Uncommon findings in idiopathic hypertrophic cranial pachymeningitis

[Idiopathic hypertrophic pachymeningitis]

The article presents a case of idiopathic hypertrophic pachymeningitis of a 61-year-old male patient with severe cephalgia and progressive neuropathy of the oculomotor nerves. The diagnosis was confirmed by MRI with gadolinium, which revealed thickening of the dura mater with accumulation of paramagnetic in the convexital parts of the frontal and temporal regions, as well as on the base of the skull and tentorium. During the use of pulse therapy with glucocorticosteroids (GCS) the symptoms regressed, but when the therapy was stopped, there was a relapse of ptosis and oculomotor abnormalities on the other side followed by a slower effect of GCS therapy. The article also presents a brief review of current knowledge about this pathology.

Idiopathic Hypertrophic Cranial Pachymeningitis With Chiari Type I Malformation: Case Report and Review of the Literature

Idiopathic hypertrophic cranial pachymeningitis (IHCP) is a rare chronic inflammatory disease characterized by diffuse thickening of the dura mater. Although IHCP mostly presents as a diffuse lesion, it may also occur as focal tumour-like lesions. Here we present the first reported case of IHCP associated with a Chiari type I malformation (CMI). A 65-year-old man presented with a one-year history of chronic headache and vertigo exacerbated by standing and neck flexion. The neurological examination was unremarkable except for tongue wasting and fasciculations. MRI demonstrated features of CMI and findings suggestive of IHCP.

Posterior fossa decompression resulted in significant symptomatic improvement and the diagnosis of IHCP was confirmed on histopathology. Though there is no consensus about the management of IHCP in this case, we advocate surgical decompression with prolonged steroid therapy.

Paquimeningite hipertrófica idiopática espinhal: Relato de caso

Idiopathic hypertrophic pachymeningitis is rare cause of neurological symptoms with myelopathy due to spinal cord compression. We report a case of pachymeningitis, which was manifested primarily by tetraparesis after low-energy trauma and recurrence the myelopathy symptoms after 5 years of surgery. The patient, a 19-year-old woman, was subjected to extensive investigation without evidence of any underlying disease. A meningeal biopsy was performed and showed an unspecific inflammatory process with extensive fibrosis of the dura mater. These findings, associated with the exclusion of other causes, suggest idiopathic hypertrophic pachymeningitis.

Immunoglobulin G4-related hypertrophic pachymeningitis with spinal cord compression: A case report

IgG4-related disease (IgG4-RD) is a recently recognized inflammatory condition that can be found in many organs. However, spinal involvement is rare and has been described only in case reports and series. Here, we report a rare case of spinal IgG4-RD that resulted in hypertrophic pachymeningitis with spinal cord compression. This case expands the phenotypic presentation for the neurological sequelae of IgG4-RD. Our case hints that spinal IgG4-RD may be misdiagnosed, and IgG4-RD in patients should be considered when the patient has a dural mass. Although early surgery, steroids, and/or immunosuppressive therapy may prevent neurological complications, the side effects should receive more attention during treatment.

[A case of subacute hypertrophic pachymeningitis caused by Pseudomonas aeruginosa infection presenting with subdural hygroma]

A 78-year-old woman with bilateral fungal sinusitis, which resulted in right orbital apex syndrome, underwent endoscopic sinus surgery and optic nerve decompression. Two months after the operation, she complained of anxiety and insomnia. Head CT showed subdural hematoma-like effusion and burr hole drainage was conducted. The collected fluid was not hematoma, but bloody, xanthochromic effusion with no pathogenic bacteria. Ten days later, she underwent drainage and dural biopsy after craniotomy because of relapse of subdural hygroma and progression of hypertrophic pachymeningitis associated with aggravation of psychiatric symptoms. A sample of the dura mater showed dense fibrosis with thickening, and Pseudomonas aeruginosa (P. aeruginosa) was detected by culture. Although otitis or sinusitis secondary to P. aeruginosa infection has been reported as a leading cause of infectious pachymeningitis, psychiatric symptoms alone and concomitant refractory subdural hygroma are atypical and unreported manifestations. In patients with pachymeningitis and a history of transnasal endoscopic surgery, P. aeruginosa infection should be considered, irrespective of an atypical clinical course and negative blood or fluid culture. Additionally, dural biopsy might help in detection of pathogenic bacteria.

Postdural Puncture Headache and Acute Subdural Haematoma in Sjögren's Syndrome

Although spontaneous intracranial hypotension cases related to connective tissue diseases have been reported in the literature, to the best of our knowledge, no cases of iatrogenic intracranial hypotension have been described. In this paper, we plan to discuss a case of acute subdural haematoma and postdural puncture headache that developed after spinal anaesthesia in a patient with Sjögren's syndrome.

Diplopia With Dural Fibrotic Thickening

Idiopathic hypertrophic pachymeningitis (HP) is a rare disorder of diffuse thickening of the cranial or spinal dura mater without an identifiable cause. Most common in adult males, idiopathic HP typically presents with headache with or without varied associated focal neurologic deficits and findings of dural enhancement on magnetic resonance imaging in a linear, nodular, or combined pattern. As it is felt to be an autoimmune disorder, treatment with high-dose corticosteroids is typically recommended, and without intervention, the course is usually progressive. The disease can commonly progress with a relapsing remitting course requiring other immune modulators such as methotrexate, azathioprine, or cyclophosphamide for control. Here, we describe a unique case of idiopathic HP as it presented in a pediatric patient and resolved without immunomodulatory therapy.

Focal status epilepticus as a manifestation of idiopathic hypertrophic cranial pachymeningitis

BACKGROUND

Idiopathic hypertrophic cranial pachymeningitis (IHCP) is an uncommon disease of unknown etiology characterized by thickening of the cerebral dura mater with possible associated inflammation. The most frequently described clinical symptoms include headache, cranial nerve palsy, and cerebellar dysfunction. Epilepsy and/or status epilepticus as main presentation is very uncommon.

CASE PRESENTATION

Two consecutive cases are presented of patients manifesting focal status epilepticus secondary to IHCP, with clinical, laboratory [blood test and cerebrospinal fluid (CSF) analysis], neuroradiologic [magnetic resonance imaging (MRI) at 3 Tesla and digital subtraction angiography (DSA)], and therapeutic data. One patient underwent meningeal biopsy; pathology findings are also included. Corticosteroid therapy resulted in clinical improvement in both cases, and neuroimaging showed decreased abnormal morphology, compared to initial findings.

CONCLUSION

In the diagnostic approach to focal status epilepticus or epilepsy, IHCP must be considered a potential, although extremely infrequent, cause. Anti-inflammatory treatment is an effective addition to antiepileptic drug therapy in patients with IHCP.

Sex-, stress-, and sympathetic post-ganglionic-dependent changes in identity and proportions of immune cells in the dura

Aim of investigation Due to compelling evidence in support of links between sex, stress, sympathetic post-ganglionic innervation, dural immune cells, and migraine, our aim was to characterize the impacts of these factors on the type and proportion of immune cells in the dura. Methods Dural immune cells were obtained from naïve or stressed adult male and female Sprague Dawley rats for flow cytometry. Rats with surgical denervation of sympathetic post-ganglionic neurons of the dura were also studied. Results Immune cells comprise ∼17% of all cells in the dura. These included: macrophages/granulocytes ("Macs"; 63.2% of immune cells), dendritic cells (0.88%), T-cells (4.51%), natural killer T-cells (0.51%), natural killer cells (3.08%), and B-cells (20.0%). There were significantly more Macs and fewer B- and natural killer T-cells in the dura of females compared with males. Macs and dendritic cells were significantly increased by stress in males, but not females. In contrast, T-cells were significantly increased in females with a 24-hour delay following stress. Lastly, Macs, dendritic cells, and T-cells were significantly higher in sympathectomized-naïve males, but not females. Conclusions It may not only be possible, but necessary to use different strategies for the most effective treatment of migraine in men and women.

Prevalence of and Factors Associated with Dural Thickness in Patients with Mild Cognitive Impairment and Alzheimer's Disease

BACKGROUND AND PURPOSE

We performed this study to evaluate the prevalence of and factors associated with dural thickening in patients with mild cognitive impairment and Alzheimer's disease.

METHODS

Alzheimer's disease neuroimaging initiative participants with axial FLAIR sequence magnetic resonance imaging (MRI) images were analyzed. Dural thickness was defined by a linear strip of hyperintense tissue signal along the dura mater observed in at least two different images without evidence of leptomeningeal involvement.

RESULTS

Dural thickening was seen in 83 (34%) of 242 persons analyzed (mean age [±SD] 74±7 years: 150 were men) with either mild cognitive impairment or Alzheimer's disease. The mini mental score was not different in persons with (26±0.3) and without (26±0.2) dural thickening (p = 0.6). The proportion of patients with moderate or severe cognitive impairment (defined by mini mental status score) was similar at baseline and at 12-month evaluations. The rates of annual progression according to Alzheimer's disease assessment scale (p = 0.06) and clinical dementia scale (p = 0.001) were higher in persons without dural thickening. The annual rate of volume loss in entorhinal cortex was higher among persons with dural thickening.

CONCLUSIONS

We found relatively high prevalence of dural thickening in patients with mild cognitive impairment and Alzheimer's disease.

Hypertrophic pachymeningitis with sarcoidosis: a rare cause of craniocervical compression

We describe a case of a 58-year-old woman with a suspected dural tumour. She presented with progressive pyramidal weakness. MRI confirmed compression of the medulla oblongata and spinal cord at the level of C1-3. The localised dural mass lesion homogenously enhanced on T1 MRI and was considered most likely to be a meningioma. Incidentally, CT scan of the chest revealed peribronchial soft tissue thickening, suggestive of pulmonary sarcoidosis. Owing to the progressive nature of her weakness, she had a posterior occipitocervical decompression with a C1-3 laminectomy and resection of the thickened dura. Histology showed densely collagenous tissue with scanty psammoma bodies and multinucleate giant cells, consistent with hypertrophic pachymeningitis (HP)-a rare, chronic inflammatory condition, characterised by thickening and fibrosis of the dura. This case demonstrates that masses in the craniocervical junction can be varied in pathology and when there is evidence of systemic inflammation, HP should be considered.

Infiltrative mass of the skull base and nasopharynx: A diagnostic conundrum

Inflammatory skull base masses are enigmatic and often behaviourally unpredictable. We present a case of idiopathic hypertrophic pachymeningitis (IHP) forming a central skull base mass to illustrate the process required when one investigates such skull base lesions. This is the first description of mass forming or tumefactive IHP extending into the nasopharynx. A 32-year old woman presented with frontal headaches and nasal discharge. She then deteriorated and was admitted with worsening headaches, serosanguinous nasal discharge and bilateral ophthalmoplegia. Multimodality imaging confirmed a destructive central skull base soft tissue mass involving the posterior clivus, floor of sphenoid sinus, nasopharynx and extending into both cavernous sinuses. Unfortunately, the patient continued to deteriorate despite treatment with broad-spectrum antibiotics. Cerebrospinal fluid, blood tests and transnasal biopsies for histology and microbiology did not reveal a diagnosis. Further neuroimaging revealed extension of the mass. Early corticosteroid treatment demonstrated radical improvement although an initial reducing regime resulted in significant rebound deterioration. She was stable on discharge with slowly reducing low dose oral prednisolone and azathioprine. We discuss the complexity of this case paying special attention to the process followed in order to arrive at a diagnosis of idiopathic hypertrophic pachymeningitis based on both the clinical progression and the detailed analysis of serial skull base imaging. Knowledge of the potential underlying aetiologies, characteristic radiological features, common pathogens and the impact on blood serology can narrow the potential differentials and may avoid the morbidity associated with extensive resective procedures.

•

Timely thorough investigation is critical to reduce the risk of irreversible damage.

•

Prompt biopsy is essential to exclude both neoplasia and inflammatory conditions.

•

Early corticosteroid administration is necessary to limit local infiltration.

Immunoglobulin-G4-related hypertrophic pachymeningitis with antineutrophil cytoplasmatic antibodies effectively treated with rituximab

We describe a 52-year-old man with hypertrophic pachymeningitis (HP) who was both seropositive for antineutrophil cytoplasmatic antibodies (ANCA) against myeloperoxidase, and had an immunoglobulin G4 (IgG4) positive fibroinflammatory response in meningeal biopsy. HP is a chronic inflammatory thickening of the dura mater which typically presents with headache, cranial nerve dysfunction and other neurological deficits. While first-line treatment with corticosteroids is recommended, many patients relapse and need additional immunosuppression. One recently described etiology is IgG4-related disease and in a subgroup of idiopathic patients, evidence suggests a crucial role of ANCA. To our knowledge, the simultaneous occurrence of IgG4-related disease and ANCA has not been reported so far. This man suffered life-threatening disease progression despite the administration of high dose steroids, cyclophosphamide and azathioprine. Treatment with rituximab was initiated which led to disappearance of clinical symptoms and decrease of dural thickening within weeks. This patient presents a possible disease overlap of IgG4-related and ANCA-associated HP and illustrates the effectiveness of rituximab in refractory IgG4-related HP.

Arachnoid involved in idiopathic hypertrophic pachymeningitis

The cerebrospinal fluid (CSF) shows inflammatory changes in patients with idiopathic hypertrophic pachymeningitis (IHP), which is a rare disorder. However, systemic CSF research including immunoglobulins in patients with IHP are substantially lacking. In the study, clinical, laboratory, neuroradiologic and therapeutic data from 9 patients with IHP were retrospectively studied, and CSF changes were analyzed. Intracranial pressure was elevated in 4 patients. Protein levels in CSF were elevated in 5 patients (< 1g/L). IgA was elevated in 7 patients (> 0.5mg/dL), IgG was elevated in 8 patients (> 3.4 mg/dL) and IgM was elevated in 6 patients (>0.13 mg/dL) with IHP. CSF immunoglobulins, including IgA, IgG and IgM, were significantly elevated compared with levels in the control (P = 0.021, 0.018, 0.019). There were no linear correlations between IgG, IgM and protein in CSF, but there was a linear correlation between IgA and protein. In conclusion, CSF in IHP shows inflammatory changes, and protein levels are low to moderately elevated. CSF immunoglobulins, including IgA, IgG and IgM, also increased. The arachnoid is involved in IHP, a proportion of immunoglobulins may originate from the blood because of damage to the blood-CSF barrier at the arachnoid. Other intrathecal synthesis of immunoglobulins may be a secondary change due to alteration in the CSF's content to stabilize the internal environment or may be secreted by activated immune memory cells in the brain, which need further research.

Idiopathic hypertrophic cranial pachymeningitis: Three biopsy-proven cases including one case with abdominal pseudotumor and review of the literature

Hypertrophic pachymeningitis (HP) is a rare disorder of diverse etiology. It presents with headaches, cranial neuropathies and ataxia occurring alone or in combination. Dural biopsy is essential to exclude secondary causes of pachymeningitis. There is paucity of data on biopsied cases of HP. We report three biopsy-proven cases of idiopathic hypertrophic cranial pachymeningitis. All our patients had headaches and multiple cranial neuropathies; ataxia was seen in one patient. One patient had recurrent anterior and posterior cranial neuropathies, while one each had recurrent anterior and posterior cranial neuropathies. Two patients had profound irreversible mono-ocular visual loss. All of them showed prominent pachymeningeal thickening on imaging. Infarcts were seen in one patient, which have rarely been documented. All patients showed biopsy evidence of meningeal thickening and nonspecific chronic inflammation of the dura. The disease may have a remitting and relapsing course, and usually responds to steroids. Clinical improvement was excellent in two patients and modest in one on steroid therapy. All our patients required azathioprine during the course of therapy. Early institution and long-term maintenance of steroid therapy prevents neurologic sequelae. Occurrence of abdominal inflammatory pseudotumor in a patient of HP possibly as part of multifocal fibrosclerosis has not been described earlier.

Aspergillus pachymeningitis mimicking nasopharyngeal carcinoma

Objectives:

We report a case of otogenic fungal pachymeningitis in a diabetic patient who presented with multiple cranial nerve palsies and nasopharyngeal swelling.

Methods:

We present a case report, we describe the investigations, management and clinical course of fungal pachymeningitis, and we present a review of the world literature on fungal and non-fungal pachymeningitis.

Results:

To our knowledge, this is the first report of fungal pachymeningitis with magnetic resonance imaging features suggestive of nasopharyngeal carcinoma. It is also the first reported case with aspergillus cultured from both a dural biopsy and the ear canal.

Conclusion:

Fungal pachymeningitis is a rare condition which may present to otorhinolaryngologists. Its clinical and radiological findings can be confused with those of nasopharyngeal carcinoma; fungal pachymeningitis should thus be included in the differential diagnosis of nasopharyngeal carcinoma.

Idiopathic hypertrophic cranial pachymeningitis misdiagnosed as acute subtentorial hematoma

A case of idiopathic hypertrophic cranial pachymeningitis (IHCP) misdiagnosed as an acute subdural hematoma is reported. A 37-year-old male patient presented with headache following head trauma 2 weeks earlier. Computerized tomography showed a diffuse high-density lesion along the left tentorium and falx cerebri. Initial chest X-rays revealed a small mass in the right upper lobe with right lower pleural thickening, which suggested lung cancer, such as an adenoma or mediastinal metastasis. During conservative treatment under the diagnosis of a subdural hematoma, left cranial nerve palsies were developed (3rd and 6th), followed by scleritis and uveitis involving both eyes. Magnetic resonance imaging (MRI) revealed an unusual tentorium-falx enhancement on gadolinium-enhanced T1-weighted images. Non-specific chronic inflammation of the pachymeninges was noticed on histopathologic examination following an open biopsy. Systemic steroid treatment was initiated, resulting in dramatic improvement of symptoms. A follow-up brain MRI showed total resolution of the lesion 2 months after steroid treatment. IHCP should be included in the differential diagnosis of subtentorial-enhancing lesions.

Imaging features of meningeal inflammatory myofibroblastic tumor

BACKGROUND AND PURPOSE

Meningeal inflammatory myofibroblastic tumor (IMT) has been rarely reported, and its prognosis is still unclear. Our purpose was to describe the imaging features of patients with meningeal IMT and their results on follow-up studies.

MATERIALS AND METHODS

Twenty-four MR images in 10 consecutive patients with pathologically proved meningeal IMTs were retrospectively evaluated, focusing on the lesion distribution, signal intensity (SI), and contrast-enhancement pattern with a review of the clinical records.

RESULTS

Eight patients with intracranial IMT showed localized (n = 4) or diffuse (n = 4) dural thickening, a single mass (n = 5) or 2 (n = 2) dural-based masses with surrounding edema, dural venous sinus thrombosis (n = 5), and leptomeningeal involvement (n = 5). Extracranial involvement of the mastoid (n = 2) and orbit (n = 2) was also associated. Each of the 2 patients with intraspinal IMT showed a dural-based mass and a segmental dural thickening, respectively. All of the thickened dura showed low SI on T2-weighted images, iso-SI on T1-weighted images, and diffuse contrast enhancement. Variable recurrences with dural-based masses, mastoid involvement, or nasolacrimal duct involvement were observed in all 4 patients with diffuse intracranial IMT, but not in the others.

CONCLUSIONS

Localized or diffuse dural thickening of T2 low SI and diffuse contrast enhancement combined with dural-based masses are a common MR imaging finding of meningeal intracranial IMT. Adjacent leptomeningeal involvement and dural venous sinus thrombosis are frequently associated. The diffuse type has a tendency toward recurrence.

Idiopathic hypertrophic cranial pachymeningitis presenting with headache

Idiopathic hypertrophic cranial pachymeningitis is a rare inflammatory disease, usually involving the dura mater of skull base, tentorium, and falx. Chronic headache is the most common clinical manifestations. We report a case of idiopathic hypertrophic cranial pachymeningitis that was, initially, misdiagnosed as acute subdural hematoma along the tentorium cerebelli and posterior falx on the brain precontrast CT scan of a patient with severe headache. Correct diagnosis of pachymeningitis was made only after brain magnetic resonance imaging and meningeal biopsy.

Idiopathic hypertrophic cranial pachymeningitis causing progressive polyneuropathies in a child

We describe the clinical manifestations, radiological features and response to therapy of a 10-year-old child with idiopathic hypertrophic cranial pachymeningitis, a rare condition with potentially severe disabling neurological consequences. The child presented with progressive cranial polyneuropathies secondary to dural compression of the neural and vascular structures within the cavernous sinus. Corticosteroids and methotrexate proved effective in inducing near complete and sustained remission of the condition. To our knowledge, this is the first case reported of idiopathic hypertrophy cranial pachymeningitis in a child. The experience with oral methotrexate to treat this entity in a child has also never been reported. Idiopathic cranial hypertrophic pachymeningitis should be considered in children presenting with a progressive cranial polyneuropathies.

Idiopathic hypertrophic cranial pachymeningitis treated by oral methotrexate: a case report and review of literature

Idiopathic hypertrophic cranial pachymeningitis (IHCP) is a rare clinical entity, characterized by a chronic inflammation causing thickening of the dura. Adequate therapeutic management is still a matter of debate. We present a patient with an IHCP, non-responsive to corticotherapy. Oral methotrexate was introduced (12.5 mg weekly) and total remission was observed after 6 weeks, both clinically and after neuro-imaging. We conclude that methotrexate can be effective and a therapeutical option in patients with IHCP who are resistant to corticotherapy or present major side-effects of chronic corticosteroids use.

Mastoiditis complicated with Gradenigo syndrome and a hypertrophic pachymeningitis with consequent communicating hydrocephalus

We present the clinical, radiological and pathological features of a case of a cranial hypertrophic pachymeningitis that developed in the course of mastoiditis and petrous apex inflammation and responded to immunosuppressive therapy only. Documented by the development of clinical findings, magnetic resonance imaging, cerebrospinal fluid changes, histopathology findings, by otosurgical intervention and finally by the insertion of a ventriculo-peritoneal shunt, the case illustrates a gradual development of pachymeningitis with consequent hydrocephalus and intracranial hypertension. We consider this disease development an example of immune-induced proliferative fibrotic changes in meninges.

An external cause for 'idiopathic' pachymeningitis?

In a 67-year-old man with a history of professional asbestos exposure and persistent headaches since one year, a diagnosis of idiopathic pachymeningitis was made. IHCP (idiopathic hypertrophic cranial pachymeningitis) is in literature referred to as one of the presentations of Multifocal Idiopathic Fibrosclerosis or MIF, representing a group of fibro-inflammatory and pathologically similar diseases, including also retroperitoneal fibrosis, mediastinal fibrosis and sclerosing cholangitis. Since recent literature links asbestos exposure to a risk of development of retroperitoneal fibrosis, the present case suggests to focus in future research of IHCP on possible external causes.

[Hypertrophic cranial pachymeningitis as a rare cause of headache]

Hypertrophic cranial pachymeningitis is an uncommon, fibrosing, inflammatory process that involves the dura mater. The condition is being reported more frequently owing to the use of cranial MRI. The main clinical feature is headache, whereas cranial nerve lesions, cerebellar symptoms, and epileptic seizures occur more rarely. A variety of autoimmune and infectious diseases can result in this condition, which is labeled as idiopathic in the absence of any definite inciting factor. The diagnosis of hypertrophic cranial pachymeningitis is based on neuroimaging of thickened and enhancing dura mater. It can be defined pathologically on biopsy. A specific treatment is indicated in some cases of secondary hypertrophic cranial pachymeningitis. Mostly, treatment relies on corticosteroids and immunosuppressive agents. This review summarizes the current knowledge on causes, clinical presentation, diagnosis, and treatment of this disorder.