Neuroradiological manifestations of intracranial sarcoidosis

The leptomeninges as a critical organ for normal CNS development and function: First patient and public involved systematic review of arachnoiditis (chronic meningitis)

BACKGROUND & IMPORTANCE

This patient and public-involved systematic review originally focused on arachnoiditis, a supposedly rare "iatrogenic chronic meningitis" causing permanent neurologic damage and intractable pain. We sought to prove disease existence, causation, symptoms, and inform future directions. After 63 terms for the same pathology were found, the study was renamed Diseases of the Leptomeninges (DLMs). We present results that nullify traditional clinical thinking about DLMs, answer study questions, and create a unified path forward.

METHODS

The prospective PRISMA protocol is published at Arcsology.org. We used four platforms, 10 sources, extraction software, and critical review with ≥2 researchers at each phase. All human sources to 12/6/2020 were eligible for qualitative synthesis utilizing R. Weekly updates since cutoff strengthen conclusions.

RESULTS

Included were 887/14286 sources containing 12721 DLMs patients. Pathology involves the subarachnoid space (SAS) and pia. DLMs occurred in all countries as a contributor to the top 10 causes of disability-adjusted life years lost, with communicable diseases (CDs) predominating. In the USA, the ratio of CDs to iatrogenic causes is 2.4:1, contradicting arachnoiditis literature. Spinal fusion surgery comprised 54.7% of the iatrogenic category, with rhBMP-2 resulting in 2.4x more DLMs than no use (p<0.0001). Spinal injections and neuraxial anesthesia procedures cause 1.1%, and 0.2% permanent DLMs, respectively. Syringomyelia, hydrocephalus, and arachnoid cysts are complications caused by blocked CSF flow. CNS neuron death occurs due to insufficient arterial supply from compromised vasculature and nerves traversing the SAS. Contrast MRI is currently the diagnostic test of choice. Lack of radiologist recognition is problematic.

DISCUSSION & CONCLUSION

DLMs are common. The LM clinically functions as an organ with critical CNS-sustaining roles involving the SAS-pia structure, enclosed cells, lymphatics, and biologic pathways. Cases involve all specialties. Causes are numerous, symptoms predictable, and outcomes dependent on time to treatment and extent of residual SAS damage. An international disease classification and possible treatment trials are proposed.

Neurosarcoidosis presenting as an isolated mass of the quadrigeminal plate

A rare case of neurosarcoidosis presenting as an isolated quadrigeminal plate mass without systemic manifestation of this disease is reported. This 26-year-old man presented with symptoms of acute intracranial hypertension including headache, morning vomiting as well as a right homonymous hemianopsia. Magnetic resonance imaging (MRI) showed an expansive tectal mass causing hydrocephalus secondary to an aqueductal obstruction. An external ventricular drainage was inserted and the mass, postulated to be a glioma, was removed through an occipital transtentorial craniotomy. Histopathological examination revealed numerous sarcoid granulomas. Postoperative course was relevant for bilateral hypoacusis and tinnitus, blurred vision, bilateral palpebral ptosis and bilateral internuclear ophthalmoplegia. Chest X-ray was normal. Postoperative thoracic computed tomography (CT) scan showed mediastinal adenopathies. Lung function tests were normal. Angiotensin converting enzyme (ACE) cerebrospinal fluid (CSF) blood ratio was normal. Postoperative treatment and follow-up included corticosteroids, serial lung function tests and cerebral MRI. Neurosarcoidosis may present with protean clinical manifestations and unusual radiological features. This rare diagnosis has to be kept in mind when facing isolated intracerebral mass lesions.

Obstructive hydrocephalus and progressive psychosis: rare presentations of neurosarcoidosis

BACKGROUND

Neurosarcoidosis presents with meningitis, cranial nerve involvement, and parenchymal masses. Usually, abnormal MR enhancement and/or structural lesion(s) are present. Communicating hydrocephalus arises from meningeal arachnoid granulation involvement. Reported cases of obstructive hydrocephalus have all involved obstructing ventricular lesions.

CASE DESCRIPTION

A 40-year-old African American man presented with papilledema, diplopia, and headache. Magnetic resonance imaging revealed "aqueductal stenosis" without abnormal enhancement or obstructive lesion. Although symptoms resolved with shunting, he soon developed progressive psychotic symptoms. Serial MR scans remained free of abnormal enhancement or structural mass lesion(s) but revealed long repetition time and proton density signal changes within the medial temporal lobe structures and deep white matter that remained stable over 8 months despite clinical progression. Serial CSF studies were nondiagnostic. Open temporal lobe brain and meningeal biopsy revealed noncaseating granulomas within the parenchyma and meninges consistent with sarcoid. Total-body computed tomography scans ruled out systemic sarcoid. The patient steadily improved on steroid therapy.

CONCLUSION

Neurosarcoid psychiatric symptoms are usually associated with diffuse meningeal enhancement from meningitis. Our case reveals that absence of abnormal enhancement or structural mass lesion on MR and normal CSF ACE levels do not rule out neurosarcoid. Based on a patent cerebral aqueduct and the T2 MR and pathology findings, we postulate that altered brain tissue compliance with impairment of normal pulsatile augmentation of aqueduct CSF flow was the likely cause of obstructive hydrocephalus. This represents a very rare psychiatric presentation and reports a new potential mechanism for the development of hydrocephalus with neurosarcoid.

Neurosarcoïdose : état des connaissances

The origins of neurosarcoidosis, a multisystemic granulomatous disease, remain unknown. Nervous system localizations remain rare, but severe. Lymphocytic meningitis, psychiatric disorders, diabetes insipidus and cranial nerve palsy are the most frequent signs. Cerebral fluid test and cervical medullar and cerebral MRI with gadolinium have to be performed first. In some cases, histological evidence of granuloma have to be obtained with neuromuscular, meningeal or cerebral biopsies. Functional impairment and life-threatening conditions require early corticosteroid therapy. In worsening cases or in the event of no therapeutic response or poor tolerance to corticosteroids, other immunosuppressive agents should be associated. Maintenance therapy and most often life long maintenance therapy allow a continuous success while avoiding relapse.

Neurosarcoidosis without systemic sarcoidosis--case report

A 20-year-old male presented with symptoms of isolated neurosarcoidosis including epilepsy. Magnetic resonance imaging disclosed multiple enhanced right temporal and frontal lesions. Cerebrospinal fluid examination identified mild lymphocytic pleocytosis, and histological examination of a stereotactic brain biopsy specimen demonstrated noncaseating granulomas, so fungal or other inflammatory or granulomatous diseases were excluded. The diagnosis was cerebral sarcoidosis, despite the absence of systemic manifestations. Corticosteroid therapy improved his neurological state and radiological findings. Neurosarcoidosis is a well-recognized occurrence in systemic sarcoidosis, but diagnosis may be difficult in the absence of extracerebral manifestations.

Micturitional disturbance in a patient with neurosarcoidosis

We report a case of neurosarcoidosis in which urodynamic studies showed neurogenic bladder dysfunction. A 30-year-old man began to have slowly progressive gait ataxia of vestibular origin, deafness, and hallucination, which developed into versive seizure and stupor. Brain computed tomography and magnetic resonance imaging showed the anteromedial frontal lobe lesion with mild ventricular enlargement. The cerebrospinal fluid examination revealed pleocytosis with raised total protein and angiotensin-converting enzyme levels. Endoscopic lung biopsy showed epithelioid granuloma. Oral prednislone (60 mg/day) ameliorated his symptoms. After tapering steroids, however, he developed urinary urgency, frequency, urge urinary incontinence, and a relapse of gait ataxia. The urodynamic study showed detrusor hyperreflexia. Prednisolone treatment again improved his urinary and neurological symptoms. The anteromedial frontal lobe lesion seems to be responsible for the micturitional disturbance in our patient with neurosarcoidosis.

[Sarcoidosis of the central nervous system: clinical and radiological polymorphism]

Central nervous system (CNS) neurosarcoidosis was considered to be infrequent. Clinical and radiological polymorphism explained the delay before diagnosis. With magnetic resonance imaging (MRI), diagnosis is more easily performed, especially in paucisymptomatic cases. A review of the most important clinical and radiological studies and three personal cases are reported. This underlines variable characteristics of hemispheric localizations, especially pseudotumoral forms.

Radiation therapy for sarcoid of the thalamus/posterior third ventricle: case report

There are a limited number of previously reported cases involving the use of radiation therapy for sarcoid of the brain. The case of a 22-year-old man with a thalamic/posterior third ventricle sarcoid mass that grew despite steroid medication is presented. The patient was treated with external beam radiation to a total dose of 20 Gy, with 2-Gy fractions over 14 elapsed days. A complete radiographic response was achieved 4 months after radiation was completed. Radiographic follow-up through 8 months postradiation shows no evidence of disease recurrence. Fractionated radiation therapy in low-to-moderate doses appears to be efficacious in steroid-refractory sarcoid of the brain.

Intrasellar mass with hypopituitarism as a manifestation of sarcoidosis. Case report

A 45-year-old woman was admitted suffering from headache, weight loss, asthenia, pedal edema, and amenorrhea. Morphological and functional studies revealed an intrasellar mass causing hypopituitarism without diabetes insipidus. Histological examination of the tissue obtained at transsphenoidal surgery was compatible with a diagnosis of sarcoidosis. The clinical and histological features, together with the presence of cutaneous anergy and ocular lesions, led to the diagnosis of sarcoidosis. The presentation of sarcoidosis in this patient was very unusual because it was not accompanied by characteristic intrathoracic findings or by diabetes insipidus.

Progression of hydrocephalus during corticosteroid therapy for neurosarcoidosis

We describe a patient with sarcoid meningitis and hydrocephalus who improved rapidly after initiation of oral prednisone therapy, but who later decompensated acutely and required an emergency ventriculoperitoneal shunt. Hydrocephalus associated with neurosarcoidosis may progress despite steroid treatment, even when symptoms have improved. If hydrocephalus associated with neurosarcoidosis is treated with corticosteroids and without a shunt procedure we suggest that the corticosteroids should be continued at high doses for a prolonged period.

Subdural mass lesion secondary to sarcoid granuloma MR and CT findings and differential diagnosis

A patient with surgical and neuropathologically confirmed subdural sarcoid granuloma was evaluated using angiography, contrast-enhanced CT and MR. MR images were obtained on a superconducting magnet with T1, intermediate and multi-echo T2 weighted sequences. Review of the 2 prior cases of subdural sarcoid granuloma from the literature evaluated with MR confirm the variable nature of signal intensities of the lesion. MR was most useful in anatomically evaluating the lesion and planning neurosurgical intervention but both CT and MR alone, in this case, did not definitely obviate the other differential diagnosis including meningioma en-plaque, lymphoma, or metastasis.

Sarcoidosis with hydrocephalus: report of a case successfully treated with a ventriculo-peritoneal shunt and methylprednisolone pulse therapy

We describe a female patient with systemic sarcoidosis and hydrocephalus. She was initially satisfyingly treated with peroral steroids. When she later deteriorated, the treatment had to be changed due to side-effects. High dose intravenous methylprednisolone pulse therapy was tried with some, but insufficient, improvement. Therefore, a ventriculoperitoneal shunt operation was performed with immediate improvement. After that she was treated with intravenous methylprednisolone and her condition has remained proper and stable for 5 years. The possibility that pulse therapy might have contributed to the favourable course in our patient is discussed.

A case of hypothalamic sarcoidosis with hypopituitarism and prolonged remission of hypogonadism

A 21-year-old man developed hypopituitarism, with symptomatic hypogonadism and diabetes insipidus (DI), as well as uveitis, retinal vasculitis, and papilledema in association with systemic sarcoidosis. A suprasellar tumor was demonstrated by computed tomography (CT). Although ophthalmic symptoms disappeared with prednisone and the DI was controlled with Desmopressin (DDAVP), the hypogonadism did not improve with human menopausal gonadotropin (HMG) and human chorionic gonadotropin (HCG). In long-term follow-up, the hypogonadism unexpectedly resolved.

Meningeal neurosarcoidosis mimicking convexity en-plaque meningioma

A 34-year old man presented with headaches. Computed tomography scanning revealed an enhancing subdural mass extending from the skull base to the convexity, thought to represent an en-plaque meningioma. Pathologic study revealed extraaxial subdural granulomatous inflammation consistent with neurosarcoidosis.

Neurosarcoidosis involving optic nerves and leptomeninges: computed tomography findings

A case of neurosarcoidosis with extensive involvement of both optic nerves and intracranial leptomeninges is reported. Computed tomography demonstrates diffuse enlargement of the optic nerves and extensive nodular contrast medium enhancement of the leptomeninges of the anterior and middle cranial fossae extending into the frontal convexity. Only one such case has been previously reported in the computed tomography literature. Marked therapeutic response was obtained clinically and demonstrated on a follow-up computed tomography after therapy with corticosteroids. Differential diagnosis of computed tomography findings is discussed.

Presentation of central nervous system sarcoidosis as intracranial tumors

Five cases of sarcoid presenting as an intracranial tumor are reported. In one instance, the lesion presented as a tumor in the cerebellopontine angle, a site not previously reported for the initial presentation of sarcoid isolated to the central nervous system. The role of computerized tomography, surgery, and steroid therapy is discussed. In the absence of pulmonary involvement, serum angiotensin-converting enzyme levels do not appear to be helpful in predicting steroid response.

Granulomatous diseases of the CNS as demonstrated by computerized tomography

The CT findings in 32 patients with pathological conditions characterized by granulomatous disorders are reviewed. The characteristic CT finding in caseating granuloma due to tuberculous disease is a nodular enhancing lesion with a central hypodense region. The granulomas representing sarcoidosis show homogeneous enhancing nodular lesions. The granulomas due to cryptococcal fungal disease showed ring pattern with large central hypodense region which represented cyst formation. In certain vasculitides which affected the CNS and had pathological evidence of granuloma formation, CT showed nodular enhancing lesions. Based upon the CT findings, it was not possible to differentiate these nodular enhancing lesions which represented granulomatous disease from other intracranial diseases, i.e. abscesses, neoplasms, multiple sclerosis, gliosis.

Clinical and computed tomography findings in intracranial sarcoidosis involving the juxtasellar region

Two patients with endocrine and visual disturbances had CT evidence of an intra- and suprasellar enhancing mass. Both patients showed clinical improvement following treatment with systemic corticosteroids. In one case, there was no evidence of systemic sarcoidosis; and the exact nature of the juxtasellar lesion was established by surgical biopsy.

Rare multiple orbital localizations of sarcoidosis. A case report

We report a case of bilateral orbital sarcoidosis without other systemic lesions. Steroid therapy did not improve the clinical status of the patient.

Intracranial subdural sarcoid granuloma. Case report

A patient is reported in whom a subdural sarcoid granuloma caused symptoms of an intracranial mass lesion, and disappeared following steroid therapy. Twenty-three previous cases with large intracranial sarcoid granulomas have been documented, a review of these 24 cases leads the authors to conclude that: 1) neither symptoms nor nonhistological diagnostic studies, including computerized tomography, differentiate sarcoid from cerebral neoplasms or other central nervous granulomas; and 2) because sarcoid mass lesions frequently respond well to corticosteroid therapy, surgery should probably be reserved for cases in which there is diagnostic uncertainty, a need for emergency decompression, or lack of response to steroids.

Angiography and computed tomography in the diagnosis of primary lymphoma of the brain

Three patients with primary lymphomas of the brain are presented. The angiographic and computed tomographic (CT) appearances resembled the few cases reported previously. In all three cases angiography showed avascular tumours with little vessel displacement or involvement whereas the CT scans showed large strongly and homogeneously enhancing tumour masses. Neither method alone gives pathognomonic appearances, but taken together angiography and CT should suggest the diagnosis of this rare tumour.

Pituitary and parapituitary tumours on computed tomography. A review article based on 230 cases

This paper is based on a retrospective study of 230 tumours in the sellar area. All, except a few, were examined with the EMI 160 x 160 matrix and verified histologically. The main features of each pathological entity are described and most of the previous literature is reviewed. The degree of resolution of the scanner used precludes its reliability for detecting tumours less than one centimetre in diameter. Out of 30 microadenomas, only two were detectable on CT. This reflects an incidence of false negative results in 93% of microadenomas or 22% of all adenomas in the series. CT was also negative in 6% of craniopharyngiomas and 30% of chordomas. These findings emphasize the need for further neuroradiological tests in patients with clinically evident disease in the pituitary area. Many CT appearances are shared by more than one pathological entity; few are specific. However, if the CT findings are viewed in the light of the clinical presentation, a pathological diagnosis is possible in a large proportion of cases. Angiography is valuable; not only to exclude lesions of vascular origin, or show neovascularity, but also to demonstrate the relationship of the internal carotid arteries to the sphenoidal sinus prior to transsphenoidal surgery.