomidine infusion without anticholinergic treatment, and oxygen saturation remained at 100% with spontaneous ventilation preserved. The block provided analgesia for about 12 hours, with pain score 1/10 at rest at 24 hours, and satisfaction 10/10. No clinically evident respiratory compromise, Horner's syndrome, or postoperative delirium was observed, although diaphragmatic and cognitive function were not formally assessed. The patient was discharged on postoperative day 2. CONCLUSIONS In this single patient, low-volume STB combined with SCPB was a feasible sole regional anesthetic technique, supported by sedation, for proximal humerus ORIF, completed without conversion to GA or clinically evident respiratory compromise. Respiratory and cognitive outcomes were clinically uneventful but not formally measured; broader utility remains to be established.

Horner syndrome is a well-recognized constellation of symptoms resulting from the disruption of the sympathetic pathway. It may occur in a variety of clinical contexts, including trauma, tumors, or iatrogenic causes. We report a rare case of transient Horner syndrome following rotator cuff repair with interscalene nerve block. Imaging ruled out structural or vascular causes. The syndrome resolved spontaneously by postoperative day 3. This case highlights the importance of clinician awareness regarding this benign but alarming postoperative complication. This case was presented as a meeting abstract at the 2020 American Academy of Neurology (AAN) Annual Scientific Meeting, April 25 to May 1, 2020.

Foville syndrome is a rare pontine tegmental syndrome classically characterized by ipsilateral abducens and peripheral facial nerve palsies with contralateral hemiparesis. Extended variants involving additional ocular motor, sensory, and autonomic pathways are uncommon, particularly when caused by hemorrhagic stroke. We report a 59-year-old Filipino male with uncontrolled hypertension who presented within hours of symptom onset with left lateral rectus paresis, left peripheral facial palsy, moderate dysarthria, right hemiparesis, and mild right hemisensory loss, with a National Institutes of Health Stroke Scale (NIHSS) score of 7. Non-contrast computed tomography demonstrated a focal left pontine tegmental hemorrhage. On the first hospital day, the left abducens deficit progressed to complete palsy, the right-sided sensory deficit worsened, and left internuclear ophthalmoplegia and Horner's syndrome emerged, with an increase in NIHSS to 9. The patient was managed conservatively and underwent rehabilitation. At 1.5 months postictus, he was ambulatory with assistance with a modified Rankin Scale (mRS) score of 3. At 8 months, his NIHSS had improved to 6 and his mRS to 2, with independent ambulation despite residual focal neurological deficits. This case demonstrates the value of serial neurological examination and clinicoradiologic correlation in localizing evolving pontine tegmental lesions and illustrates meaningful functional recovery despite persistent deficits following focal pontine hemorrhage.

Differentiating cervical sympathetic ganglion (CSG) from metastatic lymph nodes in the central neck compartment remains a diagnostic challenge, particularly in patients with thyroid carcinoma. Conventional imaging modalities, including contrast-enhanced computed tomography (CT) and ultrasound, may yield indeterminate findings due to overlapping morphological characteristics. We present a case with papillary thyroid microcarcinoma that was referred for thermal ablation. Preoperative CT suggested a suspicious level VI lymph node. Contrast-enhanced ultrasound (CEUS) combined with diagnostic ultrasound-guided nerve block for differentiating cervical sympathetic ganglion from metastatic lymph node was performed. The appearance of Horner syndrome after nerve block indicates that this lesion is a sympathetic ganglion.