Midline Shift Induced by the Drainage of Cerebrospinal Fluid in Three Patients With External Decompression.

It is not rare that progressive hydrocephalus worsens clinical conditions in a patient with external decompression and drainage or shunt surgery is required. However, spinal drainage or shunt surgeries potentially carry a risk of causing paradoxical herniation in a patient with decompressive craniectomy, particularly in a comatose case with wide craniectomy. Careful and strict observations are necessary for such patients. In our three comatose cases with craniectomy, paradoxical herniation occurred due to excessive drainage after 5-7 days of shunt surgery and lumbar drainage, although the drainage pressure was set at more than 10 cmH2O. Fortunately, in the three cases, the herniation improved within a few days after the drain was clamped and the bed was flattened. However, the Trendelenburg position and epidural blood patch might be necessary if paradoxical herniation occurs acutely after lumbar puncture or drainage because delayed resolution can be fatal in the herniation.

Headache in patients with chronic subdural hematoma: analysis in 1080 patients.

Headache is a major symptom in chronic subdural hematoma (CSDH) patients. However, some CSDH patients do not complain headache although the hematoma is thick with definite midline shift. This clinical study was performed to identify the mechanism of headache in CSDH patients. We compiled clinical data of 1080 surgically treated CSDH patients (711 males and 369 females), and in 54 cases, the pressure of hematoma was measured during burr hole surgery using a glass-stick manometer. Headache was recognized in 22.6% of patients, while nausea or vomit suggesting increased intracranial pressure was detected in only 3.0%. Ophthalmological examination was performed in 238 patients, and papilledema was identified in only one patient (0.4%). The mean age of patients with headache (59.8 ± 16.9 years) was significantly younger than that of those without (75.7 ± 11.2 years) (P < 0.01). In 54 cases, the mean hematoma pressure was not significantly different between patients with (17.1 ± 6.2 mmH2O) and without (18.4 ± 7.2 mmH2O) headache (P > 0.10). Hematoma thickness was significantly greater in patients without headache (P < 0.01), but the ratio of midline shift to hematoma thickness was significantly greater in patients with headache (P < 0.01). In our results, the status of increased intracranial pressure was rare in CSDH patients, and high hematoma pressure was not a cause of headache. Midline shift was the most influenced factor for headache in our study, and based on the results, the authors consider that the potential cause of headache in CSDH might be stretching or twisting of the pain-sensitive meninges and meningeal arteries or veins.

Glioblastoma multiforme versus pleomorphic xanthoastrocytoma with anaplastic features in the pathological diagnosis: a case report.

BACKGROUND: Pleomorphic xanthoastrocytoma (PXA) with anaplastic features should be strictly distinguished from glioblastoma multiforme (GBM). CASE PRESENTATION: A case of PXA that was initially diagnosed as GBM is presented. A 42-year-old man visited our clinic because of right hemiparesis and total aphasia. Head magnetic resonance imaging demonstrated enhanced multiple cystic lesions in the left temporal lobe suggesting an intra-parenchymal brain tumor. The lesion was partially removed and GBM with a Ki-67 index of 20 % was diagnosed by pathological examination of the resected specimen. Despite receiving radiation and chemotherapy, the patient died 6 months after the first admission. At autopsy, the boundary between the tumor and normal brain tissue was clear. Large parts of the tumor demonstrated typical features of PXA, including pleomorphism, clear xanthomatous cells with foamy cytoplasm, positive silver staining, and a Ki-67 index of less than 1 %. DISCUSSION AND CONCLUSIONS: GBM should be diagnosed only when the majority of the tumor cells are undifferentiated. Although the operative specimen appeared typical GBM histologically, the diagnosis of GBM was subsequently excluded by the autopsy finding that much of the tumor had the characteristic features of a benign PXA. Therefore, the final diagnosis in this case was PXA with anaplastic features. PXA with anaplastic features should be carefully distinguished from GBM to facilitate appropriate decisions concerning treatment.

Delayed post-traumatic large subgaleal hematoma caused by diastasis of rhomboid skull suture on the transverse sinus.

PURPOSE: This study aimed to consider an appropriate treatment for large subgaleal hematoma with skull fracture and epidural hematoma (EDH). CASE REPORT: A 6-year-old boy presented at our hospital with head trauma, and computed tomography (CT) showed a thin EDH in the right temporo-occipital area and cranial diastasis in the right lambdoidal suture. However, no neurological deficits were identified in the patient. One week after trauma, he visited our hospital again with a massive fluctuant watery mass extending from the forehead to the right temporoparietal areas, and laboratory data revealed that he was anemic. CT showed a massive subgaleal hematoma with extremely high density around the cranial diastasis. Damage of the transverse sinus was suspected, and emergent sinus repair surgery was performed. The surgery disclosed that bleeding from the transverse sinus was flowing out extracranially through the cranial diastasis. The subgaleal and epidural hematomas were removed, and bleeding from the sinus was stopped by dural tacking sutures along the transverse sinus. Postoperative CT demonstrated complete disappearance of epidural and subgaleal hematomas. The patient recovered from general fatigue without blood transfusion and was discharged 9 days after surgery. CONCLUSIONS: The therapeutic strategy for massive subgaleal hematoma is individualized. However, treatment for massive subgaleal hematoma with skull fracture should not be considered the same as for hematoma without skull fracture. Emergent surgery is recommended before neurological deterioration is recognized in the patient if damage to the dural sinus is suspected.

Radiation-induced meningiomas in multiple regions, showing rapid recurrence and a high MIB 1 labeling index: a case report and review of the literature.

Combined chemotherapy and prophylactic cranial irradiation has improved the prognosis of children with acute leukemia. However cranial irradiation carries a latent risk of the induction of secondary intracranial tumors. We encountered a patient who developed multiple intracranial radiation-induced meningiomas (RIMs) 25 years after prophylactic cranial irradiation for the treatment of acute leukemia in childhood. The patient had 3 intracranial lesions, 1 of which showed rapid growth within 6 months; another of the tumors also enlarged within a short period. All of the tumors were surgically treated, and immunohistochemistry indicated a high MIB-1 labeling index in each of the multiple lesions. In the literature, the MIB-1 labeling indices of 27 tumors from 21 patients were examined. Among them, 12 recurrent tumors showed higher MIB-1 labeling indices compared to the MIB-1 labeling indices of the non-recurrent tumors. Overall, 11 of the patients with RIM had multiple lesions and 8 cases developed recurrence (72.7%). RIM cases with multiple lesions had higher MIB-1 labeling indices compared to the MIB-1 labeling indices of cases with single lesions. Collectively, these data showed that the MIB-1 labeling index is as important for predicting RIM recurrences, as it is for predicting sporadic meningioma (SM) recurrences. RIMs should be treated more aggressively than SMs because of their greater malignant potential.

Molecular status of pituitary carcinoma and atypical adenoma that contributes the effectiveness of temozolomide.

There have been several reports of temozolomide (TMZ) treatment of pituitary carcinomas and atypical adenomas. O(6)-methyl-guanine-DNA methyltransferase is not the sole molecule determining the sensitivity to TMZ in pituitary carcinomas and atypical adenomas. The Japan Society of Hypothalamic and Pituitary Tumors study suggests that MSH6, one of mismatch repair pathway enzyme, fulfills a contributory role to the efficacy of TMZ treatment for pituitary carcinomas and atypical adenomas. The preserved MSH6 function might be essential for the responsiveness to TMZ treatment in pituitary carcinomas and atypical adenomas.

Clinicopathological and molecular histochemical review of skull base metastasis from differentiated thyroid carcinoma.

Skull base metastasis from differentiated thyroid carcinoma including follicular thyroid carcinoma (FTC) and papillary thyroid carcinoma (PTC) is a rare clinical entity. Eighteen FTC cases and 10 PTC cases showing skull base metastasis have been reported. The most common symptom of skull base metastasis from FTC and PTC is cranial nerve dysfunction. Bone destruction and local invasion to the surrounding soft tissues are common on radiological imaging. Skull base metastases can be the initial clinical presentation of FTC and PTC in the presence of silent primary sites. The possibility of skull base metastasis from FTC and PTC should be considered in patients with the clinical symptoms of cranial nerve dysfunction and radiological findings of bone destruction. A variety of genetic alterations in thyroid tumors have been identified to have a fundamental role in their tumorigenesis. Molecular histochemical studies are useful for elucidating the histopathological features of thyroid carcinoma. Recent molecular findings may provide novel molecular-based treatment strategies for thyroid carcinoma.

Preoperative acetazolamide SPECT is useful for predicting outcome of shunt operation in idiopathic normal pressure hydrocephalus patients.

PURPOSE OF THE REPORT: Good outcome of shunt surgery for idiopathic normal pressure hydrocephalus (iNPH) patients are highly dependent on accurate preoperative assessments. Acetazolamide ethylcysteinate-dimer-single photon emission computer tomography (SPECT) was applied to iNPH patients for more exact preoperative evaluation. PATIENTS AND METHODS: Sixty-five patients were categorized into 3 groups: group I (normals, n = 30), group II (with ventriculomegaly due to age-relating changes, n = 10), and group III (who underwent shunt surgery based on the diagnosis of iNPH, n = 25). Acetazolamide SPECT was performed in all patients, and mini-mental state examination (MMSE) was performed before and 1 month after the surgery in group III. RESULTS: Acetazolamide SPECT study demonstrated normal increase of cerebral blood flow (CBF, more than 40%) in groups I and II. Group III was classified into 2 subgroups on the examination; a mean increasing percentage (%increase) of CBF was less than 20% in group IIIa and more than 40% in group IIIb. One month after the surgery, acetazolamide SPECT showed normal %increase of CBF in IIIa, and the increase in postoperative MMSE score was significantly greater in group IIIa than IIIb (P < 0.05). In iNPH patients, less than 20% increase in preoperative acetazolamide SPECT predicted improvement of MMSE score with 100% sensitivity and 60% specificity. CONCLUSIONS: Poor %increase of CBF by acetazolamide implies a low capacity for vasodilation in the brain due to compression and stretching by ventriculomegaly. Acetazolamide SPECT study is not an absolute examination but one of the valuable supplementary objective examinations to determine the surgical indication in iNPH-suspected patients.

Urinary growth hormone level and insulin-like growth factor-1 standard deviation score (IGF-SDS) can discriminate adult patients with severe growth hormone deficiency.

Adult growth hormone (GH) deficiency (AGHD) in Japan is diagnosed based on peak GH concentrations during GH provocative tests such as GHRP-2 stimulation test. In this study, we aimed to evaluate the ability of serum insulin-like growth factor-1 (sIGF-1) and urinary GH (uGH) at the time of awakening to diagnose AGHD. Fifty-nine patients with pituitary disease (32 men and 27 women; age 20-85 y (57.5 ± 15.5, mean ± SD) underwent GHRP-2 stimulation and sIGF-1 testing. Thirty-six and 23 patients were diagnosed with and without severe AGHD, respectively based on a peak GH response of <9 ng/mL to GHRP-2 stimulation. Serum IGF-1 was evaluated as a standard deviation score (IGF-1 SDS) based on age and sex. We determined whether uGH levels in urine samples from 42 of the 59 patients at awakening were above or below the sensitivity limit. We evaluated IGF-1 SDS and uGH levels in a control group of 15 healthy volunteers. Values for IGF-1 SDS were significantly lower in patients with, than without (-2.07 ± 1.77 vs.-0.03 ± 0.92, mean ± SD; p < 0.001) AGHD whereas the range of IGF-1 SDS substantially overlapped at > -1.4. IGF-1 SDS discriminated AGHD more effectively in patients aged ≤60 years. The χ2 test revealed a statistical relationship between uGH and AGHD (test statistic: 7.0104 ≥ χ2 (1; 0.01) = 6.6349). When IGF-1 SDS is < -1.4 or uGH is below the sensitivity limit, AGHD can be detected with high sensitivity.

Endoscopic extracapsular removal of pituitary adenoma: the importance of pretreatment of an adjacent unruptured internal carotid artery aneurysm.

The presence of an intracranial aneurysm together with a pituitary adenoma presents tremendous risk of subarachnoid hemorrhage, during transsphenoidal surgery, particularly when the aneurysm lies near the operative field. A left supraclinoid internal carotid artery aneurysm and a clinically nonfunctioning pituitary adenoma coexisted in a 57-year-old woman. Initially, the aneurysm was treated by endovascular coil placement, and then the patient underwent pseudocapsule-based extracapsular resection of the pituitary tumor via a transnasal transsphenoidal endoscopic approach. Pseudocapsule-based extracapsular total resection was safely performed, because of the extirpated risk of rupture of the coil-treated aneurysm. Recently, transsphenoidal pseudocapsule-based extracapsular resection approach for pituitary adenomas provides a more effective and safe alternative compared to the traditional intracapsular one because of its higher tumor removal and remission rates and lower recurrence rate. Compared with conventional subcapsular removal, pseudocapsule-based extracapsular resection has more risks of aneurysmal rupture that is located adjacent to pituitary adenoma. Thus, in a patient having a cerebral aneurysm with the proximity to the operative field, the cerebral aneurysm should be first treated with endovascular coil placement or direct surgical procedure; subsequently, pseudocapsule-based extracapsular resection of the pituitary tumor via a transnasal transsphenoidal endoscopic approach should be performed.

Isolated recurrence of intracranial and temporal bone myeloid sarcoma--case report.

A 52-year-old man presented with a rare case of isolated recurrence of myeloid sarcoma (MS) manifesting as rapidly growing intracranial and temporal bone masses 5 years after complete remission (CR) of acute myeloid leukemia (AML) (M2 in the French-American-British classification). Magnetic resonance imaging and computed tomography of the head revealed enhanced mass lesions on the superior aspect of the right petrous bone and within the right mastoid air cells, extending into the right middle ear cavity without bone destruction. Peripheral blood testing found no evidence of relapse. As the right temporal bone mass showed significant growth into the right temporal lobe over one month and diagnostic tissue was not available, he was admitted to our department for biopsy. On admission, blood testing showed relapse of AML and tumoral hemorrhage in the right temporal lobe. Emergent evacuation of the hematoma and biopsy of the right temporal lobe tumor was performed, resulting in a diagnosis of MS. Chromosomal analysis of the peripheral blood identified t(8;21)(q22;q22) abnormality. Before initiation of anti-AML chemotherapy, tumoral bleeding occurred again and he died 12 days after the operation of brain herniation. Autopsy revealed leukemia cell infiltrations in the perivascular region of the peritumoral brain parenchyma associated with hemorrhage, indicating vascular damage caused by leukemic cell infiltration from MS induced cerebral hemorrhage. Although relapse after 5 years of CR is uncommon in patients with AML, the possibility of MS recurrence must be considered.

Combination therapy with rituximab and temozolomide for recurrent and refractory primary central nervous system lymphoma.

High-dose methotrexate-based chemotherapy has extended survival in patients with primary central nervous system lymphoma (PCNSL). However, although salvage treatment is necessary in recurrent and refractory PCNSL, this has not been standardized. We herein describe the efficacy of a combination of rituximab and temozolomide (TMZ) in two consecutive patients with recurrent and refractory PCNSL. Based on the immunohistochemical study, case 1 had a non-germinal center B-cell-like (non-GCB) subtype, was positive for bcl-2 and negative for O6-methylguanine-DNA methyltransferase (MGMT). Case 2 was GCB subtype, bcl-2-, and MGMT+. Because of the positive expression of MGMT, interferon-beta was additionally given in case 2. Complete responses and partial responses were obtained after the third and fourth cycles of combination therapy, respectively. This was maintained for 12 months, with acceptable toxicity. The combination of rituximab and TMZ was effective in tumors with different immunohistochemical profiles. This combination therapy warrants further study in a larger population.

A case of multiple brain metastases of uterine leiomyosarcoma with a literature review.

Brain metastasis from uterine leiomyosarcoma is extremely rare, and prognostically alarming despite various treatments. The authors report a case of multiple brain metastases from uterine leiomyosarcoma who took a favorable course after tumor resection and γ-knife treatment. A 50-year-old woman with a history of hysterectomy for uterine leiomyosarcoma two years earlier, presented with a recent onset of headaches and vomiting. Multiple cerebral lesions were found by magnetic resonance imaging (MRI). The Karnofsky performance scale (KPS) was 40 with left hemiparesis and cerebellar ataxia. She was treated by resection of the left occipital and cerebellar tumors, followed by γ-knife irradiation of the residual tumors. KPS was 70 at her discharge from the hospital. MRI failed to show recurrence of the intracranial lesions 6 months after irradiation. She remained at home until she died from massive intra-abdominal bleeding. This is the first case with multiple brain metastases from uterine leiomyosarcoma, who survived with remarkable neurological improvement for 12 months. No comparable survival has been reported in the literature. It is evident that surgical resection and additional γ-knife irradiation contributed to early neurological recovery.

A case of subarachnoid hemorrhage with pituitary apoplexy caused by idiopathic hypertrophic pachymeningitis.

Steroid therapy is considered to improve clinical symptoms in hypertrophic pachymeningitis. We present a 70-year-old man with idiopathic hypertrophic pachymeningitis, whose clinical signs progressively worsened despite steroid therapy. He died of subarachnoid hemorrhage (SAH) with pituitary apoplexy 2 months after the admission regardless of improvement of laboratory data and magnetic resonance imaging appearance by one-and-half-month steroid therapy. Autopsy revealed thickened dura mater supporting the diagnosis of hypertrophic pachymeningitis. Brain parenchyma is generally not affected by the disease; however, histological investigation suggested that inflammation of the dura caused damage to superior hypophyseal artery resulting in SAH and apoplexy in the anterior lobe of the pituitary gland. The higher dose and the longer duration of steroid therapy should have achieved in our case although most laboratory data recovered within the normal range. The aggressiveness of hypertrophic pachymeningitis must be evaluated by clinical signs rather than by laboratory data or imaging examinations.

Intrathecal endoscopy to enhance the diagnosis of tethered cord syndrome.

OBJECT: Tethered cord syndrome (TCS) is being diagnosed in an increasing number of adults and late teens. Before referral to neurosurgeons, however, the majority of patients in this group suffers back and leg pain for a long period without a definitive diagnosis. The diagnostic difficulty derives from 2 factors: the signs and symptoms are subtle and easily overlooked, and the combination of an elongated cord and a thickened filum is lacking in 65% of patients. When a patient presents with signs and symptoms typical for TCS but demonstrates no elongated cord or thickened filum on MR imaging, one must search for a more reliable finding to establish a diagnosis of TCS. Based on the authors' earlier surgical experiences, posterior displacement of the terminal filum is consistently found at surgery in all patients with TCS. In previous publications they interpreted this finding as the lower cord and filum traveling along the concave side of the lumbosacral spinal canal to minimize cord tension. In the present prospective study, the authors attempt to confirm posterior displacement of the filum terminale by using intrathecal endoscopy prior to wide exposure of the spinal cord and filum. Further, the stretch test was applied to the terminal filum to evaluate its elasticity. METHODS: Sixty-eight patients with signs and symptoms as well as MR imaging studies indicative of TCS underwent endoscopic examination of the filum and cauda equina. After lumbar or sacral laminectomy, a flexible endoscope was inserted through a small dural and arachnoid incision into the subarachnoid space. The filum and cauda equina fibers were identified. Once the dura mater and arachnoid were opened widely, a stretch test was done to confirm filum inelasticity. In 3 patients, percutaneous endoscopy was also performed before open surgery to determine its applicability as compared with the open method. RESULTS: On inserting the endoscope into the intrathecal space, the filum was immediately identified medioposterior to the cauda equina fibers in all 68 patients. The stretch test revealed a lack of filum elasticity in all patients. Preoperative percutaneous endoscopy was equally effective in identifying the position of the filum. CONCLUSIONS: Currently, endoscopic identification of the posteriorly displaced filum, which was confirmed at open surgery, is the essential diagnostic study for TCS or the tethered spinal cord. Furthermore, the stretch test of the filum proves its inelasticity, and filum sectioning leads to ascension and relaxation of the caudal spinal cord. These results can be linked to the impaired oxidative metabolism of the lumbosacral cord under excessive tension and to the metabolic and neurological improvements seen after filum sectioning.

Skull base metastasis from follicular thyroid carcinoma -two case reports-.

A 58-year-old woman and a 71-year-old woman presented with extremely rare skull base metastases from follicular thyroid carcinoma (FTC). Surgical removal and external radiotherapy were performed followed by iodine-131 ((131)I) brachytherapy and thyroid hormone administration. The metastatic tumors in the skull base were well controlled. Treatment for skull base metastasis from FTC includes surgical debulking of the metastatic lesion, as well as complete resection of the thyroid gland, followed by internal irradiation with (131)I, external irradiation, and administration of thyroid hormone to prevent tumor growth by suppression of endogenous thyroid-stimulating hormone. Skull base metastases may be the initial clinical presentation of FTC, with silent primary sites. The possibility of skull base metastasis from FTC should be considered in patients with clinical symptoms of cranial nerve dysfunction and radiological findings of bone destruction.

Bypass coaptation for cervical root avulsion: indications for optimal outcome.

OBJECTIVE: Previously, we reported bypass coaptation of the C3 and C4 anterior rami to the upper trunk of the brachial plexus for restoration of the muscles denervated as a result of C5 and C6 nerve root avulsion. This procedure is thought to be superior to the transfer of individual peripheral nerve fibers to the brachial plexus branches. Therefore, the benefits of the bypass coaptation procedures in the treatment of various root avulsions are presented. METHODS: Twenty-six patients were selected as suitable candidates for bypass coaptation procedures. They were divided into 3 groups: 1) Erb-Duchenne palsy due to C5 and C6 root avulsion, 2) Klumpke palsy due to C8 and T1 root avulsion, and 3) the flail arm (or flail upper limb) due to C5 through T1 root avulsion. The surgical techniques are described in detail. RESULTS: The coaptation procedures for the first group resulted in excellent recovery of all the denervated muscles. The patients in the second group showed reinnervation of the finger muscles and finger sensory distributions in infants within the first year after surgery. The flail arm group regained satisfactory proximal muscle function but only mild distal muscle function. One exception was a child who showed significant recovery in proximal and distal motor and sensory function. CONCLUSION: We recommend the bypass coaptation as a useful procedure for the following categories: Erb-Duchenne palsy due to C5 and C6 root avulsion in all ages, Klumpke palsy due to the C8 and T1 avulsion, and the flail arm due to C5 through T1 avulsion in young children. However, bypass procedures for the flail limb in adults require additional innovative methods to facilitate the growth rate of regenerating nerves.

Pathophysiology of tethered cord syndrome and similar complex disorders.

Tethered cord syndrome (TCS) is a stretch-induced functional disorder of the spinal cord due to the fact that its caudal portion is anchored by an inelastic structure. The functional lesion of TCS is generally situated in the lumbosacral cord, and many authors have shown that the syndrome is reversible via surgery to untether the cord. To clarify the expressions relevant to TCS, such as "cord tethering" and "tethered cord," the authors have formulated three categories. These categories include cases that show the anatomical appearance of spinal cord stretching. Among them, Category 1 is isolated to represent the "true TCS." The authors focus their discussion of the pathophysiology of TCS on Category 1 to explain the impaired oxidative metabolism and electrophysiological derangements within the tethered spinal cord, which is the primary intrinsic cause of the dysfunction. Furthermore, they extend the discussion to the extrinsic (outside the spinal cord) factors and other complex conditions that mimic TCS.

Clinico-pathological significance of RCAS1 expression in gliomas: a potential mechanism of tumor immune escape.

RCAS1, one of the tumor cell surface antigens, is strongly expressed in aggressive tumors. RCAS1 suppresses the in vitro growth of immune effector cells. We investigated the expression of RCAS1 in 57 gliomas using immunohistochemistry. Furthermore, we examined the association of the RCAS1 expression with the infiltration of tumor infiltrating lymphocyte (TIL). RCAS1 overexpression was significantly correlated with high histological grade and poor prognosis. Reduced infiltration and increased apoptosis of TILs was observed in RCAS1-positive regions. Apoptotsis of TILs appeared to be induced by RCAS1. RCAS1 expression in gliomas may play roles in tumor progression and tumor immune escape.

Primary malignant B-cell-type dural lymphoma: Case report.

BACKGROUND: The primary malignant dural lymphoma of B-cell type is rare. Our review of the literature (24 cases) indicated that patients with this tumor had female predominance, immunocompetency, and longer survival compared with those with primary malignant intracerebral lymphomas. Based on its clinicopathological features, this dural lymphoma may be classified differently from other types of malignant lymphomas in the central nervous system. CASE DESCRIPTION: The authors report an example of a patient who had a favorable course of malignant dural lymphoma. A 59-year-old woman presented with primary malignant dural lymphoma in the frontal area. Histological diagnosis was a diffuse large B-cell-type lymphoma of intermediate malignancy, but MIB-1 index was extremely high. Subtotal tumor removal was followed by 4 courses of chemotherapy. Thirty months after surgery, the patient is asymptomatic with no MRI evidence of recurrence. A combination of subtotal resection and chemotherapy for a primary malignant dural lymphoma is an effective means to attempt cure of this tumor. CONCLUSION: These rare tumors may be managed successfully by subtotal resection and postoperative treatment. We believe that chemotherapy is the treatment of choice after subtotal resection of malignant dural lymphomas, as experienced in our case.