Outcome of Two Treatment Regimens in the Management of Intracranial Fungal Granuloma

Abstract

Objective: Two treatment regimens means either you have to completely/near total excise the granuloma with sinus clearances (extra-dural) OR don’t touch it, even minimal invasive procedure such as burr hole biopsy can be fatal (intra-dural).

Introduction: The diagnosis of intracranial fungal granuloma almost always remained a challenge for neurosurgeons because of their rarity, alter behavior and lack of diagnostic tools. These infections are now easily diagnosed because of increased awareness and understanding regarding this pathology, better diagnostic tools and an increase in immunocompromised/immunocompetent hosts (from any cause). Most often, the fungal granulomas are due to contiguous spread of the infection from the paranasal sinuses and ear. Rarely, they may be due to hematogenous spread from a focus in the lungs. The infection can spread from sinuses to invade the brain parenchyma. Once it involves the brain parenchyma then the course of the disease is fulminant. Contrast enhanced C.T. and MRI of brain are investigations of choice. Although morbidity and mortality from central nervous system (CNS) mycosis has improved over years; mortality often reaches 75 – 100% despite an intensive treatment strategy (surgery followed by antifungal medications). Fungal hyphae are better demonstrated on periodic acid Schiff and Gomorimethanamine silver stain. This study will help us to describe an improved management approach to such patients with intracranial fungal granuloma depending upon the extent of spread, whether extradural or intradural. If the granuloma is extradural, the better management is extensive surgical approach with sinuses clearance followed by antifungals remains the gold standard. If the granuloma is intradural, then surgery is abandoned/ avoided to the extent possible.

Study Design: Case series.

Setting of Study: Department of Neurosurgery, Lahore General Hospital, Lahore.

Duration: One year from June 2012 to July 2013.

Materials and Methods: Twenty patients of intracranial fungal granuloma were included in this study.

Results: The mean ± SD age was 33.76 ± 5.43 years. Out of total 20 patients, most of the patients 10 (50%) were in age group between 20 – 30 years, 6 (30%) were between 31 – 40 year, and 3 (15%) patients were between 41 – 50 years. Only 1 (5%) patient was in age group of 51 – 60 year. There were 12 (60%) male and 8 (40%) were female patients. Thus the male to female ratio was 1.5:1. Out of total 20 cases, there were 18 (90%) patients had Aspergillosis type and only 2 (10%) patients had Mucormycosis type of fungal infection.

Conclusions:

• According to the two treatment regimens, whenever the granuloma is intradural/ intraparenchymal surgery is avoided/ abandoned but when the granuloma is extradural a more aggressive surgical approach is planned.
• In our study most of the patients were within the age range 20 – 30 years of age with a mean age of 33.76 years with male to female ratio of 1.5:1.
• There were 90% of patients of aspergillosis and only 10% patients of mucormycosis.

Abbreviations: MRI: Magnetic Resonance Imaging. CT: Computed Tomography. CNS) Central Nervous System.