Occlusion of the posterior communicating artery in isolation, without tandem lesions, is extremely rare. To our knowledge, only one prior report has described mechanical thrombectomy on a pure posterior communicating artery occlusion. This report describes the diagnostic and technical nuances involved in treating such an occlusion via mechanical thrombectomy.

A 70-year-old male was admitted to our emergency department with left-sided hemiparesis. A computed tomography scan excluded intracranial hemorrhage. Follow-up computed tomography angiography and perfusion imaging were performed. The right P1 segment cannot be appreciated on computed tomography angiography, suggesting occlusion. Mechanical thrombectomy with a combined stent-aspiration technique achieved thrombolysis in cerebral infarction grade 3 in one pass. The patient tolerated the procedure well and was discharged to a rehabilitation hospital with a modified Rankin Scale score of 2.

Posterior communicating artery occlusion is extremely rare, with only one documented report to date. The pressure difference between the internal carotid artery and the posterior cerebral artery across the posterior communicating artery is considerably low; thus, the likelihood of a thrombus passing from either side through the posterior communicating artery is low. In our case, the right posterior communicating artery fetal type with a normal posterior cerebral artery, where the right posterior cerebral artery is naturally hypoplastic, while the contralateral posterior cerebral artery was normal in size, thus misleading us into assuming the occlusion was in the P1 segment. We used a stent-retrieving into an aspiration catheter technique, which proved feasible and resulted in complete recanalization.

Mechanical thrombectomy with the combined aspiration-stent retriever technique is feasible and safe for treating posterior communicating artery occlusion.

Spontaneous internal carotid artery dissection is a relatively common cause of stroke in younger patients. The occurrence of spontaneous internal carotid artery dissection with lower cranial nerve palsy is quite rare. However, few studies have reported its natural course or an effective treatment policy. We received a 42-year-old man with spontaneous internal carotid artery dissection presenting with multiple lower cranial nerve palsies. He exhibited difficulty in swallowing, dysarthria, and tongue deviation. After 2 months of conservative therapy, stent placement with coils was performed because the symptoms did not improve. The patient was discharged 4 days after the operation without any complications and showed evident improvement in symptoms. We reviewed cases of multiple lower cranial nerve palsies reported in the literature up to January 2025 and discussed the appropriate period of observation and the effectiveness of endovascular therapy for spontaneous internal carotid artery dissection with multiple lower cranial nerve palsies.

A lumbar facet joint cyst is a relatively uncommon lumbar spinal disease that includes synovial and ganglion cysts associated with the adjacent facet joint. Some studies have suggested that posterior decompression surgery is linked to the development of facet joint cysts due to postoperative local instability. Although an interlaminar approach may be anatomically suitable for resecting lumbar facet joint cysts, it can be technically challenging after interlaminar decompression surgery because of epidural adhesions and scar tissue. Full-endoscopic surgery via a transforaminal approach under local anesthesia is 1 of the least invasive spine surgery techniques. A 52-year-old woman presented with right leg radicular pain caused by a facet joint cyst at the L4-5 level following a partial laminectomy. Conservative treatment was not effective, and she opted for additional surgery. To minimize invasiveness, we performed a full-endoscopic ventral facetectomy and resection of the facet joint cyst via a transforaminal approach under local anesthesia. At the beginning of the procedure, facet joint arthrography with indigo carmine injection was performed to stain the facet joint cyst blue for easier visualization during the full-endoscopic procedure. Following the resection of the facet joint cyst, the patient's right leg resolved immediately. One year post-surgery, there has been no recurrence of the facet joint cyst or evidence of intervertebral instability. When resecting lumbar facet joint cysts after laminectomy, the full-endoscopic ventral facetectomy technique using a transforaminal approach under local anesthesia, combined with intraoperative facet joint arthrography and indigo carmine injection, can be a useful method to make the surgery less invasive and safer.

Spontaneous internal carotid artery dissection is a rare condition that generally affects middle-aged individuals. Most cases of reported spontaneous internal carotid artery dissections are unilateral, but approximately 10%-20% involve bilateral internal carotid arteries. Spontaneous internal carotid artery dissection generally presents with neck pain, ischemic cerebral symptoms, and/or Horner's syndrome. Pulsatile tinnitus is present in around 5%-10% of spontaneous internal carotid artery dissection cases. However, this is generally accompanied by other major internal carotid artery dissection symptoms. Herein, we report a case of bilateral spontaneous internal carotid artery dissection that presented with unilateral pulsatile tinnitus of sudden onset as an isolated symptom. An otherwise healthy 50-year-old man visited a neurosurgical clinic complaining of right temporal pulsatile tinnitus that had begun 1 day prior. In addition to tinnitus, a thorough symptom interview revealed mild heavy-headedness. Magnetic resonance angiography showed bilateral extracranial internal carotid artery dissections and severe stenosis of the true lumen of the right internal carotid artery. No cerebral ischemic lesions were observed. Administration of 5 mg/day amlodipine and 100 mg/day aspirin was initiated. Following the 9th day after onset, the pulsatile tinnitus gradually improved. Around the 40th day after onset, the pulsatile tinnitus disappeared, and magnetic resonance angiography showed an improvement of the right internal carotid artery stenosis. Magnetic resonance angiographies at 5 and 9 months after onset revealed complete disappearance of the false lumen and slight stenosis of the right internal carotid artery at the entrance of the carotid canal. This case suggests that the sudden onset of isolated unilateral pulsatile tinnitus can be a clue to the diagnosis of spontaneous internal carotid artery dissection.

Intraosseous arteriovenous fistulas are rare vascular anomalies, with an increasing number of reports describing successful endovascular treatments in recent years. Although some cases of acute subdural hematoma caused by intraosseous arteriovenous fistulas have been reported, the precise mechanism remains unclear. In this study, we present a case of surgical treatment for an intraosseous arteriovenous fistula with acute subdural hematoma. A 58-year-old woman presented to our hospital with a sudden headache and nausea. Computed tomography revealed a left acute subdural hematoma with an abnormal diploic space in the frontal bone. Digital subtraction angiography confirmed an intraosseous arteriovenous fistula supplied by the middle meningeal artery and draining into the diploic vein. Because of concerns about potential tumor involvement, direct surgery was performed. Intraoperatively, vascularized tissue surrounding the fistula extended through the dural defect and connected to the subdural space, suggesting a possible cause of the acute subdural hematoma. The feeder and draining vein were dissected and removed along with the abnormal tissue. Histopathological analysis revealed fibrous tissue with hemorrhage and increased vascularity but no tumorous changes. Postoperative angiography confirmed successful arteriovenous fistula occlusion, and the patient recovered with minimal neurological deficit. This case suggests that intraosseous arteriovenous fistulas may cause acute subdural hematoma owing to the anatomical feature of vascularized tissue around the fistula extending through the dural defect into the subdural space.

Myxoid glioneuronal tumour (MGNT) is a new WHO classification of brain tumours and is defined as tumours with PDGFRA p.K385 mutations. MGNT has a predilection for the septum pellucidum, their clinical features have not yet been clarified because only a few reports exist. In this report, we present the case of a patient with an MGNT that was suitable for endoscopic resection. We discuss the clinical characteristics of MGNTs discovered during a literature review. A 19-year-old female presented with a worsening headache and a disturbance of consciousness. Head MRI revealed a mass lesion in the septum pellucidum and severe obstructive hydrocephalus. She underwent neuroendscopic surgery under general anaesthesia, and near total resection was achieved. Her symptoms improved immediately after surgery, and she was discharged without any morbidities. Pathological examination and genetic testing confirmed the diagnosis of an MGNT. A literature review revealed that 7 of 18 MGNTs developed in the septum pellucidum. Three patients had disseminated lesions at initial diagnosis, and one showed dissemination during the follow-up period. Among the 14 patients who underwent tumour resection surgery, 3 experienced recurrence or regrowth and required additional treatments. All 18 patients were alive at the last follow-up. An MGNT is a tumour that predominantly affects young people and is currently considered to have a good prognosis. However, close postoperative observation is needed because an MGNT often disseminates intracranially and/or into the spinal cord. In addition, we believe that MGNTs located in the septum pellucidum are good candidates for endoscopic resection.

A 5-year-old boy presented to our hospital with ptosis and an abnormal ocular position. Magnetic resonance imaging showed a well-defined mass measuring 20 mm in diameter in the medial sphenoid bone extending to the orbit and compressing the external ocular muscle. The patient underwent total surgical excision and was subsequently diagnosed with a solid variant of aneurysmal bone cyst via molecular integrated diagnosis. Solid variant of aneurysmal bone cyst is an extremely rare subtype of aneurysmal bone cyst, accounting for 0.2% of all primary bone tumors. It is characterized by the absence of a solid cystic component, which is difficult to diagnose via conventional hematoxylin and eosin staining. Molecular analyses revealed that this subtype is also characterized by the rearrangement of USP6 and the absence of the H3F3A mutation. This report discusses the clinical features of this extremely rare neoplastic lesion, the importance of an integrated diagnosis, and treatment options.

Cerebral venous sinus thrombosis (CVST) is rare but serious adverse complication of coronavirus disease 2019 (COVID-19) vaccination. CVST can sometimes lead to development of dural arteriovenous fistula (DAVF), but DAVF secondary to CVST following COVID-19 vaccination is rarely reported. Here, we present a case of CVST occurring after COVID-19 vaccination, followed by subsequent development of DAVF, which was successfully treated. A 45-year-old male presented with headache and progressive visual impairment beginning 4 days after COVID-19 vaccination. Papilledema was noted. Cerebrospinal fluid pressure was elevated at 300 mmH₂O, and magnetic resonance imaging (MRI) revealed right transverse sinus thrombosis, prompting initiation of anticoagulant therapy. Four months later, MRI suggested DAVF in right transverse sinus, and he was referred to our department. Digital subtraction angiography confirmed DAVF in right transverse sinus, as well as concurrent convexity DAVF and pial arteriovenous fistula over right vein of Labbé, all draining solely into right vein of Labbé. Anticoagulation therapy was discontinued due to aggressive nature of this DAVF. Transarterial embolization (TAE) with Onyx was performed in 2 sessions, achieving complete occlusion of shunt. Postoperatively, anticoagulation therapy was not resumed. Ten months later, the patient again experienced visual deterioration. Recurrence of convexity DAVF over right vein of Labbé was identified, and TAE with Onyx was performed again, resulting in successful shunt occlusion. Postoperatively, anticoagulant therapy was resumed. The patient's visual acuity gradually improved, and at 18 months post-treatment, no recurrence was observed. CVST following COVID-19 vaccination can progress to DAVF; therefore, careful follow-up is recommended.

Meningiomas are benign tumors outside the brain parenchyma that usually progress slowly but occasionally develop suddenly. We report a 40-year-old woman who presented with symptoms of cerebral herniation within a few hours of the onset of a headache. She felt no particular change until going to bed, when she noticed a headache, vomited, and fell into a coma. At the time of admission, she had a large anisocoria on the right side. A computed tomographic scan revealed a tumor of more than 6 cm in the right frontal region, and cerebral angiography showed tumor staining in multiple branches of the anterior cerebral artery. Intracranial perfusion was slow, suggesting severe intracranial hypertension. An emergency craniotomy was performed, and severe brain swelling was found after the dural incision, requiring an additional craniotomy. The tumor was prone to bleeding, which prolonged the operation time; consequently, the tumor was only partially removed and external decompression with duraplasty was required. After the cerebral swelling improved, tumor-feeding vessel embolization was performed, and then the remaining tumor was completely resected. The pathological diagnosis was atypical meningioma. Eleven months after surgery, the patient can walk by herself despite sensory impairment on the left side, and there has been no evidence of tumor recurrence. Emergency surgery may be required for meningiomas and may have to be performed in a situation where preoperative examinations are not sufficient. In such situations, it is desirable to select an appropriate surgical procedure, including two-stage surgery, and to perform prompt treatment.

The incidence of syphilis is increasing rapidly worldwide and has become a public health threat. Although osseous lesions are commonly observed in congenital or tertiary syphilis, some cases of skull involvement have been reported in earlier stages of the disease. A 22-year-old woman with a history of tension headaches presented with a severe, new-onset headache localized to the forehead. Imaging studies revealed multiple osteolytic lesions confined to the skull, and serological tests confirmed cranial syphilitic osteomyelitis in the early stage of syphilis. The patient's condition improved with antibiotic therapy. This case highlights the importance of considering syphilitic osteomyelitis in young adults with unexplained headaches and emphasizes the importance of early recognition and treatment.

Calcified lumbar disc herniation is a challenging subtype of lumbar disc herniation to treat owing to high associated risks of nerve root injury and dural tears. Traditional treatments favor open surgery, but recent advances have increased the use of full-endoscopic discectomy. The patient was a 72-year-old woman with a 4-year history of severe right lower extremity pain. Computed tomography indicated right foraminal stenosis at L2/3 caused by extraforaminal calcified lumbar disc herniation. Full-endoscopic discectomy was performed under local anesthesia through a transforaminal approach. Drilling was conducted within the herniated disc; next, the calcification was broken and removed piece by piece. Symptoms improved after the surgery, and the calcified lumbar disc herniation disappeared. In conclusion, transforaminal full-endoscopic discectomy under local anesthesia is a safe and effective approach for calcified lumbar disc herniation, especially in cases with extraforaminal involvement. The technique described in this study, "intradiscal drilling," avoids the need to detach adhesions, minimizing the risk of nerve injury.

Spinal epidural lymphoma is a rare pathological entity that usually responds well to chemotherapy. However, it occasionally requires immediate surgical treatment for progressive neurological symptoms caused by a bulky epidural mass and bone destruction. In the management of spinal epidural lymphoma, the role of surgical interventions has not yet been fully defined, and few reports on long-term functional outcomes are available. We report 3 cases of thoracic spinal epidural lymphoma that required emergent surgical management for neural decompression and were followed postoperatively over 2 years or until death. Two patients (cases 1 and 2) underwent spinal instrumentation to prevent subsequent spinal deformity, whereas instrumentation was avoided in case 3 due to atopic dermatitis, which increases the risk of surgical site infection. During the 2-year postoperative period, 2 patients (cases 1 and 3) maintained disease-free survival and achieved sufficient neurological recovery to remain ambulant, while the other patient (case 2) died due to spinal epidural lymphoma relapse. Given the high treatment responsiveness and the potential for long-term disease-free survival in spinal epidural lymphoma, treatment should aim to maximize functional outcomes. Prompt surgical decompression is mandatory in patients with neurological deficits. Although spinal instrumentation is typically recommended to prevent spinal deformity, it should be withheld if it poses a risk of delaying chemotherapy, such as in cases with a high risk of surgical site infection. Therefore, spinal surgeons play several essential roles in managing spinal epidural lymphoma from the acute to the chronic phase, aiming to improve patients' prognosis and quality of life.

Introduction: Dural arteriovenous fistula is an abnormal shunt between arteries and veins located within or around the dural venous sinuses, comprising 10%-15% of cerebrovascular malformations. Falcotentorial dural arteriovenous fistula with hydrocephalus is extremely rare, with only a few cases reported. This paper presents the technical approach to managing such a condition.

Case Description: A 56-year-old man presented with gait disturbance and cognitive decline for 3 months. Magnetic resonance angiography revealed hydrocephalus and a vascular malformation near the third ventricle. Digital subtraction angiography confirmed a falcotentorial dural arteriovenous fistula with multiple arterial feeders and deep venous drainage. Trans-arterial embolization was performed, achieving complete occlusion of the fistula while preserving the venous varices. The patient tolerated the procedure well, with both clinical and radiological improvement.

Discussion: Hydrocephalus in dural arteriovenous fistula is often caused by aqueductal compression from dilated venous structures. Treating hydrocephalus before addressing the fistula may risk hemorrhage due to fragile leptomeningeal vessels. In this case, embolization was performed with particular attention to preserving the venous varix located caudally at the fistula site. Embolizing this pouch could have led to acute thrombosis and worsening hydrocephalus. Following embolization, ventricular dilation regressed, and the patient's symptoms improved.

Conclusion: Falcotentorial dural arteriovenous fistula with hydrocephalus is exceptionally rare. During embolization, preserving the venous ectasia compressing the Sylvian aqueduct may help prevent the aggravation of hydrocephalus and support progressive ventricular size reduction.

Marginal zone B cell lymphoma, which can sometimes resemble a meningioma, originates in the dura mater. Reports of marginal zone B cell lymphoma complicated by intracranial hemorrhage are rare. There have been five reported cases of dural marginal zone B cell lymphoma complicated by acute subdural hematoma. To our knowledge, this is the first reported case of dural marginal zone B cell lymphoma diagnosed at the onset of a non-traumatic acute epidural hematoma. A 74-year-old man presented to our hospital with complaints of right hemiparesis without a history of head injury. He was diagnosed with left acute epidural hematoma based on the results of a computed tomography scan of the head; however, his serum soluble interleukin-2 receptor level was elevated (3,520 U/mL), and whole-body contrast-enhanced computed tomography revealed intra-abdominal and bilateral inguinal lymphadenopathy. Contrast-enhanced magnetic resonance imaging of the head revealed a well-enhanced, thickened dura mater with an acute epidural hematoma. The patient underwent a biopsy of the thickened dura mater and a hematoma removal, which on histopathology revealed dural marginal zone B cell lymphoma, as did a biopsy of an inguinal lymph node. After chemotherapy, the thickened dura mater shrank, and the marginal zone B cell lymphoma lesions showed remission. However, the mechanism underlying acute epidural hematoma in the dural marginal zone B cell lymphoma remains unclear. This case report provides new insights into dural marginal zone B cell lymphoma as a cause of non-traumatic acute epidural hematoma.

An anti-neutrophil cytoplasmic antibody-associated vasculitis is a systemic autoimmune disease characterized by small-vessel inflammation, with rare central nervous system manifestations such as subarachnoid hemorrhage. Cerebral artery dissection, a rare but serious condition that can lead to ischemic stroke or subarachnoid hemorrhage, predominantly affects young to middle-aged adults and is less common in elderly patients. We report the case of an 86-year-old male with anti-neutrophil cytoplasmic antibody-associated vasculitis who developed subarachnoid hemorrhage due to a ruptured posterior inferior cerebellar artery aneurysm, suggestive of dissection. Despite diagnostic challenges related to the patient's advanced age, repeated vascular imaging indicated arterial dissection, and parent artery occlusion successfully prevented re-rupture. This case highlights the importance of considering cerebral artery dissection as a potential cause of subarachnoid hemorrhage in patients with anti-neutrophil cytoplasmic antibody-associated vasculitis, even in octogenarians, and underscores the need for comprehensive vascular evaluation to ensure timely diagnosis and management.

We present an extremely rare case of lung cancer that metastasized to a gonadotroph pituitary neuroendocrine tumor, along with other organs. A 73-year-old man presented with dysarthria and bitemporal hemianopia. Head magnetic resonance imaging revealed cerebellar infarction and a pituitary tumor. Endoscopic transnasal pituitary tumor resection was performed. Pathologically, the tumor consisted of a well-differentiated neuroendocrine component, suggestive of a pituitary neuroendocrine tumor, alongside a poorly differentiated, highly malignant tumor with invasive growth. One month postoperatively, gadolinium-enhanced head magnetic resonance imaging revealed rapid growth of the residual tumor. Whole-body computed tomography and positron emission tomography revealed a 10-mm lung tumor and multiple muscle and bone metastases. Pathological examination of the pituitary tumor revealed poorly differentiated malignant cells. It was initially hypothesized that the pituitary neuroendocrine tumor had undergone malignant transformation with systemic metastases. However, further pathological examinations revealed steroidogenic factor 1-positive differentiated cells and steroidogenic factor 1-negative, synaptophysin-negative, cytokeratin-7-positive, and thyroid transcription factor-1-positive poorly differentiated malignant cells. The final diagnosis classified the tumor as a poorly differentiated lung adenocarcinoma that had metastasized to a gonadotroph pituitary neuroendocrine tumor, which showed rapid growth. Radiation and chemotherapy were administered; however, the patient died 6 months after surgery. Tumor metastasis to a pituitary neuroendocrine tumor is typically seen in older adults with non-functioning pituitary neuroendocrine tumors and no diabetes insipidus. Hence, clinicians should consider both metastatic pituitary neuroendocrine tumors and tumor metastasis to a pituitary neuroendocrine tumor when diagnosing a rapidly growing pituitary tumor in patients with signs of systemic metastasis.

The clinical course of pyogenic spondylodiscitis varies based on its etiology. To the best of our knowledge, there have been only 7 cases of spondylodiscitis caused by Klebsiella oxytoca. This bacterium typically affects patients with underlying comorbidities or develops as a secondary infection. This case illustrates a rare instance of lumbar spondylodiscitis caused by Klebsiella oxytoca. A direct biopsy via endoscopic surgery may be beneficial when multiple bacterial culture investigations yielded negative results. It is important to recognize that identifying the causative pathogen is crucial when initiating antibiotic therapy for spondylodiscitis.

Chordoid glioma is a rare, slow-growing neoplasm of the central nervous system. To select an appropriate surgical approach, chordoid glioma should be differentiated from other third ventricle/suprasellar tumors, such as craniopharyngiomas. In this report, we present 3 cases of chordoid glioma. Magnetic resonance images of all cases showed a round or ovoid-shaped tumor with significant enhancement with contrast medium on T1-weighted images. Moreover, preoperative T2-weighted coronal images revealed high intensity along the bilateral hypothalamus. The tumor was removed using the trans-lamina terminalis approach. Gross total resection and partial resection were achieved in 2 cases and 1 case, respectively. Immunohistochemical staining showed strong positivity for glial fibrillary acidic protein and thyroid transcription factor-1, indicating a chordoid glioma. Tumor cells also showed diffuse immunoreactivity for matrix metalloproteinase 9, indicating that the high intensity was caused by vasogenic edema. High-intensity bilateral hypothalamus on T2-weighted images is a unique feature of chordoid glioma and plays an important role in improving clinical outcomes through local tumor control and functional preservation.

Extracorporeal membrane oxygenation is utilized in the treatment of severe acute cardiac failure and respiratory failure. While it provides the advantage of oxygenating blood through extracorporeal circulation, it also carries risks of intracranial ischemic and hemorrhagic complications due to the continuous presence of artificial materials within the body. We encountered a case in which venoarterial extracorporeal membrane oxygenation was initiated for fulminant myocarditis, and the patient subsequently developed a large vessel occlusion. The diagnosis was confirmed using perfusion computed tomography. A visible thrombus was observed on the arterial cannula of the extracorporeal membrane oxygenation circuit, and the large vessel occlusion was determined to have been caused by thromboembolism. An immediate extracorporeal membrane oxygenation circuit exchange was performed, followed by endovascular thrombectomy. The patient experienced no perioperative complications and achieved a favorable neurological outcome. Endovascular thrombectomy in extracorporeal membrane oxygenation patients requires careful perioperative management and should be promptly performed in eligible cases of thromboembolic events. Furthermore, because patients on extracorporeal membrane oxygenation are often sedated and under intensive systemic management, regular neurological assessments and intracranial monitoring are essential for the early detection of intracranial pathologies.

Flow diverter stents are used for the treatment of intracranial aneurysms and require long-term antiplatelet therapy, which has been associated with complications such as intracranial hemorrhage. We encountered a case in which rapid increases in the size and number of cerebral microbleeds were observed shortly after flow diverter stent placement. It is known that microthrombosis within a stent can occur after flow diverter stent placement, and this microthrombosis is thought to cause cerebral microbleeds. The patient was a 77-year-old man who underwent flow diverter stent placement for an unruptured intracranial aneurysm. Postoperatively, he developed disorientation and limb paralysis, with magnetic resonance imaging showing diffuse cerebral infarction but no hemorrhagic lesions. Subsequent imaging revealed numerous cerebral microbleeds that were not present earlier and progressively worsened despite dual antiplatelet therapy and blood pressure management. Adjustments to medications, including delaying aspirin and adding antihypertensives, were made. Sodium ozagrel was introduced but later discontinued due to further increases in cerebral microbleeds. At 30 days post-surgery, imaging showed stabilization. By 3 months, residual cerebral microbleeds remained without further progression, and the patient had a modified Rankin scale score of 1. By adjusting antiplatelet medication and controlling blood pressure, it was possible to somewhat manage cerebral hemorrhage. Even when antiplatelet medications are maintained within the optimal therapeutic range, there remains a risk of cerebral hemorrhage. This risk must be carefully considered, and appropriate adjustments to antiplatelet therapy are essential during the perioperative period.

We report a concurrent case of aneurysmal subarachnoid hemorrhage and acute aortic dissection. A 47-year-old woman presented to our hospital unconscious. Subarachnoid hemorrhage was diagnosed by brain computed tomography on arrival. Computed tomography angiography revealed 2 aneurysms in the right internal carotid artery. Computed tomography angiography from the cervical to thoracic regions, which was initially performed to inspect the access route for interventional radiology, demonstrated the presence of Stanford type A acute aortic dissection. Neck clipping and total aortic arch replacement were performed for the 2 aneurysms and the acute aortic dissection, respectively. Only a few reports have described the coexistence of acute aortic dissection and subarachnoid hemorrhage. Managing these 2 pathologies requires a thorough evaluation of each therapeutic strategy and careful management of the patient's systemic and neurological conditions. We believe our case report enhances the understanding of this specific pathological condition and will provide valuable insights for treating future patients with similar conditions.

Pediatric vertebro-vertebral arteriovenous fistulas are exceptionally uncommon. Most of those patients have undergone digital subtraction angiography for making a diagnosis and transarterial embolization as the treatment. Here, we report a 4-month-old boy with congenital heart disease brought to our department after developing an iatrogenic vertebro-vertebral arteriovenous fistula as a result of a central venous catheter. Magnetic resonance angiography revealed the exact location of the shunt point. Furthermore, three-dimensional computed tomography angiography accurately described the vascular configuration, including the venous drainage route, which was chosen as a potential approach route for endovascular therapy. The shunt was completely occluded by transvenous embolization of the vertebral venous plexus around the shunt point. Magnetic resonance angiography and three-dimensional computed tomography angiography provide useful information for planning treatment strategies for vertebro-vertebral arteriovenous fistulas, particularly in pediatric patients who are at a higher risk of undergoing digital subtraction angiography. Additionally, transvenous embolization can be the first line of treatment for pediatric patients with vertebro-vertebral arteriovenous fistulas due to its safety and effectiveness.

As the name implies, new-onset refractory status epilepticus is a condition wherein a pediatric or a young adult patient with no previous history of epilepsy suddenly develops idiopathic, uninterrupted, and difficult-to-control seizure episodes. While different neurosurgical interventions in new-onset refractory status epilepticus have already been reported, they are primarily used for palliation and diagnostic purposes. Here we report a young comatose patient who significantly improved after being subjected to intensive intracranial pressure management. Our patient was a 20-year-old male construction worker who was transferred to our institution after he was managed for 13 days (X day [day of ictus] to X+12 days) at a local hospital as a case of refractory status epilepticus. Since the patient has non-convulsive status epilepticus induced by minor stimuli, despite continuous midazolam administration, a central venous catheter-based percutaneous thermoregulation system was inserted on the day of the transfer (X+13 days), which depressed the temperature to 37°C, effectively suppressing the electrographic seizure to some extent. Moreover, on X+15 days, an intracranial pressure sensor was implanted, and a ventriculostomy was done to control the increased intracranial pressure induced by uncontrolled seizures. Because the seizure episodes ceased on X+22 days, intracranial pressure monitoring was eventually terminated. Four days later (X+26 days), the patient's wakefulness improved from Glasgow Coma Scale score of 3 (E1V1M1) to8 (E4VTM4) and was transferred to a rehabilitation facility with a modified Rankin Score of 1. Aside from medical management, neurosurgical interventions should be considered if indicated to improve the survival of a condition with a grave prognosis, such as new-onset refractory status epilepticus.

DuraGen, a collagen matrix-based artificial dura mater, is widely used in neurosurgery because of its biocompatibility and ease of use. Although generally considered safe, we present a rare case of a foreign body reaction to DuraGen presenting as a sterile inflammatory response. A 40-year-old woman underwent total resection of a right convexity meningioma, with dural repair using DuraGen. On postoperative day 31, she developed headache, nausea, and vomiting. Imaging revealed significant cerebral edema around the surgical cavity with midline shift but no signs of infection on diffusion-weighted imaging. To rule out infection, reoperation was performed. Intraoperatively, there was no purulence or necrosis, but DuraGen was found adherent to the cortical surface. The artificial dura was removed and replaced with Gore-Tex. Microbiological cultures were negative. Histopathology showed inflammatory granulation tissue with eosinophilic infiltration, indicating a foreign body reaction. The patient's symptoms resolved immediately after surgery, and follow-up imaging at 5 months confirmed complete radiological resolution. This case highlights a rare but significant complication of DuraGen, demonstrating that foreign body reactions can mimic infectious processes and lead to severe cerebral edema and intracranial hypertension. Awareness of this potential complication is important for neurosurgeons, especially when infection is suspected but not clearly supported by imaging or intraoperative findings. Timely recognition and removal of the offending material can lead to rapid clinical and radiological improvement. This case underscores the importance of considering foreign body reaction in the differential diagnosis of delayed deterioration after duraplasty, particularly when infection is not definitively confirmed.

Intrathecal baclofen therapy has become a widely adopted and effective surgical treatment for severe spasticity. However, it is known to carry a range of potential complications. We report a case of catheter kinking that occurred during long-term follow-up following initial intrathecal baclofen pump implantation using an Ascenda catheter. The patient was diagnosed with cerebral palsy in infancy, and spasticity in all 4 limbs gradually progressed. At 5 years of age, an intrathecal baclofen pump was implanted using an Ascenda catheter, which improved spasticity. However, at 14 years of age, she began to exhibit gradual worsening of spasticity. The percentage of drug delivery deviation was 65.50% at 9 years and 5 months after the initial surgery. Radiography showed that the tip of the Ascenda catheter had migrated caudally. In addition, scoliosis progression over the past 4 years was noted. Three-dimensional computed tomography revealed catheter kinking proximal to the anchor. Kinking of the Ascenda catheter was determined to be the cause of underdelivery of the drug and the subsequent worsening of spasticity. Catheter revision surgery was performed. The kinked segment of the previous catheter was removed and cut, and the newly inserted catheter was connected. Postoperatively, spasticity rapidly improved. Patients undergoing intrathecal baclofen therapy, especially those with cerebral palsy and scoliosis, should be clinically monitored for worsening spasticity and significant changes in drug delivery deviation, even when using Ascenda catheters. Rapid worsening of spasticity or marked drug delivery deviation changes should raise suspicion of catheter-related complications. Progression of scoliosis in patients with intrathecal baclofen may lead to catheter kinking, warranting ongoing close monitoring.

Internal neurolysis has been shown to be effective in treating trigeminal neuralgia without vascular compression. However, its use in glossopharyngeal neuralgia has been rarely reported, with only a single previous case described in the literature, despite the similarities in the underlying mechanisms of neurovascular compression. This study reports 2 cases of glossopharyngeal neuralgia without vascular compression that were successfully treated with internal neurolysis. Patient 1, a 57-year-old woman with 32 months of untreated episodic pain, underwent microvascular decompression, but no vascular compression was identified. Internal neurolysis was performed, generating immediate pain relief and resolution of transient dysphagia and hoarseness within days. The patient remained pain-free at 18-month follow-up. Patient 2, a 65-year-old man with recurrent pain after prior microvascular decompression and gamma knife radiosurgery, underwent a second microvascular decompression, which failed to resolve his symptoms. Internal neurolysis was performed 21 months later, leading to sustained pain relief and no recurrence at 12-month follow-up. These cases suggest that internal neurolysis is a feasible and potentially effective treatment for glossopharyngeal neuralgia without vascular compression. However, the procedure presents technical challenges due to the fragile and mobile nature of the glossopharyngeal nerve, necessitating meticulous handling and precise dissection to avoid nerve injury. Further studies are required to evaluate its long-term efficacy and safety.

Most pseudoaneurysms after traumatic vertebral artery injuries are caused by penetrating or blunt injuries without vertebral fractures. Here, we report a cervical spinal cord injury in a patient with a giant vertebral artery pseudoaneurysm within a split cervical vertebral fracture. An 82-year-old man presented with a history of complete paralysis of the left side of his body due to basilar artery occlusion. He fell while riding in a wheelchair and presented with obstructive respiratory failure 2 days before transfer to our hospital. Radiological examination revealed C4-5 split fractures with diffuse idiopathic skeletal hyperostosis and a suspected cervical spinal cord injury. A contrast-enhanced lesion was observed within the fracture cavity of the C5 vertebral body, which was suggestive of a pseudoaneurysm originating from the left vertebral artery. Because of a history of basilar artery occlusion and a right vertebral artery that terminated in the posterior inferior cerebellar artery, we did not perform emergency interventional treatment. After conservative treatment under sedation for 3 days, cerebral angiography revealed the almost complete disappearance of the pseudoaneurysm. The patient was deemed to have undergone fracture reduction, posterior decompression, and fusion (C3-7) without risk of aneurysm rupture. Although his neurological recovery was limited, the pseudoaneurysm disappearance and tendency of the fractured vertebral body to fuse were confirmed. Pseudoaneurysms of the vertebral artery associated with vertebral body fractures are extremely rare. This report suggests that pseudoaneurysms within a split cervical vertebral fracture could spontaneously disappear with conservative treatment, with care to avoid rupture and embolism.

Mycotic cerebral aneurysms secondary to infective endocarditis carry a high risk of fatal rupture. Early identification and appropriate intervention are critical. We present a case in which a punctate hyperdense lesion on noncontrast-enhanced computed tomography appeared several days before aneurysm formation and rupture. A 43-year-old man with infective endocarditis presented with a ruptured mycotic aneurysm in the peripheral left middle cerebral artery. The patient underwent emergency craniotomy. During the postoperative follow-up, 2 new punctate hyperdense lesions were detected on noncontrast-enhanced computed tomography. A total of 3 days later, one of these lesions progressed to aneurysm formation and hemorrhage, requiring repeat surgery. The outcome was favorable, with a modified Rankin scale score of 2. This case highlights that punctate hyperdense lesions on noncontrast-enhanced computed tomography may serve as an early radiological marker of impending mycotic aneurysm formation and suggests the importance of close imaging surveillance to prevent catastrophic rupture.

Moyamoya disease is a progressive steno-occlusive cerebrovascular disorder that may be complicated by intracranial aneurysms, particularly, in the posterior circulation, which are at higher risk of rupture than those in the general population. Clazosentan, a selective endothelin A receptor antagonist, has been approved in Japan for the prevention of cerebral vasospasm after aneurysmal subarachnoid hemorrhage. However, cerebral hemodynamics after subarachnoid hemorrhage and safety of clazosentan in patients with moyamoya disease remain unknown. We report the case of a 46-year-old man with bilateral moyamoya disease who presented with severe subarachnoid hemorrhage caused by a ruptured saccular aneurysm in the right P2 segment of the posterior cerebral artery. Coil embolization was successfully performed, and clazosentan (10 mg/hr), along with cilostazol, was administered to prevent vasospasm. Fluid balance was carefully managed, and no clazosentan-related adverse events were observed. Follow-up radiological examinations showed no evidence of cerebral vasospasm or ischemic lesions. The patient made a favorable recovery and was discharged with a modified Rankin scale score of 1. Four months later, revascularization surgery was performed to reduce hemodynamic stress and the risk of hemorrhage from choroidal collaterals. The aneurysm remained occluded, the choroidal channels regressed, and no recurrent strokes occurred during 1 year of follow-up. To the best of our knowledge, this is the first report of successful clazosentan therapy for aneurysmal subarachnoid hemorrhage in a patient with moyamoya disease. Careful perioperative management allowed the safe use of clazosentan without complications. Further studies are needed to evaluate its broader safety and efficacy in this population.

Intracranial cryptococcoma is an uncommon manifestation of central nervous system cryptococcosis. Imaging commonly shows ring-enhancing lesions that resemble malignant tumors radiologically. Early diagnosis and extended antifungal treatment are crucial for decreasing morbidity and enhancing outcomes. Treatment typically involves a minimum of six weeks of induction therapy, followed by 6-18 months of maintenance therapy. Limited information is available on the complete clinical progression in cases where remission is not attained with initial treatment. A 66-year-old immunocompetent man presented with ten ring-enhancing lesions in the brain parenchyma and an infiltrative lesion in the lungs. Complete resection of the largest lesion in the left frontal lobe confirmed a histopathological diagnosis of cryptococcoma. Despite receiving eight weeks of induction therapy with liposomal amphotericin B and oral flucytosine, exceeding standard recommendations, the lesions only partially regressed, failing to achieve complete remission. Fluconazole maintenance therapy was initiated. At five months, lesion recurrence was observed. Induction therapy was resumed for three weeks, followed by a switch back to fluconazole. However, the patient's level of consciousness deteriorated, making oral medication impossible. The patient died 15 months after the initiation of antifungal treatment.

Cryptococcoma is a critical diagnostic complication. When chest imaging findings are not characteristic of a typical malignancy, a biopsy is essential before determining the appropriate treatment strategy. When lesions do not completely resolve after induction therapy, careful clinical and radiological follow-up is crucial because the risk of recurrence remains significant.

Dynamic assessment by computed tomography angiography or digital subtraction angiography is important for the diagnosis of vascular eagle syndrome, although these require the use of contrast media. Magnetic resonance angiography with neck flexion and extension, named dynamic magnetic resonance angiography, can dynamically evaluate the relationship between the internal carotid artery and the styloid process with no use of contrast media. A 74-year-old male with chronic kidney disease was rushed to our hospital due to recurrent infarction in the left cerebral hemisphere. Magnetic resonance angiography in the neutral neck position showed no abnormality in the left internal carotid artery, but computed tomography revealed bilateral elongated styloid process. Dynamic magnetic resonance angiography was performed to show that the left internal carotid artery was compressed by the styloid process during neck flexion but not during neck extension. Carotid ultrasound revealed a thrombus in the high cervical portion of the left internal carotid artery. Styloidectomy was performed, and cerebral infarction has not recurred since then. Dynamic magnetic resonance angiography may be a useful diagnostic modality without using contrast media for vascular eagle syndrome.