Best Cases from the AFIP

AFIP ARCHIVES 1075 Best Cases from the AFIP Idiopathic Tumefactive Hypertrophic
Pachymeningitis 1 Editors Note.Every-
one who has taken the
course in radiologic pa-
thology at the Armed
Forces Institute of Pa-
thology (AFIP) remem-
bers bringing beautifully
illustrated cases for ac-
cession to the Institute.
In recent years, the staff
of the Department of
Radiologic Pathology
has judged the best
cases by organ system,
and recognition is given
to the winners on the last
day of the class. With each
issue of RadioGraphics,
one or more of these
cases are published,
written by the winning
resident. Radiologic-
pathologic correlation is
emphasized, and the
causes of the imaging
signs of various diseases
are illustrated. Imran A. Kazem, MD Natasha L. Robinette, MD Norbert Roosen, MD Michael F. Schaldenbrand, MD Joon K. Kim, MD History A 42-year-old man presented with complaints of chronic daily right frontal
headaches for the past 9 months. His headaches were worse in the morning and
throbbing in nature. The headaches had increased in intensity, with minimal
relief of symptoms provided by acetaminophen or ibuprofen. Decreased visual
acuity in the right eye, loss of balance over the past 6 months, and an uninten-
tional weight loss of 50 pounds over the past year were also noted. Results of
neurologic examination conrmed decreased visual acuity in the right eye but
were otherwise essentially unremarkable. Results of a complete blood work-up
and comprehensive metabolic testing were normal. In addition, rheumatologic,
oncologic, and infectious disease work-ups were negative. The patients past
medical history was noncontributory, and family history was signicant only for
scleroderma in the patients mother. Magnetic resonance (MR) imaging of the
brain revealed a large right frontal lobe mass, which was thought to represent a
meningioma and possible en plaque meningioma or coexisting meningeal dis-
ease. The patient underwent cerebral angiography followed by surgical resec-
tion of the mass. Imaging Findings MR imaging of the brain (1.5T GE Signa Excite; GE Healthcare, Waukesha,
Wis) demonstrated a lobulated right frontal lobe mass measuring 7.0 4.1 5.0 cm in the anteroposterior, transverse, and craniocaudal dimensions, respec-
tively. The mass was thought to be extraaxial in location, abutting the dura ma-
ter. An adjacent 1.0 1.0 1.0-cm satellite mass with similar features was identied more laterally in the right frontal lobe (Fig 1). There was signicant
mass effect compressing the right lateral ventricle and the frontal horn of the left
lateral ventricle, as well as midline shift to the left (Fig 2a). The white matter
demonstrated surrounding vasogenic edema and transependymal cerebral spi-
nal uid ow along the left occipital horn from compression of the foramen of
Monroe (Fig 2b, 2c). Abbreviation: IHP idiopathic hypertrophic pachymeningitis RadioGraphics 2005; 25:10751080 Published online 10.1148/rg.254045207 Content Code: 1 From the Department of Radiology, Oakwood Healthcare System, 18101 Oakwood Blvd, Dearborn, MI 48124. Received December 1, 2004; revi- sion requested January 10, 2005 and received February 21; accepted February 25. All authors have no nancial relationships to disclose. Address
correspondence to I.A.K. (e-mail: doctorkazem@yahoo.com).

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