T1 pre and post-contrast axial images showing meningeal thickening with abnormal enhancement in the left parietal convexity.
Similar type of pachymeningeal enhancement is also seen in bilateral parieto-occipital convexities also.
(T1 MPRAGE Post Contrast Sagittal Image)
(T1 MPRAGE Post Contrast Sagittal Image)
This young female patient had presented with history of multiple cranial nerve palsies, including few episodes of visual blurring, with symptoms over past few months. No abnormal enhancement of the basal dura were seen during this scan. Scan was performed to rule out any demyelinating diseases like MS.
The brain parenchyma showed no abnormal T2 FLAIR hyper intensities. Screening of the whole spine with T2 Sagittal images showed no cord hyper intensities or swelling.
There were no evidence of Intracranial Hypotension ( like tonsillar herniation, rounded adenohypophysis, distended venous sinuses, sagging of corpus callous or brainstem). Patient is not a known cancer patient.
Differential Diagnosis of Hypertrophic Pachymeningitis
1.Infection / Inflammation
Sarcoidosis : Usually have other lesions. Difficult to differentiate.
TB : More common is leptomeningeal involvement.
Wegener's Granulomatosis : Recurrent sinus disease. Lung or Kidney pathologies.
RA, SLE, Sjogren's : Have systemic symptoms.
Inflammatory Pseudotumor
2. Intracranial Hypotension : Usually have other associated features as mentioned above.
3. Tumors like en plaque meningioma, lymphoma, metastases. (Lymphoma usually have associated systemic component). En plaque meningioma may have associated bone erosion or hyperostosis, and a long non-neoplastic dural tail.
4. Dural sinus occlusion : Engorged collaterals will be seen. Empty delta sign.
5. Chronic SDH : Usually have some SWI/GRE blooming artifacts and T1/T2 signal abnormalities.
6. Normal dural enhancement.
Hypertrophic pachymeningitis can be caused by a plethora of conditions. Will need meningeal biopsy correlation for a specific diagnosis.
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