Carbon-11 methionine positron emission tomography (11C-methionine PET; Met-PET) is widely used in neuro-oncology for preoperative tumor characterization, differentiating recurrence from radiation necrosis, and determining stereotactic biopsy targets. Although its role in gliomas has been well established, evidence supporting its value in germ cell tumors, particularly teratomas, remains limited. An 18-year-old man presented with diplopia, photophobia, and a headache. Magnetic resonance imaging (MRI) revealed a pineal tumor. Serum AFP was 31.5 pg/mL, serum β-HCG < 1.0 mIU/mL, and CSF PLAP 23.6 pg/mL. After three courses of CARE chemotherapy and local radiotherapy, gross total resection was performed at another hospital. He subsequently developed hydrocephalus and underwent endoscopic third ventriculostomy at our institution. MRI and Met-PET showed no residual lesions. Additional ICE chemotherapy resulted in the normalization of tumor markers. However, MRI performed 4 months after resection demonstrated a new enhancing lesion in the right posterior thalamus, and Met-PET revealed new uptake (SUVmax, 2.64; TNR, 2.08), suggesting recurrence. A second craniotomy achieved gross total resection of the whitish, elastic, well-demarcated lesion. Histopathology showed mainly granulomas with inflammatory changes, but no viable tumor cells. The postoperative course was uneventful, and no recurrence has been observed for 3 years. This case suggests that in germ cell tumors, particularly teratomas, Met-PET findings may be misleading and do not necessarily indicate viable tumor tissue. Further studies are required to clarify the clinical significance of Met-PET for teratomas.

Purpose: To report a rare case of Vogt-Koyanagi-Harada disease (VKH)-like uveitis following drug reaction with eosinophilia and systemic symptoms (DRESS) syndrome associated with human herpesvirus 6 viremia. Methods: A single case was reviewed. Results: A 34-year-old man presented with bilateral blurred vision and photophobia 3 months after an episode of DRESS secondary to antipsychotic medications. Ocular examination revealed bilateral anterior chamber and vitreous inflammation, serous macular retinal detachments, optic disc edema, and bacillary detachment in the left eye. Diagnostic testing was negative for infectious and inflammatory causes but demonstrated eosinophilia. A diagnosis of VKH-like disease secondary to DRESS was made. Systemic corticosteroid and steroid-sparing therapies were initiated, resulting in complete resolution of symptoms and clinical findings over 8 months. Conclusions: VKH-like disease may rarely be triggered by DRESS syndrome, although this association has not been previously reported in the ophthalmic literature. Further research is necessary to understand the relationship between these entities and the role of human herpesvirus 6 in their pathogenesis.

Background: Menstrual migraine (MM), including pure menstrual migraine (PMM) and menstrually related migraine (MRM), is characterized by attacks occurring in close temporal association with menstruation and is often more severe, longer lasting, and less responsive to treatment than non-menstrual migraine. Prostaglandin-mediated inflammation and calcitonin gene-related peptide (CGRP) release play a key role in MM pathophysiology. Phycocyanin (PC) and palmitoylethanolamide (PEA) are nutraceutical compounds with anti-inflammatory, analgesic, and neuroprotective properties that may be beneficial as short-term perimenstrual prophylaxis. Objectives: To evaluate the effectiveness of an oral supplementation combining phycocyanin and palmitoylethanolamide as a short-term prophylaxis for menstrual migraine in a real-world clinical setting, a retrospective observational study without a control group was conducted in five Italian centers between May 2023 and June 2025. Methods: Clinical records of 800 women were reviewed, and 220 patients receiving perimenstrual supplementation with phycocyanin and palmitoylethanolamide were screened. Sixty-one women diagnosed with migraine without aura, according to the International Classification of Headache Disorders, met all inclusion criteria and were analyzed. Phycocyanin and palmitoylethanolamide were taken at a dosage of two capsules daily from five days before to five days after the onset of menstruation for three consecutive months. Outcomes during the perimenstrual window were compared with a three-month period without supplementation. Primary outcomes included migraine severity, frequency, and duration of the attacks; secondary outcomes included analgesic consumption and menstrual migraine-associated symptoms. Results: Among the 61 included patients, phycocyanin and palmitoylethanolamide supplementation was associated with a significant reduction in migraine severity across all monitored perimenstrual days (p < 0.0001). While the overall monthly frequency of migraine attacks did not change, the number of migraine days during the perimenstrual window significantly decreased from the first month of supplementation (p < 0.05). Moreover, migraine duration during the perimenstrual window was significantly reduced at one, two, and three months of phycocyanin and palmitoylethanolamide supplementation compared with baseline. Analgesic use and the number of days with migraine-associated symptoms (nausea, vomiting, photophobia/phonophobia) were also significantly reduced. Treatment was well tolerated. Conclusions: In this real-world retrospective study, perimenstrual supplementation with phycocyanin and palmitoylethanolamide was associated with reduced severity, duration, and perimenstrual frequency of menstrual migraine attacks, along with decreased analgesic use, suggesting a safe and potentially beneficial short-term prophylactic strategy for women with menstrual migraine.

Atropine is an emerging therapy for myopia, yet the optimal concentration for prescription remains uncertain. We searched PubMed, Embase, Web of Science, Cochrane Library, World Health Organization International Clinical Trials, and ClinicalTrials.gov registry platforms. We included the randomized clinical trials (RCTs) that compared any dose of atropine against a placebo in myopic children. Among 3,566 studies assessed, we identified 33 eligible RCTs involving 6,301 children aged 4 to 18 years, with 10 different concentrations and a mean follow-up time of 19.5±12.3 months. A nonlinear relationship was observed between atropine dosage and treatment efficacy (P<0.001). Compared to placebo groups, the mean differences in reducing annual spherical equivalent refraction progression for atropine concentrations of 0.01%, 0.02%, 0.03%, 0.04%, and 0.05% were 0.21 D (95% CI, 0.13 to 0.28), 0.35 D (95% CI, 0.23 to 0.46), 0.42 D (95% CI, 0.28 to 0.56), 0.45 D (95% CI, 0.30 to 0.60), and 0.46 D (95% CI, 0.32 to 0.61) respectively For higher concentrations, the estimates were 0.49 D (95% CI, 0.34 to 0.63) for 0.1% and 0.99 D (95% CI, 0.66 to 1.31) for 1%, although these were based on fewer and smaller trials. Higher doses of atropine were associated with decreased amplitude of accommodation (P=0.02), increased pupil diameters (P=0.01) and a higher frequency of photophobia (P=0.02). Our findings suggest that the increase in treatment efficacy with higher concentrations may plateau beyond a certain range, and that the current practice of increasing atropine concentrations for children who show inadequate responses to lower doses should be confined to a specific concentration range. This analysis is limited by the number, design heterogeneity, and sample sizes of available trials for higher concentrations, and by the frequent lack of pre-intervention refractive history in included studies. Therefore, estimates-particularly for doses exceeding 0.1%-should be interpreted with caution.

Intracranial hypertension can mimic acute meningitis, especially in immunosuppressed patients presenting with fever and meningism, often prompting urgent empirical treatment. Distinguishing infectious from non-infectious causes is crucial to avoid unnecessary antimicrobials and delayed diagnosis. We report a 20-year-old woman with systemic lupus erythematosus on rituximab and a recent corticosteroid taper who presented with fever, severe headache, photophobia, and neck stiffness. She was started on empirical antibiotics for suspected meningitis. Lumbar puncture showed a markedly raised opening pressure (43 cm H2O) with otherwise normal cerebrospinal fluid (CSF). Neuroimaging excluded structural lesions and cerebral venous sinus thrombosis, while ophthalmologic examination confirmed papilloedema. Her symptoms improved after a therapeutic lumbar puncture and acetazolamide. This case highlights the value of measuring CSF opening pressure and reconsidering the diagnosis in immunosuppressed patients with meningitic features.

Pediatric pseudotumor cerebri syndrome (PTCS) is an uncommon cause of raised intracranial pressure in children. We report a case of PTCS temporally associated with standard-dose oral N-acetylcysteine (NAC). A 6-year-old boy (20 kg) presented with 1 week of worsening nocturnal headaches, vomiting, and photophobia. Examination revealed bilateral optic disc swelling. Brain magnetic resonance imaging and magnetic resonance venography were normal. Lumbar puncture showed an opening pressure of 80 cm H2O and normal cerebrospinal fluid composition. The patient had been treated with oral NAC 200 mg twice daily for 4 weeks before symptom onset. Acetazolamide and topiramate were started with no improvement; symptoms and papilledema improved rapidly within 24 hours of NAC discontinuation. The patient remained asymptomatic at 6 months of follow-up. This case suggests a possible association between therapeutic-dose NAC and intracranial hypertension. Clinicians should consider medication-induced PTCS in children who present with new-onset headaches and papilledema. Further pharmacovigilance and reporting are warranted.

BackgroundClinicians encounter difficulties in differentiating between headache/facial pain of true sinogenic origin, and clinically similar pain related to primary headache disorders, such as migraine. The International Classification of Headache Disorders and International Classification of Orofacial Pain, together with clinical definitions of acute and chronic rhinosinusitis as refined by the European Position Paper on Rhinosinusitis and Nasal Polyps, have produced a unique opportunity to improve the current diagnostic criteria of headache/facial pain attributed to rhinosinusitis.MethodsAn international multidisciplinary panel reviewed clinical evidence regarding the overlap of primary headaches and rhinosinusitis in order to harmonize and clarify diagnostic frameworks.ResultsThe proposal integrates validated rhinologic definitions into headache and facial pain classifications. Key suggestions include the removal or adjustment of non-specific criteria (e.g., headache exacerbated by pressure applied over the paranasal sinuses) which also frequently occur in primary headache disorders. To enhance specificity, evidence-based negative predictors - such as the absence of nausea, osmophobia or photophobia and phonophobia - are introduced. Only for chronic rhinosinusitis, it has been proposed to include endoscopic or radiological evidence of inflammation, as necessary to confirm the diagnosis.ConclusionAligning ICHD-4 with contemporary rhinologic guidelines through the use of positive and negative predictors may help improve diagnostic accuracy, ensure appropriate therapy and increase the reliability of trial design.

Recurrent benign lymphocytic meningitis (RBLM) or Mollaret meningitis is an uncommon manifestation of herpes simplex virus type 2 (HSV-2) infection, characterized by self-limiting aseptic meningitis with complete recovery between episodes. Despite high background prevalence of HSV-2 in people living with HIV (PLWH), RBLM remains extremely rare in this population. Only two cases, both involving female patients, have been reported. We report the case of a man with HIV who experienced recurrent HSV-2 meningitis despite sustained virological suppression for HIV, preserved CD4 cell count at the time of the current episode, and several recent recurrences. A 55-year-old Japanese man with virologically suppressed HIV infection presented with fever, headache, and photophobia, consistent with nine prior episodes of HSV-2 meningitis. HSV-2 polymerase chain reaction testing of cerebrospinal fluid was negative likely because of early lumbar puncture and prior antiviral initiation. The episode rapidly resolved after intravenous administration of 10 mg/kg acyclovir every 8 h, followed by oral valacyclovir. He adopted a self-initiated episodic oral antiviral strategy at symptom onset, which may have attenuated clinical severity. This case shows that RBLM can occur in immunologically preserved PLWH and suggests that early patient-initiated antiviral therapy may be a feasible approach to mitigate recurrence-associated morbidity.

Streptococcus salivarius is a gram-positive viridans group streptococcus that primarily colonizes the oral cavity and gastrointestinal tract and is generally regarded as a benign commensal organism. Although invasive infections have been reported, they typically occur in immunocompromised hosts or following invasive gastrointestinal or spinal procedures. We present a rare case of S. salivarius bacteremia complicated by meningitis and infective endocarditis in an elderly immunocompetent patient following a routine dental cleaning. A 74-year-old woman with a history of atrial fibrillation, hypertension, chronic obstructive pulmonary disease, and hypothyroidism presented with acute-onset severe headache, photophobia, nausea, and vomiting. Initial evaluation revealed leukocytosis and severe hypertension without focal neurological deficits. Within 24 hours, she developed acute encephalopathy. Blood cultures grew S. salivarius/vestibularis group. Cerebrospinal fluid analysis demonstrated marked neutrophilic pleocytosis and elevated protein, consistent with bacterial meningitis, though cultures were negative. Brain magnetic resonance imaging (MRI) raised concerns for purulent material, and computed tomography (CT) angiography revealed a small arterial communicating artery aneurysm. Transthoracic and transesophageal echocardiography identified mitral valve vegetation with moderate regurgitation, confirming infective endocarditis. The patient was treated with intravenous ceftriaxone with significant clinical improvement and eventual resolution of the vegetation on follow-up imaging. This case is notable for the occurrence of S. salivarius bacteremia and infective endocarditis in an elderly, immunocompetent patient, emphasizing that this organism, though typically nonpathogenic, can cause severe invasive disease even in the absence of traditional risk factors.

Reversible cerebral vasoconstriction syndrome (RCVS) is a condition characterized by severe, sudden headaches, and transient cerebral artery constriction, often triggered by medications, physical activities, or comorbidities. Recent studies have linked RCVS to SARS-CoV-2 infection. This case report presents a novel instance of RCVS with nonaneurysmal subarachnoid hemorrhage (SAH) following COVID-19. A 44-year-old female with COVID-19 presented with a sudden, severe headache, confusion, dizziness, and photophobia. Imaging revealed extensive SAH and hydrocephalus. Despite the absence of classic RCVS triggers, a cerebral angiogram showed multifocal vasospasms in both anterior and posterior circulations which later resolved on repeat cerebral angiography. The patient's condition improved with external ventricular drainage followed by symptomatic treatment. She was diagnosed with RCVS after achieving an RCVS2 score of seven points. She had a final modified Rankin scale of zero at 40-month follow-up. This case highlights the potential association between COVID-19 and RCVS, even in the absence of common triggers. While causality cannot be definitively established, the temporal relationship and plausible biological mechanisms warrant further investigation. This report underscores the importance of considering RCVS in patients with neurological symptoms following COVID-19 and contributes to the understanding of the virus's impact on the vasculature.