Idiopathic Chronic Hypertrophic Craniocervical Pachymeningitis: Case Report

Progressive myelopathy due to meningeal thickening in shunted patients: description of a novel entity and the role of surgery

INTRODUCTION

Spinal cord compression due to meningeal thickening is a rare occurrence in shunted patients. Because of the long delay to clinical onset, this complication has not been identified as yet.

AIMS

We report on nine cases of shunt-related progressive myelopathy due to meningeal thickening (SPMMT).

MATERIALS AND METHODS

We reviewed our database of shunted children, for cases having developed progressive tetraparesis due to cervical meningeal thickening.

RESULTS

We identified nine observations of SPMMT, eight of these with hydrocephalus due to neonatal meningitis; the last case had Dandy-Walker malformation shunted at birth and suffered postoperative meningitis. The age of clinical onset of myelopathy was between 6 and 20 years (median 12.8). All patients presented with slowly progressive walking difficulties with falls and no spinal pain. Magnetic resonance imaging (MRI) showed typically a thickened dura mater with collapse of the arachnoid space, compensatory expansion of the epidural fat, and T2 hyperintensity in the spinal cord. We operated on seven patients for surgical decompression and arachnoidolysis: One died postoperatively because of shunt malfunction, and two others died later of complications of tetraplegia. Three patients were aggravated after surgery, three experienced partial improvement, but one of these subsequently deteriorated again.

CONCLUSION

SPMMT appears to be a novel and well-defined clinical and pathological entity; its pathological and radiological features are stereotyped; however, the diagnosis is delayed because of the slow pace of the disease. Although surgical decompression may be the only option, its results were poor in our experience; earlier surgery might improve this grim prognosis.

Idiopathic granulomatous meningoencephalitis presenting as an intracranial tumor

A 2-year-old girl presented with a single episode of generalized seizure. Magnetic resonance imaging examination showed an intracranial mass with a diameter of 2.5 cm in the right parieto-occipital region of the cerebrum. These clinicoradiological findings were suggestive of intracranial tumor. Histologically, fibroblastic proliferation of storiform pattern was noted, associated with epithelioid granulomas. The etiological pathogens for the granulomas could not be detected even though investigation of special histochemical staining, immunohistochemical study and DNA analysis of Mycobacterium tuberculosis by polymerase chain reaction technique was performed. On electron microscopic examination, the area appearing as a storiform pattern consisted of fibroblasts showing much dilated rough endoplasmic reticulum and slender tappering cytoplasmic processes without cellular junctional complex. No organisms were identified in the granulomatous area of the lesion. From those findings the diagnosis as idiopathic granulomatous meningoencephalitis was made.