IgG4-negative pituitary inflammatory pseudotumor with sphenoidal involvement resembling a macroadenoma

BACKGROUND

Inflammatory pseudotumors (IPTs) are rare benign conditions of unknown etiology that can affect any part of the body. IPTs are most commonly associated with Immunoglobulin G4 (IgG4)-related disease. Central nervous system IPTs, especially with pituitary involvement, are even rarer entities. The presence of an IgG4-negative pituitary IPT with simultaneous extracranial involvement has not been reported.

CASE REPORT

We present the case of a 41-year-old female with past medical history of rheumatoid arthritis and a diagnosis of pituitary IPT with coexisting sphenoidal (extracranial) involvement mimicking a pituitary macroadenoma at presentation. The patient underwent multiple consecutive biopsies, and an extensive workup prior to establishing the diagnosis. Laboratory work-up showed normal serum IgG4 and unremarkable liver function tests.

CONCLUSION

Pituitary lesions with simultaneous sphenoidal involvement in patients with IgG4-negative systemic inflammatory disease should raise the clinical suspicion for intracranial IPTs, as these tumors can mimic aggressive counterparts causing adjacent bony erosion, and local invasion.

Tumefactive Demyelination: A Common Radiological Masquerader of Malignancy and the Expeditious Diagnostic Applicability of Crush Smear Cytology

Tumefactive demyelinations (TDs) are demyelinating central nervous system lesions that masquerade as neoplastic lesions on radiological images. Brain biopsy is often required for confirmatory diagnosis. Since crush cytology has become a routine practice, a thorough knowledge of the cytomorphologic features of TD is required to prevent misdiagnosis. In this report, we describe the cytomorphological and histomorphological features of a case of TD.

Calcified Pseudoneoplasm of the Neuraxis (CAPNON)-A Rare Cause for Temporal Lobe Epilepsy: Not all Warrant a Surgical Intervention

Epilepsy is a common neurological condition with varied etiological causes, with temporal lobe epilepsy being the most common. Among the varied etiologies of temporal lobe epilepsy, mesial temporal sclerosis is an important one and it presents as intractable epilepsy. However, we describe here a case of intractable temporal lobe epilepsy with a rather rare etiology, calcifying pseudo neoplasm of neuraxis (CAPNON) syndrome. CAPNON is a rare benign lesion that can occur anywhere in the central nervous system. The thought process till date is to excise any intracranial space occupying lesion to relieve pressure and for a better prognosis, which is not questionable. However, we feel in case of CAPNON, wait and watch protocol can be used to a better effect with radiological and clinical follow-up. Above all surgical excision was primarily done due to imaging confusion over CAPNON and this article comes up with few key findings to clinch the radiological diagnosis of CAPNON.

Intradural calcifying pseudoneoplasm of the neuraxis presenting as a cauda equina syndrome

BACKGROUND

Calcifying nonneoplastic pseudoneoplasms of the neuraxis (CAPNON) have been reported in 59 cases in literature, however, they rarely involve the spinal cord. Owing to the advances in immunohistochemical markers, their structure and origin are better understood now.

CASE REPORT

We present the case of a 72-year-old female who had longstanding history of low back pain that exacerbated 20 days prior to the presentation to the emergency room with a frank cauda equina syndrome. The lumbar computed tomography scan showed a hyperdense lesion, suggestive of calcified tumor, whereas the magnetic resonance imaging revealed a hypointense lesion on theT1 and T2-weighted images, without contrast enhancement or edema on fluid-attenuated inversion recovery. She underwent an emergent L2-L4 laminectomy and L3-L4 discectomy with resection of L2 intradural tumor, following which she regained normal function.

CONCLUSION

A 72-year-old female presented with a cauda equina syndrome attributed to an L2 intradural CAPNON. Following gross total resection, the patient was neurologically intact.

[Giant inflammatory pseudotumor of the cranial base]

The inflammatory pseudotumour (IPT) is a non-neoplastic entity of unknown origin, and is characterised by a proliferation of connective tissue and a polyclonal inflammatory infiltrate. Central nervous system involvement is uncommon, and usually represents a diagnostic and therapeutic challenge even for the experienced clinician. This reports deals with the case of a 56year-old woman diagnosed with a giant, infiltrating mass centred in the left cavernous sinus, who had a rapid clinical and radiological response to steroid therapy. Biopsy specimens were diagnostic for IPT. The progression of a small orbital residual lesion was detected after steroid withdrawal. Treatment with cyclophosphamide induced a complete response that remains stable after six years of follow-up.

The use of neuroimaging to guide the histologic diagnosis of central nervous system lesions

Recent advances in neuroimaging techniques, particularly in magnetic resonance imaging, have led to substantially improved spatial anatomic resolution such that subtle or small central nervous system lesions, which could go undetected on gross examination of brain sections, are now readily identified on imaging. Although neuroimaging is generally considered the surrogate of gross neuropathology, it is still not a substitute for tissue diagnosis. Rather, it can be a valuable tool for the surgical pathologist in the process of formulating a differential diagnosis based on location and imaging features, as well as in identifying radiologic/pathologic discordance, such as the possible undersampling of a heterogenous glioma, which could lead to underestimation of the tumor grade. The following review focuses on the application of neuroimaging techniques, mainly magnetic resonance imaging, to the histologic diagnosis of central nervous system lesions, and the correlation of imaging features of infiltrative gliomas with histologic findings pertinent to tumor grading. The use of advanced functional magnetic resonance methods, specifically diffusion-weighted imaging, perfusion-weighted imaging, and magnetic resonance spectroscopy is also discussed, as well as the common pitfalls in imaging interpretation.