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Recently, the improvements in the prognosis of childhood brain tumors have made it necessary to consider the risk of radiation-induced brain tumor development in long-term survivors. In this report, we describe a case of radiation-induced meningioma (RIM) treated surgically 36 years after radiotherapy. A 46-year-old woman, who underwent craniotomy for suprasellar germ cell tumor at 10 years of age with additional postoperative radiotherapy, was admitted to the emergency room with consciousness disturbance and right hemiplegia. One year earlier, magnetic resonance imaging (MRI) revealed a 1-cm diameter tumor in the left middle cranial fossa. This MRI showed an enlarged brain tumor in same lesion with clearly enhanced by gadolinium. A RIM located on a left sphenoid ridge with a fast growth rate was diagnosed, and the gross total removal was achieved by a left frontotemporal craniotomy. Histological diagnosis of atypical meningioma (World Health Organization grade II) was made. RIMs are frequently atypical, anaplastic meningiomas that have already been treated with radiotherapy, making additional postoperative radiotherapy difficult; the removal rate must be increased to achieve a good prognosis. In the case of long-term survivors after childhood radiotherapy, a strict follow-up with the occurrence of RIM in mind is necessary.

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Background: Despite the proven benefit of stent retriever thrombectomy for acute ischemic stroke caused by large-vessel embolic occlusion, acute revascularization in the setting of underlying intracranial, atherosclerosis-related, and emergent large-vessel occlusion remains to be a challenge. In this case report, we present a novel revascularization technique that can be used to treat acute ischemic stroke caused by suspected intracranial, atherosclerosis-related, and emergent large-vessel occlusion of the internal carotid artery (ICA). Case Description: This case report presents two patients with intracranial, atherosclerosis-related, and emergent large-vessel occlusion of the ICA: a 73-year-old man with a right-sided hemiparesis and aphasia and a 60-year-old man with altered level of consciousness. These patients were treated using the prolonged deployment and partial resheath method with a stent retriever, using the following devices: Solitaire Platinum, Trevo Trak 21, and AXS catalyst 6 for suction. On prolonged deployment of the Solitaire Platinum device, underlying focal atherosclerotic disease was noted. The device remained in place for more than 10 min, until the blood vessel was occluded. Next, the device was partially resheathed into the Trevo Trak 21 to reduce the radial force and minimize vessel injury during the pull. The partially constrained device was then retrieved under continuous aspiration at the lesion site and blood flow was successfully restored. Both patients recovered without any new deficits. Conclusion: The prolonged deployment and partial resheath method using a stent retriever may be safe and effective in the treatment of intracranial, atherosclerosis-related, and emergent large-vessel occlusion of the ICA.

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Intracranial dermoid cysts are rare congenital lesions that result from abnormal sequestration of ectodermal cells during neural tube formation. These tumors are especially rare in lateral areas such as in the temporal lobe. In this study, we report a case of dermoid cyst located in the right temporal lobe. A 50-year-old man was referred for further treatment of a tumor. CT revealed a low-density mass lesion in the right temporal lobe, with calcification. MRI showed the lesion with high signal intensity on diffusion-weighted imaging, high-low mixed signal intensity on T1-weighted imaging, and iso-high signal mixed intensity on T2-weighted imaging; the capsule was enhanced with gadolinium. Differential diagnosis included dermoid cyst, epidermoid cyst, teratoma, and neurenteric cyst. We decided to perform surgery for the improvement of his symptom, histopathological diagnosis, and radical cure. A right temporal craniotomy was performed, and the tumor was found adherent to the surrounding brain tissue. The tumor was completely removed under subpial dissection. Hair was confirmed in the tumor content. On histopathology, the cyst wall was lined with stratified squamous epithelium, sebaceous glands, small vessel aggregates, and inflammatory infiltrate. Keratinized material and hair were found in the lumen. The patient was discharged 7 days after surgery with no new neurologic deficits. This case was unusual in terms of the effect of gadolinium enhancement on MRI, and the presence of adipose tissue and calcification were useful for diagnosis. It is vital to consider prevention of chemical meningitis due to intrathecal dissemination of the tumor content intraoperatively.

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In chronic subdural hematoma (CSDH) patients, motor functions usually recover quickly after burr-hole surgery; however, in a rare case, the hemiparesis showed poor improvement after surgery. In that case, investigation of cerebral infarctions is important. Among the 284 CSDH patients with motor weakness, magnetic resonance image (MRI) and MR angiography (MRA) were acquired in 82 patients before surgery when the hemiparesis progressed rapidly. Small lacunar infarction was identified on the hematoma side in five cases; all were older than 80 years with hypertension, and diabetes mellitus had been diagnosed in two. In all the five patients (100%), MRA demonstrated a downward or upward shift of the M1 portion of the middle cerebral artery on the hematoma side, where the perforating arteries originate. Conversely, only 4 CSDH patients (5.2%) without lacunar infarction demonstrated M1 downward shift. The risk factors of lacunar infarction were high in the five detected cases; however, distortion, twisting, or elongation of the lenticulostriate arteries might be a cause of the lacunar infarctions, rather than the formation of lipohyalinosis or microatheroma in the arteries. Therefore, anti-platelet treatment might not be necessary for CSDH-inducing lacunar infarction. The lacunar infarctions caused by CSDH were small, the patients' hemiparesis was mild, a prognosis of all the patients was good, and they recovered well from the motor weakness after physical rehabilitation. MR examinations before surgery are recommended for CSDH patients especially when a patient complains of sudden onset or rapid deterioration of motor weakness.

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WHAT IS KNOWN AND OBJECTIVE: Perampanel, an anticonvulsant, might induce psychological reactions. CASE DESCRIPTION: A 70-year-old woman, who had been taking 2500 mg/day levetiracetam, complained of right-hand minor-convulsion. Perampanel of 2 mg/day was additionally prescribed, and the dosage was increased to 4 mg/day. Two weeks after taking 4 mg/day perampanel, she changed her personality and kept insulting her husband; however, the patient herself was aware of her strange behaviour. She regained her normal personality after quitting the perampanel medication. WHAT IS NEW AND CONCLUSION: This self-awareness is crucial to distinguish the perampanel-induced reaction from psychosis.

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BACKGROUND: Nervus intermedius neuralgia is an extremely rare craniofacial neuralgia characterized by paroxysmal episodes of pain located deep in the ear, typically triggered by sensory or mechanical stimuli at the wall of the auditory canal without underlying pathology. Pain is sometimes associated with disorders of lacrimation, salivation, and taste. CASE DESCRIPTION: We present a case of a surgically treated 68-year-old man with left paroxysmal deep ear pain for 20 years before presentation. Preoperative 3-dimensional magnetic resonance cisternography/magnetic resonance angiography (3D-MRC/MRA) fusion imaging showed severe compression of the facial nerve by the anterior inferior cerebellar artery in the cisternal portion with associated nerve deformity. We suspected nervus intermedius neuralgia and decided to perform microvascular decompression of the facial nerve. Transposition of the artery led to sufficient decompression of the nerve. The pain disappeared immediately after surgery. CONCLUSIONS: It is important to keep in mind the possibility of nervus intermedius neuralgia in patients who present with intermittent episodes of pain located deep in the ear. Furthermore, 3D-MRC/MRA fusion imaging is useful for decision-making in surgery. Microvascular decompression was highly effective in our case. Based on radiological findings, microvascular decompression should be considered a viable treatment option.

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