Idiopathic hypertrophic pachymeningitis

Long-Term Clinical Landscapes of Spinal Hypertrophic Pachymeningitis With Anti-Neutrophil Cytoplasmic Antibody-Associated Vasculitis

BACKGROUND AND OBJECTIVES

Spinal hypertrophic pachymeningitis (HP) is an extremely rare disorder characterized by the thickening of the spinal dura mater, which harbors distinct repertoires of immune cells due to the unique partitioning of the arachnoid blood-CSF barrier. The objectives were to identify the pathogenesis and therapeutic strategies for spinal HP.

METHODS

This retrospective cohort study analyzed the clinical and pathologic profiles of patients with idiopathic/immune-mediated HP including spinal HP.

RESULTS

Among 61 patients with idiopathic/immune-mediated HP, all 6 Japanese patients with spinal HP, with a median observation period of 88.8 months, were myeloperoxidase (MPO)-anti-neutrophil cytoplasmic antibody (ANCA)-seropositive. The MPO-ANCA+ spinal HP cohort had the following characteristics: (1) a predominance of older women; (2) all patients were classified as having microscopic polyangiitis based on the 2022 American College of Rheumatology/European League Against Rheumatism criteria; (3) 83% of patients developed subacute/chronic myelopathy due to extramedullary spinal cord compression; (4) 50% of patients had lesion extension to the epidural compartment and vertebral column; (5) 50% of patients presented with chronic sinusitis, otitis media, or mastoiditis; (6) 33% of patients had involvement of the lower airways or kidneys; (7) a higher disease activity of the nervous system was noted based on the Birmingham Vasculitis Activity Score (BVAS), in contrast to MPO-ANCA+ cranial HP; (8) granulomatous inflammation with myofibroblasts, immune cells including granulocytes, and B-cell follicle-like structures were observed in the thickened dura mater; (9) immunotherapies (with or without surgical decompression) were effective in reducing the modified Rankin Scale score and reduced BVAS during the first active insults; (10) combined immunotherapies with glucocorticoids and cyclophosphamide/rituximab helped in reducing relapses in the long term; and (11) surgical decompression, including laminectomy and duraplasty, was necessary for compressive myelopathy. These data suggest that MPO-ANCA+ spinal HP shares common features with MPO-ANCA+ cranial HP (1, 2, 6, 8, 9, and 10), but also has unique clinical features (3, 4, 5, 7, and 11).

DISCUSSION

Our findings highlight the significant pathogenic role of ANCA in spinal HP. MPO-ANCA+ spinal HP, as an organ-threatening disease, should be positioned as having unique characteristics, whether limited to the CNS or as part of a generalized form in ANCA-associated vasculitis.

Is endoscopic optic nerve decompression useful in cases of optic neuropathy secondary to pachymeningitis?

This case reports the outcome of endoscopic optic nerve decompression in a rare case of idiopathic pachymeningitis in a patient solely reliant on the affected eye. A 70 year old man with complete blindness in his left eye presented with deterioration of vision in his right eye. An MRI head and orbits was suggestive of idiopathic pachymeningitis extending into the right orbital apex, causing a compressive optic neuropathy. He subsequently underwent endoscopic optic nerve compression. Visual acuity and colour vision were measured pre-operatively, and at 6 weeks and one year post operatively. Pre-operative visual acuity was measured at 6/9, compared to 6/9 at 6 weeks post operatively and 6/60 at one year. Colour vision was measured at 0/17 pre-operatively and did not improve post-. We report a rare case of optic neuropathy secondary to pachymeningitis, in which endoscopic nerve decompression did not offer the expected benefit of halting visual deterioration.

18F-FDG PET/CT Findings in Idiopathic Hypertrophic Pachymeningitis with Cranial Nerves Dysfunction

Hypertrophic pachymeningitis is an uncommon inflammatory process with thickening of the dura mater and may be idiopathic or secondary to various conditions such as vasculitis, Sjögren syndrome, rheumatoid arthritis, sarcoidosis, and infections. A 67-year-old man who presented with bilateral hearing loss, vision loss in the left eye, right-sided facial paralysis, and right-side headache underwent 18F-FDG PET/CT for further evaluation. Herein, we have presented a patient who showed diffuse increased radiotracer uptake in the cranial nerves and intracranial dura mater on 18F-FDG PET/CT and was diagnosed as idiopathic hypertrophic pachymeningitis based on laboratory and MRI findings.

Optic neuropathy as an early manifestation of granulomatosis with polyangiitis: a case report and literature review

Introduction

Ophthalmic involvement occurs in up to 40% of patients with granulomatosis with polyangiitis (GPA), usually confined to the anterior segment. Herein, we describe patients presenting with optic neuropathy as an early manifestation of GPA, without other signs of ocular or adnexa involvement.

Methods

We report a case of isolated optic neuropathy without other ocular or adnexal involvement and examine the reported clinical features of 17 additional patients through a literature review. We analyzed clinical characteristics and neuro-ophthalmological findings and discuss the clinical implications for the early detection of GPA-associated optic neuropathy.

Results

Among the 17 patients, 10 had optic neuropathy confined to one eye, three exhibited simultaneous bilateral optic neuropathies at initial presentation, and four had unilateral involvement initially; however, the fellow eye was subsequently affected during follow-up. Nine patients had optic neuropathy as the first clinical presentation and no prior diagnosis of GPA (9/17, 53%). Among the 21 eyes (15 patients, excluding two without descriptions), disc edema was observed in five eyes (24%). Visual impairment was often profound; the measurements of 23 affected eyes at the initial presentation showed that the patient's acuity was to count fingers or worse (14/23, 61%). The final visual outcome was often poor, with significant visual recovery in only eight eyes (8/23, 35%). Other constitutional symptoms or systemic involvements were found in most patients (15/16, 94%), mostly affecting the lung (n = 10), sinus (n = 9), and pachymeninges (n = 8). Furthermore, 88% of the patients (15/17) showed positive results on antineutrophil cytoplastic antibody. Elevated CRP (n = 6) or ESR (n = 5) was found in 56% of cases.

Discussion

Our case and literature review indicates that optic neuropathy can present in the context of systemic inflammation of GPA, without any other signs of ocular or orbital involvement. Catching other clinical, imaging, and laboratory signs of systemic inflammation is important in cases of GPA-associated optic neuropathy with atypical presentations.

Non-infectious hypertrophic pachymeningitis associated with orbital inflammatory disease: a pooled analysis

PURPOSE

To describe four cases of non-infectious hypertrophic pachymeningitis (HP)-associated with orbital inflammatory disease (OID). This study summarises the clinico-radiological features, outcomes, and management of HP-associated OID.

METHODS

Retrospective case-series of patients with radiological evidence of HP and OID. Comprehensive literature review of all published English-language non-infectious causes of HP-associated OID. Reference lists were screened for inclusion of relevant articles.

RESULTS

Thirty-seven cases of HP-associated OID (Mean age: 49.2 ± 17.4 years old; Male: 15) were identified, including four cases from our institution. Aetiologies included ANCA-associated vasculitis (12/37), non-specific/idiopathic (11/37), IgG4/multifocal fibrosclerosis (11/37), neurosarcoidosis (1/37), inflammatory myofibroblastic tumour (1/37), and giant cell arteritis (1/37). Orbital pain, headache, visual deterioration, and cranial nerve palsies were common clinical presentations. Both "focal" and "diffuse" HP were observed, with the most common sign of orbital involvement being an inflammatory orbital mass, typically with orbital apex involvement. Orbital myositis and dacryoadenitis were less common. The cavernous sinus was the most common site of extra-orbital inflammation. There was no single differentiating specific radiological feature between non-specific and specific forms of HP-associated OID.

CONCLUSION

The clinico-radiological manifestations of HP-associated OID differ from those described in isolated HP or OID. There is no single specific radiological marker differentiating non-specific/idiopathic disease from secondary causes; however, the co-existence of HP in OID should prompt suspicion of an underlying cause. The disease may be refractory or resistant to initial treatment, although guidelines surrounding its management and the long-term prognosis remain to be determined.

The Thickening Dilemma: A Rare Case of Idiopathic Hypertrophic Pachymeningitis Mimicking Granulomatosis With Polyangiitis

Idiopathic hypertrophic pachymeningitis (IHP) is a rare, chronic inflammatory disorder characterized by fibrotic thickening of the dura mater. The etiology of IHP is currently unknown; however, IHP often mimics other inflammatory conditions (causes of secondary hypertrophic pachymeningitis) including neurosarcoidosis, granulomatosis with polyangiitis (GPA), and IgG4-related disease. IHP manifests clinically with a spectrum of neurologic symptoms, including headache, paresthesia, cranial nerve (CN) palsies, and seizures. Here, we discuss the diagnosis and management of a patient presenting with multiple CN palsies following influenza B infection who was initially suspected to have GPA (due to positive cytoplasmic antineutrophil cytoplasmic antibody (c-ANCA), cranial polyneuropathies, and possible nasopharyngeal involvement) but was ultimately diagnosed with IHP which was evident on diagnostic imaging. The patient was managed with rituximab due to its efficacy in steroid-refractory pachymeningitis and as a precautionary for ANCA-associated disease, and corticosteroids. A 41-year-old man with hypertension, chronic otitis media requiring myringotomy with tympanostomy tube placement, and mastoiditis requiring mastoidectomy presented with dysphagia, dysarthria, and left facial weakness over the course of 10 days following an influenza B infection. Despite initial treatment with corticosteroids for inflammation, the patient developed CN polyneuropathy (CN V, VII, X, XII). Positive c-ANCA, cranial polyneuropathies, and possible nasopharyngeal involvement led to primary suspicion of GPA, so corticosteroids were initiated which improved dysarthria and dysphagia. However, subsequent steroid taper led to severe headaches. MRI then revealed smooth dural thickening and enhancement consistent with pachymeningitis. The patient was diagnosed with IHP by exclusion of all other known etiologies and MRI findings. He was treated with intravenous methylprednisolone, followed by rituximab. Despite resolution of complex neurologic symptoms, including dysphagia and CN polyneuropathies, recurrent headaches necessitated several emergency department visits, where migraine cocktails and increased prednisone provided relief. He remains under neurology care for ongoing management. Although we are currently uncertain as to the exact underlying pathophysiology responsible for his recurrent headaches, the mechanisms we propose as possibilities involve a combination of corticosteroid withdrawal (as headaches often followed steroid taper) and sequelae of IHP itself (active and chronic inflammation of the dura). Furthermore, it is currently unknown as to whether his otolaryngologic history was contributory. The case highlights the diagnosis and management of a rare case of IHP in a situation where a patient with a significant otolaryngologic history experienced intractable neurologic symptoms following a viral infection. An extensive work-up was conducted to identify the source of presentation. The patient was managed with medications that proved to be safe and beneficial to the outcome of this patient.

Pediatric Meningeal Diseases: What Radiologists Need to Know

Evaluating altered mental status and suspected meningeal disorders in children often begins with imaging, typically before a lumbar puncture. The challenge is that meningeal enhancement is a common finding across a range of pathologies, making diagnosis complex. This review proposes a categorization of meningeal diseases based on their predominant imaging characteristics. It includes a detailed description of the clinical and imaging features of various conditions that lead to leptomeningeal or pachymeningeal enhancement in children and adolescents. These conditions encompass infectious meningitis (viral, bacterial, tuberculous, algal, and fungal), autoimmune diseases (such as anti-MOG demyelination, neurosarcoidosis, Guillain-Barré syndrome, idiopathic hypertrophic pachymeningitis, and NMDA-related encephalitis), primary and secondary tumors (including diffuse glioneuronal tumor of childhood, primary CNS rhabdomyosarcoma, primary CNS tumoral metastasis, extracranial tumor metastasis, and lymphoma), tumor-like diseases (Langerhans cell histiocytosis and ALK-positive histiocytosis), vascular causes (such as pial angiomatosis, ANCA-related vasculitis, and Moyamoya disease), and other disorders like spontaneous intracranial hypotension and posterior reversible encephalopathy syndrome. Despite the nonspecific nature of imaging findings associated with meningeal lesions, narrowing down the differential diagnoses is crucial, as each condition requires a tailored and specific treatment approach.

Hypertrophic pachymeningitis with cranial nerve palsy as the initial symptom: A case report

RATIONALE

Hypertrophic pachymeningitis (HP) is a rare and complex condition marked by inflammation and thickening of the dura mater. It can occur either on its own or as a result of various underlying medical issues. This type of granulomatous meningitis is extremely rare and poorly understood, making diagnosis and treatment particularly challenging. Patients with HP may experience severe headaches and cranial nerve defects, but in some cases, the condition can occur without any symptoms, making it undetected. We detail the case of patient who was diagnosed with HP after presenting with abducens nerve palsy, a condition that significantly affected her vision and quality of life. Remarkably, she showed substantial recovery following a course of methylprednisolone pulse therapy, coupled with careful radiographic diagnosis and follow-up assessments. The decision to report this case stems from its rarity and the diverse clinical manifestations associated with this condition, which can vary widely among patients.

PATIENT CONCERNS

A 26-year-old Asian female, sought medical attention at The First Affiliated Hospital of Zhejiang Chinese Medical University, where she reported experiencing diplopia, a troubling symptom indicative of abducens nerve palsy.

DIAGNOSIS

To establish a definitive diagnosis, second-generation sequencing biological detection was employed to rule out any infectious causes, while radiographic imaging provided confirmation of HP.

INTERVENTIONS

In terms of intervention, the patient was promptly initiated on a regimen of methylprednisolone pulse therapy, followed by a carefully monitored oral sequential reduction of the medication. Throughout her treatment, she underwent regular liver function tests to ensure her safety, and liver protective drugs were also administered as a precautionary measure.

OUTCOMES

As of now, the patient has successfully completed her treatment and is reported to be doing well, marking a positive outcome in her recovery journey.

LESSONS

This case underscores the critical importance of imaging examinations in the clinical diagnosis of patients presenting with diplopia, as they play a vital role in both diagnosing and differentiating between various diseases. Furthermore, it is essential to rule out any infection-related factors in patients diagnosed with HP before commencing treatment with glucocorticoids, ensuring a comprehensive approach to patient care.

Myelopathy Due to Hypertrophic Pachymeningitis Associated With ANCA Vasculitis: A 10-Year Follow-up Case Report

This case report describes a rare presentation of antineutrophil cytoplasmic antibodies-associated hypertrophic pachymeningitis in a 49-year-old woman with cranial and spinal lesions. Initial management comprised decompressive laminectomy and steroid therapy, with the subsequent addition of immunosuppressant therapy following symptom recurrence. After a ten-year follow-up, significant symptom improvement and return of motor function were noted. This case emphasizes the crucial role of early diagnosis, a multidisciplinary approach, and combined medical therapy in managing this rare condition.

Garcin Syndrome in a Patient with Hypertrophic Pachymeningitis Following Otitis Media with Antineutrophil Cytoplasmic Antibody (ANCA)-Associated Vasculitis (OMAAV)

A 72-year-old Japanese woman presented to our hospital with progressive hearing loss and dysphagia. Blood tests revealed elevated C-reactive protein and myeloperoxidase-antineutrophil cytoplasmic antibody (MPO-ANCA). Contrast-enhanced magnetic resonance imaging of the head showed hypertrophic pachymeningitis of the left middle cranial fossa with compression of the cranial nerves, including the trigeminal (V), facial (VII), glossopharyngeal (IX), and vagal (X) nerves, resulting in cranial nerve palsy. She was diagnosed with Garcin syndrome associated with otitis media with ANCA-associated vasculitis (OMAAV) and treated with high-dose glucocorticoid therapy followed by intravenous cyclophosphamide and rituximab. Therefore, OMAAV should be considered in the differential diagnosis of refractory otitis media with unilateral cranial nerve involvement.

Contribution of advanced neuroimaging in diagnosis of cerebral syphilitic gumma: a case report

Background

Cerebral syphilitic gumma is a rare intracranial infectious disorder. Without a clear history of syphilis and comprehensive serological examinations, it's challenging to diagnose it accurately prior to surgery through routine magnetic resonance imaging (MRI). Advanced neuroimaging techniques have been widely used in diagnosing brain tumors, yet there's limited report on their application in cerebral syphilitic gumma. This report presents a case of an elderly male patient with cerebral syphilitic gumma and analyzes its characteristics of advanced neuroimaging.

Case presentation

A 68-year-old male patient was admitted to our institution presenting with bilateral hearing loss complicated with continuing headaches without obvious cause. Laboratory tests indicated positive treponema pallidum. Conventional MRI showed nodules closely related to the adjacent meninges in bilateral temporal lobes. The patient underwent surgical resection of the nodule in the right temporal lobe due to the mass effect and the final pathological diagnosis revealed cerebral syphilitic gumma.

Conclusions

With the return of syphilis in recent years, accurate diagnosis of cerebral syphilitic gumma is a matter of great urgency. Advanced neuro-MRI can serve as a significant complement to conventional MRI examination.

Two cases of MPO-ANCA-positive hypertrophic pachymeningitis mimicking as intracranial infection

Hypertrophic pachymeningitis (HP) is a rare disorder marked by thickening of the dura mater due to diverse etiologies. MPO-ANCA-positive HP represents a variant of AAV confined to the central nervous system, distinguished by the presence of serum MPO antibodies. Distinguishing HP triggered by MPO-ANCA from other causes can be challenging.In this study, we present two cases of MPO-ANCA-positive HP initially misdiagnosed as intracranial infections. Case 1 underwent surgery for chronic suppurative otitis media, with histopathological findings revealing inflammatory changes without definitive suppuration. He was presumed to have a secondary intracranial infection resulting from the surgery. However, his condition deteriorated despite two weeks of antibiotic and antiviral treatment. Case 2 presented with headache and was initially suspected of having intracranial Brucellosis given his serum Brucella positivity. Despite treatment for brucellosis, his symptoms persisted, and he developed visual and hearing impairments. Both patients were ultimately diagnosed with MPO-ANCA-positive HP, exhibiting serum MPO antibody positivity. Their symptoms showed improvement with glucocorticoid and immunosuppressive therapy.Based on these observations, we propose that MPO-ANCA-positive HP may initially present as intracranial infection. For HP patients presenting with headache, mastoiditis, otitis media, and visual loss, it is imperative to conduct ANCA antibody-related tests to enhance diagnostic precision.

Myelin Oligodendrocyte Glycoprotein Antibody-Associated Disease Complicated by Pachymeningitis: A Case Report

Myelin oligodendrocyte glycoprotein antibody-associated disease (MOGAD) is a rare autoimmune disorder that primarily affects the central nervous system (CNS). We present a unique case of MOGAD complicated by pachymeningitis, which is characterized by inflammation of the dura mater. The clinical presentation included vertigo, nausea, and vomiting. A diagnostic workup confirmed MOGAD complicated by pachymeningitis. This case underscores the diverse clinical manifestations of MOGAD and highlights the challenges in diagnosis and management, particularly when complicated by rare manifestations like pachymeningitis.

Cogan's Syndrome Combined with Hypertrophic Pachymeningitis: A Case Report

Cogan's syndrome (CS) is a rare chronic inflammatory disease, characterized by interstitial keratitis and vestibular auditory dysfunction. Hypertrophic pachymeningitis (HP) is a rare chronic aseptic inflammatory disease of the central nervous system. This article reports a patient with CS coexisting with HP. The patient was a 66-year-old male with fever, headache, red eyes, hearing loss, and significantly elevated inflammatory markers. Cerebrospinal fluid examination, blood culture, and tests for autoantibodies such as antinuclear antibodies were negative. Pure tone audiology (PTA) indicated bilateral sensorineural deafness. Both Positron emission tomography-computed tomography (PET/CT) and vascular color Doppler ultrasound suggest the presence of vasculitis. Considering Cogan's syndrome, the patient received 40 mg of methylprednisolone intravenously once daily. The brain's magnetic resonance imaging (MRI) revealed slightly thickened and enhanced dura mater, suggesting HP. The dose of methylprednisolone was increased to 40 mg intravenously every 8 hours, leading to the patient's improved symptoms and decreased inflammatory markers. Both CS and HP are rare chronic inflammatory diseases, and their coexistence is even rarer, with only two reported cases in literature up to date. The coexistence of CS and HP should be considered when the CS patients with headaches do not respond well to treatment.

Hypertrophic Pachymeningitis: An Unusual Cause of Headache

Hypertrophic pachymeningitis (HP) is a rare condition characterized by inflammation and thickening of the dura mater. It can be idiopathic or secondary to various causes, including infections, tumors, or systemic inflammatory diseases. Diagnosis is challenging due to its rarity and the overlap of symptoms with other conditions. We present the case of a 42-year-old Hispanic woman with diabetes mellitus type 2 and end-stage kidney disease who presented with chest pain, dry cough, mild dyspnea, and chronic occipital headaches. Physical examination revealed cranial VI nerve palsy. Imaging showed pulmonary cavitary lesions and mediastinal lymphadenopathy. Elevated inflammatory markers and positive autoimmune tests, including rheumatoid factor and antineutrophil cytoplasmic antibody (ANCA), led to further investigation. Brain imaging revealed dural thickening, confirming HP. The patient's medical history revealed double ANCA positivity and a lung biopsy confirmed granulomatous pneumonitis. A diagnosis of ANCA-associated vasculitis (granulomatosis with polyangiitis (GPA)) was established, and treatment with rituximab and high-dose corticosteroids led to symptom improvement. GPA rarely involves meningeal inflammation, but severe and persistent headaches are common early symptoms. Inflammatory markers are often elevated, and around two-thirds of HP cases related to GPA have positive serum ANCA. MRI is the primary diagnostic tool, with characteristic findings of dural thickening and contrast enhancement. This case highlights HP as a rare cause of chronic headaches and the importance of a comprehensive medical history in diagnosis. Early recognition and treatment are crucial for improving outcomes in GPA-related HP.

Granulomatosis with polyangiitis presenting headache: A case report and review of literature

RATIONALE

Central nervous system involvement is a rare manifestation of active-phaselocalized Granulomatosis with polyangiitis (GPA). In hypertrophic dura meningitis, GPA with headache is typical. In this case, cerebral magnetic resonance (MR) enhancement revealed no meningeal thickening, to our knowledge, this manifestation had not been found previously.

PATIENT CONCERNS

The patient presented to the Rheumatology and Immunology Clinic with severe headache and hearing loss, and central nervous system granulomatosis with polyangiitis was confirmed after a series of examinations. The patient had no significant effect after treatment with cyclophosphamide (CTX), but after the use of rituximab, the headache and hearing loss were significantly improved, and laboratory indicators returned to normal levels.

DIAGNOSIS

We comprehensively screened for craniocerebral infection and malignant tumors, diagnosed central nervous system granulomatosis with polyangiitis.

INTERVENTIONS

We gave sequential treatment of rituximab.

OUTCOMES

All indicators are mostly back to normal when the patient was monitored at the outpatient clinic.

LESSONS

GPA and severe headache are more prevalent in hypertrophic dura meningitis, but the patient early headache could not be explained by hypertrophic dura meningitis or localized granulomatous lesions that invaded the central nervous system. Patients with severe headaches likely have vascular inflammation and local bone destruction at the base of the skull.

Clinical Observation of Various Types of Idiopathic Hypertrophic Cranial Pachymeningitis

BACKGROUND

To assist doctors in making better treatment decisions and improve patient prognosis, it is important to determine which therapy modalities are suitable for various forms of idiopathic hypertrophic cranial pachymeningitis (IHCP).

METHODS

All cases were received from the hospital medical record system, and some follow-up information was gathered through telephone follow-up.

RESULTS

A total of 26 patients, 14 men and 12 women, with ages ranging from 20 to 73 years and a mean of 47.42 years, were included in the research. Regular types were less likely to recur than irregular and nodular types, focal types were less likely to recur than diffuse types, and corticosteroid-refractory types were more likely to recur than corticosteroid-sensitive types.

CONCLUSIONS

The extent and shape of the lesion and susceptibility to corticosteroids are potential factors that could influence recurrence. Futhermore, this paper also proposes the fibroblasts as a new therapeutic target which may improve the quality of prognostic survival of patients.

Immunoglobulin G4-related hypertrophic pachymeningitis with an isolated scalp mass mimicking a brain tumor: a case report and literature review

Immunoglobulin G4-related disease (IgG4-RD) is an autoimmune disorder associated with fibroinflammatory conditions that can affect multiple organs. Hallmark histopathological findings of IgG4-RD include lymphocytic infiltration of IgG4-positive plasma cells, storiform fibrosis, and obliterative phlebitis. However, little is known about central nervous system involvement of IgG4-RD. Hypertrophic pachymeningitis (HP) has recently been reported as a manifestation of IgG4-RD, which may have previously been demonstrated in a significant percentage of idiopathic cases. Herein, we report a rare case of a 63-year-old male who presented with a scalp mass that mimicked a brain tumor. He was diagnosed with IgG4-related HP (IgG4-RP) after surgery. This case suggests that awareness of a possibility of IgG4-RP in patients with isolated scalp masses, even in the absence of systemic symptoms, is crucial. A combination of careful history taking, evaluation of serum IgG4-levels and imaging as an initial work-up, followed by tissue biopsy, is important for the differential diagnosis of IgG4-RP, malignancy, and other infectious diseases.

[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 Spinal Pachymeningitis

Hypertrophic pachymeningitis (HP) is a rare presentation with duramater thickening and fibrosis which can result in cranial or spinal compressive disease. Most cases of spinal HP require surgical management. We present an uncommon case of idiopathic hypertrophic spinal pachymeningitis (IHSP) in a 40-year-old male who showed complete improvement to steroids without any further relapses. The patient presented with bilateral upper limb weakness with magnetic resonance imaging (MRI) spine showing diffuse dural thickening of the entire spine with cervical cord compression. He had an extensive workup for underlying etiology and worsening symptoms until he was diagnosed with IHSP. Later, he was started on high-dose steroids with good response and no relapse after 2 years. A descriptive analysis of IHSP cases since 2009 including ours showed that it usually occurs after 50s with female preponderance. Weakness and sensory loss are the most common complaints with 50% patients showing clinical signs of myelopathy like hyperreflexia, clonus, Babinski sign and sensory level. Cerebrospinal fluid (CSF) and inflammatory markers like erythrocytic sedimentation rate (ESR) and C-reactive protein (CRP) can be used to assess disease progression and prognosis. Surgical removal of HP followed by steroids is the best line of management while steroids alone can be tried in cases where clinical signs of myelopathy are absent.

Quantitative evaluation of the thickened dura mater impacting clinical signs in immune-mediated hypertrophic pachymeningitis

OBJECTIVE

This study evaluated the volume of thickened dura mater lesions and their impact on clinical findings in immune-mediated hypertrophic pachymeningitis (HP).

METHODS

The volume of contrast-enhanced dura mater on magnetic resonance imaging was evaluated using the imaging feature quantification system in 19 patients with immune-mediated HP, including 12 with antineutrophil cytoplasmic antibody-related, 4 with IgG4-related, and 3 with idiopathic HP, as well as 10 with multiple sclerosis (MS) as controls. The implications of HP volume on neurological manifestations and cerebrospinal fluid (CSF) laboratory markers were statistically analyzed in patients with immune-mediated HP.

RESULTS

The volumes of the contrast-enhanced dura mater in the convexity, cranial fossa, and tentorium cerebelli were significantly higher in patients with immune-mediated HP than in those with MS. Among patients with immune-mediated HP, those with cranial nerve (CN) VIII neuropathy had a significantly higher volume of the contrast-enhanced dura mater in the cranial fossa than those without CN VIII neuropathy. The volume of the contrast-enhanced dura mater in the tentorium cerebelli was positively correlated with CSF protein levels.

CONCLUSION

Quantification of the thickened dura mater is useful for elucidating the relationship with the clinical findings in immune-mediated HP. Thickened dura mater lesions in the cranial fossa may be implicated in the development of CN VIII neuropathy. The enlargement of HP lesions in the tentorium cerebelli can increase CSF protein levels.

A selected case series of idiopathic hypertrophic pachymeningitis in a single center: Pathological characteristics and case-oriented review

Hypertrophic pachymeningitis (HP) is a relatively rare disease of the central nervous system characterized by local or diffuse fibrous thickening of the dura mater. At present, there is still insufficient research on the pathogenesis and treatment strategies of this disease. We reported a continuous case series of seven patients with idiopathic HP (IHP), and also details one case of immunoglobulin G4-related HP requiring surgical intervention. Early diagnosis and appropriate surgical intervention for IHP could prevent the progression of permanent neurological damage and spinal cord paraplegia.

IgG4-related hypertrophic pachymeningitis with chronic subdural haematoma

Hypertrophic pachymeningitis is a rare disorder of the dura mater of the spine or brain. It can be caused by inflammatory, infective or neoplastic conditions or can be idiopathic. We report a man with hypertrophic pachymeningitis and bilateral chronic subdural haematoma caused by IgG4-related disease. We highlight the diagnostic challenges and discuss possible underlying mechanisms of subdural haematoma formation in inflammatory conditions. Isolated IgG4-related hypertrophic pachymeningitis with chronic subdural haematoma is very rare; previously reported cases have suggested a possible predilection for men in their sixth decade, presenting with headache as the dominant symptom. Given the rarity and complexity of the condition, it should be managed in a multidisciplinary team setting.

The Spectrum of Intracranial Hypertrophic Pachymeningitis at an Eastern Indian Tertiary Care Center

Introduction

Hypertrophic pachymeningitis (HP) is a treatable, rare inflammatory disease, either primary or secondary to systemic causes.

Aims

To characterize the etiology, clinical manifestations, and treatment outcomes of HP patients and determine the factors influencing the radiological resolution of the pachymeningeal enhancement and recurrence of symptoms within the follow-up period.

Materials and Methods

We collected data for this prospective observational study between March 1, 2021 and May 31, 2022, at the Bangur Institute of Neurosciences, Kolkata, and the patients were followed for a 6-month period. Demographic, clinical, laboratory, and treatment-related data were collected. A univariate logistic regression model was used for comparison between patients with and without radiological resolution of pachymeningitis and between patients with and without symptom recurrence.

Results

Among 44 patients, the male: female ratio was 1.2:1. The median age at disease onset was 35.5 (28.5-49.5) years. The etiologies were idiopathic (56.8%), tuberculosis (22.8%), immunoglobulin G subtype 4 (IgG4) disease (9.2%), other infections (6.8%), and neoplastic (4.4%). Headache was the most common presentation (95.4%), followed by cranial neuropathies (68.2%). Optic and oculomotor neuropathies were the most common. In terms of radiological features, 27.27, 29.54, and 43.18% of patients had diffuse, focal regular, and focal irregular enhancement, respectively. Temporal (50%), followed by cavernous sinus (38.63%) enhancement, was the most common. Recurrence occurred in 36 and 50% of idiopathic and IgG4-related HP cases, respectively. Mycophenolate mofetil was added to their steroid regimen with no further recurrences.

Conclusion

The cohort had a marked absence of (antineutrophil cytoplasmic antibodies) ANCA-associated HP. The severity of clinical manifestations or distribution of pachymeningitis did not differ significantly among the etiological groups. The presence of idiopathic etiology and focal regular enhancement had a significantly higher chance of radiological resolution. The response to therapy was satisfactory. Recurrence was significantly related to shorter steroid courses ( Collapse

Key Words

• Hypertrophic pachymeningitis
• IgG4
• idiopathic
• recurrence
• resolution
• tuberculosis

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Affiliation(s)

Suman Das Department of Neuromedicine, North Bengal Medical College, Darjeeling District, West Bengal, India Department of Neuromedicine, Bangur Institute of Neurosciences, Kolkata, West Bengal, India
Biman Kanti Ray Department of Neuromedicine, Bangur Institute of Neurosciences, Kolkata, West Bengal, India

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Neurosarcoidosis: Diagnostic Challenges and Mimics A Review

PURPOSE OF REVIEW

Neurosarcoidosis is a rare manifestation of sarcoidosis that is challenging to diagnose. Biopsy confirmation of granulomas is not sufficient, as other granulomatous diseases can present similarly. This review is intended to guide the clinician in identifying key conditions to exclude prior to concluding a diagnosis of neurosarcoidosis.

RECENT FINDINGS

Although new biomarkers are being studied, there are no reliable tests for neurosarcoidosis. Advances in serum testing and imaging have improved the diagnosis for key mimics of neurosarcoidosis in certain clinical scenarios, but biopsy remains an important method of differentiation. Key mimics of neurosarcoidosis in all cases include infections (tuberculosis, fungal), autoimmune disease (vasculitis, IgG4-related disease), and lymphoma. As neurosarcoidosis can affect any part of the nervous system, patients should have a unique differential diagnosis tailored to their clinical presentation. Although biopsy can assist with excluding mimics, diagnosis is ultimately clinical.

Idiopathic hypertrophic pachymeningitis in a patient with a history of diffuse large B cell lymphoma

A man in his early 70s with a 4-year history of diffuse large B cell lymphoma (DLBCL) was admitted to our hospital with diplopia and achromatopsia. Neurological examination revealed visual impairment, ocular motility disorder and diplopia on looking to the left. Blood and cerebrospinal fluid investigations showed no significant findings. MRI revealed diffusely thickened dura mater and contrast-enhanced structures in the left apical orbit, consistent with hypertrophic pachymeningitis (HP). We performed an open dural biopsy to distinguish the diagnosis from lymphoma. The pathological diagnosis was idiopathic HP, and DLBCL recurrence was ruled out. Following methylprednisolone pulse and oral prednisolone therapy, his neurological abnormalities gradually receded. Open dural biopsy played an important role not only in diagnosing idiopathic HP but also in relieving the pressure on the optic nerve.

Spinal Hypertrophic Pachymeningitis in Antineutrophilic Cytoplasmic Antibody-Negative Vasculitis: A Case Report

Hypertrophic pachymeningitis (HPM) is a rare but extremely debilitating disease. It is even rarer for HPM to be seen in association with antineutrophil cytoplasmic antibody (ANCA)-negative vasculitis. In this case, we are presenting HPM that was diagnosed in a 28-year-old female patient who presented with worsening back pain. Imaging revealed dural-based enhancing masses affecting the thoracic spinal cord with compression. Infectious etiologies were ruled out and a total of three biopsies failed to show any evidence of granulomatous inflammation, malignancy, or evidence of immunoglobulin G4-related disease. ANCA was negative on repeated testing. The patient was managed with repeated short courses of steroids that resulted in symptomatic control as well as radiological stability of the disease. This is an extremely rare case of atypical presentation of spinal HPM that is likely associated with granulomatous and polyangiitis without other manifestations of the disease except for nasal septal perforation. This case is a supplement to a limited body of knowledge and established cases of HPM in ANCA-negative, ANCA-associated vasculitis.

Hypertrophic pachymeningitis in ANCA-associated vasculitis: Clinical and immunopathological features and insights

Hypertrophic pachymeningitis (HP) is an inflammatory disorder characterized by intracranial and spinal thickened dura mater, leading to several neurological manifestations including headaches, cranial neuropathies, seizures, and sensorimotor disorders. Antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV) is a crucial disease that is implicated in the development of immune-mediated HP. HP is observed throughout the clinical course of AAV, and 3%-4% of patients with AAV experience HP as the initial clinical episode. However, patients with ANCA-related HP are unclassifiable in the classification criteria of AAV when HP is the only manifestation, suggesting that ANCA-related HP can be identified as a central nervous system-limited type of AAV. Among patients with AAV, those who develop HP have predominantly been classified as having granulomatosis with polyangiitis (GPA). Myeloperoxidase-ANCA positivity has been more frequently demonstrated than proteinase 3-ANCA positivity in patients with ANCA-related HP. The ear, nose, and throat manifestations, such as otitis media, sinusitis, and mastoiditis, as well as mucous membranes/eyes manifestations including sudden visual loss, are robustly associated with HP in AAV. The histology of thickened dura mater tissues includes fibrotic changes and infiltration of several immunocompetent cells, but the typical findings of GPA, such as granulomatous inflammation with necrotizing vasculitis, are not observed in all patients with ANCA-related HP. Corticosteroids are the first-line therapy for ANCA-related HP, while the concomitant use of immunosuppressive agents including cyclophosphamide, methotrexate, and mycophenolate mofetil, is an ideal strategy for achieving remission. Rituximab is a useful agent in refractory ANCA-related HP.

Pachymeningitis associated with IgG4-related disease and ANCA positivity: Case report and review of the literature

OBJECTIVE

Hypertrophic pachymeningitis is a rare clinical disorder involving localized or diffuse thickening of the dura mater. Considering pachymeningitis is both in the clinical spectrum of IgG4-RD and ANCA vasculitis (specifically granulomatosis with polyangiitis), an overlap syndrome is discussed.

METHODS

We report a case of hypertrophic pachymeningitis revealed by headache and cranial nerve dysfunction, and coexistence of biopsy-proven IgG4-RD pachymeningitis and MPO-ANCA positivity. Furthermore, all cases previously reported in the literature of pachymeningitis with IgG4-RD and presence of ANCA were analyzed.

RESULTS

Thirteen patients with pachymeningitis, IgG4-RD and ANCA were analyzed. Patients with HP-related IgG4 and ANCA are mainly male (8, 62%). Median age at diagnosis was 64 years. Main clinical manifestations at diagnosis were localized to the head and neck with headaches (10, 77%), cranial nerve dysfunction (7, 54%), hearing impairment (6, 46%) and vertigo (4, 31%). Except 1 patient with diffuse aortitis, no other systemic manifestation was observed at diagnosis and during follow-up. Serum IgG4 was often elevated (11, 85%) and ANCA was mainly with myeloperoxidase specificity (11, 85%). Seven patients had cerebrospinal fluid analyse with lymphocytic pleocytosis in 5 cases (71%), elevated proteins in 4 cases (57%), positive oligoclonal bands in 3 cases (42%) and decreased glucose in one case (14%). On the MRI, the thickening of the dura mater concerned most often the posterior fossa, in 7 cases (54%). Among 10 cases with histological findings, all showed increased IgG4-positivity of plasma cells, 50% lymphocytic infiltrate but none presented the three major histological criteria of IgG4-related disease. Three (30%) showed histological signs of vasculitis with vascular wall damage and/or giant cells. Among the 12 patients treated with steroid therapy, a clinical improvement was noted in 11 cases (92%). Relapse occurred during tapering in 4 patients (33%). An immunosuppressive drug was added in 2nd line for 7 cases (54%), with a clinical improvement in all.

CONCLUSION

Pachymeningitis with IgG4 and ANCA seems a localized disease to the head and neck. Leptomeningeal biopsy commonly found IgG4 criteria and no vasculitis. All patients responded well to steroid therapy and immunosuppressive drugs, especially rituximab, with clinical and radiological improvement but relapse and/or sequelae are not uncommon.

IgG4-Related Spinal Hypertrophic Pachymeningitis With Neurological Deficit: A Report of 2 Cases

CASE

Immunoglobulin G4 (IgG4)-related spinal hypertrophic pachymeningitis (IgG4-RHP) is a rare disease characterized by diffuse inflammatory fibrosis of the spinal dura mater that can cause myelopathy and neurological deficits. Here, we report 2 cases in which both patients presented with myelopathy and paraplegia. They underwent decompressive laminectomy, and the diagnoses were confirmed through histopathologic examination. Both patients received prednisolone postoperatively, which was subsequently switched to methotrexate for maintenance.

CONCLUSION

Two cases of IgG4-RHP were successfully treated with decompressive laminectomy and combined therapy with steroids and other immunosuppressive agents.

Difficulties of diagnosing idiopathic hypertrophic pachymeningitis in children: Case report and literature review

Hypertrophic pachymeningitis (HP) is a rare inflammatory disorder characterised by local or diffuse thickening of the cranial and spinal dura mater. HP occurs owing to idiopathic or secondary causes, including autoimmune disease, infection, and trauma. HP has mainly been reported in adults, with few reported cases in children. We encountered an 11-year-old boy with idiopathic HP who presented with chronic inflammation and daily occipital headache. Gadolinium (Gd)-enhanced magnetic resonance imaging (MRI) helped us to diagnose him with HP. He was successfully treated with corticosteroids and azathioprine with no recurrence. We also conducted a literature review of childhood-onset HP and found only 16 cases, including our patient. Seven patients had idiopathic HP, and the remaining nine had secondary HP, including two with rheumatic disease. The most common clinical symptoms were headache (68.8%) and cranial nerve-related symptoms (68.8%). Inflammatory laboratory markers were elevated in 60% of patients with available data. Fifteen cases were diagnosed using Gd-enhanced MRI. The main initial treatment was steroids and/or immunosuppressants, to which 87.5% of patients responded. However, two patients with HP associated with trauma and neuroblastoma (12.5%) died, and seven patients (43.8%) had left cranial nerve-related sequelae. As the prognosis for childhood HP is poor, early diagnosis and treatment are essential. Children with headache, cranial nerve symptoms, and elevated inflammatory marker levels should be suspected of having HP and Gd-enhanced MRI should be considered.

Locations and Predictive Factors of Hypertrophic Pachymeningitis in Otitis Media With Antineutrophil Cytoplasmic Antigen-Associated Vasculitis

OBJECTIVE

To determine the locations and predictive factors of hypertrophic pachymeningitis (HP), a serious central complication of otitis media with antineutrophil cytoplasmic antigen-associated vasculitis (OMAAV).

STUDY DESIGN

Retrospective study.

SETTING

University hospital.

PATIENTS

Thirty-six patients with OMAAV underwent contrast-enhanced magnetic resonance imaging (CE-MRI) of the brain, of whom 18 and 18 had or did not have HP, respectively.

MAIN OUTCOME MEASURES

The location of HP lesions, which were detected as dural thickening on CE-MRI, was reviewed. Clinical characteristics, laboratory data, and audiometric data before treatment were correlated with the occurrence of HP.

RESULTS

HP lesions were most frequently observed in the middle cranial fossa, followed by the internal auditory meatus, tentorium cerebelli, and posterior cranial fossa, which were adjacent to the middle ear primary lesion. Headache was more frequently observed in patients with HP than without HP. The neutrophil-to-lymphocyte ratio (NLR) of the HP (+) group (median, 3.91; interquartile range, 2.50-6.06) was higher than that of the HP (-) group (median, 2.40; interquartile range, 2.01-3.03). The area under the receiver operating characteristic curve for the NLR was 0.741. An NLR of 3.46 had the highest sensitivity (61.1%) and specificity (94.4%) for predicting HP. Other markers of systemic inflammation and comorbidities of systemic diseases were not different between the groups.

CONCLUSIONS

HP may not be a systemic manifestation of OMAAV but may be related to local lesions in the adjacent brain. A high NLR may be a predictive factor for comorbid HP. Therefore, CE-MRI should be considered for patients with a high NLR.

Hypertrophic Pachymeningitis Presenting as “Eyebrows” Sign on 18F FDG PET/CT

Hypertrophic pachymeningitis refers to linear or nodular thickening of the dura mater covering the brain and spinal cord following various inflammatory/infective processes. Usually, magnetic resonance imaging brain shows uniform thickening with enhancement of involved meninges. Fluorodeoxyglucose positron emission tomography/computed tomography (PET/CT) findings of pachymeningitis are rarely reported in literature. We describe the PET/CT findings of a patient with hypertrophic pachymeningitis involving the bilateral supraorbital regions depicting as “eyebrows” on brain maximum intensity projection image.

Hypertrophic pachymeningitis in ANCA-associated vasculitis: a cross-sectional and multi-institutional study in Japan (J-CANVAS)

BACKGROUND

This study investigated the characteristics of hypertrophic pachymeningitis (HP) in antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV), using information from a multicenter study in Japan.

METHODS

We analyzed the clinical information of 663 Asian patients with AAV (total AAV), including 558 patients with newly diagnosed AAV and 105 with relapsed AAV. Clinical findings were compared between patients with and without HP. To elucidate the relevant manifestations for HP development, multivariable logistic regression analyses were additionally performed.

RESULTS

Of the patients with AAV (mean age, 70.2 ± 13.5 years), HP was noted in 30 (4.52%), including 20 (3.58%) with newly diagnosed AAV and 10 (9.52%) with relapsed AAV. Granulomatosis with polyangiitis (GPA) was classified in 50% of patients with HP. A higher prevalence of GPA was significantly observed in patients with HP than in those without HP in total AAV and newly diagnosed AAV (p < 0.001). In newly diagnosed AAV, serum proteinase 3 (PR3)-ANCA positivity was significantly higher in patients with HP than in those without HP (p = 0.030). Patients with HP significantly had ear, nose, and throat (ENT) (odds ratio [OR] 1.48, 95% confidence interval [CI] 1.03-2.14, p = 0.033) and mucous membrane/eye manifestations (OR 5.99, 95% CI 2.59-13.86, p < 0.0001) in total AAV. Moreover, they significantly had conductive hearing loss (OR 11.6, 95% CI 4.51-29.57, p < 0.0001) and sudden visual loss (OR 20.9, 95% CI 5.24-85.03, p < 0.0001).

CONCLUSION

GPA was predominantly observed in patients with HP. Furthermore, in newly diagnosed AAV, patients with HP showed significantly higher PR3-ANCA positivity than those without HP. The ear and eye manifestations may be implicated in HP development.

Rapid bilateral visual loss as the initial clinical manifestation in idiopathic hypertrophic cranial pachymeningitis

A 59‐year‐old patient presented with 4‐day acute painless bilateral visual loss, MRI results showed dura enhancement of the frontal, anterior cranial fossa. The patient was considered to have idiopathic hypertrophic cranial pachymeningitis based on laboratory tests and MRI data. After treatment with hormones, the visual acuity obviously improved.

Anti-GFAP Antibody-Associated Hypertrophic Pachymeningitis

BACKGROUND

Autoimmune glial fibrillary acidic protein (GFAP) astrocytopathy is an inflammatory central nervous system (CNS) disorder that usually presents as steroid responsive encephalitis, meningitis, myelitis, or meningoencephalomyelitis. Hypertrophic pachymeningitis (HP) is an uncommon disorder that causes a localized or diffuse thickening of the dura mater. Depending on the etiology, HP can be idiopathic or secondary to a wide variety of other diseases. There are no reports of autoimmune GFAP astrocytopathy presenting as HP.

METHODS

In this case report, we describe a rare case of pediatric HP possibly associated with anti-GFAP antibody.

RESULTS

A 13-year-old previously healthy girl presented with headache for nearly 8 months with left-sided peripheral facial palsy and left-sided abductor nerve palsy in the second month of course. Magnetic resonance imaging (MRI) of the brain revealed contrast enhancement of hypertrophic dura mater. Anti-GFAPα antibodies were positive in serum and cerebrospinal fluid. The patient improved clinically after steroid treatment with partial resolution of abnormal intracranial MRI lesions.

CONCLUSION

The present study suggests that HP may be one of the clinical phenotypes for autoimmune GFAP astrocytopathy or GFAP antibody is a biomarker for HP.

Hypertrophic Pachymeningitis Demonstrated by Whole-Body 67Ga Scintigraphy

ABSTRACT

Hypertrophic pachymeningitis is a rare inflammatory process characterized by thickening of the dura mater that can be idiopathic or secondary to a variety of conditions such as ANCA-related vasculitis, IgG4-related disease, Sjögren syndrome, rheumatoid arthritis, sarcoidosis, and infections. It can cause various neurological alterations such as headache, cranial nerve disorder, cerebellar disorder, sensory impairment, and weakness. Brain MRI is useful for imaging diagnosis of hypertrophic pachymeningitis, showing focal thickening and enhancement of the dura mater. Here we report 4 cases of idiopathic hypertrophic pachymeningitis where 67Ga clearly accumulated in the dura mater.

Clinical approach to neuro-rheumatology

Recognizing the neurologic manifestations of systemic rheumatologic diseases and certain isolated autoimmune neurologic diseases poses challenges to the clinician. Using a systematic approach allows the clinician to diagnose these conditions more readily and to initiate treatment more rapidly. Specific neurological syndromes frequently associated with rheumatologic or specific autoimmune conditions can suggest the diagnosis. A targeted history and examination can identify neurological and systemic clues that help to identify an underlying rheumatologic condition. Judicious use of laboratory and radiographic studies can help confirm suspected diagnoses. This article will review some of the neurological syndromes typical of rheumatologic disease and outline an approach to evaluating for unknown rheumatologic disease in this context.

Comparison of the Morphologic and Mechanical Features of Human Cranial Dura and Other Graft Materials Used for Duraplasty

OBJECTIVE

This study aimed to compare the thickness and mechanical properties of the frontal; parietal; temporal; occipital human dura; autogenous grafts (facia lata, temporal fascia, galea aponeurotica); and artificial dura.

METHODS

Sagittal and transverse dura samples were obtained from standard regions of the cranial dura from 30 autopsies for histologic and mechanical property measurements. Identical measurements were made for the autogenous grafts artificial dura, and the results were statistically analyzed.

RESULTS

The thickness of the temporal (0.35 ± 0.11 mm), parietal (0.44 ± 0.13 mm), frontal (0.38 ± 0.12 mm), and occipital (0.46 ± 0.18 mm) dura showed regional variations. The parietal and occipital dura were significantly thicker than the temporal dura. The occipital dura was considerably thicker than the frontal dura. The frontal and temporal dura of males were significantly thicker than females. The sagittal maximum tensile force measurements were significantly greater than transverse, for the frontal, temporal, and occipital dura. The stiffness measurements in sagittal direction were greater than the measurements in transverse direction for the frontal dura. The mechanical properties and thickness of the autogenous and artificial dura were not similar to the human dura.

CONCLUSIONS

The thickness and mechanical properties of the regional cranial dura should be taken into consideration for a better cure and fewer complications. The mechanical properties of sagittal and transverse dura should be kept in mind for the preference of dura material. The present study's data can pave the way to produce artificial regional dura by mimicking the thickness and mechanical properties of the human dura.

Audiovestibular Symptoms in Patients With Idiopathic Hypertrophic Pachymeningitis: Systematic Literature Review

BACKGROUND AND OBJECTIVE

Hypertrophic pachymeningitis is an infrequent inflammatory disease resulting in thickening and fibrosis of the dura mater. In most cases, the cause in unknown and is called idiopathic hypertrophic pachymeningitis (IHP). Audiovestibular symptoms are infrequent and the pathogenesis is still unclear.

MATERIALS AND METHODS

A systematic literature review of cases with IHP and vestibular symptoms from 2000 to February 2020 was performed. PRISMA Checklist was followed and PubMED database, Web of Science and Cochrane library were searched. We report a case of an adolescent with a diagnosis of vestibular neuritis in the context of IHP attended in our clinic.

RESULTS

We reviewed 5 articles related to IHP and vestibular disorders. A total of 7 cases (5 women and 2 men), with ages between 27 and 68 years with IHP were found. They all had audiovestibular symptoms. In contrast to our patient, uni or bilateral neurosensorial hearing loss was reported in all cases. Furthermore, there is no other case report published describing the association between IHP and vestibular neuritis. High dose steroids improved symptoms in 85.7% of the patients.

CONCLUSION

Vestibular symptoms in IHP are uncommon and the pathogenesis is still debatable. Entrapment of nerves in the internal auditory canal and secondary neuronal damage could be suspected as the main cause of hearing and vestibular loss.

Hypertrophic pachymeningitis in polyarteritis nodosa: a case-based review

Hypertrophic pachymeningitis (HP) is a rare neurological disorder with focal or diffuse thickening of the dura mater, which usually causes headache, cranial neuropathies, seizures, and motor or sensory impairments. The development of HP is attributed to an immune-mediated mechanism, and some autoimmune diseases have been implicated in the development of HP. Herein, we describe the case of a 73-year-old woman with persistent headache ascribable to HP, which developed approximately 3 years after a diagnosis of polyarteritis nodosa (PAN). She was treated with high-dose corticosteroid and cyclophosphamide that resulted in immediate disappearance of headache and improved radiological findings of thickened dura mater. In addition, she was subsequently administered methotrexate, ultimately resulting in maintenance of remission and regular reduction of prednisolone. In our review of published English articles, only two cases of HP in patients with PAN have been reported to date, suggesting that HP is a rare complication in PAN. However, it should be recognized that HP may develop as a neurological involvement related to PAN.