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Preoperative simulation images creates an accurate visualization of a surgical field. The anatomical relationship of the cranial nerves, arteries, brainstem, and related bony protrusions is important in skull base surgery. However, an operator's intention is unclear for a less experienced neurosurgeon. Three-dimensional(3D)fusion images of computed tomography and magnetic resonance imaging created using a workstation aids precise surgical planning and safety management. Since the simulation images allows to perform virtual surgery, a déjà vu effect for the surgeon can be obtained. Additionally, since 3D surgical images can be used for preoperative consideration and postoperative verification, discussion among the team members is effective from the perspective of surgical education for residents and medical students. Significance of preoperative simulation images will increase eventually.

Objective: We report an unusual case of tentorial dural arteriovenous fistula(DAVF)with bithalamic lesions and bilateral intracranial hemorrhage., Case Presentation: A 73-year-old man presented with lethargy and progressive cognitive decline. Imaging demonstrated bithalamic edematous lesions and bilateral basal ganglia hemorrhage in the right putamen and left internal capsule. Angiography revealed tentorial DAVF fed by both the internal and external carotid arteries. A shunted pouch was present in the superior petrosal sinus, and retrograde reflux drainage was see in the deep venous system, including the basal vein, vein of Galen, and internal cerebral veins with congestion. Initially, transarterial embolization was palliatively performed, and subsequently, a microsurgery achieved obliteration of the tentorial DAVF. Postoperatively, the bilateral thalamic changes disappeared, although sequela of the intracranial hemorrhage persisted., Conclusion: Deep venous congestion due to tentorial DAVF induced unusual bithalamic lesions and bilateral basal ganglia hemorrhage. Tentorial DAVF was treated with combined endovascular and surgical operations. Tentorial AVF is an aggressive vascular disease, and prompt diagnosis and treatment are necessary.

We present a case of middle cerebral artery (MCA) dissection that was treated with intravenous administration of recombinant tissue plasminogen activator (rt-PA). A 72-year-old woman suddenly developed dysarthria and left motor weakness without headache. On arrival at the hospital, her NIH stroke scale (NIHSS) score was 13. Magnetic resonance imaging (MRI) revealed severe stenosis of the right proximal MCA segment; this appeared to be the cause of atherothrombosis. After the MRI study, her NIHSS score improved to 5, but the evidence of MCA stenosis indicated the need for thrombolytic treatment. We injected rt-PA 102 min after the symptom onset; however, her NIHSS score fluctuated thereafter; at worst, it was 13 at 78 min after the initiation of rt-PA treatment. Eventually, her neurological status improved and after 12 hours, her NIHSS score improved to 1 but the MRI showed cerebral infarction restricted in the right putamen. Since persistent irregularity of the right MCA was shown by follow-up magnetic resonance angiography (MRA), digital subtraction angiography was performed on the 14th day after admission. Double lumen of the right MCA was detected, which was a definite proof of artery dissection. Here, we discuss the difficulties encountered in the diagnosis and treatment for MCA dissection.