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Intradural spinal malignant peripheral nerve sheath tumors (MPNST) are extremely rare, with only 20 adult patients reported to our knowledge, and only four primary tumors arising from the cauda equina. A 49-year-old man presented with back pain, constipation, and lower extremity weakness and was found to have a large intradural lesion involving the cauda equina. Imaging of the rest of his neuraxis revealed additional small left temporal lobe, cervical, and thoracic lesions. The patient underwent laminectomy for tumor debulking and biopsy, as gross total resection was not possible due to envelopment of the cauda equina. Histopathology revealed a MPNST with high cellularity, elevated proliferative indices, and nerve fascicle invasion. After the debulking, the patient reported improvement in his symptoms. However, 6 weeks later, the patient began having severe headaches, and his left temporal lobe lesion was found to have increased significantly in size, requiring craniotomy for palliative resection. The authors report the first adult patient with sporadic spinal MPNST with craniospinal metastasis to our knowledge. Imaging of the entire neuraxis is recommended for initial workup of these lesions, which are capable of intradural spread. The best treatment approach is unclear, but total surgical resection should be attempted, barring infiltration and engulfment of the nerve roots or widespread dissemination.

Dural arteriovenous fistulas (DAVF) of the cavernous sinus most commonly present with ocular symptoms and can be observed or treated with endovascular approaches, surgery, or radiosurgery. Combined surgical-endovascular approaches have been used for fistulas that are not amenable to standard endovascular approaches. A 40-year-old man presented with ocular symptoms from a cavernous sinus DAVF. Multiple previous transarterial and transvenous embolization attempts had failed. The patient underwent craniotomy for surgical exposure and cannulation of an arterialized sylvian vein. Subsequently he underwent coiling and onyx embolization of the DAVF. The intervention resulted in effective obliteration of the fistula. If a cavernous sinus DAVF is refractory to treatment, surgical exposure and cannulation of a cortical draining vein can facilitate transvenous endovascular treatments.

Contralateral hematoma formation following acute subdural hematoma (ASDH) evacuation is a well-described complication. The most common type of contralateral hematoma is an epidural hematoma. Rarely, ASDH develops on the contralateral side. We report an elderly woman who presented with a post-traumatic ASDH and underwent ipsilateral hematoma evacuation by craniotomy and subsequently developed a contralateral ASDH. Because of the potential consequences of a delayed ASDH, there should be a low threshold for early post-operative imaging following ASDH evacuation, especially in elderly patients and those with additional associated intracranial injuries.