1979, British Journal of Radiology, 52, 328-329 Case reports
Leptomeningeal aspergillosis causing internal carotid artery stenosis By U. Kyaw Aung, M.B., B.S., D.M.R.D., F.R.C.R., U. Kyi Lin, M.B., B.S., D.M.R.D., and U. Saw Nyunt, M.D. Departments of Radiological and Neurological Services, Rangoon General Hospital, Rangoon, Union of Burma (Received July, 1978)
fossa. Biopsy demonstrated aspergillus involving the leptomeninges. A culture could not be obtained. The patient was treated with antifungal drugs but died almost a month later. An autopsy was not performed.
Fungus infection of the leptomeninges is uncommon. Aspergillosis is known to occur in patients with debillitating disease, drug addiction, chemotherapy and following prolonged steroid treatment (Dayal et al.y 1974). It presents predominantly as proptosis and associated sinus disease due to involvement of the orbit and base of the skull. The diagnosis of aspergillosis of the central nervous system is rarely established pre-operatively and this case report highlights some of the difficulties.
DISCUSSION
The presentation in this young female with exophthalmos and painful ophthalmoplegia suggested a number of possibilities. The association of orbital fissure destruction, ethmoid and sphenoid involvement and internal carotid artery occlusion suggested
CASE REPORT
A 22-year-old housewife first complained of headache during the eighth month of pregnancy. This was followed by retrobulbar pain and blurring of vision 22 days after delivery necessitating admission to the Department for Neurological Services. Clinical examination revealed proptosis of the left eye with complete ophthalmoplegia in a patient in obvious pain. The EEG, ultrasound and brain scan were all normal. Radiographic examination showed widening of the left superior orbital fissure with reactive basal sclerosis of the sphenoid (FIG. 1). The optic foramen was normal. Angiography revealed narrowing of the internal carotid artery with complete interruption of flow at the level of the sella (Fig. 2). A biopsy of the naso-pharynx was not conclusive. Her condition deteriorated with worsening of the pain and proptosis. Repeat skull examination one month later showed further destruction of the orbital fissure, erosion of the optic foramen and opacity of the ethmoids. Angiograplvy revealed more extensive narrowing of the internal carotid artery on the left. The right remained normal. At operation, pus was aspirated from the retrobulbnr space on the left and from the floor of the anterior cr:mi;il
FIG. 1.
Plain film of the orbits shows normal right side and widening of the superior orbital fissure on the left side.
FIG. 2. Left carotid angiogram shows narrowed internal carotid artery. The contrast medium can be visualized only to the sella.
328
APRIL 1979
Case reports a neoplasm. A primary carcinoma of the sphenoid sinus with secondary involvement of adjacent structures was suspected. This was not confirmed by nasopharyngeal biopsy, a situation which has been previously recorded (Taveras and Wood, 1964). Mucocoele of the sphenoidal sinus may give a similar pattern of bone destruction but is not usually associated with occlusion of the internal carotid artery. The diagnosis was established by histological examination of the leptomeninges which showed that the hyphae were actually embedded in the arterial wall and the occlusion was due to these becoming entangled in the lumen. In this instance the fungus itself acted as a nidus for thrombosis. The angiographic demonstration of multiple occlusions and arteritis in aspergillosis has been documented (Newton and Potts, 1974). Fungal infections are opportunistic. Cerebral infarction has been reported secondary to fungal embolism complicating aspergillous infection of aortic valve prosthesis (Kaufman et al., 1976). There are few reports of intra-cranial aspergilloma. Necro-
tizing inflammatory vascular occlusion is usually rapidly fatal (Samuel, 1968). Another fungus disease, mucormycosis may be seen in poorly controlled diabetics, in pregnancy and in patients undergoing chemotherapy (Hedges and Leung, 1976). Orbital and basal bone destruction may occur with venous and cavernous sinus thrombosis and occlusion or narrowing of the internal carotid artery. REFERENCES DAYAL, Y., WEINDLING, H. M. and PRICE, D. L., 1974.
Cerebral infarction due to fungal embolus. A complication of aspergillus infection on an aortic valve prosthesis. Neurology, 24, 76-79. HEDGES, T. R. and LEUNG, L. E., 1976. Parasellar and
orbital apex syndrome caused by aspergillosis. Neurology, 26,117-120. KAUFMAN, D. M., THAL, L. J. and FARMER, P. M., 1976.
Central nervous system aspergillosis in two young adults. Neurology, 26, 484-488. NEWTON, T. H. and POTTS, D. G., 1974. Radiology of the
Skull and Brain (C. V. Mosby Co., St. Louis.) SAMUEL, E., 1968. Inflammatory disease of nose and paranasal sinuses. Seminars in Roentgenology, 3, 148—1 59. TAVERAS, J. M. and WOOD, E. H., 1964. Diagnostic Neuro-
radiology (Williams and Wilkins, Baltimore.)
Book reviews L'angiographie digestive chez Vadulte et Venfant. By D. Doyon, A. Roche and P. Chaumont, pp. viii+182, illus., 1978 (Editions Masson, Paris), F.192. ISBN 2-225-49380-4. The authors of this French atlas of gastro-intestinal angiography are two radiologists and a clinician from the "Hopital de Bicetre, Faculte de Medecine Paris-Sud." Their presentation covers all aspects of the field ranging from technique, inflammatory and neoplastic diseases to emergency angiography in digestive pathology. There is an excellent section on paediatric gastro-enterology with full discussion on the particular problems in performing angiograms on the very young. Especially impressive is the respect the authors give to the dosage of contrast media used in children and to radiation protection. It is unfortunate for readers who are not fluent in French that the text, captions and extremely good index are completely in French. The format of each chapter consists of short discussions and tables of differential diagnoses, the emphasis being on numerous radiographic illustrations and line drawings. The radiographs are uniformly superb and it is a tribute to Gallic inventiveness that many of them are literally as small as postage stamps, yet the relevant information, be it extravasation of contrast or encasement of vessels, is clearly present. A full bibliography of both English and French authors is included. This concludes the book, the lack of references within the individual chapters making for easier reading. A set of challenging problem exercises forms the last section of a book which could well become a best seller if it were published in languages other than French.
Atlas of brain anatomy for CT scans {using EMI terminology). By F. C. Shipps, J. McAndrew Jones and A. D'Agostino, pp. vii + 51, illus., 2nd edn., 1977 (Charles C. Thomas, Springfield, Illinois, U.S.A.), $16.75. The second edition of this atlas retains the format of the first edition in which anatomical brain sections cut at 0 deg and 15 deg to the orbital meatal line in the plane of the usual CT projections, are presented with labelled plastic overlays, which are very useful for self-instruction. Comparable CT sections are mounted opposite the 15 deg angle brain sections. The subject material has been expanded to include chapters on artefacts, absorption values and methods of localizing CT data in relation to the lateral skull film and of obtaining corresponding brain sections from autopsy specimens. The anatomical sections are excellent, but the labelling is limited to the major structures and will be of value only to those who are commencing study of the subject. The CT sections are mainly of good quality, but a few are not up to standard and should be replaced. The scope of a future edition could be profitably increased by including the orbit, coronal slices and perhaps sagittal reconstruction, which have a logical place in a book of this nature. There is much unused space on which such additions could be made without adding to the bulk of the volume. The second edition of the atlas is a marked improvement on the first. Its main value is in providing anatomical sections corresponding to the usual CT slices and it is recommended for this purpose.
R. DICK.
329
BRIAN KENDALL.
Leptomeningeal aspergillosis causing internal carotid artery stenosis By U. Kyaw Aung, M.B., B.S., D.M.R.D., F.R.C.R., U. Kyi Lin, M.B., B.S., D.M.R.D., and U. Saw Nyunt, M.D. Departments of Radiological and Neurological Services, Rangoon General Hospital, Rangoon, Union of Burma (Received July, 1978)
fossa. Biopsy demonstrated aspergillus involving the leptomeninges. A culture could not be obtained. The patient was treated with antifungal drugs but died almost a month later. An autopsy was not performed.
Fungus infection of the leptomeninges is uncommon. Aspergillosis is known to occur in patients with debillitating disease, drug addiction, chemotherapy and following prolonged steroid treatment (Dayal et al.y 1974). It presents predominantly as proptosis and associated sinus disease due to involvement of the orbit and base of the skull. The diagnosis of aspergillosis of the central nervous system is rarely established pre-operatively and this case report highlights some of the difficulties.
DISCUSSION
The presentation in this young female with exophthalmos and painful ophthalmoplegia suggested a number of possibilities. The association of orbital fissure destruction, ethmoid and sphenoid involvement and internal carotid artery occlusion suggested
CASE REPORT
A 22-year-old housewife first complained of headache during the eighth month of pregnancy. This was followed by retrobulbar pain and blurring of vision 22 days after delivery necessitating admission to the Department for Neurological Services. Clinical examination revealed proptosis of the left eye with complete ophthalmoplegia in a patient in obvious pain. The EEG, ultrasound and brain scan were all normal. Radiographic examination showed widening of the left superior orbital fissure with reactive basal sclerosis of the sphenoid (FIG. 1). The optic foramen was normal. Angiography revealed narrowing of the internal carotid artery with complete interruption of flow at the level of the sella (Fig. 2). A biopsy of the naso-pharynx was not conclusive. Her condition deteriorated with worsening of the pain and proptosis. Repeat skull examination one month later showed further destruction of the orbital fissure, erosion of the optic foramen and opacity of the ethmoids. Angiograplvy revealed more extensive narrowing of the internal carotid artery on the left. The right remained normal. At operation, pus was aspirated from the retrobulbnr space on the left and from the floor of the anterior cr:mi;il
FIG. 1.
Plain film of the orbits shows normal right side and widening of the superior orbital fissure on the left side.
FIG. 2. Left carotid angiogram shows narrowed internal carotid artery. The contrast medium can be visualized only to the sella.
328
APRIL 1979
Case reports a neoplasm. A primary carcinoma of the sphenoid sinus with secondary involvement of adjacent structures was suspected. This was not confirmed by nasopharyngeal biopsy, a situation which has been previously recorded (Taveras and Wood, 1964). Mucocoele of the sphenoidal sinus may give a similar pattern of bone destruction but is not usually associated with occlusion of the internal carotid artery. The diagnosis was established by histological examination of the leptomeninges which showed that the hyphae were actually embedded in the arterial wall and the occlusion was due to these becoming entangled in the lumen. In this instance the fungus itself acted as a nidus for thrombosis. The angiographic demonstration of multiple occlusions and arteritis in aspergillosis has been documented (Newton and Potts, 1974). Fungal infections are opportunistic. Cerebral infarction has been reported secondary to fungal embolism complicating aspergillous infection of aortic valve prosthesis (Kaufman et al., 1976). There are few reports of intra-cranial aspergilloma. Necro-
tizing inflammatory vascular occlusion is usually rapidly fatal (Samuel, 1968). Another fungus disease, mucormycosis may be seen in poorly controlled diabetics, in pregnancy and in patients undergoing chemotherapy (Hedges and Leung, 1976). Orbital and basal bone destruction may occur with venous and cavernous sinus thrombosis and occlusion or narrowing of the internal carotid artery. REFERENCES DAYAL, Y., WEINDLING, H. M. and PRICE, D. L., 1974.
Cerebral infarction due to fungal embolus. A complication of aspergillus infection on an aortic valve prosthesis. Neurology, 24, 76-79. HEDGES, T. R. and LEUNG, L. E., 1976. Parasellar and
orbital apex syndrome caused by aspergillosis. Neurology, 26,117-120. KAUFMAN, D. M., THAL, L. J. and FARMER, P. M., 1976.
Central nervous system aspergillosis in two young adults. Neurology, 26, 484-488. NEWTON, T. H. and POTTS, D. G., 1974. Radiology of the
Skull and Brain (C. V. Mosby Co., St. Louis.) SAMUEL, E., 1968. Inflammatory disease of nose and paranasal sinuses. Seminars in Roentgenology, 3, 148—1 59. TAVERAS, J. M. and WOOD, E. H., 1964. Diagnostic Neuro-
radiology (Williams and Wilkins, Baltimore.)
Book reviews L'angiographie digestive chez Vadulte et Venfant. By D. Doyon, A. Roche and P. Chaumont, pp. viii+182, illus., 1978 (Editions Masson, Paris), F.192. ISBN 2-225-49380-4. The authors of this French atlas of gastro-intestinal angiography are two radiologists and a clinician from the "Hopital de Bicetre, Faculte de Medecine Paris-Sud." Their presentation covers all aspects of the field ranging from technique, inflammatory and neoplastic diseases to emergency angiography in digestive pathology. There is an excellent section on paediatric gastro-enterology with full discussion on the particular problems in performing angiograms on the very young. Especially impressive is the respect the authors give to the dosage of contrast media used in children and to radiation protection. It is unfortunate for readers who are not fluent in French that the text, captions and extremely good index are completely in French. The format of each chapter consists of short discussions and tables of differential diagnoses, the emphasis being on numerous radiographic illustrations and line drawings. The radiographs are uniformly superb and it is a tribute to Gallic inventiveness that many of them are literally as small as postage stamps, yet the relevant information, be it extravasation of contrast or encasement of vessels, is clearly present. A full bibliography of both English and French authors is included. This concludes the book, the lack of references within the individual chapters making for easier reading. A set of challenging problem exercises forms the last section of a book which could well become a best seller if it were published in languages other than French.
Atlas of brain anatomy for CT scans {using EMI terminology). By F. C. Shipps, J. McAndrew Jones and A. D'Agostino, pp. vii + 51, illus., 2nd edn., 1977 (Charles C. Thomas, Springfield, Illinois, U.S.A.), $16.75. The second edition of this atlas retains the format of the first edition in which anatomical brain sections cut at 0 deg and 15 deg to the orbital meatal line in the plane of the usual CT projections, are presented with labelled plastic overlays, which are very useful for self-instruction. Comparable CT sections are mounted opposite the 15 deg angle brain sections. The subject material has been expanded to include chapters on artefacts, absorption values and methods of localizing CT data in relation to the lateral skull film and of obtaining corresponding brain sections from autopsy specimens. The anatomical sections are excellent, but the labelling is limited to the major structures and will be of value only to those who are commencing study of the subject. The CT sections are mainly of good quality, but a few are not up to standard and should be replaced. The scope of a future edition could be profitably increased by including the orbit, coronal slices and perhaps sagittal reconstruction, which have a logical place in a book of this nature. There is much unused space on which such additions could be made without adding to the bulk of the volume. The second edition of the atlas is a marked improvement on the first. Its main value is in providing anatomical sections corresponding to the usual CT slices and it is recommended for this purpose.
R. DICK.
329
BRIAN KENDALL.
