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Intracranial fungal infection is a rare entity. This disease is mainly concentrated in dry and hot climates, such as India, Africa, California, and usually occurs in patients with immune deficiency. Now, we retrospectively analyzed the clinical manifestations, pathologic manifestations, imaging features, surgical methods, and prognosis of 4 patients with fungal infection who were confirmed by postoperative pathology. Intermittent pricking on the right face was presented in 2 patients, headache in 2 patients, orbital apex syndrome in 2 patients, and 1 patient presented with fever. Imaging showed the lesions of all patients were located in the right temporal, including 2 patients involving the right orbital, 1 patient involving the right trigeminal semilunar ganglion, 1 patient involving the right brainstem and tentorium cerebellum, 1 patient involving the right internal carotid artery. Craniotomy was performed in 2 patients, endoscopic biopsy in 1 patient, and stereotactic surgery in 1 patien. Aspergilloma was the most common pathogenic bacteria. One patient relapsed repeatedly and died. Secondary aneurysm complicated with subarachnoid hemorrhage occurred in 1 patient. Therefore, the author confirmed that intracranial fungal infection has diverse clinical, imaging, and pathologic manifestations. Neurosurgeons should be aware of the possibility of intracranial fungal infection when they find abnormal intracranial lesions, neurologic deficits, and inflammation of paranasal sinuses. Combining multiple clinical data may help doctors to improve the accuracy of diagnosis. Individualized and diversified surgical protocols should be selected for diverse lesions. Notably, secondary intracranial fungal vasculitis is common, with high mortality and disability rates.

Microvascular decompression (MVD) has a satisfactory safety, and it is the only surgical treatment for neurovascular compression diseases, such as hemifacial spasm, trigeminal neuralgia, and glossopharyngeal neuralgia, from the perspective of etiology. Bilateral dilated and fixed pupils have long been regarded as a sign of life threatening, which is common in patients with cerebral herniation due to cranial hypertension. However, transient dilated pupils after MVD have not been previously reported. Here, we presented 2 patients with bilateral transient dilated and fixed pupils after MVD and discussed the possible etiologies through the literature review. Physical examination of both patients showed bilateral pupils were normal and without a medical history of pupil dilation. They underwent MVD under general anesthesia and used propofol and sevoflurane. In both cases, the vertebral artery was displaced, and Teflon pads were inserted between the vertebral artery and the brain stem. Postoperation, we found transient bilateral mydriasis without light reflection in both patients. The emergency head computed tomography revealed no obvious signs of hemorrhage and cerebral herniation. About 1 hour later, this phenomenon disappeared. Therefore, the authors think if MVD is successfully carried out, bilateral transient mydriasis may not necessarily indicate brain stem hemorrhage, cerebral herniation, and other emergency conditions, which can be recovered within a short time. The causes could be related to stimulation of the sympathetic pathway in the brain stem during MVD and side effects of anesthetics.

Primary hemifacial spasm (HFS) is likely related to a vascular compression of the facial nerve at its distal cisternal portion root exit Zone that has been reported during recent years. Most of these cases were found during secondary surgery or intraoperative monitoring of lateral spread response (LSR). Here we reported 2 patients with typical HFS caused by distal neurovascular compression that were successfully treated with microvascular decompression. Magnetic resonance imaging in both cases suggested that there was a contact between the vessel in cisternal segment and the facial nerve. LSR immediately disappeared after decompression of distal neurovascular compression. Resolution of spasm after the operation was achieved in both of these cases, with a short duration of vertigo and mild facial paralysis in case 1. Reviewing the literature, the majority of cases of distal neurovascular compression are found under the following 2 conditions:(1) When patients underwent a second operation. (2) When surgeons explored the distal part, the cisternal portion, after exploring the traditional root exit Zone without LSR disappearing. Therefore, it is the distal neurovascular compression at cisternal segment that may also be the cause of HFS. As for this kind of special HFS, these patients may also present with cranial nerve symptoms of VIII. In addition, magnetic resonance imaging can provide some information about compression sites. When we perform microvascular decompression, we should carefully pay attention to having an entire-root-exploration with intraoperative electrophysiology to find and decompress the real neurovascular compression.