Medknow Publications on behalf of the Neurological Society of India
Abstract
Background: Intracranial fungal masses (IFMs, granulomas and abscesses)
are uncommon lesions, infrequently encountered by neurosurgeons. There
is no conclusive evidence on the ideal surgical management of these
lesions. Aims: To summarize the recent literature on the prevalence,
presentation, surgical management and outcome of patients with IFMs.
Materials and Methods: The recent published literature was searched
using standard search engines (PubMed and Google) for articles
reporting on the databases and surgical management of IFMs. A special
effort was made to include publications from Indian centers. Results:
Intracranial fungal masses were rarely seen even in major neurosurgical
centers in India with a prevalence of around one to two per year. While
most patients with IFM have immunosuppressed states, nearly 50% of
patients with IFMs (especially in India) have no obvious predisposing
causes and are apparently immunocompetent. The clinical presentation
could be categorized into three groups: 1. Involvement of the cranial
nerves 1 to 6 with orbital and nasal symptoms. 2. Focal neurological
deficits due to involvement of any part of the neuraxis; and 3.
"Stroke-like" presentation with sudden onset of hemiparesis. Based on
the presence or absence of radiological evidence of paranasal sinus
disease, IFMs were classified into two types: 1. Rhinocerebral type; 2.
Purely intracranial type that was further divided into a. intracerebral
or b. extracerebral forms. Aspergillus species was the commonest fungal
organism causing IFMs but a number of other fungi have been reported to
cause IFMs. Surgery for IFMs can be of different types, namely 1.
Stereotactic procedures; 2. Craniotomy; 3. Shunt surgery; and 4.
Treatment of fungal aneurysms. Generally, radical surgery is advocated
for IFMs but there is no unanimity regarding the radicality of the
excision especially for the rhinocerebral form of the disease. Surgery
should always be followed by antifungal therapy for prolonged periods.
Mortality and morbidity in patients with IFMs is very high and ranges
from 40-92%. Immunosuppressed patients with IFMs and those in whom the
diagnosis is delayed have the highest mortality rates, with
immunocompetent patients with the rhinocerebral form of the disease
having the best outcome. Conclusions: There should be a high index of
suspicion for IFMs not only in patients with known risk factors for the
development of fungal infections but also in immunocompetent patients
in India. Intraoperative pathological diagnosis should be obtained in
any patient suspected to have an IFM and tissue should be processed for
fungal cultures. Prompt diagnosis, radical and safe surgery and
aggressive and prolonged treatment with anti-fungal agents may lead to
a better outcome especially in immunocompetent patients