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LETTER TO EDITOR
Year : 2017  |  Volume : 65  |  Issue : 5  |  Page : 1169-1170

Intracranial inflammatory pseudotumor presenting as an en plaque mass


Department of Neurosurgery, Chettinad Hospital and Research Institute, Chettinad Academy of Research and Education, Kelambakkam, Chennai, Tamil Nadu, India

Date of Web Publication6-Sep-2017

Correspondence Address:
Vengalathur G Ramesh
Department of Neurosurgery, Chettinad Hospital and Research Institute, Chettinad Academy of Research and Education, Kelambakkam, Chennai - 603 103, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/neuroindia.NI_395_17

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How to cite this article:
Gautam S, Ramesh VG, Karthikeyan KV, Krishnakumar M. Intracranial inflammatory pseudotumor presenting as an en plaque mass. Neurol India 2017;65:1169-70

How to cite this URL:
Gautam S, Ramesh VG, Karthikeyan KV, Krishnakumar M. Intracranial inflammatory pseudotumor presenting as an en plaque mass. Neurol India [serial online] 2017 [cited 2019 Aug 21];65:1169-70. Available from: http://www.neurologyindia.com/text.asp?2017/65/5/1169/214049




Sir,

Inflammatory pseudotumor (IPT), also called inflammatory myofibroblastic tumor or plasma cell granuloma, is a rare, benign condition of unusual etiopathogenesis and histopathology affecting almost all organ systems of the body. Intracranial occurrence of an IPT is relatively rare. Only a few case reports are available.

A 62-year old lady presented with recurrent episodes of right focal motor seizures since 2 months. The neurological examination was normal. Magnetic resonance imaging of the brain showed evidence of a contrast-enhancing en plaque lesion in the left high parietal region, with surrounding edema [Figure 1]a,[Figure 1]b,[Figure 1]c. The patient was a known case of hypertension, hypothyroidism, and coronary artery disease. She underwent a left parietal craniotomy and excision of the lesion. Intraoperatively, the tumor was soft, whitish, moderately vascular, and appeared extraparenchymal with attachment to the dura mimicking a meningioma, and was excised completely. Histopathology showed features of IPT [Figure 2]. The patient made an uneventful recovery. The follow-up imaging done a year later showed no evidence of recurrence [Figure 1]d.
Figure 1: MRI brain (T1 contrast) axial (a), sagittal (b) and coronal (c), showing the en plaque tumor in the left high parietal region and postoperative MRI (d) after I year showing no evidence of recurrence

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Figure 2: Histopathology picture (H and E, ×40) showing thick-walled blood vessels with adjacent fibrous areas and polymorphous infiltrate of lymphocytes and plasma cells

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An orbital IPT was first described by Birch-Hirschfield in 1905. It was named an ‘inflammatory pseudotumor’ by Umiker et al., in 1954 because of its clinical and radiological similarity to a malignant lesion.[1] An IPT of the central nervous system (CNS) is rare and is usually seen in children and young adults. These patients usually either have no symptoms or present with constitutional symptoms such as fever and weight loss, as well as symptoms caused by the local mass effect of the lesion. In the brain, IPT is either found in the parenchyma or is attached to the dura, or may be present as a part of both these structures. In such patients, MR spectroscopy shows a lactate peak, suggesting the presence of inflammation and hypoxia, and an increase in the choline peak, suggesting increased cellularity and cell membrane synthesis caused by inflammation.[2] A histopathological examination is necessary for establishing the definitive diagnosis of IPT. The biopsy ideally shows nonspecific infiltration of inflammatory cells comprising lymphocytes, plasma cells, neutrophils, and macrophages. Due to the chronic nature of the condition, a varying degree of necrosis is seen. Variable giant cells, calcification, and circumferential fibrosis of the small veins is also seen.[3] Administration of steroids and performing surgical resection are the treatment modalities available for IPT of the head and neck. If the tumor is resectable, complete excision is the preferred treatment of choice. Recurrence after preliminary treatment with surgical excision is also common. Pascual-Gallego (2013) reported a case of recurrent meningeal inflammatory myofibroblastic tumor and reviewed 18 previous cases of recurrence.[4] Surgical excision with adjuvant chemotherapy is advocated in such cases. Radiotherapy has been tried with varying degrees of success.

There are not many reported cases of IPT of the brain in the literature. It should be considered as one of the differential diagnosis for dural-based or parenchymal tumors of the brain.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
De Vuysere S, Hermans R, Sciot R. Extraorbital inflammatory pseudotumor of the head and neck: CT and MR findings in three patients. Am J Neuroradiol 1999;20:1133-9.  Back to cited text no. 1
    
2.
McKinney AM, Short J, Lucatol L. Inflammatory myofibroblastic tumor of the orbit with associated enhancement of the meninges and multiple cranial nerves. Am J Neuroradiol 2006;27:2217-20.  Back to cited text no. 2
    
3.
Coffin CM, Watterson J, Priest JR, Dehner LP. Extrapulmonary inflammatory myofibroblastic tumor (inflammatory pseudotumor): A clinicopathologic and immunohistochemical study of 84 cases. Am J Surg Pathol 1995;19:859-72.  Back to cited text no. 3
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4.
Pascual-Gallego M, Yus-Fuertes M, Jorquera M, Gonzalez-Maté A, Ortega L, Martínez-Martínez A, et al. Recurrent meningeal inflammatory myofibroblastic tumor: A case report and literature review. Neurol India 2013;61:644-9.  Back to cited text no. 4
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