A 50-year-old female was admitted with a paroxysmal boring pain in the left parietal and left frontal region for 9 months, accompanied by progressive vomiting and decreasing of visual acuity and proptosis in the left eye. Headache could be relieved by diclofenac sodium. Two months prior to presentation, her headache worsened extending to the whole left side of the face, accompanied by numbness. No light perception or reflex was detected in the left eye. Horizontal movement was limited in the left eye. Pre-operative CT showed a 29 × 20 mm isodense lesion with heterogeneously enhancement in the region of the left cavernous sinus, left orbital apex, left optic nerve canal, and sphenoid sinus. Bone destruction could be seen in the left wall of the sphenoid sinus. The optic nerve could not be distinguished from the lesion (Fig. a). MRI showed a 21 × 26 mm patchy lesion that was isointense on T1WI and hyperintense on T2WI in the left cavernous sinus region (Fig. b, c). Enhanced-MRI showed noticeable enhancement of the lesion. The lesion was closely related to the dura mater and extended to the sphenoid sinus and optic apex, partly surrounding the left internal carotid artery (Fig. d). MRA suggested stenosis in the cavernous segment of the left internal carotid artery and A1 segment of the left anterior cerebral artery. The patient underwent partial mass excision via a pterional craniotomy due to its close attachment to the ophthalmic branch and maxillary branch of the trigeminal nerve. The lesion was partly fibrotic and partly a milk-white viscous substance. A biopsy was performed immediately and histopathologic examination revealed Aspergillus species (Fig. e). The patient was administered voriconazole after surgery. Post-operative images indicated the resection of the mass (Fig. f). Examination after a follow-up of 15 months showed a complete resolution of the headache. Her vision of the left eye was not regained.
A 73-year-old male was admitted to our hospital with the complaints of headache persisting for approximately three months, and presented with progressive visual deterioration and ptosis in the right eye. He had no known disease and no apparent immune deficiencies. On physical examination, he was afebrile, but he had experienced unintentional weight loss and fatigue. His general condition was poor as a result of malnutrition. The neurological examination revealed a ptosis, ophthalmoplegia, and impairment of visual acuity on the right eye. His laboratory results were as follows : white cell count, 9.100/µL; sedimentation rate, C-reactive protein, peripheral smear and biochemical tests were all in normal range. Viral markers were negative.\nMagnetic resonance imaging (MRI) revealed a mass in the right cavernous sinus, extended to the anterior crainial fossa and the superior orbital fissure with an iso-signal intensity in T1-weighted iamge. The lesion showed a slightly low signal intensity in T2-weighted sequences and strong enhancement (). Based on these MRI findings, the impression was inflammatory abscess, but meningioma or metastatic tumor were also suspected. The patient underwent a pterional approach craniotomy for pathologic diagnosis and decompression of neural structures. During surgery, a well-encapsulated pus pocket was found at the clinoid process, and severe adhesion with the surrounding tissue was encountered. An intra-operative frozen biopsy revealed a fungal infection. The biopsy material showed inflammatory granulation tissue and micro abscesses containing a large number of hyphae with 45 degree angulations and spores (). The pathology result was consistent with aspergillus infection.\nPostoperatively, the patient was treated by systemic administration of antifungal drug (Amphotericin-B and Voriconazole), to which he showed only a minimal response. Despite appropriate medical and surgical treatment, the disease progressed and the patient eventually died from fatal cerebral ischemic change and severe brain swelling on the 23rd postoperative day ().