Saeed Mazher, Abdul Ali Khan, Zaheen Shibli, Abdul Lateef, Shafaatullah, Zeeshan Faisal.
Diagnostic dilemma of Intracranial fungal granuloma risk versus benefit assessment before Neurosurgical management.
Pak J Surg Jan ;36(4):321-7.

Objective: MRI and outcome based learning experience in the management of intracranial fungal granulomas and atypical brain infections (IFG) considering risk versus benefit before neurosurgical interventions. Material and Methods: We performed a retrospective analysis of all patients with diagnosed IFG or anticipated diagnosis based predominantly on imaging from 2011 to 2019 collected data included clinical history, lab results treatment and review of all imaging studies performed. Among these cases, one case required additional consideration of histo-pathological confirmation due to refractory response to anti-fungal medication and subsequent deterioration of neurology of patient hence neurosurgical intervention was done in that individual case. The organized data covered clinical history, lab results and treatment outcome, review of imaging. Results: The most prominent symptoms noted were headache 80%, proptosis 20%, hypertelorism and visual diminution. Other symptoms like unilateral body weakness and cranial neuropathies were found among couple of patients. Pre-disposing risk factors notified were diabetes, renal dialysis and preexisting tumor. Location was primarily frontal 1 parasellar 1 in each involvement. One patient underwent frontal craniotomy for resection of fungal granuloma abscess histopathology revealed aspergilloma. All patients were treated with itraconazol except the one in whom the isolated bacterial organism was reported therefore she was kept on sensitive antibiotics for 3 to 6 months. Few were offered fluconazole, flucytosine and amphotericin B for a brief period. Mortality 1 secondary to meningo-encephalitis. Conclusion: Early diagnosis, risk versus benefit assessment oriented surgical decompression and prophylactic anti-fungal course according to variability of case with prompt initiation of antifungal therapy showed better outcome. Administration of itrconazol therapy showed improvement in the clinical neurology and over all outcomes with in the period of 6 months to one year. In future perspective, firm clinical therapeutic recommendations can be established by the help of larger trials.

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