CNS aspergillosis is rare. However, the number of reported cases increased significantly in the last decade ()7,10-14,16,19)
. Aspergillus can reach the CNS by three different routes. The first is by hematogenous spread from a remote extracranial focus. The second is by extension from a contiguous extracranial location, and the third is direct introduction of aspergillus by a neurosurgical procedure iatrogenically3)
Reported cases of CNS aspergillosis in an immunocompetent patient in the last decade
CNS aspergillosis is very serious, with a mortality of more than 90%2,15)
. CNS aspergillos presents as meningitis, encephalitis, brain abscesses, subdural abscesses, mycotic arteritis or sellar abscess5)
Preoperative diagnosis of parasellar aspergillus abscess is difficult because clinical presentation and imaging findings in these patients are very similar to the symptoms and imaging results in patients with neoplasms9,17)
. Headaches and unilateral ophthalmologic signs, including orbital pain, visual deterioration and progressive ophthalmoplegia dominate the clinical presentation of parasellar aspergillus abscess. Ptosis is reported in up to 46% of published reports4)
. MRI is the best technique for the radiological evaluation of a sellar abscess, but the definitive diagnosis is made with histological tests1,8)
. On an MRI, the sellar abscess usually appears as a hypo-isointense sellar mass on T1-weighted sequences, as a hyperintense mass on T2-weighted sequences, and as a cystic lesion with peripheral ring enhancement after the administration of a contrast medium. In our patients, imaging findings suggested parasellar tumor, but the contrast enhanced rims of the masses and the clinical findings led us to reconsider the preoperative diagnoses.
Patients with aspergillosis have historically been treated with amphotericine B or combined therapy with amphotericine B and flucytosine or itraconazole. The superiority of voriconazole and caspofungin over amphotericin B as initial therapy for aspergillosis infection in terms of response rate, survival rate, and safety has now been demonstrated in a large randomised study6,18)
. The aim of treatment should be the complete removal of the masses as early as possible. Even with the invasive type, providing intra dural extension had not yet occurred, total excision was curative without systemic use of antifungal agents. However, in patients in whom total removal cannot be achieved or intra dural invasion has already been confirmed, intensive systemic therapy with antifungal agents must be administered postoperatively to prevent subsequent lethal vasculitis or meningoencephalitis developing. In our case, treatment by voriconazole and amphotericine B was effective in patient, but patient died of cerebral ischemic change, possibly due to resistance for antifungal agents, or developing vessel invasion.