Parafalcine and bilateral convexity neurosarcoidosis mimicking meningioma: case report and review of the literature

Intracranial necrotising sarcoid granulomatosis mimicking petroclival meningioma

We present a unique case of biopsy-proven necrotising sarcoidosis involving the central nervous system in a man in his 40s. The patient presented with a 2-week history of right-sided headache and diplopia. He had right trochlear and abducens nerve palsy, sensory blunting over V1 and V2 segment of right trigeminal sensory nerve and right sensory neural hearing loss. A contrast-enhanced MRI revealed an enhancing dural-based mass lesion in the petroclival area suggestive of probable meningioma. Surgical resection was attempted and intraoperative consultation with frozen section revealed granulomata. So, the lesion was biopsied and surgical intervention was terminated. A diagnosis of necrotising neurosarcoidosis was confirmed on histopathology. He was treated with steroids after excluding other causes of intracranial necrotising granulomas like tuberculosis and he clinically responded favourably. We report one of the very few case reports of histologically proven necrotising sarcoidosis involving the central nervous system mimicking petroclival meningioma.

Neurosarcoidosis resembling multiple meningiomas: A misleading presentation of the disease and diagnostic challenge

Sarcoidosis is characterized by the presence of noncaseating granulomatous inflammation in the affected organs. Neurosarcoidosis denotes the involvement of the nervous system and can be either isolated or coexisting with extraneural systemic inflammation. The diagnosis of isolated neurosarcoidosis may be challenging due to unspecific symptoms and similar appearances with other disease processes. This report presents an uncommon case of intracranial sarcoidosis mimicking multiple meningiomas. Familiarity with the spectrum of magnetic resonance imaging findings in neurosarcoidosis is crucial to prevent interpretive errors which may in turn lead to an inappropriate diagnosis and treatment.

Tuberculous meningoencephalitis in a pregnant woman presenting 7 years after removal of a cerebral granuloma

We describe the unusual case of a young woman with a history of seizures and a granulomatous, likely tuberculous brain lesion that was surgically removed. She had an uneventful recovery without any additional therapy other than anti-epileptics. Seven years later, she presented during pregnancy with culture-confirmed tuberculous meningoencephalitis. This case highlights the spectrum of tuberculous central nervous system disease and the challenges in diagnosis.

Neurosarcoïdose : état des connaissances

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

Metastatic Prostate Carcinoma Mimicking Meningioma

BACKGROUND

Intracranial dural-based lesions can be due to benign or malignant processes. Imaging characteristics cannot always discern between different pathologic conditions. A thorough clinical evaluation may reveal likely diagnostic possibilities. However, in certain cases, the etiology of the underlying lesion may require biopsy or resection to appropriately treat the patient.

REVIEW SUMMARY

We report the case of a large dural-based adenocarcinoma of the prostate clinically and radiographically mimicking a meningioma. We review the history and physical evaluation of the patient and subsequent treatment and response. We discuss the implications of dural-based intracranial lesions in patients with prostate cancer and review the literature of dural metastases, including the pathogenesis, tumor types, and clinical presentations.

CONCLUSION

The differential diagnosis of dural-based lesions in the brain varies from incidental and benign to symptomatic and malignant. Careful vigilance in patients with a history of cancer and presenting with new symptoms or imaging evidence of dural-based lesions is critically important to provide timely intervention.

Intramedullary neurosarcoidosis in the medulla oblongata: a case report

OBJECTIVE

We present a rare case of neurosarcoidosis mimicking an intramedullary tumor in the medulla oblongata. The features of the clinical presentation, magnetic resonance (MRI) appearances, and management strategy are discussed.

CASE PRESENTATION

A 59-year-old man without evidence of systemic sarcoidosis was presented with a history of progressive numbness and deep sensation disturbance in bilateral lower extremities. MR imaging revealed an enhanced intra-axial mass lesion on the dorsal side of medulla. Under neurophysiological monitoring, tumor biopsy was performed. Pathologic evaluation revealed noncaseating granuloma composed of large epithelioid cells with multinucleated giant cells, suggesting sarcoidosis. Findings of comprehensive hematologic laboratory studies; cerebrospinal fluid examination; and examinations for bacteria, fungi, and acid fast bacilli were all negative. This mass lesion was diagnosed as medullary neurosarcoidosis, and then high-dose steroid therapy was tried. On follow-up, nearly complete resolution of the neurosarcoidosis on MRI was revealed.

CONCLUSION

To our knowledge, this is the first reported case of neurosarcoidosis manifested in the medulla oblongata. A biopsy is sufficient for a diagnosis and high-dose steroid is recommended.

Dural lesions mimicking meningiomas

Recently, a number of neoplastic and nonneoplastic entities have been reported that radiographically and clinically mimic meningiomas. Because these lesions occur infrequently and may resemble a meningioma during intraoperative analysis, they may not be considered in the differential diagnosis. This review (and case illustrations) considers some of the newly recognized and notable lesions that can mimic meningiomas, including solitary fibrous tumors, gliosarcomas, leiomyosarcomas, hemangiopericytomas, melanocytomas, Hodgkin's disease, plasmacytomas, inflammatory pseudotumors, neurosarcoidosis, plasma cell granulomas, Rosai-Dorfman disease, Castleman's disease, xanthomas, rheumatoid nodules, and tuberculomas. Awareness that these lesions involve the dura may facilitate intraoperative recognition and, in some cases, preclude unnecessary additional surgery.

Necrotizing neurosarcoidosis of the cranial base resembling an en plaque sphenoid wing meningioma: case report

OBJECTIVE AND IMPORTANCE

Necrotizing sarcoid granuloma (NSG) has been recognized as a histological variant of sarcoidosis. Two cases of neurosarcoidosis (NS) with NSG with concomitant systemic disease have been described previously. We present an unusual case of primary NS-NSG that resembled an en plaque cranial base meningioma.

CLINICAL PRESENTATION

A 51-year-old man presented with a 3-month history of progressive left visual deterioration and proptosis. Brain magnetic resonance imaging demonstrated a large cranial base lesion occupying the left anterior clinoid process and sphenoid wing, extending to the left frontotemporal convexity. A second dura-based lesion was observed in the right parietal convexity. Both lesions enhanced homogeneously after administration of intravenous contrast medium. Magnetic resonance imaging characteristics were consistent with a typical clinoidal meningioma with an en plaque extension laterally.

INTERVENTION

A left frontotemporal craniotomy with extradural removal of the anterior clinoid process was performed. When the dura was opened, a red fibrous mass was identified. Intraoperative histological analysis revealed the presence of necrotizing and noncaseating granulomas. Postoperatively, cerebrospinal fluid, erythrocyte sedimentation rate, C-reactive protein, and serum and cerebrospinal fluid angiotensin-converting enzyme values were normal. The search for acid-fast bacilli or fungi was negative. A diagnosis of primary NS-NSG was made. The patient began long-term high-dose corticosteroid therapy. One and a half years after surgery, his vision had improved significantly and the lesions were stable as revealed by magnetic resonance imaging.

CONCLUSION

The first case of primary NS-NSG in the absence of systemic sarcoidosis is reported. NS should be included in the differential diagnosis of dura-based lesions resembling meningioma.

Primary cerebral sarcoid granuloma: the importance of definitive diagnosis in the high-risk patient population

Sarcoidosis of the central nervous system has been variously reported in 5-15% of all sarcoid patients. However, presentation of sarcoidosis as an isolated 'intracranial tumor' is rare. A 35-year-old African-American woman presented with intractable headaches. Neuroimaging revealed a tumor that was suggestive of a glioma or meningioma or metastasis. The symptoms did not respond to steroids, and an open biopsy of the lesion revealed non-caseating granuloma. A thorough work-up for systemic sarcoidosis was negative. The patient remains symptom-free at a 2-year follow-up. Primary sarcoid granuloma of the brain is rare. Once systemic disease has been excluded, early tissue diagnosis is crucial. This is particularly relevant for patients in the high-risk population before considering empirical radiosurgery.

Neurosarcoidosis without systemic sarcoidosis--case report

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

Necrotizing sarcoid granulomatosis mimicking an intracranial neoplasm: clinicopathologic features and review of the literature

We present a unique case of biopsy-proven necrotizing sarcoidosis involving the central nervous system (CNS) in a 52-year-old woman. The patient presented with a 3-month history of left-sided headache and sharp, shooting pains on the left side of her face. She also has a previous history of sarcoidosis, histopathologically confirmed on parotid gland biopsy 24 years before. Imaging studies of the present lesion revealed a 1.8 x 1.4-cm mass in the left temporal lobe with signal intensity suggestive of meningioma or low-grade glial neoplasm. Surgical resection was initiated, and intraoperative consultation with frozen sections revealed granulomata. The lesion was biopsied, and surgical intervention was terminated. Permanent sections failed to reveal bacteria, mycobacteria, fungi, or foreign bodies. A diagnosis of necrotizing neurosarcoidosis was rendered. The patient was administered steroid therapy and clinically responded favorably. At the most recent follow-up almost 2 years later, there was no evidence of recurrence or progression. Necrotizing sarcoidosis has been reported most commonly in the lungs and rarely in other organ systems. We report the first histologically proven case involving the CNS as well as a rare example of sarcoidosis and necrotizing sarcoid granulomatosis in the same patient. Sarcoidosis and its necrotizing variant should be considered in the differential diagnosis of a granulomatous mass lesion involving the CNS, particularly in the context of a history of systemic disease.

Role of radiology in the diagnosis of neurosarcoidosis

Clinical studies report a rate of 5% and autopsy results a rate of 25% of brain involvement in sarcoidosis. The aim of this study was to evaluate the role of radiology in the diagnosis of patients with neurosarcoidosis. The chest radiographs and MRI brain scans of 22 patients with sarcoidosis were retrospectively reviewed, along with the information that was provided in the request form and clinical charts. All patients had neurological signs and symptoms; 21 patients were examined with contrast enhancement. Facial nerve paralysis was the most common clinical manifestation identified in 10 patients. A wide spectrum of MR findings was noted: periventricular high-signal lesions on T2-weighted images (46%); multiple supratentorial and infratentorial brain lesions (36%); solitary intra-axial mass (9%); solitary extra-axial mass (5%); and leptomeningeal enhancement (36%). Neurological signs and symptoms can be significant manifestations of sarcoidosis. Magnetic resonance imaging shows a wide spectrum of brain abnormalities associated with neurosarcoidosis. The patient's history and chest X-ray are helpful in arriving at the correct diagnosis, but in selected cases with isolated brain involvement biopsy may still be required.