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Halo orthosis is used for cervical spine fixation after spinal surgery or injury. Although superficial infection at pin sites occurs frequently, intracranial development of infection, including brain abscesses, is very rare. We experienced subdural empyema due to methicillin-resistant Staphylococcus aureus (MRSA) caused by intracranial penetration of halo pins. A 38-year-old woman with a 4-year history of rheumatoid arthritis experienced severe myelopathy due to atlanto-axial dislocation and vertical subluxation. Reduction and immobilization using a halo vest resulted in neurologic improvement; she later underwent occipital bone to C2 fusion using posterior instrumentation. Three months after halo orthosis fixation, she complained of a headache, experienced a generalized tonic-clonic seizure, and became unconscious for 10 min. Computed tomography revealed pneumoencephalus, and Gd-enhanced magnetic resonance imaging revealed edema, enhancement of the overlying dura in the left partial lobe, and subdural and subarachnoidal empyema. Following removal of the halo vest, there was a purulent discharge from the left-posterior pin site. Culture of the discharge was positive for MRSA. The patient was treated with intravenous vancomycin for 2 weeks, followed by cefozopran hydrochloride for 4 weeks. Her symptoms improved, and additional surgery was not required. At latest follow-up, 10 years after the seizure, she is neurologically stable without any recurrence of the infection.

Meningeal melanocytoma is a rare benign tumor of the central nervous system (CNS) that develops in the cranial and spinal leptomeninges. Symptomatic subarachnoid hemorrhage associated with this tumor has been rarely reported. We describe a patient with a sudden onset of paraplegia due to a subarachnoid hemorrhage associated with an intradural extramedullary meningeal melanocytoma. As both the meningeal melanocytoma and hematoma in the subacute phase are black in color, their co-occurrence was difficult to distinguish in the surgical field. Following a subtotal resection, there has been no evidence of local recurrence after one year, although careful follow-up with radiation therapy is essential. Clinicians should be aware of meningeal melanocytoma as an intradural neoplasm.