Granulomatosis with polyangiitis (GPA) is a rare Antineutrophil Cytoplasmic Antibodies (ANCA)-associated vasculitis that typically affects the upper and lower respiratory tract and kidneys. In adolescents, atypical presentations with predominant neuro-otological features may delay diagnosis. We report a 15-year-old boy who presented with progressive bilateral sensorineural hearing loss, facial nerve palsy, multiple lower cranial nerve deficits, dysphagia, and hoarseness, initially suggestive of chronic meningitis. Magnetic resonance imaging showed pachymeningeal enhancement with skull-base involvement. There was no renal or classical sinonasal involvement. Pulmonary infiltrates were initially attributed to aspiration pneumonia, and an infectious etiology was suspected. Prolonged antimicrobial therapy, however, did not result in sustained improvement. Lung biopsy demonstrated necrotizing granulomatous inflammation, and PR3-ANCA positivity confirmed GPA. Immunosuppressive therapy led to marked clinical improvement. Predominant neuro-otological involvement with misleading pulmonary findings can pose a significant diagnostic challenge in adolescent GPA.

To explore the clinical characteristics and long-term prognosis of nervus intermedius sectioning via a retrosigmoid approach for the treatment of nervus intermedius neuralgia (NIN). A total of 10 NIN patients treated at the First Affiliated Hospital of Fujian Medical University between May 2016 and October 2024 were included retrospectively. All patients underwent nervus intermedius sectioning through the retrosigmoid approach, with combined microvascular decompression (MVD) performed for those with concomitant trigeminal neuralgia (TN) or glossopharyngeal neuralgia (GN) based on intraoperative findings. Surgical efficacy was evaluated using the Barrow Neurological Institute (BNI) Pain Intensity Score, with a follow-up period of 14-109 months. Among the 10 patients [3 males, 7 females; mean age: (58.7±11.5) years; median disease duration: 3.0 years], pain was predominantly electric shock-like (6 cases, 60.0%) and stabbing (3 cases, 30.0%). Beyond typical deep ear pain (6 cases, 60.0%), pain also involved the periauricular area (4 cases, 40.0%), cheek (2 cases, 20.0%), root of tongue (1 cases, 10.0%) and 2/3 of the tongue (1 case, 10.0%). Intraoperative exploration identified offending vessels in 7 cases (anterior inferior cerebellar artery in 5 cases and posterior inferior cerebellar artery in 2 cases). The immediate postoperative efficacy rate (BNI Ⅰ-Ⅱ) was 90.0% (9/10). Over a mean follow-up period of (61.5±31.8) months, the long-term efficacy rate at the last follow-up was 70.0% (7/10). Complications included facial paralysis, taste impairment, and wound infection in 1 case each, with no instances of hearing loss or intracranial infection. Nervus intermedius sectioning is an effective treatment for NIN with a high immediate relief rate, although a certain risk of long-term recurrence remains. For patients with concomitant cranial neuralgias, nervus intermedius sectioning combined MVD can enhance overall therapeutic outcomes.

Pituitary apoplexy is a rare but potentially life-threatening complication of pituitary macroadenomas that classically presents with acute headache, visual field deficits, and signs of optic chiasm compression. However, atypical neuro-ophthalmologic presentations without chiasmal involvement may delay recognition and treatment. This report highlights an unusual presentation of pituitary apoplexy associated with radiographic oculomotor nerve compression secondary to cavernous sinus extension in a patient with prolactinoma. We report the case of a 29-year-old Hispanic woman who presented to the emergency department (ED) with acute right-sided headache, dizziness, and transient blurry vision after the reinitiation of cabergoline therapy for a previously diagnosed prolactinoma. The patient had a prolonged history of migraine-like headaches, amenorrhea, intermittent galactorrhea, and inconsistent adherence to dopamine agonist therapy due to medication intolerance. Magnetic resonance imaging (MRI) revealed a 1.5 cm right sellar macroadenoma with intralesional hemorrhage consistent with pituitary apoplexy. Imaging demonstrated extension into the right cavernous sinus with compression and lateral displacement of the oculomotor nerve, without contact or compression of the optic chiasm or optic nerves. Endocrine evaluation demonstrated hyperprolactinemia and secondary adrenal insufficiency. The patient underwent endoscopic transsphenoidal resection with subsequent clinical stabilization and normalization of prolactin levels. Pathology confirmed a lactotroph pituitary adenoma. This case highlights an atypical presentation of pituitary apoplexy without classic chiasmal syndrome and emphasizes the importance of recognizing cavernous sinus cranial neuropathy as a potential presenting feature. Clinicians should maintain suspicion for pituitary apoplexy in patients with prolactinoma presenting with acute headache and cranial nerve (CN) abnormalities, even in the absence of visual field defects or optic pathway compression.

Tolosa-Hunt syndrome is a rare disorder of idiopathic granulomatous orbital inflammation associated with ipsilateral orbital pain and cranial nerve palsy. The patient is a 42-year-old Hispanic female with Ecuadorian ancestry who presented in remission of episodes of horizontal diplopia, left eye proptosis, and 8/10 sharp left eye pain that occurred 10 years ago and four years ago. Both episodes resolved with about five weeks of oral methylprednisolone dosing prescribed at onset of symptoms. She is successfully maintained on oral methylprednisolone six-day dose pack about twice yearly for moderate orbital pain. At the time of the diplopia four years ago, Magnetic Resonance Imaging showed a left cavernous sinus mass, which resolved on subsequent imaging. Her interleukin 6 (IL-6) serum level done during remission and during clinical episodes was highly elevated at 90.5 pg/ml (normal <5 pg/ml) and 68.7 pg/mL, respectively. Lower level during clinical episode may be due to use of oral steroid medication. The cytokine elevation may provide clues regarding the pathophysiology of this unusual neurological disorder.

We report a case of immune-related aseptic meningitis (irAE meningitis) presenting with multiple cranial nerve symptoms during immune checkpoint inhibitor therapy for lung adenocarcinoma. A 72-year-old woman diagnosed with left lower lobe lung adenocarcinoma initiated combination therapy consisting of carboplatin, paclitaxel, bevacizumab, and atezolizumab. Paclitaxel was subsequently discontinued due to peripheral neuropathy, and maintenance therapy with bevacizumab and atezolizumab followed. Eight months after starting treatment (after four cycles of atezolizumab maintenance), the patient presented with a three-week history of dysgeusia, anosmia, trismus, and neck pain. Cerebrospinal fluid (CSF) analysis revealed lymphocytic and monocytic pleocytosis, while cytological examination showed no malignant cells and bacterial cultures were negative. Brain and neck magnetic resonance imaging (MRI) showed no alternative etiologies. Intravenous prednisolone led to a rapid resolution of all symptoms. The patient was diagnosed with irAE meningitis with concomitant cranial nerve involvement, including the olfactory (I), trigeminal (V), facial (VII), and/or glossopharyngeal (IX) nerves. Intravenous prednisolone led to a rapid resolution of all symptoms. Although irAE meningitis is a known rare adverse event, cases complicated by multiple cranial nerve symptoms are extremely uncommon. This case highlights the phenotypic diversity of neurotoxicity associated with immune checkpoint inhibitors.

Skull base osteomyelitis (SBO) is a rare and potentially fatal deep-space infection most commonly arising from malignant external otitis in immunocompromised or diabetic patients. Vascular complications, including septic thrombosis of the internal carotid artery (ICA) and dural venous sinuses, are among the most severe and life-threatening sequelae, yet remain underreported in the radiological literature. We present the case of a 59-year-old male with type 2 diabetes mellitus who initially presented with severe, refractory left-sided otalgia, purulent otorrhea, and progressive lower cranial nerve palsies. He was diagnosed with left-sided SBO on MRI, characterised by extensive infiltration of the carotid, lateral pharyngeal, and perivertebral spaces, with osseous involvement of the clivus, left occipital condyle, the anterior arch of C1, and the left mastoid. Critically, MRI demonstrated encasement and non-opacification of the cervical segment of the left internal carotid artery, thrombosis of the left internal jugular vein with extension to the left sigmoid sinus, and ipsilateral otomastoiditis. This case illustrates the pivotal diagnostic value of multiparametric MRI, combining fluid-attenuated inversion recovery, diffusion-weighted, and post-gadolinium sequences, in characterising the full extent of SBO and its neurovascular complications, findings that are critical for guiding urgent multidisciplinary management.

We report a diagnostically challenging case of polymicrobial orbital apex syndrome in an immunocompromised patient, emphasizing the importance of early multidisciplinary intervention and consideration of fungal aetiologies in high-risk individuals. A 70-year-old woman with multiple comorbidities presented with subacute left orbital pain and frontotemporal headache, with early signs of cranial nerve VI palsy. Despite initial stability, the patient deteriorated over 2 weeks, developing complete left ophthalmoplegia, proptosis, and vision loss. Further investigation demonstrated a polymicrobial skull base osteomyelitis with orbital apex and cavernous sinus involvement. Histopathology revealed necrotic material with chronic inflammation, and cultures identified Aspergillus flavus, Pseudomonas aeruginosa, Staphylococcus aureus, and Candida parapsilosis. The patient was treated with intravenous vancomycin, oral ciprofloxacin, and voriconazole for 6-8 weeks. Diagnosing orbital apex syndrome in immunocompromised individuals is complex and early imaging is critical. A high clinical suspicion for fungal infection should be maintained, with a strong role for timely tissue diagnosis. Coordinated multidisciplinary care and targeted antimicrobial therapy can prevent further morbidity from intracranial extension.