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Hide and seek. Surv Ophthalmol 2018; 65:109-115. [PMID: 30521818 DOI: 10.1016/j.survophthal.2018.11.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2017] [Revised: 11/22/2018] [Accepted: 11/28/2018] [Indexed: 11/22/2022]
Abstract
A 51-year-old woman with a previous history of rheumatoid arthritis experienced painless progressive visual loss in the left eye for 3 weeks. Fundus examination revealed optic disk pallor in her left eye. Magnetic resonance imaging of the brain and orbits showed enhancement of the pachymeninges and hypersignal at the left optic nerve. Meningeal biopsy was performed. Immunohistochemical staining for IgG4 revealed several IgG4-positive plasma cells, which in some areas reached the number of 50 cells/high-power field. In this case, the clinical and histopathological features of the patient met diagnostic criteria for rheumatoid arthritis and IgG4-related disease, respectively. Rheumatoid arthritis sometimes occurs with abundant IgG4 plasma cells and fulfills the histological diagnostic criteria for IgG4-related disease. This case demonstrates that overlapping features of IgG4-RD and rheumatoid arthritis may present in a single patient.
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2
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Fain O, Mekinian A. Les pachyméningites. Rev Med Interne 2017; 38:585-591. [DOI: 10.1016/j.revmed.2017.03.011] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2017] [Accepted: 03/10/2017] [Indexed: 01/29/2023]
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3
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Saito T, Fujimori J, Yoshida S, Kaneko K, Kodera T. [Case of cerebral venous thrombosis caused by MPO-ANCA associated hypertrophic pachymeningitis]. Rinsho Shinkeigaku 2015; 54:827-30. [PMID: 25342019 DOI: 10.5692/clinicalneurol.54.827] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
This report describes a 72-year-old woman presenting MPO-ANCA-associated hypertrophic pachymeningitis and venous thrombosis. Five years prior, positive MPO-ANCA and renal dysfunction had been indicated. At that time, oral steroids and tacrolimus were given to treat systemic vasculitis. During the course of the disease, she repeated otitis media. Saddle nose appeared. She was suspected of having localized type granulomatosis with polyangiitis (GPA). She was hospitalized because of consciousness disturbance and was diagnosed as having MPO-ANCA-associated hypertrophic pachymenigitis and venous thrombosis. Brain MRI detected thick dura mater with abnormal enhancement, predominantly on the right cerebral hemisphere, and tentorium cerebella partially along with the cerebral sulci. MRI revealed vasogenic brain edema lesions in the right occipital, parietal, and temporal lobes and cytotoxic edema lesions in the right parietal lobe and centrum semiovale. MR venography revealed stenosis of the venous sinus including confluence of sinuses, straight sinus, and right transverse sinus. Subsequent treatment with corticosteroids, an immunosuppressant, and an anticoagulant led to recovery. No patient with MPO-ANCA-associated hypertrophic pachymenigitis and venous thrombosis that developed alternation of consciousness has ever been reported. This is therefore regarded as a rare case.
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Affiliation(s)
- Tsutomu Saito
- Department of Neurology, Tohoku Pharmaceutical University Hospital
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4
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Ramirez L, D'Auria A, Popalzai A, Sanossian N. Bilateral Vision Loss Secondary to Pachymeningitis in a Patient with IgG4-Related Disease. Front Neurol 2014; 5:192. [PMID: 25352825 PMCID: PMC4195318 DOI: 10.3389/fneur.2014.00192] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2014] [Accepted: 09/15/2014] [Indexed: 12/24/2022] Open
Abstract
IgG4-related disease (IgG4-RD) is a recently recognized fibroinflammatory condition associated with disease in nearly every organ, including the meninges. A proportion of idiopathic hypertrophic pachymeningitis cases may involve a component of meningeal IgG4-RD. We present a patient with severe bilateral vision loss found to have thickening of the dura mater on MRI, and subsequently diagnosed with IgG4-RD after dural biopsy.
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Affiliation(s)
- Lucas Ramirez
- Roxanna Todd Hodges Comprehensive Stroke Clinic, University of Southern California , Los Angeles, CA , USA
| | - Andrea D'Auria
- Roxanna Todd Hodges Comprehensive Stroke Clinic, University of Southern California , Los Angeles, CA , USA
| | - Adeel Popalzai
- Roxanna Todd Hodges Comprehensive Stroke Clinic, University of Southern California , Los Angeles, CA , USA
| | - Nerses Sanossian
- Roxanna Todd Hodges Comprehensive Stroke Clinic, University of Southern California , Los Angeles, CA , USA
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5
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Caldas AR, Brandao M, Paula FS, Castro E, Farinha F, Marinho A. Hypertrophic cranial pachymeningitis and skull base osteomyelitis by pseudomonas aeruginosa: case report and review of the literature. J Clin Med Res 2012; 4:138-44. [PMID: 22505989 PMCID: PMC3320125 DOI: 10.4021/jocmr777w] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/25/2011] [Indexed: 11/29/2022] Open
Abstract
Hypertrophic cranial pachymeningitis (HCP) is an uncommon disorder characterized by localized or diffuse thickening of the dura mater, and it usually presents with multiple cranial neurophaties. It has been associated with a variety of inflammatory, infectious, traumatic, toxic and neoplasic diseases, when no specific cause is found the process is called idiopathic. The infectious cases occur in patients under systemic immunosuppression, which have an evident contiguous source or those who have undergone neurosurgical procedures. We describe a case of a 62-year-old immunosuppressed woman with diabetes and rheumatoid arthritis, which had HCP and osteomyelitis of the skull base caused by pseudomonas aeruginosa, presenting with headache and diplopia. We believe this is the second documented case of pachymeningitis secondary to this microorganism. As a multifactorial disease, it is essencial to determine the specific causative agent of HCP before making treatment decisions, and great care is needed with immunocompromised patients.
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Affiliation(s)
- Ana Rita Caldas
- Medicine Department, Santo Antonios' Hospital, Largo Prof. Abel Salazar, 4099-001 Porto, Portugal
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6
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Reversible Sensorineural Hearing Loss due to Pachymeningitis Associated with Elevated Serum MPO-ANCA. Clin Exp Otorhinolaryngol 2011; 4:155-8. [PMID: 21949583 PMCID: PMC3173708 DOI: 10.3342/ceo.2011.4.3.155] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2009] [Accepted: 10/03/2009] [Indexed: 11/24/2022] Open
Abstract
Hypertrophic pachymeningitis is a progressive disease resulting in a diffuse thickening of dura mater due to inflammation, tumor or autoimmune diseases, but most cases are idiopathic. It is seldom reported to be related to sensorineural hearing loss, but it can cause sensorineural hearing loss which can be potentially reversed through treatment. Here, we report the case of a 54-year-old woman who had progressive, bilateral, worse in the left, sensorineural hearing loss and visual disturbance with an accompanying headache over several months. Brain MRI showed diffusely thickened dura mater, highly enhanced after gadolinium administration, which was consistent with pachymeningitis. It was assumed to be related to autoimmune pathogenesis on the basis of elevated serum myeloperoxidase-antineutrophil cytoplasmic antibody (MPO-ANCA) titers. After empirical steroid and cyclophosphamide therapy, auditory impairment improved, especially in the high frequency region of the pure tone audiogram, and significant improvement in the word recognition test. Moreover, a follow-up MRI revealed much decreased enhancement of the dura mater, and the MPO-ANCA titer decreased to within the normal range. In the case of rapidly progressive sensorineural hearing loss or hearing impairment accompanying other cranial neuropathy, pachymeningitis should be taken into consideration, and brain MRI with gadolinium enhancement is the best method of detecting it. Also, to ensure proper treatment, a cautious evaluation including an ANCA work-up should be performed.
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7
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Uruha A, Koide R, Bandoh M, Isozaki E, Yoshida H. Neuro-Ophthalmic Manifestations of Hypertrophic Cranial Pachymeningitis Associated With Antineutrophil Cytoplasmic Antibody for Myeloperoxidase. Neuroophthalmology 2010. [DOI: 10.3109/01658101003778242] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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8
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Idiopathic hypertrophic cranial pachymeningitis. J Clin Neurosci 2008; 15:465-9. [DOI: 10.1016/j.jocn.2006.11.020] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2006] [Accepted: 11/01/2006] [Indexed: 11/21/2022]
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Idiopathic hypertrophic cranial pachymeningitis treated by oral methotrexate: a case report and review of literature. Rheumatol Int 2007; 28:713-8. [PMID: 18094971 PMCID: PMC2292418 DOI: 10.1007/s00296-007-0504-5] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2007] [Accepted: 11/17/2007] [Indexed: 10/28/2022]
Abstract
Idiopathic hypertrophic cranial pachymeningitis (IHCP) is a rare clinical entity, characterized by a chronic inflammation causing thickening of the dura. Adequate therapeutic management is still a matter of debate. We present a patient with an IHCP, non-responsive to corticotherapy. Oral methotrexate was introduced (12.5 mg weekly) and total remission was observed after 6 weeks, both clinically and after neuro-imaging. We conclude that methotrexate can be effective and a therapeutical option in patients with IHCP who are resistant to corticotherapy or present major side-effects of chronic corticosteroids use.
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10
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Ismail AR, Clifford L, Meacock WR. Compressive optic neuropathy in fungal hypertrophic cranial pachymeningitis. Eye (Lond) 2006; 21:568-9. [PMID: 17173014 DOI: 10.1038/sj.eye.6702649] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
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11
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Chan JW. Acute Monocular Visual Loss in Carcinomatous Hypertrophic Pachymeningitis Mimicking Giant Cell Arteritis. J Clin Rheumatol 2006; 12:30-1. [PMID: 16484877 DOI: 10.1097/01.rhu.0000200423.12270.18] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
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.
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Affiliation(s)
- Jane W Chan
- Department of Neurology, University of Nevada School of Medicine, Las Vegas, Nevada 89102, USA.
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12
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Chan JW. Acute monocular visual loss in carcinomatous hypertrophic pachymeningitis mimicking giant cell arteritis. Rheumatol Int 2005; 26:683-4. [PMID: 16341701 DOI: 10.1007/s00296-005-0049-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2005] [Accepted: 08/13/2005] [Indexed: 11/25/2022]
Abstract
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.
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Affiliation(s)
- Jane W Chan
- Department of Neurology, University of Nevada School of Medicine, 1707 W. Charleston Blvd, Suite 220, Las Vegas, NV 89102, USA.
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Lampropoulos CE, Zain M, Jan W, Nader-Sepahi A, Sabin IH, D' Cruz DP. Hypertrophic pachymeningitis and undifferentiated connective tissue disease: a case report and review of the literature. Clin Rheumatol 2005; 25:399-401. [PMID: 16249830 DOI: 10.1007/s10067-005-0018-z] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2005] [Accepted: 03/10/2005] [Indexed: 10/25/2022]
Abstract
A 63-year-old man with hypertrophic pachymeningitis (HP) and an undifferentiated connective tissue disease is described. Combined therapy with prednisolone and azathioprine improved his symptoms. The association between an undifferentiated connective tissue disease and HP is discussed.
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Affiliation(s)
- Christos E Lampropoulos
- Lupus Research Unit, The Rayne Institute, St. Thomas' Hospital, 4 Lambeth Palace Road, London, UK
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14
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Muthukumar N, Senthilbabu S, Usharani K. Idiopathic hypertrophic cranial pachymeningitis masquerading as Tolosa-Hunt syndrome. J Clin Neurosci 2005; 12:589-92. [PMID: 16051099 DOI: 10.1016/j.jocn.2004.08.016] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2003] [Accepted: 08/05/2004] [Indexed: 10/25/2022]
Abstract
Idiopathic hypertrophic cranial pachymeningitis is a rare condition. A case of idiopathic hypertrophic cranial pachymeningitis presenting as Tolosa-Hunt syndrome is being reported. The importance of neuroimaging in patients with suspected Tolosa-Hunt syndrome is discussed. Tolosa-Hunt syndrome might represent a focal manifestation of Idiopathic hypertrophic cranial pachymeningitis. Future studies are necessary to further clarify the relationship between these two conditions.
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Affiliation(s)
- N Muthukumar
- Department of Neurosurgery, Madurai Medical College, Madurai, India.
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15
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Oghalai JS, Ramirez AL, Hegarty JL, Jackler RK. Chronic Pachymeningitis Presenting as Asymmetric Sensorineural Hearing Loss. Otol Neurotol 2004; 25:616-21. [PMID: 15241244 DOI: 10.1097/00129492-200407000-00033] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The objective of this study was to characterize the auditory dysfunction associated with chronic pachymeningitis (inflammation of the dura mater). STUDY DESIGN AND SETTING We conducted a university-based retrospective review. RESULTS Three patients were identified who were diagnosed with chronic pachymeningitis after being referred for asymmetric sensorineural hearing loss. All patients were found to have other neurologic symptoms and signs during careful neurotologic evaluation. Two varieties of chronic pachymeningitis exist: a hypertrophic mass lesion and a linear dural thickening. Although the hypertrophic variety could be easily detectable by noncontrast magnetic resonance imaging (MRI), the linear form is only visible with the use of gadolinium enhancement. CONCLUSION Chronic pachymeningitis is a rare form of sensorineural hearing loss that could portend an underlying disease of greater concern. Extensive evaluation is needed to exclude identifiable causes of chronic pachymeningitis, including infectious, neoplastic, and autoimmune diseases. SIGNIFICANCE The clinician should be aware that the evaluation of a patient with asymmetric sensorineural hearing loss involves more than simply ruling out an acoustic neuroma. Fast-spin echo MRI techniques without the use of gadolinium contrast could miss a number of potentially treatable diseases such as chronic pachymeningitis. Patients with asymmetric sensorineural hearing loss should be carefully evaluated for other neurologic findings, and imaging with enhanced MRI is recommended.
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Affiliation(s)
- John S Oghalai
- The Department of Otolaryngology-Head and Neck Surgery, University of California, San Francisco, USA.
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16
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D'Andrea G, Trillò G, Celli P, Roperto R, Crispo F, Ferrante L. Idiopathic intracranial hypertrophic pachymeningitis: two case reports and review of the literature. Neurosurg Rev 2004; 27:199-204. [PMID: 15007702 DOI: 10.1007/s10143-004-0321-1] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2003] [Revised: 10/28/2003] [Accepted: 10/30/2003] [Indexed: 11/29/2022]
Abstract
In 1949, Naffziger et al. first described idiopathic intracranial hypertrophic pachymeningitis (IIHP) as an aseptic, diffuse inflammatory disease that causes thickening of the dura mater and often headache and progressive multiple nerve palsies due to fibrous entrapment or ischemic damage of neurovascular structures. Pachymeningeal thickening can be diffuse or nodular. We report two cases of IIHP; one was affected by diffuse IIHP, while the other presented focal IIHP mimicking a convexity meningioma. We examine the differential diagnosis between IIHP and other known causes of hypertrophic pachymeningitis. We also discuss the clinical bases of treatment.
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Affiliation(s)
- Giancarlo D'Andrea
- Department of Neurological Sciences, Faculty of Medicine II, La Sapienza University, S. Andrea Hospital, Rome, Italy.
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de Deus-Silva L, Queiroz LDS, Zanardi Vd VDA, Ghizoni E, Pereira HDC, Malveira GLS, Pirani C, Damasceno BP, Cendes F. Hypertrophic pachymeningitis: case report. ARQUIVOS DE NEURO-PSIQUIATRIA 2003; 61:107-11. [PMID: 12715031 DOI: 10.1590/s0004-282x2003000100021] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/02/2023]
Abstract
Hypertrophic pachymeningits is an unusual cause of neurological symptoms and is often secondary to infections, carcinomatosis or inflammatory diseases. It may also be idiopathic. We report a case of pachymeningitis which was manifested primarily by psychosis and visual loss with optic atrophy and destruction of nasal septum. The patient, a 45 year old woman was submitted to extensive investigation without evidence of any underlying disease. A meningeal biopsy was performed and showed a mostly unspecific inflammatory process with extensive fibrosis of the dura and few early stage granulomas. These findings suggest either neurosarcoidosis or idiopathic hypertrophic pachymeningitis.
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18
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Rucker JC, Newman NJ. Diffuse dural enhancement in cavernous sinus dural arteriovenous fistula. Neuroradiology 2003; 45:88-9. [PMID: 12592490 DOI: 10.1007/s00234-002-0920-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2002] [Accepted: 11/04/2002] [Indexed: 11/30/2022]
Abstract
We describe unusually extensive contrast enhancement of the dura mater on MRI in a case of dural arteriovenous fistula of the cavernous sinus.
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Affiliation(s)
- J C Rucker
- Neuro-ophthalmology Unit, Department of Ophthalmology, Emory Eye Center, Emory University School of Medicine, 1365-B Clifton Road, Atlanta GA 30322, USA
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Esparcia Navarro A, Roig Rico P, Mínguez Vera M, Botella Asunción C. Paquimeningitis crónica hipertrófica idiopática. Aportación de dos nuevos casos y revisión de la literatura. Rev Clin Esp 2003. [DOI: 10.1016/s0014-2565(03)71268-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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20
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Case records of the Massachusetts General Hospital. Weekly clinicopathological exercises. Case 8-2001. A 61-year-old man with transient quadriplegia and apnea. N Engl J Med 2001; 344:832-9. [PMID: 11248161 DOI: 10.1056/nejm200103153441109] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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21
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Dumont AS, Clark AW, Sevick RJ, Myles ST. Idiopathic hypertrophic pachymeningitis: a report of two patients and review of the literature. Can J Neurol Sci 2000; 27:333-40. [PMID: 11097527 DOI: 10.1017/s0317167100001116] [Citation(s) in RCA: 41] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
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.
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Affiliation(s)
- A S Dumont
- Department of Clinical Neurosciences, Faculty of Medicine, University of Calgary, Alberta, Canada
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Nagashima T, Maguchi S, Terayama Y, Horimoto M, Nemoto M, Nunomura M, Mori M, Seki T, Matsukawa S, Itoh T, Nagashima K. P-ANCA-positive Wegener's granulomatosis presenting with hypertrophic pachymeningitis and multiple cranial neuropathies: case report and review of literature. Neuropathology 2000; 20:23-30. [PMID: 10935433 DOI: 10.1046/j.1440-1789.2000.00282.x] [Citation(s) in RCA: 89] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
An autopsy case of hypertrophic pachymeningitis and multiple cranial neuropathies is reported. A 53-year-old woman with paraplegia and various neurological signs which developed over a 2 year period was diagnosed as having an epidural mass with thickened dura mater extending from the lower cervical to the thoracic spinal cord. In addition, bilateral episcleritis, blephaloptosis, and blindness of the right eye with various cranial nerve deficits were found to be caused by the mass lesions involving the paranasal sinuses, orbit, and the cavernous sinus. Perinuclear antineutrophil cytoplasmic antibody (p-ANCA) was positive, but cytoplasmic antineutrophil cytoplasmic antibody (c-ANCA) was negative by enzyme-linked immunosorbent assay. The partially removed epidural mass with hypertrophied dura mater and biopsy of the paranasal lesions showed chronic granulomatous inflammation with vasculitis. The remaining lesions resolved with steroid therapy with remarkable neurological improvement. The positive p-ANCA test, paranasal involvement, the report of a similar histopathological case and a review of the literature on granulomatous pachymeningitis suggest the presence of p-ANCA-positive Wegener's granulomatosis with central nervous system involvement characterized by hypertrophic pachymeningitis and/or multiple cranial neuropathies.
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Affiliation(s)
- T Nagashima
- Department of Neurology, Teine Keijinki Hospital, Sapporo, Japan
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Hatano N, Behari S, Nagatani T, Kimura M, Ooka K, Saito K, Yoshida J. Idiopathic hypertrophic cranial pachymeningitis: clinicoradiological spectrum and therapeutic options. Neurosurgery 1999; 45:1336-42; discussion 1342-4. [PMID: 10598701 DOI: 10.1097/00006123-199912000-00014] [Citation(s) in RCA: 82] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
OBJECTIVE Idiopathic hypertrophic cranial pachymeningitis is a rare disease, of undetermined pathogenesis, that is characterized by inflammation and fibrosis of the dura mater. METHODS We encountered six patients with idiopathic hypertrophic cranial pachymeningitis and analyzed their clinical presentations, radiological findings, and treatment. RESULTS In the six patients, the main manifestations were cranial nerve palsies and headache. Three associations were present, namely optic neuropathy, Tolosa-Hunt syndrome, and diabetes insipidus. Gadolinium-enhanced magnetic resonance imaging was diagnostic, showing intense dural enhancement in a linear or nodular pattern. The responses to corticosteroid therapy were better for patients who exhibited linear, rather than nodular, dural enhancement. For one patient, surgical decompression of the superior orbital fissure provided lasting relief. The course of the disease followed one of three patterns, i.e., sustained remission, relapse with corticosteroid independence, or relapse with corticosteroid dependence. Pulse corticosteroid therapy provided significant relief, while reducing the daily corticosteroid requirement and avoiding side effects, for a corticosteroid-dependent relapsing patient. CONCLUSION Idiopathic hypertrophic cranial pachymeningitis exhibits varied clinical courses. It is important to prevent irreversible cranial neuropathy during the active phase of the disease, using daily administration of corticosteroids, pulse corticosteroid therapy, or surgical decompression.
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Affiliation(s)
- N Hatano
- Department of Neurosurgery, Nagoya University School of Medicine, Japan
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24
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LO WK, TSANG KL, LI LSW, LUI SL, CHEUNG TF. Idiopathic intracranial pachymeningitis in a patient on CAPD. Int J Organ Transplant Med 1999. [DOI: 10.1016/s1561-5413(09)60021-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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25
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Fain O, Seror O, Wirth JF, Heron C, Mathieu E, Chamouard JM, Guillevin L, Thomas M. [Cranial pachymeningitis]. Rev Med Interne 1999; 20:234-46. [PMID: 10216880 DOI: 10.1016/s0248-8663(99)83051-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
INTRODUCTION Pachymeningitis is a fibrous inflammatory process with non-specific symptoms, involving the dura mater. Due to MRI development, diagnosis is both easier and earlier. CURRENT KNOWLEDGE AND KEY POINTS We report seven cases and review current literature. Clinical features are headaches and cranial nerve palsies. CSF shows inflammatory changes, while MRI evidences thickening of the dura mater. Disease etiologies in the present study were tuberculosis in two cases, sarcoidosis, Lyme disease, lymphoma and dural puncture; in one case only the disease was of unknown origin. The condition of six patients improved with specific treatment. FUTURE PROSPECTS AND PROJECTS Further MRI development should allow detection of new forms of pachymeningitis and standardization of patients' management through the study of more important series.
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Affiliation(s)
- O Fain
- Service de médecine interne, hôpital Jean-Verdier, Bondy, France
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Abstract
A case of Wegener's granulomatosis is described in which meningeal thickening and enhancement was demonstrated on MR imaging. The diagnosis was suggested by the clinical picture, imaging findings and a positive anti-neutrophil cytoplasmic antibody; and confirmed by biopsy of ethmoidal tissue.
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Affiliation(s)
- H C Burrell
- Department of Radiology, City Hospital, Nottingham, United Kingdom
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Parney IF, Johnson ES, Allen PB. "Idiopathic" cranial hypertrophic pachymeningitis responsive to antituberculous therapy: case report. Neurosurgery 1997; 41:965-71. [PMID: 9316063 DOI: 10.1097/00006123-199710000-00041] [Citation(s) in RCA: 62] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
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.
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Affiliation(s)
- I F Parney
- Department of Surgery, University of Alberta, Edmonton, Canada
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River Y, Schwartz A, Gomori JM, Soffer D, Siegal T. Clinical significance of diffuse dural enhancement detected by magnetic resonance imaging. J Neurosurg 1996; 85:777-83. [PMID: 8893714 DOI: 10.3171/jns.1996.85.5.0777] [Citation(s) in RCA: 45] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
This study was performed to determine the clinical significance of diffuse dural enhancement (DDE) detected by magnetic resonance (MR) imaging and to typify enhancing patterns related to inflammatory or metastatic causes. The authors retrospectively evaluated the clinical, imaging, and laboratory characteristics of 20 consecutive patients with DDE. Those with DDE and an underlying neoplastic disease (13 patients) were compared to 11 consecutive patients with cytological evidence of neoplastic leptomeningeal metastasis evaluated by MR imaging. The DDE was often associated with an underlying malignancy (13 (65%) of 20 patients) but it coexisted with leptomeningeal metastasis in only one patient. Skull metastases were evident in 10 (77%) of 13 patients and cranial nerve palsies in six (46%) of 13. Other causes of DDE were related to cerebrospinal fluid (CSF) leak or shunting (five (25%) of 20), with or without symptoms of intracranial hypotension, and to dural sinus thrombosis and pachymeningitis. Dural biopsies obtained in two patients with DDE showed a narrow rim of granulation-like tissue adherent to the dural surface facing the inner skull table. Magnetic resonance subtraction, diffusion, and perfusion studies revealed unique characteristics in patients with metastatic causes as compared to those with DDE secondary to CSF leak. None of the patients with proven leptomeningeal metastasis had DDE, but four of them presented with focal dural enhancement and two displayed apparent leptomeningeal enhancement. The findings indicate that DDE is not a radiographic hallmark of leptomeningeal metastasis in spite of the similarities in clinical manifestations (for example, headache and cranial polyneuropathy). Nonetheless, DDE is most frequently associated with metastatic malignancies and particularly with skull metastases and CSF leak. Special MR techniques can discern the underlying cause and elucidate the disparity in the pathophysiological mechanisms leading to DDE.
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Affiliation(s)
- Y River
- Department of Neurology, Hadassah-Hebrew University Hospital, Jerusalem, Israel
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