✓ Although the craniovertebral junction is one of the most common sites at which anomalies develop, spina bifida occulta of the axis (C-2) associated with cervical myelopathy is extremely rare. The authors present the case of a 46-year-old man who developed progressive tetraparesis caused by a cervical canal stenosis at the level of the axis. The spinal cord was compressed by an invaginated bifid lamina of the axis. The patient made a remarkable recovery after undergoing decompressive laminectomy of C-3 and removal of the bifid posterior arch of the axis.

A 4-year-old boy presented with chopstick penetration into the cerebellum via the temporal squamosa and tentorium cerebelli, which resulted in a cerebellar abscess 1.5 years after the injury. The neuroimaging appearance of the wooden chopstick were unusual, hyperdense on computed tomography, and isointense on T2-weighted and hypointense on T2-weighted magnetic resonance imaging. Abscess aspiration and continuous drainage was performed with real-time intraoperative ultrasound guidance. The chopstick fragment was surgically removed and the patient discharged with minor neurological deficits. Wooden foreign body may show changes in properties after a long period of intraparenchymal retention. Extra care is required to remove wooden foreign bodies because of the high risk of infection.

A 61-year-old female developed subarachnoid hemorrhage after trans-sphenoidal surgery for Rathke's cleft cyst. Neuroradiological examination revealed a large aneurysm at the C₁ portion of the right in ternal carotid artery. Autopsy revealed marked proliferation of aspergillus hyphae in the wall of the aneurysm. A review of previously reported cases of fungal aneurysm proposes two developmental processes. Aneurysms secondary to fungal meningitis tend to be large in size and located in the ma jor cerebral artery trunk, but aneurysms following fungal sepsis tend to be small and in peripheral branches. The former aneurysms are probably caused by fungus invasion into the intracranium , usually from the paranasal sinus, and the latter may be due to fungal emboli like bacterial emboli in bacterial endocarditis.Ruptured fungal aneurysms are difficult to treat, so fungal meningitis or sepsis must be eradicated before an aneurysm develops.

We retrospectively evaluated the MRI from 17 patients with primary brain stem injury obtained in the acute stage. Clinical and radiological findings were analyzed in these 17 patients. T2-weighted imaging proved to be most sensitive and specific for the diagnosis of primary brain stem injury. We found two patterns of brain stem injury. The good prognosis group showed ventral brain stem lesions or dorsal superficial brain stem lesions. On the other hand the poor prognosis group showed deep dorsal brain stem lesions. These acute stage findings are seen only temporally in many cases so that it is most important to examine MRI findings in the acute stage to evaluate the prognosis of the patient. MRI was valuable in predicting the outcome. The possible mechanism of brain stem injury in patients with head injury is briefly discussed.

Cerebellar hemorrhage is regarded as a neurosurgical emergency. However, patients with deteriorating consciousness are very likely to die irrespective of the choice of therapy, and it is not clear if surgical intervention can benefit patients in a deeply comatose state. We reviewed 20 patients with a Glasgow Coma Scale score of 3 at admission to ascertain the salvage rate and determine the prognostic factors. Four patients who were managed conservatively died within 2 days. Sixteen patients underwent decompressive suboccipital craniectomy and hematoma evacuation. At discharge, three patients were moderately disabled, three were severely disabled, four were persistently vegetative, and six had died. The overall mortality was 50%. The mean interval between the onset of symptoms and the operation was 1.67 +/- 0.29 hours in patients with favorable outcome, and significantly longer at 2.42 +/- 0.49 hours in patients with an unfavorable outcome (p = 0.025). Immediate evacuation of the hematoma reduces morbidity and mortality even in deeply comatose patients, especially if the time interval between the onset and surgery is within 2 hours.