Background: Mass lesions within the insular are diagnostically and surgically challenging due to the numerous critical cortical, subcortical, and vascular structures surrounding the region. Two main surgical techniques – the transsylvian approach and the transcortical approach – provide access to the insular cortex. Of the range of pathologies encountered, abscesses in the insula are surprisingly rare. Case Description: A 34-year-old patient was admitted for surgical resection of a suspected high-grade glioma in the insula of the dominant hemisphere. A rapid clinical decline prompted emergent neurosurgical intervention using a transsylvian approach. Surprisingly, abundant purulent material was encountered on entering the insular fossa. Pathological analysis confirmed an insular abscess, although a source of infection could not be identified. The patient required a second evacuation for reaccumulation of the abscess and adjuvant corticosteroids for extensive cerebral edema. Conclusion: An abscess located in the insular cortex is an incredibly rare occurrence. Surgical management using the transsylvian approach is one option to approach this region. Familiarity with this approach is thus extremely beneficial in situations requiring emergent access to the dominant insula when awake mapping is not feasible. In addition, treatment of abscesses with adjuvant corticosteroids is indicated when extensive, life-threatening cerebral edema is present.

Introduction: There are several stroke assessment scales designed to identify large vessel occlusions (LVOs), and a rising area of research is concerned with identifying those that outperform others in accuracy. One scale that has shown promise in identifying identify large vessel occlusions (LVOs) is the vision, aphasia, and neglect (VAN) scale. Our understanding of this scale’s true performance, however, is limited as a majority of studies have been carried out in the hospital setting. The objective of this study is to evaluate the ability of the VAN scale to predict LVOs in the prehospital setting. Methods: Prospective cohort study comparing emergency medical service personnel administered VAN results to hospital discharge diagnoses to evaluate VAN’s ability to predict a large vessel occlusion stroke. Main outcome measures included VAN sensitivity, specificity, positive and negative predictive values, positive and negative likelihood ratios, and accuracy.  Results: Emergency medical service personnel administered the VAN assessment to 185 patients suspected of having a stroke. VAN had a sensitivity of 0.81 (CI, 0.61 to 0.93), specificity 0.56 (CI, 0.48 to 0.64), positive predictive value 0.24 (CI, 0.61 to 0.34), negative predictive value 0.95 (CI, 0.87 to 0.98), positive likelihood ratio 1.87 (CI, 1.45 – 2.40), negative likelihood ratio 0.33 (CI, 0.15 – 0.73), and 60% accuracy (CI, 53% - 61%) for large vessel occlusion identification. Conclusion: When negative, VAN offers relatively high assurance that the patient is not suffering a large vessel occlusion stroke. However, VAN is non-specific for large vessel occlusions and results in many false positives. Therefore, pre-hospital decision-making regarding triage should not rely exclusively on VAN due to possible over-triage to facilities with endovascular capabilities.

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BACKGROUND Arachnoid cysts are common intracranial mass lesions frequently discovered as incidental findings on radiographic imaging. It is routine practice to monitor these lesions as a large majority remain stable. Although traumatic cyst rupture is a known risk, it is rare for patients to present with spontaneous rupture. OBSERVATIONS The authors report the case of a 32-year-old patient who required emergent neurosurgical intervention for spontaneous rupture of a left hemispheric arachnoid cyst. LESSONS Patients with ruptured arachnoid cysts can present with vague, nonspecific symptoms that may delay diagnosis. If not diagnosed and treated promptly, arachnoid cyst rupture can progress to a neurosurgical emergency as the subdural collection may cause extensive mass effect and even cerebral herniation.