Hypertrophic cranial pachymeningitis causing progressive unilateral blindness: MR findings

Hypertrophic Pachymeningitis in a Southern Chinese Population: A Retrospective Study

Aims: To investigate the causes, clinical characteristics, imaging features, and therapeutic implications of hypertrophic pachymeningitis (HP) in a southern Chinese population.

Methods: We retrospectively analyzed 48 patients with HP with different causes from 1 January 2006 to 31 December 2018. Clinical manifestation, laboratory findings, and neuroimaging results were evaluated in all HP patients.

Results: The mean age at onset was 50 ± 12 years. The most common diagnosis was idiopathic HP (67%), followed by antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis (15%), tuberculous meningitis (8%), viral meningitis (6%), and bacterial meningitis (4%). Headache was the most common symptom. The most frequently changed laboratory finding was elevated erythrocyte sedimentation rate (ESR). Imaging was characterized by cerebral or spinal dura mater enhancement in MRI scan with contrast. Enhancements were mainly located in the posterior fossa for idiopathic HP; frontal, parietal, and occipital lobes for ANCA-related HP; and posterior fossa for tuberculous-associated HP. Diffuse enhancement was found in most cases, except for tuberculous-associated HP. Glucocorticoid or immunosuppressive treatment was applied in most cases.

Conclusions: The etiology of HP varied among patients, with idiopathic HP being the most common. MRI showed enhancement of the dura mater, which differed according to different etiologies. Glucocorticoid or immunosuppressive agents were the primary drugs for treatment.

Hypertrophic pachymeningitis

BACKGROUND

Hypertrophic pachymeningitis (HP) is a rare clinical entity characterized by diffuse or localized fibrous thickening of the dura mater. It is well known but rare especially in pediatric population disease of differing origins. The primary (idiopathic) form is diagnosed after excluding other possible etiologies. Similar results from magnetic resonance imaging (MRI) for patients with hypertrophic pachymeningitis and meningiomas may make the diagnosis confusing. Additionally, making a proper diagnosis without histological sampling can be difficult in some cases.

CASE DESCRIPTION

We present a case of an 18-year-old boy diagnosed with hypertrophic pachymeningitis in the area of the hypoglossal canal. The diagnosis was made after a 2-month history of hypoglossal nerve palsy and dysphagia preceded by a middle ear infection. The patient was treated surgically with suspicion of meningioma, but no evidence of a tumor was found during the operation. The postoperative period was uneventful. At the latest check-up, MRI revealed regression of all previously observed pathological changes.

Idiopathic Hypertrophic Pachymeningitis Presenting with Uveitic Glaucoma

A 73-year-old man presented with uveitic glaucoma associated with headache. Because there were no active inflammatory signs, synechiolysis and cataract extraction were performed. Even after lowering intraocular pressure, he repeatedly complained of headache, but no neuroimaging was performed. Acute bilateral visual loss was occurred 3 months after cataract surgery. Ophthalmologic examination revealed bilateral optic neuritis and a Gd-DPTA-enhanced cranial magnetic resonance imaging (MRI) showed thickened enhancement of the dura and optic nerve sheath. A final clinical diagnosis of idiopathic hypertrophic pachymeningitis associated with optic neuritis was made.

A case of idiopathic hypertrophic cranial pachymeningitis presenting high values of matrix metalloproteinase

This report concerns a 53-year-old male patient with idiopathic hypertrophic cranial pachymeningitis who presented with multiple cranial nerve palsies (I, II, III, IV, V, VI). Brain magnetic resonance imaging showed diffuse thickening and gadolinium enhancement of the cerebral dura mater. A biopsy of the cerebral dura mater showed granulomatous vasculitis with histiocyte infiltration. Although both the serum rheumatoid factor (RF) and matrix metalloproteinase-3 (MMP-3) were high, the patient showed no signs of arthritis. He was anti-cyclic citrullinated peptide antibody negative, which makes the presence of comorbid chronic rheumatoid arthritis (RA) unlikely. The aetiology of the pachymeningitis was unknown, which led to the diagnosis of idiopathic hypertrophic cranial pachymeningitis. Steroid pulse therapy successfully diminished the patient's pachymeningitis and lowered both RF and MMP-3. High values of RF suggest the possible involvement of an autoimmune mechanism, and the MMP value may be an important indicator of the aetiology of pachymeningitis with granulomatous vasculitis.

Painful ophthalmoplegia caused by idiopathic hypertrophic cranial pachymeningitis in the cavernous sinus

A 73-year-old man presenting with painful unilateral ophthalmoplegia is reported. Magnetic resonance imaging demonstrated a mass in the cavernous sinus extending to the floor of the middle cranial fossa. After resection of the lesion and anti-tuberculous chemotherapy his symptoms improved. Pathological examination revealed extensive caseous necrosis.

Acute Monocular Visual Loss in Carcinomatous Hypertrophic Pachymeningitis Mimicking Giant Cell Arteritis

This report describes a 69-year-old woman who presented with acute monocular visual loss, ipsilateral headache, and elevated sedimentation rate and C-reactive protein. Both temporal artery biopsies were negative. Neuroimaging, dural biopsy, and breast biopsy all confirmed the diagnosis of carcinomatous hypertrophic pachymeningitis associated with metastatic breast carcinoma. After treatment with corticosteroids, her vision improved. Her clinical presentation initially mimicked the symptoms and signs of giant cell arteritis. Acute monocular visual loss without other cranial nerve palsies may be an uncommon presentation of hypertrophic pachymeningitis from metastatic breast carcinoma.

Acute monocular visual loss in carcinomatous hypertrophic pachymeningitis mimicking giant cell arteritis

This report describes a 69-year-old woman who presented with acute monocular visual loss, ipsilateral headache, and elevated sedimentation rate (ESR) and C-reactive protein (CRP). Both temporal artery biopsies were negative. Neuroimaging, dural biopsy, and breast biopsy all confirmed the diagnosis of carcinomatous hypertrophic pachymeningitis associated with metastatic breast carcinoma. After treatment with corticosteroids, her vision improved. Her clinical presentation initially mimicked the symptoms and signs of giant cell arteritis. Acute monocular visual loss without other cranial nerve palsies may be an uncommon presentation of hypertrophic pachymeningitis from metastatic breast carcinoma.

Headache Profile in Patients With Idiopathic Hypertrophic Cranial Pachymeningitis

BACKGROUND

Idiopathic hypertrophic cranial pachymeningitis (IHCP) is an uncommon disorder due to localized or diffuse thickening of the dura mater. While headache is the most common manifestation, the clinical characteristics of the headache in IHCP have not been well characterized.

METHODS

From 1996 to 2002, 6 consecutive patients with IHCP presenting with headache were reviewed (3 women, 3 men; mean age: 49 years). Diagnosis was based on characteristic neuroimaging findings and the exclusion of secondary causes of cranial pachymeningitis. This study reported the headache characteristics, neuroimaging features, and longitudinal follow-up.

RESULTS

Chronic daily headache, especially chronic migraine, was the most common headache pattern observed (4/6 patients). Lateralization of headache location appeared to correlate with the distribution of the hypertrophied dural lesions. Diagnostic delay was due to failure to evaluate with gadolinium-enhanced MRI. After treatment, headache (5/6, 83%) and neurologic deficits (2/3, 67%) improved in most patients; however, follow-up MRIs (n = 5) showed deterioration in 3 patients.

CONCLUSION

The headache of IHCP is typically a chronic daily headache, often resembling chronic migraine. Correspondingly, IHCP should be considered in the differential diagnosis of refractory chronic daily headache, with or without associated cranial neuropathy or other associated neurologic deficits. The typical imaging finding on gadolinium-enhanced MRI is localized or diffuse pachymeningitis and failure to order a gadolinium-enhanced MRI is the primary reason for delayed diagnosis. Despite symptomatic improvement on longitudinal follow-up, the MRI abnormalities may not improve in parallel with the clinical symptoms.

Idiopathic Hypertrophic Cranial Pachymeningitis Associated With Total Occlusion of the Dural Sinuses-Case Report-

A 44-year-old man presented with a rare case of idiopathic hypertrophic cranial pachymeningitis manifesting as generalized seizure. Neuroimaging and pathological examinations showed the typical features of hypertrophic cranial pachymeningitis. Tuberculosis was a possible cause based on the positive purified protein-derived skin test, but the origin of the disease was not confirmed by further examinations. Cerebral angiography showed total occlusion of the dural sinuses with development of the emissary veins. Histological examination of the dura showed thickening of the fibrous tissue with rare inflammatory cells, suggestive of the extremely long duration of the disease. The diagnosis was idiopathic hypertrophic cranial pachymeningitis, but was treated only with anticonvulsants. The disease did not progress during follow up of 3 years. Idiopathic hypertrophic cranial pachymeningitis may have various causes related to unusual forms of infectious or autoimmune disorders.

Small B-cell lymphoma presenting as diffuse dural thickening with cranial neuropathies

The authors present a rare case of diffuse hypertrophy of the pachymeninges due to lymphomatous dural infiltration. This lymphoma arose late after orthotopic liver transplant, was Epstein-Barr virus (EBV)-negative, and arose in a setting of prior hepatitis C infection, a condition that may contribute to development of some non-Hodgkin's lymphomas. Biopsy of the dura demonstrated a small B-cell lymphoma, immunophenotypically most similar to those of mucosa-associated lymphoid tissues (MALT). Rapid expansion of the dura in this case resulted in profound hyperesthesia of the scalp, progressive blindness, deafness, and ataxia. As expected for MALT-lymphomas clinical symptoms responded well to cranial radiation.

Idiopathic hypertrophic pachymeningitis: a report of two patients and review of the literature

PURPOSE

We report the treatment and follow-up, including MRI, of two patients with idiopathic hypertrophic pachymeningitis and review the English language literature, with emphasis on management and outcome in this rare disorder.

METHODS AND MATERIALS

The files of two patients were reviewed, with relevant histopathology and imaging (MRI). The first patient has been followed for sixteen years (the longest MRI-documented postoperative course reported for this condition) and the second for two years. The English language literature was reviewed, including a summary of all reported patients that have been followed with MRI or CT imaging.

RESULTS

Despite extensive investigation, no underlying etiology was determined in either patient. Histopathological studies revealed a chronic inflammatory dural infiltrate in both patients, with granulomas in the first but not the second patient. The first patient underwent surgery twice and has remained stable for sixteen years, despite persistent neurologic deficits. The second patient was managed with dexamethasone after a surgical biopsy, and experienced complete resolution of all neurological deficits and abnormalities seen with MRI.

CONCLUSIONS

Although prompt and extensive surgery has been recommended for this condition, the results from our second patient indicate that complete remission can be achieved in some patients with biopsy and steroid therapy. This also supports the view that autoimmune mechanisms underlie idiopathic hypertrophic pachymeningitis. The first patient illustrates that extensive laminectomies may be an effective therapeutic option but chronic discomfort may result. If extensive surgery must be performed, laminoplasty should be done because of the potential for reduced pain and improved long-term spinal stability.

Hypertrophic cranial pachymeningitis involving dural sinuses: a pseudo signal-void appearance on MRI

A case of hypertrophic cranial pachymeningitis with an unusual and misleading manifestation is reported. CT detected calcified tentorium and superior sagittal sinus. MR imaging and MR angiography depicted tentorial thickening as well as occlusion of all major dural sinuses. Fibrocalcific occlusion of dural sinuses showed interestingly signal-void appearance on spin-echo images which could readily be interpreted as being patent sinuses.

Pachymeningitis and optic neuritis in rheumatoid arthritis: MRI findings

Rheumatoid arthritis is a systemic disease in which cerebral and eye involvement is neither common nor fully understood. Although it is rarely the cause of pachymeningitis and optic neuritis, rheumatoid arthritis should always be kept in mind in these two conditions. We present a 52-year-old male with an 8 month history of rheumatoid arthritis who was referred to the neurology department with headache and decreasing vision and was diagnosed as having rheumatoid pachymeningitis and optic neuritis on the basis of MRI findings.

"Idiopathic" cranial hypertrophic pachymeningitis responsive to antituberculous therapy: case report

OBJECTIVE AND IMPORTANCE

We present a case similar to previously described cases of idiopathic hypertrophic cranial pachymeningitis. However, our patient responded to antituberculous therapy. This raises the possibility that some cases of "idiopathic" hypertrophic cranial pachymeningitis may represent occult tuberculous disease.

CLINICAL PRESENTATION

A 55-year-old woman presented with a right fourth nerve palsy and a 5-month history of headaches. Magnetic resonance imaging with gadolinium revealed thick enhancing dura on the right half of the tentorium cerebelli, with edema of the adjacent midbrain, pons, and cerebral peduncle.

INTERVENTION

Open biopsy of the tentorial lesion revealed only dense fibrosis with histiocytic infiltration. An exhaustive search failed to demonstrate an underlying cause. In particular, mycobacterial stains/cultures were negative, there was no granuloma formation, and the chest x-ray was unremarkable. However, because of a strongly positive purified protein-derivative skin test and residence in an area endemic for tuberculosis, the patient was placed on antituberculous medications.

CONCLUSION

The patient's symptoms and signs resolved with antituberculous therapy. Resolution of the tentorial lesion was confirmed by gadolinium-enhanced magnetic resonance imaging. We conclude that this case represented occult tuberculous disease. An empiric trial of antituberculous therapy may be warranted in other cases of apparently idiopathic hypertrophic cranial pachymeningitis.

Idiopathic chronic hypertrophic craniocervical pachymeningitis: case report

A 55-year-old woman with a unique form of chronic hypertrophic pachymeningitis involving the posterior fossa and upper cervical spine is reported. Unlike other cases previously described, the clinical picture was dominated by signs of increased intracranial pressure, lower cranial nerve disorders, and a progressive cervical radiculomyelopathy. The diagnosis was made by means of a contrast-enhanced magnetic resonance imaging scan and confirmed by histological examination of the excised dura. Surgical treatment with removal of the hypertrophic dura provided temporary relief, although the natural history of the disease was not modified. Exhaustive bacteriological and histopathological studies failed to identify a specific cause for this diffuse hypertrophy of the cranial and cervical dura. The literature is reviewed, and other histologically documented cases are discussed.