278

Annals of Indian Academy of

ISSN 0972-2327
Neurology
Annals of Indian Academy of Editorial Board - 2007
Neurology is indexed/listed with
Expanded Academic ASAP, Genamics
Journal Seek, Health Reference Center EDITOR
Academic, DOAJ, MANTIS.
Sanjeev V. Thomas
The journal is official publication of the
Indian Academy of Neurology, India.
Issues are published quarterly in the Associate Editors
last week of March, June, September
and December. Journal aims to publish Asha Kishore Muralidharan Nair
articles in clinical neurology, related Abraham Kuruvilla Dinesh Nayak
disciplines and basic neurosciences, to
serve as a medium for dissemination P. S. Mathuranath Kurupath Radhakrishnan
of information and contribute to the ad-
C. Sarada
vancement of knowledge in neuroscienc-
es. Journal follows the broad guidelines
for good publications practice brought Editorial Advisory Committee
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review, no part of the publication can be
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Indian Academy of Neurology.
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Annals of Indian Academy of Neurology - October-December 2007

 279

Annals of Indian Academy of Neurology

CONTENTS
Volume 10 - Issue 4 - October-December 2007

EDITORIAL
From muscular dystrophy to chickenpox
Sanjeev V. Thomas ............. 197

PRESIDENTIAL ORATION
A neurotropic virus (chikungunya) and a neuropathic aminoacid (homocysteine)
R. S. Wadia ............. 198

REVIEW ARTICLES
Limb girdle muscular dystrophies: The clinicopathological viewpoint
J. Andoni Urtizberea, France Leturcq ............. 214
What are relative risk, number needed to treatand odds ratio?
Kameshwar Prasad ............. 225
Neuromyelitis optica
Anu Jacob, Mike Boggild ............. 231

ORIGINAL ARTICLES
Neurological complications of chickenpox
A. S. Girija, M. Rafeeque, K. P. Abdurehman ............. 240
Patterns and predictors of in-hospital aneurysmalrebleed: An institutional experience andreview of literature
Girish Ramachandran Menon, Suresh Nair, Ravi Mohan Rao, Mathew Abraham, H. V. Easwer, K. Krishnakumar ............. 247

SHORT COMMUNICATIONS
Serial nerve conduction studies of the tail of rhesus monkey (Macaca mulatta) and potential implications
for interpretation of human neurophysiological studies
William A. Graham, Richard Goldstein, Mansfield Keith, Shanker Nesathurai ............. 252
Wilson’s disease: A study of 21 cases fromnorth-west India
Ashok Panagariya, Rajender Kumar Sureka, Anjani Kumar Sharma, Amit Dev, Neeraj Agarwal ............. 255

CASE REPORTS
Niemann-Pick disease Type C - Sea-blue histiocytosis: Phenotypic and imaging observations and mini review
K. S. Praveen, S. Sinha, T. C. Yasha, U. B. Muthane, S. Ravishankar, S. Sangeetha, K. T. Shetty, A. B. Taly ............. 259
Why we missed an early diagnosis of cerebral aspergilloma: Lesson from a case
D. Goel, K. K. Bansal, C. Gupta, S. Kishor, R. K. Srivastav, S. Raghuvanshi, S. Behari ............. 263
Reversal of acquired immunodeficiency syndrome-dementia complex with antiretroviral therapy
Iyer Kamalam, S. R. Daga, Naresh Tayade ............. 266
Kleine-Levin syndrome in tubercular meningitis
Anup K. Thacker, Anupam Aeron, Jamal Haider, K. M. Rao ............. 270

IMAGES IN NEUROLOGY
Bilateral simultaneous hypertensive intracerebral hemorrhage in both putamen
Ravouf Parvez Asimi, Mushtaq Ahmad Wani, Feroze Ahmad ............. 272

LIGHTER MOMENTS
............. 273
LETTERS TO EDITOR
Neurology of consciousness: Need for Indian impetus
Ravi Prakash, Shashi Prakash ............. 274
More collaborative studies: The need of the hour in India
Sanjeev V. Thomas ............. 275

AUTHOR INDEX - 2007

TITLE INDEX - 2007
Annals of Indian Academy of Neurology - October-December 2007
 263

Case Report

Why we missed an early diagnosis of cerebral

aspergilloma: Lesson from a case
D. Goel, K. K. Bansal, C. Gupta, S. Kishor, R. K. Srivastav, S. Raghuvanshi, S. Behari1
Himalayan Institute of Medical Sciences, Swami Ram Nagar, Dehradun, Uttaranchal,
1
Sanjay Gandhi PGI, Lucknow, India

Abstract

Intracranial aspergilloma is a dreadful CNS infection with nonspecific clinical manifestation and radiological features. Therefore, delay in
the diagnosis is common, resulting in a fatal outcome in almost all the cases. We present how the diagnosis of this condition is overlooked
if we do not follow the conventional medical rules of taking history and thorough preoperative evaluation. These clinicoradiological points
can be of help in early diagnosis and better outcomes.

Keywords

Aspergillosis, early diagnosis, squash smear

For correspondence:
Dr. Deepak Goel, Neurology Department, Himalayan Institute of Medical Sciences, Swami Ram Nagar,
Doiwala, Dehradun, Uttaranchal, India. E-mail: goeld007in@yahoo.co.in

Ann Indian Acad Neurol 2007;10:263-5

Introduction and perifocal edema [Figure 1]. Preoperative MRI was

Aspergilloma is unusually considered as the differential
of intracranial mass lesion in the preoperative phase.[1]
Their presentation is subtle, often without any diagnostic
characteristics and they are frequently mistaken for
brain tumors.[2] Therefore, these cases are frequently
encountered as a clinical surprise after histological
diagnosis.
Many authors had drawn attention about the difficulties
in diagnosis of this dreadful condition with nonspeciÞc
clinical and radiological Þndings.[3] The early suspicion
of diagnosis is the only method to reduce the high
mortality.[3]
done by the neurosurgeon for better delineation of
the lesion and planning of resection. The surgery was
performed with left temporal craniotomy and a bony
hard avascular lesion with well-deÞned margins from
the medial to middle temporal gyrus was observed.
The tumor was attached to the wall of cavernous sinus.
Squash smear per-operatively showed fungal hyphae
and histological diagnosis of aspergilloma was Þnalized
[Figure 2].
Case 2
The second patient was admitted at around 6 months

We discuss how we failed to initiate a prospective

diagnosis in two cases of aspergilloma as an etiology of
cerebral mass lesion.

Case Reports

Case 1
A 32-year-old male patient with headache, proptosis,
diplopia and progressive Visual loss in left eye for last 3
months was referred to the neurosurgery department.
Referral diagnosis was malignant glioma on the basis of
brain CT scan Þnding, showing a lesion in left temporal Figure 1: Contrast CT scan showing moderately enhanced mass in the
lobe occupying a large space with contrast enhancement left frontotemporal region with perifocal edema at time of referral

Annals of Indian Academy of Neurology - October-December 2007

264
Figure 2: Squash smear showing hyphae of aspergillus branching
at acute angle (H&E ×200)
after the Þrst case. This 50-year-old male presented with
headache and progressive loss vision for Þve months.
This headache became worse over the time and after
the onset of visual symptoms, a CT scan was performed
outside that showed large mass in right frontal area. He
was referred as malignant glioma. We performed MRI
which showed an enhancing right basifrontal lesion
with a radiological possibility of anaplastic astrocytoma.
Surgery was performed with right frontal craniotomy
and excision of tumor. There was solid grayish, Þrm to
hard nonsuckable mass with deÞnite plane of cleavage.
Squash smear showed fungal hyphae; later on, it was
proved to be aspergillosis.
Two cases of aspergilloma were diagnosed at the interval
of 6 months and both were missed preoperatively. The
points we missed in favor of diagnosis were very simple
related to history taking and clinical examination.
Retrospective clinical and radiological analysis was done
in both cases after histological diagnosis of aspergilloma.
In the detailed histories, Þrst case had measles 6 months
back and got some treatment for nasal block and recurrent
sinusitis for many time in past, while the second case
underwent some nasal surgery for epistaxis 13 years back.
Second, the nasopharyngeal examination was not thought
to be important. Cerebrospinal ßuid (CSF) examination
was not done as we were biased for glioma ignored
involvement of paranasal air and large venous sinus
on MRI [Figure 3]. Both the patients were nondiabetic
and HIV serology was negative. We could not perform
other work-up for the assessment of the immune status.
Both the patients were administered with amphotericin
in postoperative period and both of them died with in
6 months.
Discussion
Aspergillosis is the most common among the fungal
Annals of Indian Academy of Neurology - October-December 2007
Goel, et al.: Early diagnosis of cerebral aspergilloma
Figure 3: T1W post-contrast MRI image showing the involvement
of paranasal sinuses, cavernous sinus orbit and left temporal lobe
infections of CNS; however, on an average, the reporting
rates suggest one case per year.[4] The predominant
symptoms involve headache, vomiting and cranial-
nerve-related symptoms, while the rare symptoms are
fever, nasal congestion and seizures. Common signs
included papilledema with cranial neuropathy (I, III/IV/
VI and V in 4, 7 and 2 patients, respectively), hemiparesis
and meningismus. Two-third cases found to have some
predisposing immunocompromised state, diabetes
being the commonest, while one-third cases have no
predisposition. The most common site of involvement is
the frontal area followed by the parasalar region.[4]
Our cases are the best examples to reemphasize that taking
the clinical history and examination is irreplaceable by
technology for reaching a correct diagnosis. Although
our patients had a number of clinicoradiological features
indicating towards the diagnosis of fungal infection, we
could only notice them after histological diagnosis.
Paranasal infections in the past and the topical use of
decongestant with steroids might play an important
role in predisposing fungal growth. Existing literature
have no account for the history of old ENT problems in
reported cases; however, radiologically, 40% patients
have evidences of paranasal sinus involvement.[4] Fungal
infection can directly extend intracranially from the
paranasal sinuses.[5-7] Therefore, at times, intracranial
lesions have continuation with paranasal sinuses. The
proximity of cranial lesion to the nasal sinus is another
point that we had failed to notice in our evaluation. Both
the patients had abnormal intensity in the paranasal
sinuses and lesions were in close proximity to these
sinuses.
The MRI signal characteristics in aspergilloma were
compared with the histologic Þndings. Irregular low-
signal zones were demonstrated between the wall of the
Goel, et al.: Early diagnosis of cerebral aspergilloma
Figure 4: T2W MRI showing heterogeneous mass with markedly
hypointense areas medially toward sinuses probably due to high iron
content
abscess and the central necrosis on T2-weighted images;
the pathology specimen revealed concentrated iron in
these transitional zones, but no hemosiderin. Iron is an
essential element for the growth of fungal hyphae. The
low-signal zones may represent the areas where there
was active proliferation of Aspergillus and the unique
location of the low signal may be a helpful imaging
characteristic for the diagnosis of abscess caused by
Aspergillus.[8] This MRI Þnding was nicely demonstrated
in our cases also [Figure 4].
Large venous sinus thrombosis is the common cause of
presentation in fungal infection of CNS. The involvement
of superior sagittal and cavernous sinus is common.[9]
This point also requires special attention during the MRI
evaluation of these patients. All our patients had venous
sinus involvement.
We realized from our errors that for the cases with
intracranial mass lesions, involving paranasal and
venous sinuses and positive nasal problem in past,
265
a detailed nasopharyngeal and paranasal evaluation
is more important than rushing for the surgery. This
may give the diagnosis in the preoperative stage and
the treatment with antifungal drugs can be started
early. The opening of vascular channels and the use of
corticosteroids in the postoperative period makes the
prognosis worst in undiagnosed cases.
The Þnal conclusion is that every patient with intracranial
space occupying lesion should be subjected to a systemic
approach of clinical history and examination rather than
rushing to the operation theater.
References
1. Alapatt JP, Kutty RK, Gopi PP, Challissery J. Middle and posterior
fossa aspergilloma. Surg Neurol 2006;66:75-9.
2. Nadkarni T, Goel A. Aspergilloma of the brain: An overview.
J Postgrad Med 2005;51:37-41.
3. Fardoun R, Rao NK, Miskeen AK. Cerebral aspergilloma: Review of
the literature apropos of a case. Neurochirurgie 1990;36:45-51.
4. Dubey A, Patwardhan RV, Sampth S, Santosh V, Kolluri S,
Nanda A. Intracranial fungal granuloma: Analysis of 40 patients
and review of the literature. Surg Neurol 2005;63:254-60.
5. Coulthard A, Gholkar A, Sengupta RP. Case report: Frontal
aspergilloma: A complication of paranasal aspergillosis. Clin Radiol
1991;44:425-7.
6. Wilms G, Lammens M, Dom R, Boogaerts M, Marchal G,
Demaerel P, et al. MR imaging of intracranial aspergilloma
extending from the sphenoid sinus in an immunocompromised
patient with multiple myeloma. J Belge Radiol 1992;75:29-32.
7. Swoboda H, Ullrich R. Aspergilloma in the frontal sinus expanding
into the orbit. J Clin Pathol 1992;45:629-30.
8. Yamada K, Zoarski GH, Rothman MI, Zagardo MT, Nishimura T, Sun
CC. An intracranial aspergilloma with low signal on T2-weighted
images corresponding to iron accumulation. Neuroradiology
2001;43:559-61.
9. Goel A, Nadkarni T, Desai AP. Aspergilloma in the paracavernous
region-two case reports. Neurol Med Chir (Tokyo) 1996;36:
733-6.
Received: 26-04-07, Revised: 11-06-07, Accepted: 12-07-07
Source of Support: Nil, Conflict of Interest: Nil
Annals of Indian Academy of Neurology - October-December 2007