Idiopathic chronic hypertrophic craniocervical pachymeningitis: case report

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.

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.

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.

A clinical approach to hypertrophic pachymeningitis

IMPORTANCE

Hypertrophic pachymeningitis (HP) is a non-usual manifestation of rheumatologic, infectious, and neoplastic diseases. Etiological diagnosis is a challenge, but when made promptly it creates a window of opportunity for treatment, with the possibility of a total reversal of symptoms.

OBSERVATIONS

HP is an inflammatory process of the dura mater that can occur as a manifestation of sarcoidosis, granulomatosis with polyangiitis, and IgG4-related disease. The HP case evaluation is extensive and includes central nervous system imaging, cerebrospinal fluid analysis, serology, rheumatologic tests, and systemic survey for other manifestations sites. After systemic investigation, meningeal biopsy might be necessary. Etiology guides HP treatment, and autoimmune disorders are treated with corticosteroids alone or associated with an immunosuppressor.

CONCLUSION

HP is a manifestation of several diseases, and a precise etiological diagnosis is crucial because of the difference among treatments. An extensive investigation of patients with HP helps early diagnosis and correct treatment.

Hypertrophic Pachymeningitis in a Southern Chinese Population: A Retrospective Study

Aims: To investigate the causes, clinical characteristics, imaging features, and therapeutic implications of hypertrophic pachymeningitis (HP) in a southern Chinese population.

Methods: We retrospectively analyzed 48 patients with HP with different causes from 1 January 2006 to 31 December 2018. Clinical manifestation, laboratory findings, and neuroimaging results were evaluated in all HP patients.

Results: The mean age at onset was 50 ± 12 years. The most common diagnosis was idiopathic HP (67%), followed by antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis (15%), tuberculous meningitis (8%), viral meningitis (6%), and bacterial meningitis (4%). Headache was the most common symptom. The most frequently changed laboratory finding was elevated erythrocyte sedimentation rate (ESR). Imaging was characterized by cerebral or spinal dura mater enhancement in MRI scan with contrast. Enhancements were mainly located in the posterior fossa for idiopathic HP; frontal, parietal, and occipital lobes for ANCA-related HP; and posterior fossa for tuberculous-associated HP. Diffuse enhancement was found in most cases, except for tuberculous-associated HP. Glucocorticoid or immunosuppressive treatment was applied in most cases.

Conclusions: The etiology of HP varied among patients, with idiopathic HP being the most common. MRI showed enhancement of the dura mater, which differed according to different etiologies. Glucocorticoid or immunosuppressive agents were the primary drugs for treatment.

Hypertrophic cervical spine pachymeningitis due to sarcoidosis: a case report

Hypertrophic pachymeningitis (HP) is a chronic, progressive diffuse inflammatory condition that leads to thickening of the dura mater and can be idiopathic or associated with sarcoidosis among other disorders. In this case report, we present a rare case of cervical spine HP in a 29-year-old woman in the post-partum period, who had a history of pituitary adenoma and juvenile rheumatoid arthritis. Magnetic resonance imaging (MRI) of the spine revealed a soft tissue mass and moderate cord compression. The patient underwent C3-C7 laminectomy. Pathological analysis of the cervical epidural mass demonstrated a reactive inflammatory cell process. Recurrence of symptoms and worsening of pachymeningitis on imaging studies warranted further work-up which revealed mediastinal/hilar lymphadenopathy. Transbronchial biopsy revealed non-caseating granulomatous disease consistent with sarcoidosis. The patient was started on oral steroids and eventually methotrexate with significant clinical and radiographic improvement. Follow-up imaging studies showed minimal dural thickening in the thoracic spine and eventually complete resolution. HP should be considered in a patient with spinal cord compression, myelopathy, and radicular pain of unclear etiology, and sarcoidosis should be considered in idiopathic cases.

Diplopia With Dural Fibrotic Thickening

Idiopathic hypertrophic pachymeningitis (HP) is a rare disorder of diffuse thickening of the cranial or spinal dura mater without an identifiable cause. Most common in adult males, idiopathic HP typically presents with headache with or without varied associated focal neurologic deficits and findings of dural enhancement on magnetic resonance imaging in a linear, nodular, or combined pattern. As it is felt to be an autoimmune disorder, treatment with high-dose corticosteroids is typically recommended, and without intervention, the course is usually progressive. The disease can commonly progress with a relapsing remitting course requiring other immune modulators such as methotrexate, azathioprine, or cyclophosphamide for control. Here, we describe a unique case of idiopathic HP as it presented in a pediatric patient and resolved without immunomodulatory therapy.

Idiopathic hypertrophic pachymeningitis as a rare cause of cervical compressive myelopathy

The spinal form of idiopathic hypertrophic pachymeningitis (IHP) is a rare condition characterized by a chronic progressive diffuse inflammatory fibrosis of the dura mater, which may evolve to the compression of the spinal cord. We present a case report about IHP focusing on its features in magnetic resonance imaging, which are determined by an intradural extramedullary mass in the cervical spine showing hypointensity on T2-weighted images and peripheral enhancement, causing compression of the spinal cord. Histological analysis showed a nonspecific chronic inflammatory process in dense fibrous tissue. The patient had a good outcome after therapy with steroids.

Idiopathic Hypertrophic Pachymeningitis in the Craniocervical Junction

Idiopathic hypertrophic pachymeningitis (IHP) is a rare disease, and it is characterized by chronic progressive inflammatory fibrosis and thickening of the dura mater with resultant compression of the spinal cord or neural structure without any identifiable cause. It can occur in the intracranial or spinal dura mater alone or as a craniospinal form. The spinal form is rarer than the cranial form and the craniospinal form is extremely rare. We report a rare case of IHP in the craniocervical junction involving both the cranial and spinal dura mater and discuss the diagnosis and management of the disease.

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.

Hypertrophic pachymeningitis with sarcoidosis: a rare cause of craniocervical compression

We describe a case of a 58-year-old woman with a suspected dural tumour. She presented with progressive pyramidal weakness. MRI confirmed compression of the medulla oblongata and spinal cord at the level of C1-3. The localised dural mass lesion homogenously enhanced on T1 MRI and was considered most likely to be a meningioma. Incidentally, CT scan of the chest revealed peribronchial soft tissue thickening, suggestive of pulmonary sarcoidosis. Owing to the progressive nature of her weakness, she had a posterior occipitocervical decompression with a C1-3 laminectomy and resection of the thickened dura. Histology showed densely collagenous tissue with scanty psammoma bodies and multinucleate giant cells, consistent with hypertrophic pachymeningitis (HP)-a rare, chronic inflammatory condition, characterised by thickening and fibrosis of the dura. This case demonstrates that masses in the craniocervical junction can be varied in pathology and when there is evidence of systemic inflammation, HP should be considered.

Idiopathic hypertrophic craniocervical pachymeningitis

PURPOSE

Hypertrophic craniocervical pachymeningitis (HCP) is a rare disease causing chronic inflammatory hypertrophy of the cranial and spinal dura mater. To increase awareness of this condition, we report the details of a case here.

METHODS

We reviewed the case of a 78-year-old man presenting with a rare case of HCP and summarized the clinical features, laboratory evaluations and treatment of the case.

RESULTS

In this case, the HCP involved the intracranial dura and high cervical regions, manifesting as lower cranial nerve palsies, headache, and neck pain, developing over 7 months. Magnetic resonance imaging revealed thickening of the dura in the craniocervical region with peripheral enhancement. Steroid therapy was commenced and the symptoms improved rapidly.

CONCLUSIONS

HCP can be diagnosed by MRI and laboratory investigations. In this case corticosteroid treatment was effective, although care must be taken when slowly reducing the dose. This case highlights HCP as a cause of progressive cerebellomedullar and cervical spinal cord symptoms.

Idiopathic Hypertrophic Spinal Pachymeningitis

A 63-year-old man revealed a four-month history of muscle weakness of the lower limbs, hypoesthesia of the L5 and S1 area and ischuria. On MRI, the spinal cord was compressed by an encircled mass, which showed hypointensity on T1- and T2-weighted images with gadolinium enhancement at the Th11 to Th12 vertebra. Because of the rapid progression of myelopathy, posterior decompression was performed and idiopathic hypertrophic spinal pachymeningitis (HSP) was finally diagnosed. The patient's neurological signs markedly improved with postoperative corticosteroid treatment. Idiopathic HSP is a clinical emergency and early surgical intervention is essential to prevent irreversible damage to the nervous system.

Idiopathic hypertrophic spinal pachymeningitis : report of two cases and review of the literature

Idiopathic hypertrophic spinal pachymeningitis (IHSP) is a rare inflammatory disease characterized by hypertrophic inflammation of the dura mater and various clinical courses that are from myelopathy. Although many associated diseases have been suggested, the etiology of IHSP is not well understood. The ideal treatment is controversial. In the first case, a 55-year-old woman presented back pain, progressive paraparesis, both leg numbness, and voiding difficulty. Initial magnetic resonance imaging (MRI) demonstrated an anterior epidural mass lesion involving from C6 to mid-thoracic spine area with low signal intensity on T1 and T2 weighted images. We performed decompressive laminectomy and lesional biopsy. After operation, she was subsequently treated with steroid and could walk unaided. In the second case, a 45-year-old woman presented with fever and quadriplegia after a spine fusion operation due to lumbar spinal stenosis and degenerative herniated lumbar disc. Initial MRI showed anterior and posterior epidural mass lesion from foramen magnum to C4 level. She underwent decompressive laminectomy and durotomy followed by steroid therapy. However, her conditions deteriorated gradually and medical complications occurred. In our cases, etiology was not found despite through investigations. Initial MRI showed dural thickening with mixed signal intensity on T1- and T2-weighted images. Pathologic examination revealed chronic nonspecific inflammation in both patients. Although one patient developed several complications, the other showed slow improvement of neurological symptoms with decompressive surgery and steroid therapy. In case of chronic compressive myelopathy due to the dural hypertrophic change, decompressive surgery such as laminectomy or laminoplasty may be helpful as well as postoperative steroid therapy.

Long-term outcome of idiopathic hypertrophic thoracic pachymeningitis

Idiopathic hypertrophic spinal pachymeningitis (IHSP) is a comparatively rare disease characterized by hypertrophic inflammation of the dura mater and clinical symptoms that progress from local pain to myelopathy. We report a case of IHSP followed up for 20 years in a 46-year-old man. Expansive laminoplasty was performed in 1991, and this case has been previously reported by a co-author. After 17 years, the patient's gait disturbance returned. Physical examination and imaging confirmed IHSP that had developed into syringomyelia at the T2-L1 conus level. This case was diagnosed as adhesive spinal arachnoiditis due to pachymeningitis caused by syringomyelia. T1-T4 laminectomy, a syringo-subarachnoid shunt (S-S shunt), and L2-L3 laminectomy were performed. The patient again developed dysesthesia and gait disturbance 3 years after the second operation. Most reports of IHSP have limited their focus to short-term follow-up after initial treatment with no long-term results. At present, there are only five reports referring to long-term results of greater than 5 years. All but one case needed additional surgery. To the best of our knowledge, this is the first case in which syringomyelia occurred in a patient with IHSP. It is important to note that syringomyelia may be a cause of symptom recrudescence during long-term follow-up in IHSP patients.

Idiopathic hypertrophic spinal pachymeningitis

Spinal idiopathic hypertrophic pachymeningitis (IHP) is a rare, chronic, nonspecific, granulomatous inflammatory disorder of the dura with unknown etiology. It can cause a localized or diffuse thickening of the dura mater with compression of the spinal canal and possible myelopathic symptoms. The authors report 3 consecutive cases of spinal IHP with a review of the literature. The diagnosis of spinal IHP was based on biopsy and pathological confirmation. Typical MR imaging findings suggestive of spinal IHP were noted in all cases. The clinical course may be marked by deterioration despite conservative therapy and may require surgical intervention to prevent irreversible neurological damage. Therefore, prompt diagnosis and institution of proper treatment is critical.

Idiopathic hypertrophic spinal pachymeningitis: a case report

A 67-year-old man presented with progressive quadriplegia. Magnetic resonance imaging (MRI) revealed spinal cord compression by a thickened dura ventral to the cord from C3 to C7. The lesion was isointense on both T1- and T2-weighted images, and showed contrast enhancement on T1-weighted gadorinium-enhanced images. A diagnosis of idiopathic hypertrophic spinal pachymeningitis was confirmed histologically after anterior decompression and fusion. Only partial excision was achieved. Marked improvement of the quadriplegia was attained only after steroid therapy. At the 3-month follow-up, the patient was able to walk with a cane. The affected site showed no remission on MRI despite continuous steroid therapy. At the 2-year follow-up, the patient could walk independently.

IgG4-related sclerosing pachymeningitis: a previously unrecognized form of central nervous system involvement in IgG4-related sclerosing disease

IgG4-related sclerosing disease is a distinctive mass-forming lesion with frequent systemic involvement, most frequently the pancreas, salivary glands, and lacrimal glands. This report describes a case manifesting with a previously unrecognized form of central nervous system involvement. The 37-year-old man presented with signs and symptoms of spinal cord compression at the thoracic level 9. Magnetic resonance imaging revealed an elongated dural mass extending from the fifth to tenth thoracic vertebra. Laminectomy and excision of the mass revealed dura expanded by a dense lymphoplasmacytic infiltrate accompanied by stromal fibrosis and phlebitis. IgG4+ plasma cells were increased and the proportion of IgG4+/IgG+ plasma cells was 85%. The patient also had a 1-year history of bilateral submandibular swelling due to chronic sialadenitis. Thus, IgG4-related sclerosing pachymeningitis represents a new member of the IgG4-related sclerosing disease family affecting the central nervous system. It seems that at least a proportion of cases described in the literature as idiopathic hypertrophic pachymeningitis belong to this disease, especially as some patients have other clinical manifestations compatible with IgG4-related sclerosing disease, such as cholangitis and orbital pseudotumor.

Painful ophthalmoplegia caused by idiopathic hypertrophic cranial pachymeningitis in the cavernous sinus

A 73-year-old man presenting with painful unilateral ophthalmoplegia is reported. Magnetic resonance imaging demonstrated a mass in the cavernous sinus extending to the floor of the middle cranial fossa. After resection of the lesion and anti-tuberculous chemotherapy his symptoms improved. Pathological examination revealed extensive caseous necrosis.

Hypertrophic cranial pachymeningitis associated with middle ear inflammation

OBJECTIVE

To describe a series of patients with hypertrophic cranial pachymeningitis (HCP) associated with chronic middle ear inflammation.

STUDY DESIGN

Retrospective case review.

SETTING

University Hospital.

PATIENTS

Six consecutive patients between the years 2000 and 2004 who had both middle ear disease and HCP (three men and three women; age range, 36-72 yr, mean age, 58.2 yr). The diagnosis of HCP was made by the use of contrast-enhanced magnetic resonance imaging scans of the brain in all patients.

INTERVENTIONS

Contrast-enhanced magnetic resonance imaging (MRI) of the brain, dural biopsy, and otomicroscopic examination.

MAIN OUTCOME MEASURE

Thickening and abnormal enhancement of the dura mater on the MRI of the brain.

RESULTS

All of the six patients had chronic inflammatory middle ear diseases. Three patients had otitis media with effusion, two had chronic otitis media, and one had postoperative otorrhea. The most common presentations of HCP were headache and cranial nerve palsies. Cranial Nerves V and VIII were the most frequently involved. On contrast-enhanced MRI examination of the brain, an enhancement of the dura mater was observed on the same side as the middle ear diseases in five of the six patients, whereas bilateral enhancement was observed in one patient. Corticosteroid therapy was effective for alleviating the symptoms in all six patients.

CONCLUSION

Chronic middle ear inflammation might be involved in the pathogenesis of HCP, probably mediated by the venous return.

Idiopathic hypertrophic cranial pachymeningitis treated by oral methotrexate: a case report and review of literature

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.

Idiopathic hypertrophic pachymeningitis resulting in delayed panhypopituitarism

OBJECTIVE

To describe an adult man with idiopathic hypertrophic pachymeningitis (IHPM) that progressed to involve the pituitary gland and caused hypopituitarism 6 years after the onset of the first symptom.

METHODS

We describe the slow 6-year progression of IHPM in a man being treated with steroids, radiation, and antineoplastic medications and present clinical, pathologic, and imaging data. The pertinent literature is also reviewed.

RESULTS

A 35-year-old man who presented with headaches, pain, and sensory loss on the right side of his face had thickened, inflamed dura without granulomas. Initially, the right middle fossa, the lateral wall of the right cavernous sinus, and the tentorium were involved. Results from a dural biopsy specimen were consistent with IHPM. His symptoms were only partially controlled with continuous high-dose steroids, cyclophosphamide, azathioprine, and radiation therapy. IHPM was diagnosed based on findings from an open brain biopsy. Other pathologic causes of inflammatory dural thickening were excluded. Six years after the onset of the first clinical manifestation of IHPM, the patient developed panhypopituitarism. Magnetic resonance imaging showed that the inflammatory process had invaded the pituitary gland. IHPM was confirmed by findings from transsphenoidal biopsy.

CONCLUSION

IHPM is a rare disorder characterized by an unexplained inflammatory thickening of the dura at the skull base. The usual clinical symptoms are intractable headache and cranial nerve palsies. Physicians must be aware that IHPM can be slowly progressive despite attempted treatment, and that the disease process can invade the sella with dysfunction of both the anterior and the posterior pituitary gland.

Progressive myelopathy due to meningeal thickening in shunted patients: description of a novel entity and the role of surgery

INTRODUCTION

Spinal cord compression due to meningeal thickening is a rare occurrence in shunted patients. Because of the long delay to clinical onset, this complication has not been identified as yet.

AIMS

We report on nine cases of shunt-related progressive myelopathy due to meningeal thickening (SPMMT).

MATERIALS AND METHODS

We reviewed our database of shunted children, for cases having developed progressive tetraparesis due to cervical meningeal thickening.

RESULTS

We identified nine observations of SPMMT, eight of these with hydrocephalus due to neonatal meningitis; the last case had Dandy-Walker malformation shunted at birth and suffered postoperative meningitis. The age of clinical onset of myelopathy was between 6 and 20 years (median 12.8). All patients presented with slowly progressive walking difficulties with falls and no spinal pain. Magnetic resonance imaging (MRI) showed typically a thickened dura mater with collapse of the arachnoid space, compensatory expansion of the epidural fat, and T2 hyperintensity in the spinal cord. We operated on seven patients for surgical decompression and arachnoidolysis: One died postoperatively because of shunt malfunction, and two others died later of complications of tetraplegia. Three patients were aggravated after surgery, three experienced partial improvement, but one of these subsequently deteriorated again.

CONCLUSION

SPMMT appears to be a novel and well-defined clinical and pathological entity; its pathological and radiological features are stereotyped; however, the diagnosis is delayed because of the slow pace of the disease. Although surgical decompression may be the only option, its results were poor in our experience; earlier surgery might improve this grim prognosis.

Paquimeningite hipertrófica idiopática craniana associada a pseudotumor orbitário: relato de caso

Paquimeningite hipertrófica se caracteriza por espessamento das meninges, podendo ser decorrente de infecção, infiltração tumoral, doença inflamatória ou idiopática. Relatamos sobre um homem de, 40 anos, com queixa de cefaléia de longa data e perda progressiva da visão em ambos os olhos acompanhadas de proptose bilateral. A imagem por ressonância magnética de crânio e órbitas revelou espessamento dural difuso e lesão orbitária bilateral. Extensa investigação não revelou qualquer afecção sistêmica. Estudo anatomopatológico realizado após biópsias de meninges e da massa orbitária evidenciou processo inflamatório crônico compatível com paquimeningite hipertrófica idiopática (PHI) e com pseudotumor orbitário respectivamente. Este caso evidencia que o acometimento orbitário pode ocorrer na PHI e que a sua identificação precoce é de fundamental importância para o prognóstico visual.

Idiopathic hypertrophic cranial pachymeningitis masquerading as Tolosa-Hunt syndrome

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.

Idiopathic hypertrophic cranial pachymeningitis with perifocal brain edema

Idiopathic hypertrophic cranial pachymeningitis (IHCP) consists of meningeal thickening due to chronic inflammation for which no cause such as infection, specific granulomatous disease, or malignancy is demonstrable. We present a case of IHCP with perifocal brain edema suggesting mass lesion with its magnetic resonance imaging (MRI) and pathologic findings. A 36-year-old woman was admitted to our hospital in August 2001 with a complaint of motor weakness in her left leg for 1 month. Magnetic resonance imaging with gadolinium revealed enhancement of the thickened dura mater and perifocal edema in the right frontoparietal region suggesting a mass lesion. Histological examination of the biopsy specimen revealed a dense fibrous cellular tissue. There was no obvious inflammatory infiltrate but in some areas between fibrous bundles one or two lymphocytes were detected. According to our knowledge, our patient is the second report in the literature of IHCP with focal edema causing a mass effect.

A case of idiopathic hypertrophic cranial pachymeningitis manifested only by positive rheumatoid factor and abnormal findings of the anterior falx

In this report, we present a rare case of a 52-year-old man with a unique form of hypertrophic pachymeningitis involving the anterior part of the falx and who was positive for rheumatoid factor. The clinical symptom was only headache, without any cranial nerve palsies or ataxia. Diagnosis was made by gallium scintigraphy and magnet resonance imaging but was not confirmed by dural biopsy. Treatment with corticosteroid alone was extremely effective for him, while in most cases hypertrophic pachymeningitis recurs or progresses despite the treatment.

Idiopathic intracranial hypertrophic pachymeningitis: two case reports and review of the literature

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.

Idiopathic hypertrophic pachymeningitis

Idiopathic hypertrophic pachymeningitis is a rare disorder of unknown origin. It is a fibrosing inflammatory process that involves the dura mater. Herein are described 14 patients with idiopathic hypertrophic pachymeningitis; their clinical, laboratory and radiological findings, as well as their treatment, are analyzed. Neuropathological findings of six cases including two autopsied cases are also presented. The main clinical features were headache and cranial nerve palsies. Many patients had mild to moderate elevation of C-reactive protein, and three patients had perinuclear antineutrophil cytoplasmic antibody. The CSF in most cases showed inflammatory changes. Neuroimaging studies revealed diffuse or localized thickening of the dura, and MRI findings were key to diagnosis of this disorder. The clinical course was chronic. All patients were treated with corticosteroid and improved intially, but half of them experienced relapses. Two patients received surgical intervention. Pathological examination in two autopsied cases revealed diffuse thickening of the dura, especially in the posterior part of the falx cerebri and the tentorium cerebelli. Microscopic examination of the dura showed dense fibrosis with inflammatory cell infiltration composed mainly of lymphocytes. The cell infiltration was marked at the surface of the dura mater. One case had necrotizing vasculitis of the small arteries located in the dura and the cerebral surface. There were no giant cells, caseation necrosis, or epitheloid granuloma. Four patients underwent biopsy of the dura, and the pathological study showed non-specific inflammatory changes. The relationship of idiopathic hypertrophic pachymeningitis with connective tissue disease or vasculitis syndrome is discussed.

Idiopathic hypertrophic cranial pachymeningitis associated with Sweet's Syndrome

A case of hypertrophic cranial pachymeningitis associated with Sweet's Syndrome is presented. Both entities have been described in association with several other chronic systemic inflammatory diseases and autoimmune conditions. To our knowledge the coexistence between Sweet's Syndrome and hypertrophic cranial pachymeningitis has not been reported up to date. We suggest a possible autoimmune or dysimmune mechanism in the pathogenesis of these two entities.

Hypertrophic pachymeningitis as a result of a retropharyngeal inflammatory pseudotumor: case report

OBJECTIVE AND IMPORTANCE

An extremely rare case of a patient with hypertrophic pachymeningitis that resulted from an inflammatory pseudotumor of retropharynx is described.

CLINICAL PRESENTATION

A 59-year-old man with a 9-year history of retropharyngeal inflammatory pseudotumor sought care for severe headache and multiple cranial nerve palsies. Magnetic resonance imaging and computed tomographic scans revealed pachymeningeal enhancement and obstructive hydrocephalus attributable to marked dural thickening around the foramen magnum.

INTERVENTION

Decompression of the foramen magnum, C1 laminectomy, and meningeal biopsy were performed. The histological examination of the biopsy specimen revealed chronic inflammatory infiltrate in the hypertrophic dura mater. Corticosteroid pulse therapy was subsequently completed. Clinical and neuroradiological findings improved remarkably.

CONCLUSION

A new case of hypertrophic pachymeningitis as a result of a retropharyngeal inflammatory pseudotumor is presented. We review and discuss the clinical features and the pathogenic mechanisms of hypertrophic pachymeningitis.

Idiopathic hypertrophic cranial pachymeningitis associated with a dural arteriovenous fistula involving the straight sinus: case report

OBJECTIVE AND IMPORTANCE

Reports of idiopathic hypertrophic cranial pachymeningitis have increased as a result of advances in magnetic resonance imaging. This is the first documented case of idiopathic hypertrophic cranial pachymeningitis associated with a dural arteriovenous fistula involving the straight sinus. We discuss possible causes of the association and the treatment options.

CLINICAL PRESENTATION

A 64-year-old man presented with a headache and visual disturbance. Gadolinium-enhanced T1-weighted magnetic resonance imaging demonstrated homogeneously stained meninges and prominent enhancement of the tentorium and falx. Angiograms demonstrated a dural arteriovenous fistula of the straight sinus.

INTERVENTION

Although surgical excision of the straight sinus and subsequent corticosteroid therapy failed to relieve the patient's visual symptoms, subsequent surgical decompression of the optic nerve resulted in improvement and stabilization.

CONCLUSION

Narrowing or occlusion of the tentorial sinuses and narrowing of the straight sinus by extensive dural fibrosis of the tentorium and falx, attributable in turn to idiopathic hypertrophic cranial pachymeningitis, may have resulted in the development of a dural arteriovenous fistula. We propose surgical decompression of the optic nerve as an alternative treatment during the active phase of the disease in patients who exhibit resistance to corticosteroid therapy.

Idiopathic hypertrophic pachymeningitis: a report of two patients and review of the literature

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.

Idiopathic hypertrophic cranial pachymeningitis: clinicoradiological spectrum and therapeutic options

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.

Hypertrophic cranial pachymeningitis involving dural sinuses: a pseudo signal-void appearance on MRI

A case of hypertrophic cranial pachymeningitis with an unusual and misleading manifestation is reported. CT detected calcified tentorium and superior sagittal sinus. MR imaging and MR angiography depicted tentorial thickening as well as occlusion of all major dural sinuses. Fibrocalcific occlusion of dural sinuses showed interestingly signal-void appearance on spin-echo images which could readily be interpreted as being patent sinuses.

[Cranial pachymeningitis]

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.

Pathogen-free granulomatous diseases of the central nervous system

Pathogen-free granulomatous diseases (PFGD) of the central nervous system (CNS) are a group of disorders with protean clinical and pathological findings. Failure to identify a causative organism leads to considerable diagnostic difficulty. The neuropathology records between 1985 and 1995 were retrospectively reviewed, and the medical records of all patients in whom a diagnosis of PFGD of the CNS was made were retrieved. Patients in whom an infective agent was shown either by culture, special staining techniques, or by immunohistochemical methods were excluded. We identified 11 patients (eight male, three female) who fulfilled the pathological criteria for this condition. Average age at diagnosis was 38.7 years (range, 17 to 78). Neurological symptoms were the presenting feature in nine patients. Neuroimaging findings included hydrocephalus (54.5%), meningeal enhancement (45.5%), and mass lesions (45.5%). Seven patients had antemortem CNS biopsies (brain/meninges [n = 6], spinal [n = 1]), which showed noncaseating granulomas. Eight patients died (mortality rate: 72.7%). Postmortem examination showed granulomatous involvement of the leptomeninges and cerebral parenchyma in all cases with systemic involvement in 50%, chiefly in the form of noncaseating granulomas of the hilar nodes. Six patients fulfilled the clinical, radiological, and pathological diagnostic criteria for neurosarcoidosis. The remaining five patients had an unclassifiable pathogen-free granulomatous disease of the CNS. PFGD of the CNS are associated with a poor prognosis. Although neurosarcoidosis may account for some of the cases, there remains an unclassifiable subgroup that continues to be a diagnostic and management challenge.

"Idiopathic" cranial hypertrophic pachymeningitis responsive to antituberculous therapy: case report

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.