engleski

Anterior fossa pachymeningitis : A case report

Introduction. Pachimeningitis in the anterior fossa is rare as resistance of dura mater to infection usually limits the inflammatory process to the epidural space. Occasionally, spread of infection occurred within the collagen and elastic fibers layers of the dura mater causing pachimeningitis, which may subsequently spread into the subdural space. Anterior fossa infections are usually spreads from frontal, or other paranasal sinus. Mixed infection of Gram-positive and Gram-negative bacterial pathogens is common. Granulomatous bacterial (tuberculosis, syphilis, brucellosis) and non-bacterial (sarcoidosis, autoimmune inflammation or vasculitis) form of pachimeningitis has also been described and may occasionally involve the scull dura. The granulomatous bacterial pachimeningitis of the vertebral column is more often and may extend from pleural, subphrenic, and perinephric inflammation into the spinal epidural space by means of intervertebral foramina. Pachimeningitis in the anterior fosse can be diagnosed using CT or MRI. Clinical details. The 50-year-old woman was at firs examined by ENT due to headache. A CT scans showed a mass within sphenoid sinus. Partial removal of the mass using flexible endoscope was performed. It was concluded that the mass is a very aggressive inflammation. A progressive visual loss on the right eye occurred after 6 months. MRI showed on T1 WI after contrast media administration extensive contrast enhancement and thickening of the dura in tuberculum sellae region. Overlying brain parenchyma was normal except moderate diffuse atrophy. Differential diagnosis included pachimeningitis or meningioma. Patient was operated by right subfrontal approach via eyebrow keyhole. The expansive mass was removed. After operation there was no recovery of the visual function. Ten months later due to painful sensation on the right temporal and zygomatic region additional MRI was done. It has shown an en plaque mass, of the some neuroradiological characteristics, of the dura in frontobasal right region, above the roof of the right orbit. On admission, she showed blindness on right eye and no other neurological signs. The "reoperation" was carried. With the same approach (subfrontal approach through right sided eyebrow keyhole craniotomy) firm and grayish mass was removed which affected region of right-sided orbital roof, both anterior clinoidal processes, created a thin ring around right optical nerve. The part of tumor mass in the region of cavernous sinus, posterior clinoidal procesus and dorsum sellae was left in place. There was no improvement in right eye visual function and without additional neurological worsening. Neuropathologic findings. The biopsy after first neurosurgical treatment yielded two pieces of hard tissue ranged 4 and 5 mm in diameter. HE sections of paraffin embedded tissue showed subacute inflammatory process in one piece of tissue, and meningothelial proliferation with subacute inflammation in the other. Subacute inflammation was composed predominantly of neutrophils, accompanied by few eosinophils, lymphocytes and plasma cells. Inflammatory cells were spread between collagen and elastic layers of dura and around dural blood vessels and nerves. Pathological diagnosis was pachimeningitis and meningioma, while the meningothelial proliferation was much more extensive than usually seen in inflammation. The biopsy after second neurosurgical treatment yielded few pieces of hard tissue ranged 7 mm in diameter. HE sections of paraffin embedded tissue showed chronic inflammatory process composed predominantly of lymphocytes, plasma cells, macrophages and lymphatic follicles. Conclusion. Extensive contrast enhancement and thickening of the dura in MRI is not obligatory en plaque meningioma, especially wen is connected with severe infections of paranasal sinuses. Extensive and aggressive pachimeningitis and dura thickening connected with sphenoid sinus inflammation and without epidural or subdural empyema are extremely rare in anterior fossa and in supraselar region.

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