hepatocellular carcinoma ( hcc ) is one of the most common malignancies and has a high mortality rate worldwide . hcc usually develops in chronically damaged liver caused by an infection with the hepatitis b virus ( hbv ) or hepatitis c virus ( hcv ) , alcoholic abuse and nonalcoholic fatty liver disease . recent progress in diagnosis and new therapeutic approaches have improved the survival and prognosis of hcc . notably , antiviral therapy such as nucleoside analogs in hbv carriers and interferon administration in hcv carriers reduced the risk of hcc [ 3 , 4 ] . however , chronic infection with hbv is often associated with the development of hcc at a young age and in the absence of liver cirrhosis . patients with hcc in advanced clinical stages still have a dismal prognosis . not only tumor progression but also metastasis determines the prognosis of a wide range of malignancies including hcc . tumor infiltration of blood vessels at the primary tumor site is responsible for metastasis and causes the formation of metastatic lesions in distant organs . it has been believed that vascular invasion , which is one of the most significant features of hcc , contributes to intrahepatic or extrahepatic metastasis . extrahepatic metastases of hcc are frequently observed in distant organs such as the lungs , regional lymph nodes , kidneys and bone marrow . intracranial metastasis frequently develops in patients with advanced tumors , palliative therapy rather than aggressive treatment tends to be selected . therefore , both the benefits of treatment and the clinical course of intracranial metastasis of hcc remain to be elucidated . here , we describe a resected case of intracranial metastasis of hcc . surgical resection of the tumor resulted in a dramatic recovery of consciousness and enabled further therapeutic intervention against hcc . a 32-year - old man was referred to our hospital because of nausea and vomiting . he had been monitored for chronic liver disease caused by hbv infection 2 years before . as multiple hcc was detected in the hepatic right lobe 1 year prior , he underwent a right hepatic trisectionectomy . since his serum level of hbv - dna was more than 5 log copies / ml at that time , a nucleoside analog , entecavir , was administered . because of recurrence in the residual liver and lung metastasis detected 6 months after surgery , he was treated with an oral multikinase inhibitor , sorafenib . as adverse events such as liver dysfunction and eruption were observed 1 month after the administration of sorafenib , the dose was reduced from 800 to 200 mg / day . on admission , serum levels of hepatobiliary enzymes and markers for renal function such as blood urea nitrogen and creatinine were normal . although blood count tests showed slight anemia ( hemoglobin 11.2 g / dl ) and thrombocytopenia ( 12.6  10/l ) , his white blood cell count was normal ( 4,800/l ) . serological tests exhibited the following hbv markers : hepatitis b surface antigen ( hbsag ) positive , hepatitis b surface antibody ( hbsab ) negative , hepatitis b envelope antigen ( hbeag ) negative , hepatitis b envelope antibody ( hbeab ) positive , and hepatitis b core antibody ( hbcab ) positive . his serum level of hbv - dna measured by real - time polymerase chain reaction was 2.9 log copies / ml . anti - hcv antibody was negative . although the level of alpha - fetoprotein was elevated to 195,400 u / ml , that of pivka - ii was within the normal range ( 32 u / ml ) . of importance , the patient 's glasgow coma scale score was 11 points ( e3v4m4 ) , but no paresis was observed . however , the consciousness level gradually deteriorated and the glasgow coma scale score decreased to 6 points ( e2v2m2 ) on the second day of hospitalization . non - enhanced computed tomography ( ct ) revealed an intra - axial tumor with surrounding edema in the left frontal lobe ( fig . the tumor was found to be hyperdense on ct and hypointense on t2-star - weighted images of magnetic resonance imaging ( mri ) consistent with hemorrhage ( fig . a preoperative diagnosis of intracranial metastasis of hcc was made and a craniotomy was performed . macroscopic examination of resected specimens revealed that the tumor was grayish - white and accompanied by necrosis and hemorrhage ( fig . pathological examination revealed that it was a moderately differentiated hcc accompanied by necrosis and hemorrhage ( fig . follow - up ct conducted 1 week after the craniotomy revealed both successful removal of the tumor and improvement in the subfalcine herniation ( fig . contrast - enhanced ct showed not only multiple residual hccs with portal vein tumor thrombus ( fig . 3d ) . subsequently , an implanted port - catheter system was constructed and he was treated with hepatic arterial infusion chemotherapy with 5-fluorouracil and cisplatin . chronic infection with hbv is known to be a major risk factor for cirrhosis and hcc . lamivudine was the first nucleoside analog to be approved for the treatment of patients with chronic hbv infection , but drug resistance frequently develops during long - term lamivudine therapy . in contrast , treatment with entecavir , another nucleoside analog against hbv , rarely results in resistance . recent reports showed that both drugs reduced the risk of developing hbv - related hcc , although an unfavorable virological response to the treatment failed to decrease the incidence of hcc in patients with cirrhosis . in our case , the patient acquired hbv vertically and developed cirrhosis and hcc . when he started to take entecavir orally after right hepatic trisectionectomy , the hbv - dna decreased but did not disappear in the peripheral blood . extrahepatic metastases are detected in 1437% of hcc patients , although intracranial metastasis only accounts for a small percentage of extrahepatic metastases . since intracranial metastasis of hcc frequently causes serious complications such as intracranial hypertension , hemorrhage and cerebral edema , the prognosis of hcc is dismal . choi et al .   reported that surgical resection and/or whole brain radiation therapy significantly prolonged survival compared with steroid treatment alone . it has been also documented that aggressive treatments such as resection and/or whole brain radiation therapy , single intracranial metastasis , and good liver reserve function serve as a prognostic factor . together , these findings indicate that sufficiently aggressive treatment may improve the prognosis for some patients with intracranial metastasis of hcc . in our case , there was only one metastatic lesion and the patient 's liver reserve function was good ( child - pugh a ) . successful resection of the intracranial tumor improved his level of consciousness dramatically and enabled further therapeutic approaches against hcc . together , it seems that surgical resection of intracranial metastasis of hcc contributed to the prolonged survival in this case . in conclusion , we report a rare case of intracranial metastasis of hcc resected successfully . considering that most extrahepatic metastases of hcc developed in patients with advanced intrahepatic lesions and vascular invasion , it is important to be aware of extrahepatic spread in patients with advanced hcc . in addition , it is necessary to determine whether aggressive treatment such as surgical resection improves the prognosis for intracranial metastasis of hcc . further examinations in large numbers of patients are necessary for both an understanding of the mechanisms underlying intracranial metastasis of hcc and the development of therapeutic approaches .