Primary intracranial leiomyosarcoma (LMS) is an extremely rare tumor of the central nervous system. Only sporadic case reports have been published, and therefore data regarding long-term prognosis remain scarce. A 76-year-old woman presented with a right parietal mass, which had grown rapidly in the month prior to admission. Neuroimaging showed a resemblance to intraosseous meningioma. Gross total resection of the tumor was achieved, and histological diagnosis confirmed LMS. Because positron emission tomography (PET) with fluorodeoxyglucose (FDG) just after the resection showed no abnormal uptake, we diagnosed the tumor as primary intracranial LMS. Follow-up PET at 16 months after treatment showed two foci of FDG uptake in the bilateral lungs. Histological diagnosis by surgical resection identified the lesions as lung metastases of LMS. In addition, follow-up head magnetic resonance imaging (MRI) at 31 months showed local recurrence, and we conducted salvage therapy using CyberKnife system (Accuray incorporated) and pazopanib. To date, for 15 months after local recurrence, she is alive with intracranial recurrent disease remained inactive.

Trigone meningiomas are considered a surgical challenge, as they tend to be considerably large and hypervascularized at the time of presentation. We experienced a case of a large and very hard trigone meningioma that was effectively treated using initial microsurgical feeder occlusion followed by surgery in stages. A 19-year-old woman who presented with loss of consciousness was referred to our hospital for surgical treatment of a brain tumor. Radiological findings were compatible with a left ventricular trigone meningioma extending laterally in proximity to the Sylvian fissure. At initial surgery using the transsylvian approach, main feeders originating from the anterior and lateral posterior choroidal arteries were occluded at the inferior horn; however, only a small section of the tumor could initially be removed because of its firmness. Over time, feeder occlusion resulted in tumor necrosis and a 20% decrease in its diameter; the mass effect was alleviated within 1 year. The residual meningioma was then totally excised in staged surgical procedures after resection became more feasible owing to ischemia-induced partial softening of the tumor. When a trigone meningioma is large and very hard, initial microsurgical feeder occlusion in the inferior horn can be a safe and effective option, and can lead to necrosis, volume decrease, and partial softening of the residual tumor to allow for its staged surgical excision.

A delayed aneurysm rupture after flow diverter therapy is a rare but serious complication. Due to the anatomical specificity, a delayed rupture of a carotid cavernous aneurysm may cause a direct carotid cavernous fistula (dCCF). We present a novel therapeutic approach for treatment of dCCF after flow diverter therapy using the Pipeline embolization device (PED). An 86-year-old woman suffered from dCCF after PED embolization. A microcatheter was advanced through the transvenous approach into the cavernous sinus (CS) and further inserted into the aneurysm sac via the rupture point. Coil embolization of both the aneurysm sac and a small part of the CS adjacent to the fistulous site could achieve not only the immediate aneurysm occlusion but also the rupture point obliteration with a small amount of coil mass in the CS.

Traumatic intracranial aneurysms are one possible complication after penetrating brain injury. A 25-year-old man with a history of major depression presented with a crossbow bolt penetrating the head. On arrival, Glasgow Coma Scale score was E4V5M6, with no apparent neurological deficit. Computed tomography (CT) of the head showed the crossbow bolt passing near the corpus callosum, with surrounding contusion. Three-dimensional rotational angiography showed no anterior cerebral artery injuries. The crossbow bolt was removed after bifrontal craniotomy, with no postoperative infection. Postoperative CT angiography (CTA) was repeatedly performed, and a 4 mm aneurysm was observed at the pericallosal artery-right posterior internal frontal artery (PIFA) bifurcation on postoperative day (POD) 35. Trapping and the right PIFA-left cortical branch side-to-side bypass were performed on POD38. A resected specimen confirmed a pathological diagnosis of pseudoaneurysm. The patient did not show any neurological deficit or cognitive dysfunction as of 8 months after admission. Traumatic anterior cerebral artery aneurysm might have formed due to proximity to the falx cerebri. As pseudoaneurysm was detected 4 weeks after trauma in our patient, follow-up CTA or digital subtraction angiography should be performed until at least 4 weeks after injury. In addition, neck clipping is occasionally unfeasible to treat traumatic pseudoaneurysm surgically, and a surgical strategy including bypass revascularization must be planned.

Craniosynostosis associated with Chiari malformation (CM) is usually found in infants with an underdeveloped posterior fossa. We here present a case of adult craniosynostosis, CM, and symptomatic syringomyelia caused by the protrusion of the posterior rim of the foramen magnum without a tight posterior fossa. A 22-year-old woman with an abnormal head shape and forearm hypesthesia was given a diagnosis of sagittal suture synostosis with CM and syringomyelia caused by foramen magnum stenosis. She underwent foramen magnum decompression with a C1 laminectomy without cranial vault expansion or duraplasty. Her symptoms and radiographical findings improved after surgery. In cases of non-operative craniosynostosis with CM, clinicians should be alert to late-onset syringomyelia and choose surgical strategies according to the pathophysiology.

Severe hypoglycemia is known to cause acute focal neurological symptoms. In cases with a medical history of diabetes mellitus (DM), the diagnosis and treatment of hypoglycemia-induced neurological symptoms are simple. However, severe hypoglycemia can occur in patients who are not taking hypoglycemic agents such as insulin or long-acting sulfonylurea drugs. We describe a 95-year-old man with sudden onset of right hemiparesis who showed high signal intensity on diffusion-weighted imaging involving the left internal capsule with corresponding reduced apparent diffusion coefficient hypointensity. Laboratory findings revealed severe hypoglycemia (27 mg/dl). However, he was not taking insulin or long-acting sulfonylurea drugs but disopyramide and clarithromycin had been administered. In addition, he had kidney dysfunction with an estimated glomerular filtration rate (GFR) of 42.9 ml/min/1.73 m². After the blood glucose level was normalized, the left hemiparesis completely recovered and abnormal findings of magnetic resonance imaging (MRI) study also became normal. A combination of disopyramide and clarithromycin may cause severe hypoglycemia-induced neurological symptoms particularly in patients with kidney dysfunction. Even in a patient with sudden-onset hemiparesis and no history of DM, the possibility of hypoglycemia-induced neurological deficit should be considered.

A 56-year-old man underwent cervical laminoplasty for cervical spondylosis. On the 7th postoperative day, he suddenly felt severe neck pain, and tetraplegia developed rapidly over 1.5 hrs. Computed tomography demonstrated a huge hematoma compressing the cervical spinal cord. Clot was evacuated 3 hrs after the onset of symptoms. The patient’s postoperative course was uneventful. His blood pressure could not be properly controlled in the perioperative period. Surgeons should keep in mind that delayed postoperative spinal epidural hematoma (DPSEH) can occur more than a week after surgery, and meticulous blood pressure control is important for more than a week after a spinal operation.