Tentorial meningiomas, not involving the cerebellopontine angle cistern or cranial nerves, rarely cause symptoms of cranial nerve disturbance. We report a case of a patient with a paramedian tentorial meningioma who presented with hearing loss as a result of indirect compression of the vestibulocochlear nerve by the herniated cerebellar flocculus into the internal acoustic meatus. A 50-year-old woman had presented with hearing loss in her right ear. Magnetic resonance imaging (MRI) revealed a large tentorial meningioma in the right posterior cranial fossa. Constructive interference in steady-state (CISS) imaging demonstrated a non-enhanced solid structure at the ipsilateral cerebellopontine angle cistern and internal acoustic meatus. During surgery, after resection of the tumor, the herniated cerebellar flocculus into the internal auditory canal was observed at the ipsilateral cerebellopontine angle. MRI obtained following meningioma resection demonstrated the herniated flocculus regressing from the fundus of the internal acoustic meatus to the cerebellopontine angle cistern, and her hearing was improved as a result of decompression. This is a rare case report of flocculus herniation caused by remote tentorial meningioma. Patients with paramedian tentorial meningiomas rarely present with hearing loss. In these cases, the causes of the hearing loss (microvascular compression, transformed brainstem, and venous circulation disorders) have been described in the literature. In this report, a new mechanism became evident: a herniated flocculus into the internal acoustic meatus by a tumor can cause hearing loss. MRI, particularly CISS imaging, can clearly show the flocculus during the entire clinical course.

The authors reported a rare case of young women with neurofibromatosis type I (NF-I) who were successfully treated from the traumatic dislocation of a thoracic vertebra caused by a simple fall, and the relevant literature was reviewed. Due to various spinal dystrophic changes, the conventional posterior spinal fusion surgery was modified for the treatment. Spinal deformity is a common feature of NF-1, and a dystrophic lesion, like dural ectasia, provokes weakness in spinal structural. Unexpectedly, only seven similar cases were found. The review suggested that it is mandatory to thoroughly examine the spine in patients with NF-1, and that a good outcome can be expected even for patients with NF-1 in severe neurological condition after acute spinal cord injuries.

We report the case of a patient with a spinal extradural arteriovenous fistula (AVF) associated with Cowden syndrome (CS) that was successfully treated by endovascular surgery. CS is an autosomal dominant disorder associated with diverse symptoms caused by a deleterious mutation in the phosphatase and tensin homolog (PTEN) gene. A 67-year-old woman was diagnosed with CS based on her medical history of multiple cancers for which she underwent abdominal surgery, macrocephaly, Lhermitte-Duclos disease, and facial papules. Her genetic testing demonstrated a PTEN mutation. She presented with progressive paraparesis and her MRI of the thoracolumbar spine showed the spinal cord edema along with flow voids. A spinal angiogram demonstrated a spinal extradural AVF with the perimedullary drainage. The AVF was successfully treated by endovascular surgery. The PTEN mutation can accelerate angiogenesis; thus, vascular anomalies are one of the diagnostic criteria of CS. However, only two cases of vascular anomalies involving the spinal cord in patients with CS have been reported previously. As the present case, both cases had a history of abdominal or retroperitoneal cancer. The PTEN mutation accompanied with abdominal surgery might have caused this vascular anomaly as the consequences of venous congestion around the thoracolumbar spine. A spinal extradural AVF should be considered in patients with CS who present with myelopathy, especially when the patient has a history of abdominal or retroperitoneal surgery. Regarding the treatment strategy, endovascular surgery should be considered because surgical insult could prompt secondary vascular anomalies resulting from neovascularization due to the PTEN mutation.

We report a case of an encapsulated subdural hematoma in the posterior cranial fossa, showing spontaneous development and rapid increase in size after cardiac surgery. An 86-year-old woman underwent aortic valve replacement for aortic valve stenosis, followed by anticoagulant therapy with heparin. Three days after the cardiac surgery, she complained of headache. Computed tomography revealed development of a subdural hematoma in the posterior cranial fossa. The hematoma rapidly increased in size within 7 days. Eleven days after cardiac surgery, she underwent removal of the subdural hematoma by craniotomy. Intraoperatively, the subdural hematoma was covered by a thick granulomatous capsule, with histopathological findings similar to those of a chronic subdural hematoma. She was discharged 2 weeks after the craniotomy without any neurological deficits. Encapsulated subdural hematoma in the posterior cranial fossa is rare and its etiology is unknown. In this case, postoperative anticoagulant therapy can promote the rapid growth of thick hematoma capsule. It is possible that previously reported cases of “posterior fossa chronic subdural hematoma” contain similar lesions to that in our patient.

The occurrence of cerebral vasospasm secondary to bacterial meningitis is relatively rare. Furthermore, there is no specific treatment cerebral vasospasm. Endovascular treatment may be essential for cases with the advanced clinical course. Balloon angioplasty or intra-arterial injection of verapamil, nicardipine, or nitroglycerin has been previously reported. We experienced successful treatment using intra-arterial infusion of fasudil hydrochloride. To our knowledge, this is the first case to report the intra-arterial injection of fasudil hydrochloride for treating cerebral vasospasm secondary to bacterial meningitis. A 37-year-old female who presented with dizziness had a right cerebellar tumor that was excised and diagnosed as glioblastoma. On postoperative day 10, Streptococcus oralis meningitis was detected. On postoperative day 20, the patient developed right hemiparesis with a severe vasospasm of the bilateral middle cerebral artery and anterior cerebral artery. Intra-arterial fasudil hydrochloride injection was performed for 3 days, following which the patient’s symptoms improved. Symptomatic cerebral vasospasm secondary to bacterial meningitis is relatively rare and difficult to treat; in selected cases, intra-arterial fasudil hydrochloride injection was an effective treatment for cerebral vasospasm secondary to bacterial meningitis.

The surgical removal of giant solid hemangioblastoma involves a high risk of perioperative bleeding and requires attentive hemostasis. Here, we present a case of a giant solid hemangioblastoma accompanied with hemophilia which was previously undiagnosed. A 35-year-old man without any past medical history was admitted with diplopia and ocular motility disorder. computed tomography (CT) and magnetic resonance imaging (MRI) revealed obstructive hydrocephalus and a solid giant tumor of more than 4.0 cm in diameter in the right cerebellopontine angle (CPA). Hemangioblastoma was suspected on cerebral angiography. After ventriculoperitoneal shunt for obstructive hydrocephalus, oozing from the skin incision continued for several days. Hemophilia type A was diagnosed based on the result of laboratory blood coagulability examination. Supplemental administration of factor VIII and coil embolization of the feeding arteries of the lesion on the CPA were performed, and the tumor was subtotally resected without hemorrhagic complications. The histopathological diagnosis was hemangioblastoma. We report this case to emphasize the importance not to overlook previously undiagnosed coagulopathy before surgical excision of hemangioblastoma. And, with appropriate perioperative management for coagulopathy, surgical treatment involving a high risk of perioperative bleeding can be safely undertaken.

We report a case of a young male who received multiple surgical treatments for repeated recurrence of skull base mesenchymal chondrosarcoma (MC). When the patient was 18 years old, we subtotally removed the skull base MC and he was treated with stereotactic radiosurgery for remnant tumors in the left cavernous sinus. After 30 months, we removed residual tumors that had regrown partially, via combined endonasal endoscopic and orbitozygomatic approaches. Over the next 65 months, the patient refused radical resection, and received six salvage surgeries, two stereotactic radiotherapies, and five stereotactic radiosurgeries for repeated recurrence. At 95 months after initial surgery, the tumors had extended to the skull base and nasal cavities. As a result, the left eye had been blinded and right visual acuity was deteriorated. We performed left anterior-middle cranial base resection, removal of nasal and intradural tumors, high flow bypass, en-bloc resection of the left cavernous sinus and clivus, and reconstruction using an abdominal flap. Even though the main tumors were removed with safety margins, tumors around the right optic nerve were removed by piecemeal to preserve right eye function. Six months after the radical resection, tumors in the right orbital apex recurred because we had been unable to remove the tumor with adequate safety margins. Skull base MC has a high tendency to recur locally, so these tumors should be radically removed with safety margins as early as possible to prevent recurrence.

Concurrent multiple tumors developing in the spinal cord are rare, except for in genetic disorders, such as neurofibromatosis and von Hippel-Lindau disease. Furthermore, concurrent tumors arising in the same spinal level with discrete histopathology are much rarer. We report two such cases. Case 1: A 53-year-old man presented with intracranial hemorrhage that manifested as disturbed consciousness and right hemiparesis. Magnetic resonance (MR) angiography demonstrated severe stenosis of the terminal portion of the bilateral internal carotid arteries, implying Moyamoya disease. Cranial MR images showed a hematoma in the left basal ganglia perforating into the lateral ventricle, which was incidentally detected as a spinal tumor compressing the cervical cord at the C2 level. After conservative management for cerebral hemorrhage, the patient underwent total removal of the spinal tumor. Surgical findings showed that the tumor consisted of extra- and intradural components. Histopathological findings showed that the extra- and intradural components were schwannoma and meningioma, respectively. Case 2: A 70-year-old man presented with progressive left hemiparesis and numbness in both lower extremities. Craniocervical MR images demonstrated a paraspinal tumor compressing the spinal cord at C2 level. Surgical findings disclosed that the tumor consisted of major extradural- and minor intradural components. Histopathological study showed that these components had discrete histological findings: extradural lesion was schwannoma and intradural lesion was meningioma. Concurrent tumors with discrete histopathology should be considered in tumors with extra- and intradural components, particularly, when they are located in the high cervical spine.

Dermoid tumors originating from the cavernous sinus are typically intradural, and thus, presentation with ophthalmoplegia is uncommon. Infantile dermoid tumors originating from the interdural space of the lateral wall of the cavernous sinus are also very rare. We herein present a 4-year-old infantile case of a dermoid cyst that was embedded in the lateral wall of the cavernous sinus. The patient presented with oculomotor nerve palsy. Magnetic resonance image demonstrated a well-circumscribed oval lesion inside the lateral wall of the left cavernous sinus. The lesion had two solid components that were hyperintense on T1- and T2-weighted images and was associated with a cystic mass that included fluid with the same signal intensity as cerebrospinal fluid. Gross total removal via a frontotemporal approach was performed. The symptoms markedly recovered in the 6-month follow-up. To the best of our knowledge, there have only been two reports of infantile dermoid cysts in the lateral wall of the cavernous sinus. We herein describe their clinical characteristics with the previous review and introduce surgical tips for the resection.

The objective of this study is to present a rare case of an invaginated inferior vena cava (IVC) aneurysm in the lumbar intradiscal space. A 73-year-old woman with lower back pain and bilateral lower extremity swelling presented to the clinic. She had undergone spinal surgery performed thrice at the same site (L4–L5) in another hospital and a separate posterolateral fusion surgery procedure 3 years previously. On plain radiography, pseudarthrosis was observed at L4–L5 segment. Contrast computed tomography (CT) imaging revealed a dilatation of the IVC in the intradiscal space of L4–L5. On the anterior side, anterior discectomy was performed. Following insertion of the allograft bone chip and cage, the invaginated IVC aneurysm was repositioned. Implant removal and screw fixation were performed posteriorly. Post-surgery, the patient’s lower back pain improved, and the start of anticoagulation treatment after vascular evaluation was planned. Although there have been numerous case reports of patients with intradiscal cysts or gas requiring surgical treatment, there have not yet been any reports of those with invaginated IVC in an intradiscal space. It is important to provide the appropriate treatment based on a thorough prior understanding of the patient’s anatomy.