Idiopathic hypertrophic cranial pachymeningitis with perifocal brain edema

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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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.

Focal status epilepticus as a manifestation of idiopathic hypertrophic cranial pachymeningitis

BACKGROUND

Idiopathic hypertrophic cranial pachymeningitis (IHCP) is an uncommon disease of unknown etiology characterized by thickening of the cerebral dura mater with possible associated inflammation. The most frequently described clinical symptoms include headache, cranial nerve palsy, and cerebellar dysfunction. Epilepsy and/or status epilepticus as main presentation is very uncommon.

CASE PRESENTATION

Two consecutive cases are presented of patients manifesting focal status epilepticus secondary to IHCP, with clinical, laboratory [blood test and cerebrospinal fluid (CSF) analysis], neuroradiologic [magnetic resonance imaging (MRI) at 3 Tesla and digital subtraction angiography (DSA)], and therapeutic data. One patient underwent meningeal biopsy; pathology findings are also included. Corticosteroid therapy resulted in clinical improvement in both cases, and neuroimaging showed decreased abnormal morphology, compared to initial findings.

CONCLUSION

In the diagnostic approach to focal status epilepticus or epilepsy, IHCP must be considered a potential, although extremely infrequent, cause. Anti-inflammatory treatment is an effective addition to antiepileptic drug therapy in patients with IHCP.

Hypertrophic pachymeningitis

BACKGROUND

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

CASE DESCRIPTION

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

Autoimmune hypophysitis presenting with intracranial multi-organ involvement: three case reports and review of the literature

Background

Autoimmune hypophysitis very rarely spreads to nearby organs outside the pituitary tissue, for unknown reasons, with only 5 reported cases of hypophysitis spreading over the cavernous sinus.

Case presentation

Three patients presented with cases of non-infectious hypophysitis spreading outside the pituitary tissue over the cavernous sinus. All three cases were diagnosed with histological confirmation by transsphenoidal surgery, and the patients showed remarkable improvement with postoperative pulse dose steroid therapy, including disappearance of abnormal signal intensities in the bilateral hypothalami on magnetic resonance imaging, resolution of severe stenosis of the internal carotid artery, and normalization of swollen pituitary tissues. Two of 3 cases fulfilled the histological criteria of immunoglobulin G4-related disease, although none of the patients had high serum immunoglobulin G4 level.

Conclusion

The true implications of such unusual spreading of hypophysitis to nearby organs are not fully understood, but the mechanism of occurrence might vary according to the timing of inflammation in this unusual mode of spreading. Pulse dose steroid therapy achieved remarkably good outcomes even in the patient with progressive severe stenosis of the internal carotid artery and rapid visual deterioration.

Immunoglobulin G4–related hypertrophic pachymeningitis involving cerebral parenchyma

The authors report a case of IgG4-related hypertrophic pachymeningitis that involved cerebral parenchyma. The mass was removed surgically. Histopathological studies showed diffuse infiltration of lymphoplasmacytic cells without evidence of Langerhans histiocytes or meningothelial cells. Immunoglobulin G4 was strongly positive on immunohistochemical staining. The Gd-enhanced lesion deep inside brain parenchyma was completely resolved after 3 months of oral corticosteroid medication. A nodular type of hypertrophic pachymeningitis that mimics a meningioma is rare. Nevertheless, preoperative presumption is very important, and immunohistochemical studies for IgG4 may be helpful in the differential diagnosis.

Idiopathic hypertrophic cranial pachymeningitis and dural sinus occlusion: two patients with long-term follow up

Idiopathic hypertrophic cranial pachymeningitis (IHPM) is a clinicopathological entity characterized by thickening and fibrosis of the dura mater with resultant clinical symptoms. It is generally steroid responsive and has a tendency to remit and relapse. We present here two patients with IHPM with associated dural sinus occlusion and describe their clinicoradiological features and long-term course and outcome.

Character changes from idiopathic cranial pachymeningoencephalitis

A 66-year-old man with idiopathic cranial pachymeningoencephalitis was described. He suffered from left orbital pain, and character changes. He became short tempered, and was very attached to trifles. Two years prior to these symptoms, he had developed transient left abducent nerve palsy. Head MRI showed a thickening and enhancement of the dura mater on gadolinium-enhanced T1-weighted images, and high signal intensity lesions at bilateral frontal lobes predominantly in the white matter on T2-weighted images. Biopsies revealed microglial proliferation in the cerebral parenchyma, and mild lymphocytic perivascular infiltration. No evidence of intracranial infection was detected. We therefore treated him with methylprednisolone pulse therapy followed by oral prednisolone. His character became gradually normalized, and bilateral frontal lobe lesions seen on MRI disappeared. This is the first case to describe recurrent pachymeningoencephalitis with character changes, and symptoms were probably due to frontal lobe dysfunction.