Ovarian hyperstimulation syndrome (OHSS) is an exaggerated response to excess hormones and is also one of the life-threatening iatrogenic complications which is associated with ovulation induction. This syndrome usually occurs in women who receive injectable hormones for the stimulation of egg development in the ovaries. This study describes a rare case of moderate ovarian hyperstimulation syndrome which has been managed and treated with high-dose cabergoline. The patient was diagnosed in the Medical Imaging and Radiation Sciences Department of Kabul University of Medical Sciences and treated in Shahrara Teaching Hospital. A 26-year-old woman was diagnosed with the development of bilateral moderate ovarian hyperstimulation syndrome after receiving clomiphene citrate in dose of 100 mg BID on day 5 of period and Human Chorionic Gonadotropin (HCG) 10,000 units for egg release on day 14 of period. The patient was given a high dose of cabergoline. The dose was adjusted to 1 mg/day for eight days since she was diagnosed with ovarian hyperstimulation syndrome. Consequently, the main outcome of our intervention was complete resolution of OHSS as well as complete recovery of the patient. As a result, it is concluded that the high dose of cabergoline prevents and reduces the occurrence, prolongation, and severity of ovarian hyperstimulation syndrome. However, more assessments through randomized controlled trials regarding the efficacy and safety of cabergoline doses and treatment duration for treatment and preventive purposes are required.

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Introduction: Meningiomas are the slow-growing and most common benign CNS tumors. They usually behave as expansive lesions, compressing the brain tissue, but some are invasive with malignant potential, causing direct invasion of the neighboring structures with extracranial extension. Malignant meningioma (MM) is rare and accounts for about 1% of all intracranial meningiomas. Computed tomography (CT) and MRI imaging are useful diagnostic tools for an accurate diagnosis. However, biopsy or resection is the only method to definitively confirm the diagnosis through histopathologic analysis and revealing the grade of meningiomas. Case presentation: A 79-year-old male presented to our neurosurgery outpatient clinic 5 years ago, complaining of a left frontal swelling. His brain MRI revealed a mass in the frontal region of the brain with minimal extracranial transcalvarial extension into the frontoparietal scalp region. During the 5 years follow up no significant progression was observed in the mass size and extension. In July 2020, he complained of speech disorder, indicating an increase in mass size and transcalvarial extension as documented by brain imaging. Surgical intervention and mass resection was done. The pathologic exam revealed a meningioma with malignant transformation. Discussion: Most of the meningiomas are benign tumors and consider grade 1. However, 1–3% of these lesions are known as malignant meningiomas, which have a high recurrence and mortality rate even after the surgery. Conclusion: Intracranial malignant meningioma with transcalvarial extension is an exceedingly rare entity. Computed tomography and MRI imaging are useful diagnostic tools for an accurate diagnosis. However, biopsy or resection is the only method to definitively confirm the diagnosis, through histopathologic analysis and revealing the grade of meningiomas. Complete surgical resection is the mainstay of the treatment and preoperative embolization is a proven ancillary management technique for intracranial meningiomas, leading to decreased operative blood loss, increased visualization of the operative field, and better resection of the tumor. Highlights

Moyamoya is a rare occlusive cerebrovascular disease characterized by progressive stenosis of the terminal portion of the internal carotid artery and the circle of Willis. Over time, collateral arteries are usually formed at the basal ganglia, the so-called Moyamoya vessels. The exact cause of Moyamoya disease is unknown, while Moyamoya syndrome refers to Moyamoya-like vasculopathy due to autoimmune diseases, neurofibromatosis type I, sickle cell disease, radiation, or rarely Down syndrome. Down syndrome is one of the most common genetic conditions, characterized by typical physical traits, associated with intellectual disability and a heterogeneous group of structural defects that may vulnerable the patient for the development of Moyamoya syndrome. The reported case is an unusual case of a 2-year-old boy with Down syndrome who presented to the hospital with seizures and right-side weakness. Brain MRI shows acute as well as old lacunar infarctions in both cerebral hemispheres. Catheter angiography of the patient demonstrates severe stenosis and occlusion of the large vessels of the circle of Willis, predominantly on the right side. The collateral vessels with the typical pattern of “puff of smoke” were also depicted in the right basal ganglia, which is a characteristic imaging finding for Moyamoya. The patient was managed conservatively and eventually discharged with a minimal improvement of the right-sided weakness. This case report is noteworthy because of the rarity of Moyamoya syndrome as a cause of a stroke as well as its possible association with Down syndrome.