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A 17-year-old boy presented with a high-grade fever. The patient had been previously diagnosed with Cornelia de Lange syndrome (CdLS). The patient visited a local physician and was diagnosed with sinusitis. Owing to persistent fever, the patient was referred to our hospital. At the initial presentation, his body temperature was 38.2°C, while maintaining previous living activities and neurological function. Despite changing the antibiotic to amoxicillin, the patient's fever persisted with worsened activity. At the second presentation, the patient presented with left hemiparesis. Blood examination revealed increased white blood cell count and serum C-reactive protein level. Emergency magnetic resonance imaging revealed acute cerebral infarcts in the right cerebral hemisphere, with evident stenosis in the right paraclinoid segment of the internal carotid artery (ICA). In addition, an abscess was found in the cerebellar hemisphere, which was punctured through the burr hole. Computed tomography performed after the completion of antibiotic therapy revealed a restored diameter of the stenotic ICA. Sinusitis can cause ischemic stroke due to compressive stenosis of the paraclinoid ICA, particularly in patients with CdLS. Sinusitis should be preferentially managed in patients with CdLS.

A 73-year-old man who previously underwent transsphenoidal surgery for a Rathke's cleft cyst presented with headache and fever. Ophthalmological examination revealed the progression of visual impairment. Cerebral magnetic resonance imaging revealed a cystic mass in the sellar and suprasellar regions with rim-like enhancement. An intralesional hyperintense area with temporal enlargement was identified using serial diffusion-weighted imaging. Lumbar cerebrospinal fluid tap findings indicated bacterial meningitis. The patient had undergone a transsphenoidal surgery; an intraoperatively implanted sheet of artificial dura mater from the previous surgery was identified adjacent to the sellar floor. After incising the floor, the pus material was drained and methicillin-sensitive Staphylococcus aureus was identified on culture. Consecutive antibiotic treatment resolved the pituitary abscess (PA). PA may develop as a late complication of transsphenoidal surgery, particularly when an artificial material is implanted during surgery. Clinical signs coupled with temporal findings on diffusion-weighted sequences can facilitate the diagnosis and activity of PA and serve as a guide for proper management.

A 74-year-old man presented with persistent hiccups and headache persisting for 2 days. An anticoagulant was administered for his coronary heart disease. Cranial computed tomography (CT) revealed an intracerebral hemorrhage (ICH) located in the right occipital lobe, without any abnormal findings around the brainstem. The patient underwent endoscopic hematoma evacuation via a burr hole, resulting in immediate resolution of hiccups. Following an uneventful postoperative course, the patient experienced recurrent hiccups on the 47th day postsurgery. A subsequent CT scan taken on the 50th day revealed a compressive chronic subdural hematoma (CSDH) situated in the right frontoparietal convexity. The patient underwent burr-hole irrigation, leading to prompt cessation of the hiccups. Persistent hiccup should be recognized as potential manifestation of supratentorial lesions, including ICH or CSDH. Surgical evacuation of such lesions can rapidly alleviate hiccups associated with these pathologies.

A 50-year-old man presented with headache and left hemiparesis. No noticeable preceding head trauma was observed. Computed tomography (CT) scans revealed a compressive chronic subdural hematoma (CSDH). The patient underwent burr-hole irrigation, during which he was considerably restless. In addition, extensive avulsion was found in the parietal dura mater posterior to the burr hole. CT performed immediately after the surgery revealed the emergence of a thick epidural hematoma (EDH) located posterior to the burr-hole. During emergency craniotomy for the EDH, there was no identifiable injury to the dura mater or the meningeal vessels. However, a review of the CT scans confirmed well-developed diploic spaces just above the center of the EDH, with connecting channels between the diploic spaces and extracranial sites. Based on these observations, we assumed that the diploic vein might have caused the EDH. Diploic veins can cause AEDH after burr hole irrigation for CSDH. Appropriate intraoperative sedation and protective irrigation maneuvers can reduce the risk of such AEDH.

A 43-year-old, previously healthy man experienced a decreased sensation in the left lower extremity without preceding spinal trauma. At presentation, the patient exhibited slight motor weakness in the left lower extremity, in addition to decreased pain sensation below the ipsilateral T7. Spinal magnetic resonance imaging (MRI) revealed abnormal findings consistent with idiopathic thoracic spinal cord herniation (ITSCH) at the T5/6 level. Computed tomography (CT) revealed a small vertebral erosion at the lower T5. The patient's symptoms gradually progressed over the next 3 years. MRI revealed marked lateral elongation of the cord at the T5/6 and apparent intravertebral cord herniation. The patient underwent ITSCH reduction through T5-6 laminectomies. The herniated cord was vertically long with a bulbous rostral part. Successful ITSCH reduction was achieved and the patient's postoperative course was uneventful. ITSCH is a progressive pathology that requires prompt surgical reduction. Certain ITSCHs may be complicated by intravertebral cord herniation.

A 53-year-old woman presented with a 2-week history of headache and vertigo. Computed tomography revealed a hyperdense tumor, measuring 30 × 31 × 36 mm in diameter, in the anteromedial parts of the cerebellar hemispheres. Cerebral magnetic resonance imaging 10 days later revealed an apparent extra-axial tumor with broad attachment to the medial tentorium cerebelli and rapid growth to a diameter of 40 × 41 × 46 mm. Cerebral angiography revealed no obvious feeding vessels or tumor stains. The patient underwent biopsy through the left occipital transtentorial route. The histological appearance was consistent with diffuse large B-cell lymphoma. Intracranial lymphoma may present as a dural tumor that mimics a meningioma. Rapid tumor growth incongruous with benign meningiomas should be assumed to be possible lymphoma, and prompt biopsy should be performed.

Abstract Spontaneous intracerebral hemorrhage (SICH) remains a devastating form of stroke. Prior use of antiplatelets or warfarin before SICH is associated with poor outcomes, but the effects of direct oral anticoagulants (DOACs) remain unclear. This study aimed to clarify trends in prior antithrombotic use and to assess the associations between prior use of antithrombotics and in-hospital mortality using a multicenter prospective registry in Japan. In total, 1085 patients were analyzed. Prior antithrombotic medication included antiplatelets in 14.2%, oral anticoagulants in 8.1%, and both in 1.8%. Prior warfarin use was significantly associated with in-hospital mortality (odds ratio [OR] 5.50, 95% confidence interval [CI] 1.30–23.26, P

A 25-year-old woman presented with exophthalmos. With the diagnosis of dural arteriovenous fistula of the transverse sinus, the patient underwent coil embolization. Fifteen years later, she sustained visual disturbance due to de novo tuberculum sellae meningioma that was resected. Surveillance magnetic resonance imaging (MRI) performed at the age of 42 years detected tumor recurrence and small, apparent meningioma in the cerebral convexity. The patient underwent the second tumor resection at the age of 46 years. The histological appearance was consistent with meningothelial meningioma. In addition, surveillance MRI at the age of 43 years detected de novo cerebral and cerebellar cavernous malformations (CMs). These CMs showed repeat hemorrhages on MRI but remained asymptomatic during the next 38 months. De novo meningiomas and CMs may develop in association with radiation exposure during endovascular therapy. Sufficiently long-term follow-up is recommended after endovascular therapy for monitoring secondary pathologies.

A 69-year-old woman suffered attacks of hearing disturbance and vertigo for seven years. Her otologic and ophthalmological examinations did not show any significant findings. Cerebral magnetic resonance imaging revealed a cystic mass in the left cerebellar convexity. Computed tomography demonstrated a contrast defect of the distal left transverse sinus. Magnetic resonance imaging revealed a cyst protruding into the transverse sinus, and enlarging in the supine. Cerebral angiography demonstrated a congestive venous flow in the left transverse sinus, at the upstream of the cyst. At rest, the venous sinus pressure was 13 cm H2O at the upstream of the cyst and 8 cm H2O at the downstream. When the patient held a breath, the upstream pressure increased to 37 cm H2O, while the maximal downstream pressure was 22 cm H2O. A large AG protruding into the cranial dural sinus may cause intermittent venous congestion and associated otologic symptoms. Movements accompanied by a transient decrease in cardiac venous return and changes in head position can attribute to an enlargement of such AG.

A 65-year-old man presented with coma. The cranial computed tomography (CT) revealed a massive hematoma in the left cerebral hemisphere, accompanied by intraventricular hemorrhage (IVH) and ventriculomegaly. Contrast examination revealed ectatic superior ophthalmic veins (SOVs). The patient underwent emergent hematoma evacuation. Contrast CT performed on postoperative day (POD) 2 showed a remarkable reduction in the diameters of both SOVs. A second patient, a 53-year-old man, presented with consciousness disturbance and right hemiparesis. CT revealed a large hematoma in the left thalamus, accompanied by massive IVH. Contrast CT demonstrated the bold delineation of the SOVs. The patient underwent endoscopic IVH removal. Contrast CT performed on POD 7 showed a remarkable reduction in the diameters of both SOVs. A third patient, a 72-year-old woman, presented with severe headache. CT revealed diffuse subarachnoid hemorrhage and ventriculomegaly. Contrast CT demonstrated a saccular aneurysm on the internal carotid artery-anterior choroidal artery branching site with the bold delineation of the SOVs. The patient underwent microsurgical clipping. Contrast CT performed on POD 68 showed a remarkable reduction in the diameters of both SOVs. The SOVs may function as an alternative venous drainage pathway in the setting of acute intracranial hypertension due to hemorrhagic stroke.

A 78-year-old woman presented after a fall and injury in the left forehead. She had undergone surgery for papillary thyroid carcinoma 14 years prior and breast carcinoma 7 years prior. The patient had exhibited uneventful postoperative courses without relapse or metastasis. Anticoagulants or antiplatelet agents were not prescribed her. At presentation, the patient exhibited no focal neurological deficits. Computed tomography revealed a 19 × 20 mm hemorrhagic lesion in the right temporal lobe. On cerebral magnetic resonance imaging, the center of the lesion exhibited inhomogeneous intensity on both T1- and T2-weighted sequences with heterogeneous enhancement. In contrast, the perilesional hemorrhagic regions, appearing hyperintense on both T1- and T2-weighted sequences, showed temporary regression followed by marked enlargement over the subsequent 123 days. The patient underwent total tumor resection. The microscopic findings of the resected specimens were consistent with papillary thyroid carcinoma. Minor head injuries may trigger intratumoral hemorrhage in metastatic brain tumors. Metastasis should be assumed when patients with a history of thyroid carcinoma present with a solitary parenchymal lesion with the appearance of cerebral cavernous malformation, even if they have been disease free for a long period.

A 31-year-old woman presented with a headache and nausea. At presentation, her blood pressure was 114/71 mm Hg with left hemiparesis. Computed tomography revealed a large hyperdense mass in the right temporal lobe accompanied by intralesional calcifications and ventricular perforation. Spot signs were not identified, and cerebral angiography did not reveal any abnormal vasculature. The patient underwent emergency craniotomy assuming an intracerebral hemorrhage. Intraoperatively, grayish tumor tissue was found to intermingle with the clots. Microscopic findings of the tumor revealed neoplastic cells possessing perinuclear halo and cell atypia, and diffusely stained with glial fibrillary acidic protein, which were consistent with anaplastic oligodendrogliomas. However, genomic analyses of the tumor showed non-mutant isocitrate dehydrogenase 1 and telomerase reverse transcriptase, in addition to wild-type O6-methylguanine DNA-methyltransferase. These are equivalent to glioblastoma multiforme. Based on the results, we assumed that anaplastic oligodendrogliomas may develop apoplectic intratumoral hemorrhages that mimic intracerebral hemorrhage. Genomic exploration is recommended for such tumors, coupled with careful follow-up, owing to its potentially aggressive nature.

A 41-year-old man presented with photophobia. The patient showed a choked disc and right-sided quadrantanopia with an intact sphincter reaction to light stimulation. Computed tomography revealed an isodense mass in the right frontal convexity, accompanied by extensive perifocal brain edema and smooth-contoured skull erosion. On cerebral magnetic resonance imaging, the tumor was dural-based, appeared inhomogeneous intensity on both T1- and T2-weighted sequences, and was intensely enhanced. Magnetic resonance angiography revealed unusually ectatic right-sided middle meningeal and superficial temporal arteries. The tumor, which was elastic hard, highly vascular, and severely adhered to the frontal cortices, was completely resected. The microscopic findings of the resected specimen were consistent with angiomatous meningioma. The patient's photophobia resolved after surgery, with resolution of the optic chiasm compression. Meningiomas arising in the frontal convexity may cause photophobia. Angiomatous meningioma should be considered when a broad-based tumor is found in the cerebral convexity accompanied by skull erosion and extensive perifocal edema.

A 34-year-old woman presented with progressive visual impairment for 2 months. Computed tomography and magnetic resonance imaging (MRI) revealed a suprasellar cyst. The patient underwent endoscopic endonasal surgery, which resulted in gross total resection with a diagnosis of craniopharyngioma. Postoperatively, the patient's visual function improved. The constructive interference steady-state (CISS) sequence revealed a remarkable resolution of hyperintense areas in the swollen optic nerve and tract. A 36-year-old woman sustained an abrupt visual loss. She had been diagnosed with cavernous malformations (CMs) in the right frontal lobe and suprasellar region 11 years ago, with an intact optic tract. Cerebral MRI at presentation revealed marked enlargement of the suprasellar CM and swelling of the right optic tract, accompanied by predominant hyperintense areas in the optic pathway. The patient's visual function showed significant improvement with conservative management. The CISS sequence performed 3 months later showed remarkable resolution of hyperintensity in the optic pathway. Prominent hyperintense areas in the optic pathway may indicate congestion of glymphatic flow. Reduction in such areas may be a radiological biomarker reflecting the improvement of visual impairment.

Background: Internal carotid artery (ICA) aneurysm may be a good target for supraorbital keyhole clipping. We discuss the surgical indications and risks of keyhole clipping for ICA aneurysms based on long-term clinical and radiologic results. Methods: This was a retrospective analysis of 51 patients (aged 35–75 years, mean 62 years) with ICA aneurysms (mean 5.8 ± 1.8 mm) who underwent clipping via the supraorbital keyhole approach between 2005 and 2017. Neurologic and cognitive functions were examined by several methods, including the modified Rankin Scale and Mini-Mental Status Examination. The state of clipping was assessed 1 year and then every few years after the operation. Results: Complete clipping was confirmed in 45 patients (88.2%), dog-ear remnants behind the clip persisted in 4 patients, and wrapping was performed in 2 patients. Mean duration of postoperative hospitalization was 3.4 ± 6.9 days. The mean clinical follow-up period was 6.6 ± 3.2 years. The overall mortality was 0, and overall morbidity (modified Rankin Scale score ≥2 or Mini-Mental Status Examination

Background: Rhabdoid meningiomas (RMs) are a rare type of malignant meningioma. Here, we report a case of intracranial RM presenting with visual disturbance and prominent hyperintensity in the optic nerve (ON). Case Description: A 20-year-old female presented with a 1-year history of headache. At presentation, her visual acuity (VA) was 20/50 on the right side and 20/40 on the left, with an intraocular pressure of 17 mmHg on both sides. Cerebral magnetic resonance imaging revealed a broad-based tumor in the right frontal convexity. It measured 82 mm × 65 mm × 70 mm in diameter, accompanied by cystic components, and was inhomogeneously enhanced. The intraorbital ONs demonstrated prominent intramedullary hyperintensity on the constructive interference steady-state sequence. Gross total tumor resection was performed and the pathology was consistent with RM. Immediately after surgery, her VA and IOP were 20/17 and 10 mmHg, respectively, with a remarkable resolution of the intramedullary hyperintensity. Conclusion: Prominent hyperintensity in the ON identified in patients with chronic intracranial hypertension may be an indicator of visual disturbance. It can rapidly resolve after resolution of intracranial hypertension with functional recovery. [ABSTRACT FROM AUTHOR]

Background: Cerebrospinal fluid (CSF) rhinorrhea with meningoencephalocele (MEC) associated with Sternberg's canal is rare. We treated two such cases. Case Description: A 41-year-old man and a 35-year-old woman presented with CSF rhinorrhea and mild headache worsening with standing posture. Head computed tomography showed a defect close to the foramen rotundum in the lateral wall of the left sphenoid sinus in both cases. Head magnetic resonance (MR) imaging and MR cisternography revealed that brain parenchyma had herniated into the lateral sphenoid sinus through the defect of the middle cranial fossa. The intradural and extradural spaces and bone defect were sealed with fascia and fat through both intradural and extradural approaches. The MEC was cut away to prevent infection. CSF rhinorrhea completely stopped after the surgery. Conclusion: Our cases were characterized by empty sella, thinning of the dorsum sellae, and large arteriovenous malformations that suggest chronic intracranial hypertension. The possibility of Sternberg's canal in patients with CSF rhinorrhea with chronic intracranial hypertension should be considered. The cranial approach has the advantages of lower infection risk and the ability to close the defect with multilayer plasty under direct vision. The transcranial approach is still safe if performed by a skillful neurosurgeon. [ABSTRACT FROM AUTHOR]

Background: To the best of our knowledge, there are no reports of penetrating orbitocranial injury (POCI) caused by a shoji frame. Case Description: A 68-year-old man fell in his living room and was stuck headfirst by a shoji frame. At presentation, marked swelling was noted in the right upper eyelid, with the edge of the broken shoji frame exposed superficially. Computed tomography (CT) revealed a hypodense linear structure located in the upper lateral sector of the orbit, partially protruding into the middle cranial fossa. Contrast-enhanced CT revealed intact ophthalmic artery and superior ophthalmic vein. The patient was managed with frontotemporal craniotomy. The shoji frame was extracted by pushing out the extradurally located proximal edge from the cranial cavity and simultaneously pulling the distal edge from the stab wound in the upper eyelid. Postoperatively, the patient received intravenous antibiotic therapy for 18 days. Conclusion: POCI can be caused by shoji frames as a result of an indoor accident. The broken shoji frame is evidently delineated on CT, which can result in prompt extraction. [ABSTRACT FROM AUTHOR]

Background: To the best of our knowledge, no study using neuroimaging modalities has documented calvarial diploic veins (DVs) connected to the extracranial sites. This study aimed to characterize them using magnetic resonance imaging (MRI). Methods: A total of 88 patients underwent thin-sliced contrast MRI. In addition, the DVs coursing through the pterional area were observed on three injected cadaver heads. Results: On postcontrast MRI, the DVs of the pterional area directly drained into the temporalis muscle or supplied branches coursing into the muscle in 43% on the right side and 40% on the left. The DVs and their branches were highly variable in diameter and number. In 9% of cases, the DV of the pterional area was found to drain into an extracranial site and connected to large venous channels distributed in the temporalis muscle. Furthermore, in 17% of cases, the DVs drained into the extracranial sites in the frontal skull region, followed by 9% in the parietal, 2% in the occipital, and 1% in the temporal regions. The DVs coursed superficially in the pterional area on both sides of all three cadaver heads. On one side, the DV in the area was open to an extracranial site. Conclusion: Part of the diploic venous flow drains extracranially in the pterional area. This area may provide an important interface between the calvarial DVs and the extracranial venous system. [ABSTRACT FROM AUTHOR]

Background: Subsequent bilateral intracerebral hemorrhage (SBICH) in the putamen and thalamus is a rare condition. Herein, we report four such cases. Case Description: Case 1: A 47-year-old woman presented with the left hemiparesis and elevated blood pressure. Neuroimaging revealed a right thalamic hemorrhage and a small left thalamic hemorrhage accompanying the hyperdense rim on computed tomography (CT) and the hypointense rim on gradient-echo T2*-weighted imaging (T2*WI). Case 2: A 53-year-old man presented with a disturbance of consciousness and elevated blood pressure. Neuroimaging revealed a left putaminal hemorrhage and a small right thalamic hemorrhage that appeared hyperdense on CT and hypointense on T2*WI. Case 3: A 65-year-old woman presented with the right hemiparesis and elevated blood pressure. Neuroimaging revealed a left putaminal hemorrhage and a small right thalamic hemorrhage accompanied by a hyperdense rim on CT and a hypointense rim on T2*WI. Case 4: A 75-year-old woman presented with the right hemiparesis and elevated blood pressure. Neuroimaging revealed a left thalamic hemorrhage and small hemorrhages in the right thalamus and cerebellar hemisphere. These hemorrhages appeared hyperdense on CT and hypointense on T2*WI. Conclusion: SBICHs are rare bilateral hemorrhages that may present with asymptomatic microbleeds in the putamen or thalamus coupled with symptomatic, subsequent hemorrhages in the contralateral counterparts. The latter hemorrhage may develop during the subacute phase of microbleeds in the putamen or thalamus. [ABSTRACT FROM AUTHOR]

Background: Langerhans cell histiocytosis (LCH) arising in the skull is rare in adulthood. Case Description: A 58-year-old woman experienced a durable headache. Cerebral magnetic resonance imaging (MRI) at presentation showed no abnormalities; however, MRI and computed tomography (CT) performed 6 weeks later revealed the emergence of a well-demarcated, heterogeneously enhancing calvarial tumor accompanied by irregular-shaped bone erosion. On MRI, the temporalis muscle and subcutaneous tissue adjacent to the tumor were extensively swollen and enhanced. The patient underwent en bloc resection. The microscopic appearance of the tumor was consistent with that of LCH. Postoperative systemic 18F-fluorodeoxyglucose positron emission tomography/CT did not detect any abnormal accumulation. Conclusion: LCH may develop within a short period. It should be considered as a differential diagnosis when a rapidly growing calvarial tumor is encountered, even when the patient is an adult. Prompt histological verification is recommended in such cases. [ABSTRACT FROM AUTHOR]

Background: Angiomatous meningioma is a rare subtype of meningiomas. To the best of our knowledge, there have been no reports of intradiploic angiomatous meningioma. Case Description: A 53-year-old previously healthy woman was diagnosed with a calvarial lesion during a brain checkup. Cerebral magnetic resonance imaging showed an intradiploic tumor, 11 × 14 × 12 mm, in the right parietal bone. It was an enhancing, lobular tumor presenting as isointensity on T1- and hyperintensity on T2-weighted sequences, with an intense enhancement of the adjacent dura mater. Computed tomography revealed bone erosion at the tumor site, extending predominantly into the inner side, and sclerotic changes in the surrounding bone. Total resection was performed. Microscopically, the tumor tissue comprised cells with lowgrade meningioma and intervening prominent vasculatures, consistent with angiomatous meningioma. Conclusion: Angiomatous meningioma should be considered as a differential diagnosis when an intradiploic tumor shows a lobular structure, intense enhancement of the adjacent dura mater, and sclerotic changes in the surrounding skull. These findings can support prompt tumor resection. [ABSTRACT FROM AUTHOR]

Orbito-zygomatic craniotomy is a widely accepted skull-based technique, but osteotomy at the malar eminence (ME) is complicated. We have developed a safe fronto-orbito-zygomatic (FOZ) osteotomy by creating small guide burr holes in the superior and lateral parts of the orbital wall and cutting the bone using a diamond-coated threadwire saw. This method involves standard two-piece osteotomy by creating small superior and lateral guide orbital burr holes instead of sectioning into the superior and inferior orbital fissures. The guide burr holes are connected using a diamond-coated threadwire saw to create the FOZ bar. This method was applied to the treatment of four patients with skull-based tumors or internal carotid and basilar artery aneurysms. Postoperative three-dimensional bone density computed tomography showed minimum bone gap in the ME. No craniotomy-related complication has occurred. FOZ osteotomy by creating guide burr holes in the orbital wall and cutting the bone using a diamond-coated threadwire saw is safe and results in minimum bone gap in the ME. [ABSTRACT FROM AUTHOR]