Triple reading hypertrophic duritis

01 Clinical history

Female, 51 years old
complaints: discomfort in the left lower limb, buttocks, headache;
Disease course: Stage 1:
Symptom of nerve root irritation of the left lower limb, and then gradually progresses to the perianal area, buttocks, and left calf, during which the suspected perianal abscess is surgically treated, and the postoperative pain is not relieved
.

Stage 2: progressive headache, with transient impaired consciousness, during which weight loss, vision loss, conjunctival hyperemia and edema
of both eyes.
After 4 months of anti-tuberculosis treatment, there was no significant improvement
.

After being admitted to our hospital on April 22, 2014, he began hormone and preventive anti-tuberculosis treatment, and his headache improved and his attacks were intermittent; On May 20, 2014, the waist was pierced, the pressure was greater than 330mmH2O, and the acid resistance soft color, ink staining, and TB-SPOT were all negative
.
This is followed by hormonal and prophylactic anti-tuberculosis therapy
.
Cyclophosphamide
was added on May 20, May 27, and June 3, 2014.

Neurological examination: decreased acupuncture sensation in the right frontal area, shallow left frontal lines and nasolabial folds, air leakage at the left corner of the mouth of the bulging cheek, dull reflex of left pupil to light, and loss of light reflex of right pupil; Decreased tendon reflexes of both lower limbs, bilateral pathological signs (+), left foot mopping
.

02Imaging examination

2014-05-15Head-enhanced MRI, 2014-05-26, 2014-09-24Head-enhanced +DWI

2014-10-28 head enhancement +T2*, 2016-06-29 head enhancement + DWI

05-29 Lumbar spine enhanced MRI images

03 Interpretation

1.
What are the important signs (multiple choice) in the above MRI images of this patient? (2014-05-15 MRI, 05-29 lumbar enhanced MRI images)
A.
bilateral dural thickening with strengthening; B.
dural thickening of the thoracolumbar segment; C.
abnormal signal of the frontal lobe;


D.
abnormal hyperintensity
of dural DWI Answer: ABC

2.
After hormonal and anti-tuberculosis treatment, the patient underwent head MRI examination, the image and time are as follows, the most likely diagnosis is ()?
A.
Meningioma
B.
Dural metastases
C.
Hypertrophic meningitis D.
Infectious meningitis

Answer: C

3.
What are the common causes of abnormal dural intensification? (Multiple choice)
A.
infectious meningitis; B.
systemic vasculitis C.
neoplastic disease;

D.
hypertrophic dural meningitis

E.
spontaneous hypocranial pressure, iatrogenic factors
Answer: ABCDE

04 Diagnosis

Hypertrophic meningitis

05 Discussion

Hypertrophic dura mater is a disease in which dural fibrosis diffuses thickening due to chronic progressive diffuse inflammation and can be divided into secondary and idiopathic
.
The former is often secondary to infectious diseases, vasculitic diseases, etc
.

Clinical manifestations:

1.
Headache, the most common symptom of the disease;

2.
Cranial nerve damage symptoms (the patient's cranial nerve symptoms can be reviewed);

3.
Cerebellar ataxia;

4.
Intention tremor;

5.
Epilepsy;

6.
Symptoms of intracranial hypertension (caused by dura mater, which obstructs the drainage of cerebrospinal fluid from arachnoid granules or damages the dural venous sinuses).

Imaging manifestations:
1.
Mainly head MRI, mainly manifested as abnormal intensification of the dura, diffuse or localization;
2.
T1WI is an equal signal, T2WI is an equal and low signal, and the reinforcement is visible when enhanced;
3.
The high-signal boundary can be seen around the low signal on T2WI, the low signal indicates dense fibrous tissue, and the high signal indicates that lymphocytes and plasma cells infiltrate or abundant blood vessels
.

Diagnosis: dural biopsy is the gold standard
for diagnosing the disease.

Treatment: the cause is clearly based on the treatment of the primary disease, and the unknown cause is mainly
steroid hormone therapy.

summary

Hypertrophic meningitis

Signs of meningeal thickening with intensification are often seen on MRI with head, and the causes of meningeal thickening are very numerous, and definitive diagnosis is relatively difficult
.
Radiologists need to learn more systematically the imaging diagnosis process of dural thickening and intensification, combined with the patient's clinical symptoms and laboratory tests, to provide clinicians with more ideas and directions
.