INTRODUCTION Granulomatous inflammation is a distinctive ...

aspergillosis was the most common cause of mycotic aneurysms (Nadkarni and Goel, 2005).
These patients may present with typical subarachnoid hemorrhage syndrome. Intraluminal
extension of the hyphae can also initiate thrombus formation. Rarely, major arterial stenosis may
occur following leptomeningeal infection. Steroids can inhibit the macrophage response to
intracellular fungus and may permit enhanced germination (Nadkarni and Goel, 2005).
Fungal invasion can continue through the arteries and veins (angiotropic).and into the adjacent
brain parenchyma (and sometimes in reverse direction). The evolving haemorrhagic infarcts
convert into septic infarcts with associated single or multiple abscesses and cerebritis. Purulent
lesions may be chronic and have a tendency towards fibrosis and granuloma formation.
Microscopically the most striking feature is the intensity of the vascular invasion with thrombosis.
In purulent lesions, pus is seen in the center of the abscesses with abundant polymorphs at the
periphery. Granulomas consist of lymphocytes, plasma cells, and fungal hyphae (Sharma et al.,
2000).
Clinical picture
Aspergillosis should be considered in cases manifesting with acute onset of focal neurological
deficits resulting from a suspected vascular or space-occupying lesions especially in
immunocompromised hosts. In patients with paranasal sinus disease, orbital extension with
proptosis, ocular palsies, visual deterioration, and chemosis may occur. The symptoms frequently
encountered are headache, vomiting, convulsions, hemiparesis, fever, cranial nerve deficits,
paralysis, and sensory impairment of varying degree. Features typical of meningitis and
subarachnoid or intracranial hemorrhage may manifest (Saravia, 1978; Hall, 1992; Sharma et al.,
2000). Patients are often afebrile or have only a low-grade fever.
In immunocompetent patients, the disease is usually slowly progressive and symptoms may persist
for months. However, if brainstem or cerebellar signs were the presenting features rapid
neurological deterioration and death usually succumbed (Hall, 1992). Goel et al in 1996, have
reported aspergilloma to involve the Gasserian ganglion in two healthy individuals. These
paracavernous tumors mimicked a meningioma and a trigeminal neuroma on preoperative
imaging and intraoperative consistency and vascularity. The lesions were successfully and
completely resected. Both patients developed major cerebral arterial territory infarcts in the
postoperative phase, remote from the site of the operation, leading to crippling neurological
deficits in one patient, and death in the other. Nadkarni et al in 2003 have reported a similar
clinical course in a 32-year-old male with paranasal sinus infection with intracranial extension.
This patient succumbed to a basilar artery thrombosis following a left frontal granuloma excision.
These cases highlight the unusual location of intracranial aspergilloma and the possibility of
ischaemic complications after surgical resection of intracranial aspergilloma (Nadkarni and Goel,
2005).
Investigations
Aspergillosis is diagnosed on direct examinations and culture, however, the diagnosis of
aspergillosis of the CNS is difficult. The mortality rate of cerebral aspergillosis approaches 100%
in these immunocompromised patients (Epstein et al., 1991), but there are occasional case reports
noting survival with combined aggressive antifungal therapy and surgical resection (Ashdown et
al., 1994). This makes early diagnosis essential. The clinical and laboratory diagnosis of cerebral
aspergillosis is difficult, so imaging modalities such as CT and MR are important (Cox et al., 1992;
Miaux et al., 1994; Yuh et al., 1994).
CSF examination