A case of meningioma originating from the lateral wall of the cavernous sinus.

Meningioma originating from the lateral wall of the cavernous sinus is rare with only two reported cases. A 67-year-old man presented with recent memory disturbance and partial seizure. Magnetic resonance imaging revealed a well-demarcated and homogeneously enhanced mass lesion originating from the lateral wall of the left cavernous sinus. Total tumor removal was performed through a combined epi- and intradural approach. Histological diagnosis was transitional meningioma. Postoperative course was uneventful. This combined approach was helpful for cranial nerve preservation, total tumor removal, and bleeding control from the feeder of the tumor.

Mixed pial and dural arteriovenous fistula after craniotomy: case report and literature review.

Dural arteriovenous fistula (AVF) is known to occur after craniotomy, but mixed pial and dural AVF after craniotomy has not been reported. A 45-year-old man who had undergone surgical clipping of an unruptured aneurysm 2 years previously presented with small subcortical hemorrhage from mixed pial and dural AVF. Surgical disconnection could not be cured completely due to the granulomatous tissue around the aneurysm, and the presence of an undetected shunt. Postoperative digital subtraction angiography showed a new pial AVF supplied by the middle cerebral artery pial branches. Many branches were associated with the remnant aneurysm and pial AVF, so we did not try to embolize the fistula. Gamma knife surgery was performed as adjuvant radiotherapy, which achieved angiographically complete occlusion of the shunt points. Multimodal approaches including surgery, endovascular intervention, and radiotherapy are needed for radiological and clinical cure of mixed pial and dural AVF. Long-term follow up is essential.

Hyperbaric hydrogen therapy improves secondary brain injury after head trauma.

Background: The pathophysiology of traumatic brain injury (TBI) is caused by the initial physical damage and by the subsequent biochemical damage (secondary brain injury). Oxidative stress is deeply involved in secondary brain injury, so molecular hydrogen therapy may be effective for TBI. Hydrogen gas shows the optimal effect at concentrations of 2% or higher, but can only be used up to 1.3% in the form of a gas cylinder mixed with oxygen gas, which may not be sufficiently effective. The partial pressure of hydrogen increases in proportion to the pressure, so hyperbaric hydrogen therapy (HBH2) is more effective than that at atmospheric pressure. Methods: A total of 120 mice were divided into three groups: TBI + non-treatment group (TBI group; n = 40), TBI + HBH2 group (n = 40), and non-TBI + non-treatment group (sham group; n = 40). The TBI and TBI + HBH2 groups were subjected to moderate cerebral contusion induced by controlled cortical impact. The TBI + HBH2 group received hyperbaric hydrogen therapy at 2 atmospheres for 90 minutes, at 30 minutes after TBI. Brain edema, neuronal cell loss in the injured hippocampus, neurological function, and cognitive function were evaluated. Results: The TBI + HBH2 group showed significantly less cerebral edema (p ≺ 0.05). Residual hippocampal neurons were significantly more numerous in the TBI + HBH2 group on day 28 (p ≺ 0.05). Neurological score and behavioral tests showed that the TBI + HBH2 group had significantly reduced hyperactivity on day 14 (p ≺ 0.01). Conclusion: Hyperbaric hydrogen therapy may be effective for posttraumatic secondary brain injury.

Intravenous Hydrogen Therapy With Intracisternal Magnesium Sulfate Infusion in Severe Aneurysmal Subarachnoid Hemorrhage.

BACKGROUND AND PURPOSE: Poor-grade subarachnoid hemorrhage still has a poor prognosis. This randomized controlled clinical trial evaluated intracisternal magnesium sulfate infusion combined with intravenous hydrogen therapy in patients with poor-grade subarachnoid hemorrhage. METHODS: Thirty-seven patients with poor-grade subarachnoid hemorrhage were randomized to Mg+H2, Mg, and control groups. Mg and Mg+H2 groups received intracisternal magnesium sulfate infusion (2.5 mmol/L) at 20 mL/h for 14 days. Mg+H2 group also received intravenous hydrogen-rich solution infusion for 14 days. Primary outcome measures were occurrence of delayed cerebral ischemia and cerebral vasospasm. Secondary outcome measures were modified Rankin Scale and Karnofsky performance status at 3 and 12 months, Barthel index at 12 months, and serum and cerebrospinal fluid malondialdehyde and neuron-specific enolase. RESULTS: Serum neuron-specific enolase levels were significantly lower in the Mg+H2 group from days 3 to 14 than in the control group. Cerebrospinal fluid neuron-specific enolase levels were also significantly lower in the Mg+H2 group from days 3 to 7 than in the control group. Incidences of cerebral vasospasm and delayed cerebral ischemia were significantly higher in the control group than in other groups. Modified Rankin Scale and Karnofsky performance status did not significantly differ between the three groups at 3 months. Modified Rankin Scale scores 0 to 2 were more common in the Mg and Mg+H2 groups at 1 year. Barthel index was higher in the Mg+H2 group than in the control group. CONCLUSIONS: Intracisternal magnesium sulfate infusion started immediately after surgery reduces the incidence of cerebral vasospasm and delayed cerebral ischemia and improves clinical outcomes without complications in patients with poor-grade subarachnoid hemorrhage. Intracisternal magnesium sulfate infusion combined with intravenous hydrogen therapy decreases serum malondialdehyde and neuron-specific enolase and improves Barthel index, indicating hydrogen has additional effects. Registration: URL: https://www.umin.ac.jp/ctr/index.htm. Unique identifier: UMIN000014696.

Lomustine and nimustine exert efficient antitumor effects against glioblastoma models with acquired temozolomide resistance.

Glioblastomas (GBM) often acquire resistance against temozolomide (TMZ) after continuous treatment and recur as TMZ-resistant GBM (TMZ-R-GBM). Lomustine (CCNU) and nimustine (ACNU), which were previously used as standard therapeutic agents against GBM before TMZ, have occasionally been used for the salvage therapy of TMZ-R-GBM; however, their efficacy has not yet been thoroughly examined. Therefore, we investigated the antitumor effects of CCNU and ACNU against TMZ-R-GBM. As a model of TMZ-R-GBM, TMZ resistant clones of human GBM cell lines (U87, U251MG, and U343MG) were established (TMZ-R-cells) by the culture of each GBM cells under continuous TMZ treatment, and the antitumor effects of TMZ, CCNU, or ACNU against these cells were analyzed in vitro and in vivo. As a result, although growth arrest and apoptosis were triggered in all TMZ-R-cells after the administration of each drug, the antitumor effects of TMZ against TMZ-R-cells were significantly reduced compared to those of parental cells, whereas CCNU and ACNU demonstrated efficient antitumor effects on TMZ-R-cells as well as parental cells. It was also demonstrated that TMZ resistance of TMZ-R-cells was regulated at the initiation of DNA damage response. Furthermore, survival in mice was significantly prolonged by systemic treatment with CCNU or ACNU but not TMZ after implantation of TMZ-R-cells. These findings suggest that CCNU or ACNU may serve as a therapeutic agent in salvage treatment against TMZ-R-GBM.

[A Case Report of Brain Metastasis from Anal Canal Carcinoma].

A 55-year-old female with adenocarcinoma of anal canal(stage IV with lung, bone, and lymph node metastasis)underwent total pelvic exenteration surgery and chemotherapy. Chemotherapy was continued after the surgery. One month later, she presented to the emergency room with gait disorder and cognitive dysfunction. CT and MRI demonstrated metastatic brain tumor in the right cerebellar hemisphere. Craniotomy and CyberKnife surgery were performed. Histological examination revealed adenocarcinoma with atypical cells forming a papillary arrangement. She died 35 weeks after the surgery. Brain metastasis from anal carcinoma is very rare, but recent advances in chemotherapy are achieving favorable results of long-term survival, and this is likely to increase in the future. Early detection, early treatment, and combined therapy may improve the long-term outcome for patients.

[Hemifacial Spasm Caused by Vertebral Artery Fusiform Aneurysm and the Anterior Inferior Cerebellar Artery].

We report a case of hemifacial spasm in which the root exit zone(REZ)of the facial nerve was compressed by both the vertebral artery(VA)aneurysm and the anterior interior cerebellar artery(AICA). A 60-year-old female had suffered left hemifacial spasm for 2 years. Three-dimensional rotational angiography with selective arterial infusion of contrast medium(3DRA-IA)revealed that a distal part of the left AICA looping at the cisternal region was contacting the dome of the left VA aneurysm, although other imaging modalities did not show the exact course of the ipsilateral AICA. Constructive interference steady state magnetic resonance imaging revealed that both the left VA aneurysm and the left AICA had compressed the REZ of the left facial nerve. She underwent aneurysm clipping and decompression of the REZ by transposition of both the clipped aneurysm and the AICA using TachoSil®. Her hemifacial spasm disappeared immediately after surgery without complication. Some fine arteries might compress the REZ in patients with hemifacial spasm associated with VA aneurysms. 3DRA-IA was more effective for accurate evaluation than other imaging modalities. Transposition of vascular structures using TachoSil® is safe and effective for microvascular decompression surgery in such complicated cases.

[A Case of Bilateral Trigeminal Neuralgia and the Possible Onset Mechanisms Based on the Operative Findings].

Several cases of bilateral trigeminal neuralgia(TN)have been reported;however, the possible onset mechanism has rarely been discussed. We encountered a case of bilateral TN occurring in two stages. A 64-year-old woman presented with left TN. Magnetic resonance imaging showed the transverse pontine vein adhering to the left trigeminal root and superior cerebellar artery adhering to the right trigeminal root;however, no symptoms were noted. Immediately after microvascular decompression(MVD)on the left side, TN disappeared completely. However, 2 years postoperatively, the patient presented with right TN. The second MVD surgery revealed that the right cerebellar surface severely adhered to the dura mater, particularly under the surface of the tentorium. The arachnoid membrane at the cerebellopontine angle was slightly adhered. The patient was completely free from pain after the second MVD. The intraoperative findings suggested that the brain stem may have shifted and the cerebellopontine cistern may have narrowed because of cerebellar adhesion to the surrounding structures and arachnoid adhesion. We speculate that such structural changes in the posterior fossa after the first operation may have caused the asymptomatic vascular adhesion to change into the symptomatic offending adhesion over time.

[A Case of Primary Intracranial Malignant Melanoma Mimicking a Traumatic Brain Contusion].

Primary intracranial malignant melanoma(PIMM)is a rare neoplasm of the central nervous system, accounting for 1% of cases of malignant melanomas and 0.1% of cases of brain tumors. Here, we report a case of PIMM that was initially considered to be a traumatic brain contusion. A 44-year-old man was transferred to a local hospital because of general tonic convulsion after falling while riding a bike. CT showed an irregular high-density area in the left temporal pole, which was diagnosed as a traumatic contusion. MRI performed 3 months after the initial episode revealed an enlarged temporal lesion with surrounding edema, suggestive of a neoplasm. The MRI showed the lesion as mixed signal intensity, suggesting both solid and cystic components. Subtotal resection was performed, except for the tumor adhering to the peripheral middle cerebral arteries(MCAs). The definitive diagnosis was made based on pathological findings and no evidence of extracranial lesions. Gamma knife surgery was performed for the remnant tumor adjacent to MCAs. The radiologically positive tumor chronologically regressed, and the patient remained progression-free for 18 months. Radiological findings of PIMM vary but typically include high density on CT and hyperintensity on T1-weighted MRI. Close observation enabled early diagnosis based on the suspicion of a neoplasm according to atypical radiological findings. PIMM has a poor prognosis with an overall survival of 12.0 months without confirmative treatment. Gamma knife surgery might achieve suppression of this highly progressive tumor.

[Three Surgical Cases of Brain Metastasis from Renal Cell Carcinoma Occurring more than 10 years after Nephrectomy:Case Reports and Literature Review].

Renal cell carcinoma(RCC)can metastasize to the brain within several years;however, 20 cases of brain metastases have been reported after>10 years of the initial nephrectomy. Here, we report three cases of brain metastasis that occurred>10 years after nephrectomy for RCC. In general, RCC is radio-resistant, but stereotactic radiosurgery has been reported to be effective in some cases. To improve the functional and survival prognoses, delayed brain metastases from RCC should be aggressively resected.

Intracellular cholesterol level regulates sensitivity of glioblastoma cells against temozolomide-induced cell death by modulation of caspase-8 activation via death receptor 5-accumulation and activation in the plasma membrane lipid raft.

Development of resistance against temozolomide (TMZ) in glioblastoma (GBM) after continuous treatment with TMZ is one of the critical problems in clinical GBM therapy. Intracellular cholesterol regulates cancer cell biology, but whether intracellular cholesterol is involved in TMZ resistance of GBM cells remains unclear. The involvement of intracellular cholesterol in acquired resistance against TMZ in GBM cells was investigated. Intracellular cholesterol levels were measured in human U251 MG cells with acquired TMZ resistance (U251-R cells) and TMZ-sensitive control U251 MG cells (U251-Con cells), and found that the intracellular cholesterol level was significantly lower in U251-R cells than in U251-Con cells. In addition, treatment by intracellular cholesterol remover, methyl-beta cyclodextrin (MßCD), or intracellular cholesterol inducer, soluble cholesterol (Chol), regulated TMZ-induced U251-Con cell death in line with changes in intracellular cholesterol level. Involvement of death receptor 5 (DR5), a death receptor localized in the plasma membrane, was evaluated. TMZ without or with MßCD and/or Chol caused accumulation of DR5 into the plasma membrane lipid raft and formed a complex with caspase-8, an extrinsic caspase cascade inducer, reflected in the induction of cell death. In addition, treatment with caspase-8 inhibitor or knockdown of DR5 dramatically suppressed U251-Con cell death induced by combination treatment with TMZ, MßCD, and Chol. Combined treatment of Chol with TMZ reversed the TMZ resistance of U251-R cells and another GBM cell model with acquired TMZ resistance, whereas clinical antihypercholesterolemia agents at physiological concentrations suppressed TMZ-induced cell death of U251-Con cells. These findings suggest that intracellular cholesterol level affects TMZ treatment of GBM mediated via a DR5-caspase-8 mechanism.

Modified Extradural Temporopolar Approach for Paraclinoid Aneurysms: Operative Nuance and Surgical Result.

BACKGROUND: Extradural temporopolar approach can provide extensive exposure of the anterior clinoid process, which can prevent intraoperative neurovascular injury in anterior clinoidectomy for paraclinoid aneurysms. The present study investigates the usefulness of this modified technique, and operative nuances are discussed here. METHODS: We retrospectively reviewed the medical charts of 30 consecutive patients with paraclinoid aneurysms who underwent treatment with this modified extradural temporopolar approach between September 2009 and March 2016. RESULTS: Worsening of visual acuity was documented postoperatively in three patients (10.0%), and visual field function worsened in three patients (10.0%). Postoperative outcome was good recovery in all patients. No operation-related mortality occurred in the series. CONCLUSION: Extradural anterior clinoidectomy via the modified extradural temporopolar approach is safe and may be recommended for surgical treatment of paraclinoid aneurysms to reduce the risk of intraoperative optic neurovascular injury.

Multistaged, multidirectional strategy for safe removal of large meningiomas in the pineal region.

OBJECTIVE Pineal region meningiomas are rare and tend to be discovered only after they grow. Several simultaneous multidirectional approaches performed as a single operation have been proposed, but the best strategy to remove these deeply situated large meningiomas involving the deep vital venous system remains to be established. The authors advocate a multistaged, multidirectional approach to safely remove these challenging tumors. METHODS Four consecutive cases of meningioma in the pineal region were treated between April 2013 and June 2016. The 3 large (> 40 mm diameter) tumors were removed via multistaged, multidirectional approaches (2 surgeries in 2 patients and 3 surgeries in 1 patient) with gravity retraction of the occipital or parietal lobe. The large occipital skin incision extending bilaterally was used for the next operation from the contralateral side. Combinations of the occipital transtentorial approach with or without the transfalcine approach, occipital bitranstentorial/falcine approach, combined supra-/infratentorial transsinus approach, and contralateral parietal interhemispheric transcallosal approach were used. RESULTS Transient visual field deficits occurred after 2 of the 8 operations, but all tumors were removed grossly or subtotally without permanent surgery-related morbidity. The galenic venous system and straight sinus remained intact in all patients. During the follow-up period (mean 29.5 months [range 13-52 months]), there were no recurrences after the final operation. CONCLUSIONS A multistaged, multidirectional strategy with an intentional large occipital scalp incision and gravity retraction of the occipital lobe is a good choice for the safe removal of large meningiomas in the pineal region.

Superficial Temporal Artery to Anterior Cerebral Artery Hemi-bonnet Bypass Using Radial Artery Graft for Prevention of Complications after Surgical Treatment of Partially Thrombosed Large/Giant Anterior Cerebral Artery Aneurysm.

BACKGROUND: Partially thrombosed large/giant aneurysm of the anterior cerebral artery is still challenging because this complex aneurysm requires arterial revascularization in the deep operation field. Therefore, direct neck clipping is often impossible. We describe our experiences with extracranial-intracranial bypass as an insurance bypass prior to clipping of partially thrombosed anterior cerebral artery aneurysms, and discuss the microsurgical technique and strategy. CLINICAL PRESENTATION: Consecutive, single-surgeon experience with the surgical treatment of partially thrombosed anterior cerebral artery aneurysms was retrospectively reviewed. Three cases of partially thrombosed anterior cerebral artery aneurysms, 2 anterior communicating artery aneurysms, and 1 postcommunicating artery (A2 segment of the anterior cerebral artery) aneurysm, presented as mass effect symptoms from giant aneurysms in 2 patients and incidentally discovered aneurysm in one patient. Superficial temporal artery-radial artery graft-anterior cerebral artery hemi-bonnet bypass was performed as an insurance bypass prior to clipping of the partially thrombosed anterior cerebral artery aneurysms. Complete aneurysm obliteration and bypass patency were demonstrated in all 3 patients. No neurological sequelae occurred. CONCLUSIONS: Superficial temporal artery-radial artery graft-anterior cerebral artery hemi-bonnet bypass prior to aneurysm dissection can avoid ischemic complication during temporary occlusion and secures permanent revascularization after complete obliteration of partially thrombosed large/giant anterior cerebral artery aneurysm.

[Treatment of Brain Metastases from Papillary Thyroid Carcinomas:Five Surgical Cases in Our Hospital and a Literature Review].

Papillary thyroid carcinoma is the most common thyroid malignancy and usually has an indolent clinical course with a good prognosis. Brain metastasis from thyroid cancer is very rare, occurring in only 0.8-1.3% of all papillary thyroid carcinomas; therefore, the prognosis and treatment of the metastatic tumor are unclear. We describe 5 cases of brain metastases from papillary thyroid carcinoma treated with surgery between 2013 and 2017. Intracranial tumor resection was performed and brain metastases were pathologically diagnosed as papillary thyroid carcinoma in 2 men and 3 women aged 62-72 years(mean 67 years). The surgical treatment for the thyroid cancer was total thyroidectomy in 3 patients, hemithyroidectomy in 1, and no treatment in 1. The duration from initial diagnosis to brain metastasis was 0-155 months(mean 73.2 months). Two patients also received radioiodine therapy. Three patients had multiple lesions and 2 had single lesions. Four patients also had other metastases. Neuroimaging demonstrated intratumoral hemorrhages in 2 patients. The other 2 patients had intratumoral hemorrhage during the course of the disease. All patients received radiation therapy after surgery for brain metastases. Two patients died, but the other 3 have survived to date. The other 2 patients who had intratumoral hemorrhage during the course of the disease received 131I radioiodine therapy. It was reported that 131I radioiodine therapy resulted in collapse of the fragile peritumoral vessels. It is safe to perform head magnetic resonance imaging(MRI)before radioiodine therapy for thyroid cancer. Papillary thyroid carcinomas carry a good prognosis but some brain metastases have a poor prognosis due to the presence of other metastases or the patient's poor general condition. Treatments for patients in good general condition are needed to improve the clinical course and prognosis.

[A Case of Retro-Odontoid Pseudotumor in a Very Elderly Individual].

Retro-odontoid pseudotumors are mainly caused by aging or rheumatoid arthritis. We treated a very elderly patient with retro-odontoid pseudotumor. A 92-year-old man was admitted with the chief complaints of difficulty walking and progressive numbness in the right upper and lower extremities. Neurological examination revealed muscle weakness and exaggerated tendon reflexes of the right upper and lower extremities, and disturbance in skilled motor activities of the fingers, bilaterally. He had no bladder or rectal disturbances. The Japanese Orthopaedic Association(JOA)score for cervical myelopathy was 10/17. Rheumatoid arthritis was interpreted as negative. Radiography of the neck showed no atlanto-axial instability. Cervical magnetic resonance(MR)imaging revealed a mass located posterior to the C2 odontoid process, severely compressing the cervical cord. The patient underwent a C1 laminectomy and C2 half laminectomy without fixation to achieve cord decompression. Postoperatively, muscle weakness in the right upper and lower extremities was remarkably improved, and gait disturbance was also improved. However, skilled motor activities of the fingers on the right hand during tasks such as writing letters, holding a cup, and using chopsticks, were not improved. JOA score was improved to 14/17. Postoperative radiography revealed no atlanto-axial instability and MR imaging revealed adequate decompression of the spinal canal. Laminectomy without fixation is recommended as an effective and less invasive treatment for retro-odontoid pseudotumor, especially in very elderly patients without atlanto-axial instability.

[A Case of Foramen Magnum Meningioma Manifesting as Hypoglossal Nerve Palsy].

We report a case of foramen magnum meningioma manifesting as hypoglossal nerve palsy. A 72-year-old woman presented with progressive hypoglossal nerve palsy and lingual atrophy on the left side. Gadolinium-enhanced T1-weighted magnetic resonance imaging revealed a heterogeneously enhanced mass lesion with dural tail sign partially extending into the hypoglossal canal. The transcondylar approach was performed to expose the hypoglossal canal and resect the tumor completely. Histological examination revealed a transitional meningioma. The postoperative course was uneventful. Hypoglossal nerve palsy improved gradually after the operation.

[Primary Intracranial Malignant Lymphoma Associated with Acquired Immunodeficiency Syndrome(AIDS):A Case Report].

The spread of human immunodeficiency virus(HIV)infection may result in an increased likelihood of surgery in patients with HIV infection. We treated a patient with intracranial malignant lymphoma associated with acquired immunodeficiency syndrome(AIDS)caused by HIV infection. The recommendations of the countermeasure manual for AIDS were followed. Only surgical staff without finger injury or inflammation were permitted to be involved in the operation. All staff were dressed in a waterproof, full-body surgical gown, and wore double gloves, double foot covers, and an N95 mask. The surgery could be performed safely with such infection control measures. Histological examination revealed a diffuse large B-cell lymphoma. The patient was referred to the Division of Infectious Diseases and Respiratory Medicine for chemotherapy.

[Surgical Treatment of a Giant Olfactory Groove Schwannoma:A Case Report].

Schwannomas originating from the olfactory nerve are extremely rare because the olfactory nerve does not normally contain Schwann cells. We describe a case of a giant schwannoma of the olfactory groove. A 73-year-old woman presented with anosmia persisting for 10 months. Head computed tomography(CT)for head trauma at another hospital demonstrated a tumor lesion located in the left frontal lobe and paranasal sinus. She had never suffered epilepsy, and past medical history and family history identified no indicators. Neurological examination revealed anosmia and dementia. Head CT demonstrated a tumor lesion with bone erosion, causing a defect of about 5cm in the frontal base. Head magnetic resonance(MR)imaging with contrast medium indicated a lesion that was 6cm in diameter, with heterogeneous enhancement and severe perifocal edema in the left frontal base, extending into the paranasal cavity. The tumor was resected through a left extradural subfrontal approach with bicoronal frontal craniotomy. The endoscopic approach was also performed simultaneously to remove the tumor in the paranasal sinus. The cystic tumor was soft and easy to bleed. Intraoperatively the right olfactory nerve was confirmed, but the left olfactory nerve could not be identified because of replacement by the tumor, suggesting that the tumor had originated from the left olfactory nerve. The defect of the dura was repaired with femoral fascia, the pedunculated periosteal flap was laid over the frontal base, and the bone defect was repaired with the inner plate of the frontal calvaria. Postoperative head MR imaging with contrast medium revealed no residual lesion. The patient was discharged 25 days after surgery, without new neurological deficits. Histological examination identified mixed Antoni type A and Antoni type B schwannoma on hematoxylin and eosin staining and S-100 protein on immunostaining.

[Surgical Treatment for Traumatic Acute Subdural Hemorrhage in the Posterior Cranial Fossa:Three Cases Reports and Review of the Literature].

Acute subdural hemorrhage(ASDH)in the posterior cranial fossa is rare. Extremely unfavorable outcomes are reported among cases accompanied by supratentorial hematoma, brainstem contusion, or intracerebellar contusion. We report three cases surgically evacuated several times for traumatic ASDH in the posterior cranial fossa simultaneously accompanied by supratentorial hematomas. In our three presented cases, the mean age was 72.3 years, and all patients were male. The mechanisms of injury included traffic accidents in two cases and fall in one. The median Glasgow Coma Scale score on admission was 6. On admission, the patients had traumatic ASDH in the posterior cranial fossa accompanied by supratentorial hematoma, so they first underwent external decompression or ICP sensor insertion for the supratentorial lesions. However, after their first surgery, all patients developed upward herniation, and subsequently underwent suboccipital craniotomy and evacuation of hematomas. Glasgow Outcome Scales were death in one case, persistent vegetable state in one case, and severe disability in one case. The patients with ASDH in the posterior cranial fossa accompanied by supratentorial hematoma should immediately undergo suboccipital craniotomy and supratentorial decompression simultaneously when the hematomas compress the brainstem and upward herniation develops.