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A 66-year-old man presented with a 6-day history of progressive posterior cervical pain that included lower back pain and fever. Neurological examinations revealed neck stiffness. Computed tomography demonstrated convexity subarachnoid hemorrhage. A spinal T2-weighted image revealed a hypointense signal lesion with contrast enhancement of the intradural extramedullary space at Th12–L1. Digital subtraction angiography showed a fusiform aneurysm with a 10 mm diameter in the artery of Adamkiewicz. We diagnosed the patient's condition as a ruptured aneurysm of the artery of Adamkiewicz. By day 41 the aneurysm had disappeared following conservative treatment. Aneurysms arising from the artery of Adamkiewicz are extremely rare and can cause both convexity and spinal subarachnoid hemorrhages. Clinicians should therefore look for spinal lesions if patients with convexity subarachnoid hemorrhage of an unknown origin have lower back pain as their initial symptom.

A 51-year-old Japanese woman was admitted to our hospital because of speech difficulty following severe headache. Neurological examination showed dysarthria and tongue weakness on the right side, indicating right hypoglossal nerve palsy. Needle electromyography of the right side of the tongue showed fibrillation potentials. Magnetic resonance angiography and computed tomography angiography revealed a right, persistent, primitive hypoglossal artery (PPHA) that met Lie's diagnostic criteria. Digital subtraction angiography showed an extended PPHA with irregular caliber in the portion running through the right hypoglossal canal. We diagnosed compression neuropathy of the hypoglossal nerve due to PPHA enlargement based on the findings of ipsilateral hypoglossal nerve palsy, fibrillation that indicated peripheral nerve palsy, and the enlarged diameter of the portion of the PPHA running through the right hypoglossal canal. We prescribed antihypertensive therapy. At 1 year after onset, her tongue weakness was alleviated. Clinicians should consider compression neuropathy due to a PPHA as one of the possibilities in the differential diagnosis of hypoglossal nerve palsy.

A 76-year-old Japanese man was admitted to our department because of aphasia and right hemiparesis. Brain magnetic resonance imaging showed cerebral infarction caused by occlusion of the left middle cerebral artery, and alteplase therapy was started. Thrombectomy was subsequently performed, resulting in recanalization. On day 4 after admission, he complained of epigastric pain when coughing. On day 8, contrast-enhanced computed tomography showed a left abdominal rectus sheath hematoma without extravasation. We carefully followed up the patient with conservative therapy, and the rectus sheath hematoma was ameliorated. Rectus sheath hematomas present as acute abdominal pain and are often misdiagnosed. Although several predisposing factors for rectus sheath hematomas have been identified, whether recombinant tissue-type plasminogen activator causes rectus sheath hematomas, remains unclear. This case highlights the need to consider a rectus sheath hematoma as a differential diagnosis of abdominal pain following treatment with recombinant tissue-type plasminogen activator.

A 31-year-old Japanese woman presented with sudden-onset unstable gait followed by nuchal pain. A neurological examination revealed right-sided limb weakness and decreased pain and thermal sensation on the left side below the level of the L1 dermatome. A lower lateral medullary infarction with ipsilateral hemiplegia, known as Opalski syndrome, caused by spontaneous vertebral artery dissection was diagnosed by magnetic resonance imaging. The spinothalamic tract in the medulla oblongata has a topographic arrangement of sensory fibers, and the dermatomal sensory deficit in this case can be explained in relation to that. This is the first reported case of Opalski syndrome with dermatomal sensory manifestations. Opalski syndrome could be a differential diagnosis for dermatomal sensory manifestations.

A 56-year-old man with a small infarct in the left precentral knob area induced both motor and sensory impairments that were similar to right ulnar nerve palsy. The only difference from ulnar nerve palsy was that the patient showed sensory disturbance not only on the ulnar side but also on the radial side of the right ring finger.