Patient with refractory seizure may undergo awake craniotomy when the area to be resected is immediately adjacent to eloquent cortex. An awake craniotomy in a 30-year-old man was conducted using a scalp block, dexmedetomidine, and remifentanil infusion without any airway device throughout the procedure. Dexmedetomidine administered at a loading dose of 1 μg/kg and maintenance dose of 0.2–0.7 μg/kg/h. Remifentanil dose was 0.02 μg/kg/min. The patient remained comfortable and hemodynamically stable throughout the procedure. Cortical electrical stimulation revealed motor cortex overlapped with seizure focus. So that surgical procedure was limited to subpial resection of the epileptic focus. Dexmedetomidine with concurrent scalp block appears to be an useful sedation for awake craniotomy when sophisticated neurological test is required.

Langerhans cell histiocytosis (LCH) is characterized by idiopathic monoclonal infiltration of Langerhans cells in different organs such as the skeleton, skin, pituitary gland, liver, spleen, lungs, and the hematopoietic system. Skin lesions are common in LCH and affect about 40% of cases. It is reported that skin lesions are usually the first manifestation of LCH in 80% of patients. Usually, cutaneous presentations of LCH in adults are generalized or seborrhea-like lesions and it is often the first manifestation of disease. Here, we describe a 45-year old female who was known case of hypothyroidism, systemic lupus erythematosus, and diabetes insipidus. In our patient, cutaneous involvement was unusual. It was single and presented in unusual site (ankle) and before developing such lesion, she had diabetes insipidus for several years due to the involvement of pituitary gland.