Intracranial aspergilloma mimicking metachronous meningioma following transsphenoidal removal of a tuberculum sellae meningioma: illustrative case

Daisuke Sato Departments of Neurosurgery

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Hirotaka Hasegawa Departments of Neurosurgery

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Hironobu Nishijima Otorhinolaryngology, and

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Kyotaro Kawase Infectious Diseases, The University of Tokyo Hospital, Tokyo, Japan

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Koh Okamoto Infectious Diseases, The University of Tokyo Hospital, Tokyo, Japan

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Akiko Iwasaki Department of Pathology and Diagnostic Pathology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan; and

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Yuki Shinya Departments of Neurosurgery

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Masahiro Abe Department of Fungal Infection, National Institute of Infectious Diseases, Tokyo, Japan

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Yoshitsugu Miyazaki Department of Fungal Infection, National Institute of Infectious Diseases, Tokyo, Japan

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Nobuhito Saito Departments of Neurosurgery

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BACKGROUND

Endoscopic transsphenoidal surgery (eTSS) is a well-established approach for resection of skull-based pathologies such as tuberculum sellae meningiomas; however, central nervous system (CNS) fungal infection is a potential complication, particularly in a patient with concomitant sinusitis.

OBSERVATIONS

A 58-year-old woman with a tuberculum sellae meningioma causing progressive visual disturbance and concurrent asymptomatic chronic maxillary sinusitis underwent eTSS. Six months later, a de novo dura-based mass with peripheral edema, which was assumed to be an aggressive metachronous meningioma, developed in the middle cranial fossa. The patient underwent frontotemporal craniotomy for complete resection of the lesion, and subsequent histological examination revealed an aspergilloma. She was then treated with an antifungal agent and endoscopic sinus surgery to clear the sinusitis, and no recurrent fungal infection occurred thereafter.

LESSONS

CNS fungal infections may appear as a dura-based mass mimicking meningioma. The current case reiterates the importance of the appropriate management of sinusitis prior to eTSS.

ABBREVIATIONS

CNS = central nervous system; CSF = cerebrospinal fluid; eTSS = endoscopic transsphenoidal surgery; MRI = magnetic resonance imaging

BACKGROUND

Endoscopic transsphenoidal surgery (eTSS) is a well-established approach for resection of skull-based pathologies such as tuberculum sellae meningiomas; however, central nervous system (CNS) fungal infection is a potential complication, particularly in a patient with concomitant sinusitis.

OBSERVATIONS

A 58-year-old woman with a tuberculum sellae meningioma causing progressive visual disturbance and concurrent asymptomatic chronic maxillary sinusitis underwent eTSS. Six months later, a de novo dura-based mass with peripheral edema, which was assumed to be an aggressive metachronous meningioma, developed in the middle cranial fossa. The patient underwent frontotemporal craniotomy for complete resection of the lesion, and subsequent histological examination revealed an aspergilloma. She was then treated with an antifungal agent and endoscopic sinus surgery to clear the sinusitis, and no recurrent fungal infection occurred thereafter.

LESSONS

CNS fungal infections may appear as a dura-based mass mimicking meningioma. The current case reiterates the importance of the appropriate management of sinusitis prior to eTSS.

ABBREVIATIONS

CNS = central nervous system; CSF = cerebrospinal fluid; eTSS = endoscopic transsphenoidal surgery; MRI = magnetic resonance imaging

Central nervous system (CNS) infection following endoscopic transsphenoidal surgery (eTSS) is a relatively uncommon complication, with an incidence ranging from 0.6% to 10.3% in patients who undergo eTSS.1,2 There has been a longstanding debate about the risk of CNS infection following eTSS in patients with coincidental rhinosinusitis.1–4 There is evidence in the literature that chronic rhinosinusitis does not always predispose to postoperative CNS infection.1,5,6

Compared with bacterial infection of the CNS, fungal infection is an extremely rare complication following eTSS. Post-eTSS CNS aspergillosis infection has been reported infrequently, usually presenting as a mycotic aneurysm subsequent to vasculitis or a local fungus ball formation.7–9 Here, we describe a case of CNS aspergilloma that developed over 6 months following eTSS for a tuberculum sellae meningioma in an immunocompetent patient who had concurrent asymptomatic fungal sinusitis at the time of the initial eTSS.

Illustrative Case

A 58-year-old woman was referred to our department following incidental detection of a tuberculum sellae meningioma. She had a medical history of papillary carcinoma of the thyroid that had been resected 5 years earlier without any recurrence. As the patient was initially asymptomatic, she underwent regular follow-up with magnetic resonance imaging (MRI). However, the tumor showed significant progression and began to cause bitemporal hemianopsia, for which the patient was scheduled for tumor resection (Fig. 1A). At that time, the imaging findings also suggested chronic sinusitis in the left maxillary sinus (Fig. 1B); however, tumor resection was prioritized given her progressively deteriorating vision and the absence of sinonasal symptoms. Simpson grade 1 removal was achieved at eTSS (Fig. 1C), and the dural defect was reconstructed in a multilayered fashion using a collagen matrix (DuraGen, Integra Japan) and inlay and onlay fascial grafts that were reinforced with fat pieces, fibrin glue, and sinus balloon. Her postoperative course was uneventful, without cerebrospinal fluid (CSF) leakage, and her vision fully improved.

FIG. 1.
FIG. 1.

A: MRI reveals a tuberculum sellae meningioma compressing the anterior optic pathways. B: Computed tomography demonstrates fluid collection with abnormal calcification in the left maxillary sinus. C: An intraoperative image obtained during the first surgery showing complete removal of the meningioma.

On follow-up MRI performed 6 months later, a small, homogeneously enhancing, dura-based mass was observed in the left middle fossa (Fig. 2A). The mass increased in size over 6 weeks (Fig. 2B) and exhibited perilesional edema (Fig. 2C). 18F-fluorodeoxyglucose positron emission tomography demonstrated an increased radiotracer uptake in the mass (Fig. 2D), for which an aggressive metachronous meningioma was primarily suspected. En bloc resection of the mass was performed through left frontotemporal craniotomy. During the surgery, the mass was found to be grayish, firm, and attached to both the lateral wall of the cavernous sinus and the temporal parenchyma, without interrupting the arachnoid membrane (Fig. 3A). Subsequent histological examination confirmed that the mass was an aspergilloma (Fig. 3B). In addition, Aspergillus fumigatus was identified by molecular analysis of formalin-fixed, paraffin-embedded tissue. Upon diagnosis, intravenous administration of voriconazole was initiated, and endoscopic sinus surgery was performed to clear the sinus infection, revealing what appeared to be a fungus ball (Fig. 3C). Oral voriconazole was continued for 6 months. Routine imaging surveillance 3 months post–transcranial removal of the aspergilloma showed no evidence of recurrent fungal infection.

FIG. 2.
FIG. 2.

A: MRI demonstrates an extra-axial mass (red arrowhead) arising from the lateral wall of the left cavernous sinus. The mass (red arrowheads) demonstrates rapid growth at follow-up imaging performed 6 months later (B) with remarkable perilesional edema (C). D: Positron emission tomography shows an increased uptake of radiotracer (red arrowhead).

FIG. 3.
FIG. 3.

A: An intraoperative photograph demonstrates a firm grayish mass (yellow asterisk) arising from the dura). B: Original magnification ×60 and inset ×800 Histopathologically, the mass is shown to be a dense infiltration of inflammatory cells (hematoxylin and eosin) and Aspergillus hyphae at the center on high magnification (inset). Since the Aspergillus hyphae are denatured, Grocott stain and periodic acid-Schiff stain revealed only weak positivity (not shown). C: An intraoperative image of the endonasal sinus surgery demonstrates fungal abscess formation (black asterisk) in the left maxillary sinus.

Discussion

Observations

In this report, we present a case of intracranial aspergilloma mimicking meningioma that progressively developed following eTSS for tuberculum sellae meningioma. We share our experience and draw important conclusions from this case.

eTSS has made great progress over the past few decades and is now commonly used for a variety of skull-base pathologies in the sellar and parasellar regions.10–13 Despite its minimal invasiveness, the risk of postoperative CNS infection is, albeit not high, nonnegligible.1,2 Given the possible risk of spreading microorganisms into the CSF space,1 controversy remains regarding the preoperative management of asymptomatic, radiologically diagnosed rhinosinusitis. Some argue that it may be considered a contraindication for eTSS; however, in reality, most neurosurgeons perform eTSS regardless of the presence of concurrent rhinosinusitis, unless sphenoid sinusitis or acute purulent rhinosinusitis is suspected.4,6 Some reports have demonstrated that the rate of post-eTSS CNS infection is not significantly higher in patients with concurrent rhinosinusitis.5,6

Fungal rhinosinusitis encompasses a wide spectrum of clinicopathological entities,14 and they are generally classified into 2 types. Invasive fungal rhinosinusitis has the potential to follow a rapid and fatal course and requires radical surgery.15 The noninvasive form is generally an accumulation of fungal hyphae in the sinus cavity that remains asymptomatic16 and does not always necessitate surgical intervention. However, our case reiterates the importance of appropriate management of noninvasive fungal rhinosinusitis prior to eTSS for intradural pathologies. Abundant fungal hyphae in the infected maxillary sinus were likely to have been the source of the CNS aspergillosis infection. Neurosurgeons should bear in mind the possibility of spreading the microorganism that is flourishing in the nasal and sinus cavities to the CNS.

CNS fungal infections are extremely rare17 and are typically encountered in immunocompromised patients.8,18 Aspergillus spp. are some of the most common causative agents and are responsible for significant mortality.19,20 CNS aspergillosis can manifest in a variety of forms, including mycotic aneurysm, arteritis, thrombosis, localized abscess, meningitis, and granuloma.21 In our case, the intracranial aspergilloma appeared as well-enhanced, dura-based mass, which was mistaken for meningioma, partly due to the recent history of meningioma in an adjacent region. This highlights the importance of recognizing CNS aspergillosis infection as a differential diagnosis for an extra-axial dura-based mass.

The mortality of CNS aspergillosis is estimated to be as high as 40%–80%.19,22 This high mortality rate may be due to the potential vascular complications of aspergillosis infection and the often impaired immunity of the affected patients; thus, these factors should be thoroughly investigated.23 In contrast, aspergillosis infection forming a solid mass has a relatively good prognosis.20,23 The recommended treatment is radical surgical excision followed by antifungal therapy in consultation with an infectious disease team.23 Voriconazole is generally advised because of its favorable penetration into the CNS.5,24 Proper selection of antifungal agents and surgical intervention without delay are critical.

Lessons

Intracranial aspergilloma may occur following eTSS, even from coincidental asymptomatic fungal rhinosinusitis, and should be recognized as an important complication of eTSS. Aspergillomas can be dura-based and thus masquerade as meningiomas. Our case reiterates the importance of timely and appropriate management of sinusitis prior to eTSS.

Disclosures

Dr. Okamoto reported personal fees from Kyorin Pharmaceutical, Nippon Becton Dickinson Company, AstraZeneca, Sanyo Chemical, Astellas Pharma, and Ono Pharmaceutical outside the submitted work. No other disclosures were reported.

Author Contributions

Conception and design: Hasegawa, Sato. Acquisition of data: Sato, Nishijima, Okamoto, Iwasaki, Shinya, Abe, Miyazaki. Analysis and interpretation of data: Sato, Okamoto, Shinya, Miyazaki. Drafting of the article: Sato. Critically revising the article: Hasegawa, Okamoto, Shinya, Abe. Reviewed submitted version of the manuscript: Hasegawa, Okamoto, Iwasaki, Shinya, Abe, Saito. Approved the final version of the manuscript on behalf of all authors: Hasegawa. Administrative/technical/material support: Abe. Study supervision: Hasegawa. Infectious disease consultation: Kawase.

References

  • 1

    Pagliano P, Caggiano C, Ascione T, et al. Characteristics of meningitis following transsphenoidal endoscopic surgery: a case series and a systematic literature review. Infection. 2017;45(6):841848.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 2

    Lee SJ, Cohen J, Chan J, Walgama E, Wu A, Mamelak AN. Infectious complications of expanded endoscopic transsphenoidal surgery: a retrospective cohort analysis of 100 cases. J Neurol Surg B Skull Base. 2020;81(5):497504.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 3

    Nyquist GG, Friedel ME, Singhal S, et al. Surgical management of rhinosinusitis in endoscopic-endonasal skull-base surgery. Int Forum Allergy Rhinol. 2015;5(4):339343.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 4

    Min JY, Chung SK, Kim HY, Kong DS, Dhong HJ. Clinical implications of rhinosinusitis detected by preoperative computed tomography for endoscopic endonasal transsphenoidal pituitary surgery. Acta Otolaryngol. 2012;132(suppl 1):S32S36.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 5

    Lee JJ, Deutsch BC, Kallogjeri D, Pipkorn P, Schneider JS, Klatt-Cromwell CN. Chronic rhinosinusitis as a risk factor for intracranial and extracranial complications after endoscopic transsphenoidal surgery. Am J Otolaryngol. 2022;43(1):103188.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 6

    Kim DH, Hong YK, Jeun SS, et al. Is coincidental rhinosinusitis a predisposing factor for postoperative central nervous system infection after endoscopic endonasal transsphenoidal surgery? J Craniofac Surg. 2018;29(3):e319e322.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 7

    Kusumi M, Oka H, Kimura H, Yamazaki H, Kondo K, Kumabe T. Fatal fungal aneurysm rupture due to aspergillosis after craniopharyngioma removal via endoscopic endonasal surgery: case report and comparison with seven reported patients. NMC Case Rep J. 2022;9:217223.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 8

    Radotra BD, Salunke P, Parthan G, Dutta P, Vyas S, Mukherjee KK. True mycotic aneurysm in a patient with gonadotropinoma after trans-sphenoidal surgery. Surg Neurol Int. 2015;6:193.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 9

    Eguchi S, Matsuoka G, Suzuki N, Ishikawa T, Yamaguchi K, Kawamata T. Aspergillus sphenoiditis growth on long cut ends of a non-absorbable sellar floor dura closure suture. Surg Neurol Int. 2021;12:567.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 10

    Honegger J, Grimm F. The experience with transsphenoidal surgery and its importance to outcomes. Pituitary. 2018;21(5):545555.

  • 11

    Nyquist GG, Rosen MR, Friedel ME, Beahm DD, Farrell CJ, Evans JJ. Comprehensive management of the paranasal sinuses in patients undergoing endoscopic endonasal skull base surgery. World Neurosurg. 2014;82(6)(suppl):S54S58.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 12

    Gardner PA, Vaz-Guimaraes F, Jankowitz B, et al. Endoscopic endonasal clipping of intracranial aneurysms: surgical technique and results. World Neurosurg. 2015;84(5):13801393.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 13

    Gómez-Amador JL, Ortega-Porcayo LA, Palacios-Ortíz IJ, Perdomo-Pantoja A, Nares-López FE, Vega-Alarcón A. Endoscopic endonasal transclival resection of a ventral pontine cavernous malformation: technical case report. J Neurosurg. 2017;127(3):553558.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 14

    Chakrabarti A, Denning DW, Ferguson BJ, et al. Fungal rhinosinusitis: a categorization and definitional schema addressing current controversies. Laryngoscope. 2009;119(9):18091818.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 15

    deShazo RD, Chapin K, Swain RE. Fungal sinusitis. N Engl J Med. 1997;337(4):254259.

  • 16

    Aït-Mansour A, Pezzettigotta S, Genty E, Faulcon P, Lecanu JB. Evaluation of the prevalence and specificities of asymptomatic paranasal sinus aspergillosis: retrospective study of 59 cases. Eur Ann Otorhinolaryngol Head Neck Dis. 2015;132(1):1923.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 17

    Jamjoom AB, al-Hedaithy SA, Jamjoom ZA, et al. Intracranial mycotic infections in neurosurgical practice. Acta Neurochir (Wien). 1995;137(1–2):7884.

  • 18

    Dubey A, Patwardhan RV, Sampth S, Santosh V, Kolluri S, Nanda A. Intracranial fungal granuloma: analysis of 40 patients and review of the literature. Surg Neurol. 2005;63(3):254260.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 19

    Memória JR Jr, Rufino EPL, Aquino PLDR, Filho FVG, Neto TM, de Vasconcelos HKNB. Brain aspergilloma in an immunocompetent individual: a case report. Surg Neurol Int. 2020;11:211.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 20

    Sung KS, Lim J, Park HH. Intracranial aspergillosis in immunocompetent adult patients without risk factors: a systematic review. Neurosurg Rev. 2022;45(3):20652075.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 21

    Nadkarni T, Goel A. Aspergilloma of the brain: an overview. J Postgrad Med. 2005;51(Suppl 1):S37S41.

  • 22

    Xiao A, Jiang S, Liu Y, Deng K, You C. Invasive intracranial aspergillosis spread by the pterygopalatine fossa in an immunocompetent patient. Braz J Infect Dis. 2012;16(2):192195.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 23

    Siddiqui AA, Shah AA, Bashir SH. Craniocerebral aspergillosis of sinonasal origin in immunocompetent patients: clinical spectrum and outcome in 25 cases. Neurosurgery. 2004;55(3):602611, discussion 611-613.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 24

    Espinel-Ingroff A. In vitro fungicidal activities of voriconazole, itraconazole, and amphotericin B against opportunistic moniliaceous and dematiaceous fungi. J Clin Microbiol. 2001;39(3):954958.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • Collapse
  • Expand
  • FIG. 1.

    A: MRI reveals a tuberculum sellae meningioma compressing the anterior optic pathways. B: Computed tomography demonstrates fluid collection with abnormal calcification in the left maxillary sinus. C: An intraoperative image obtained during the first surgery showing complete removal of the meningioma.

  • FIG. 2.

    A: MRI demonstrates an extra-axial mass (red arrowhead) arising from the lateral wall of the left cavernous sinus. The mass (red arrowheads) demonstrates rapid growth at follow-up imaging performed 6 months later (B) with remarkable perilesional edema (C). D: Positron emission tomography shows an increased uptake of radiotracer (red arrowhead).

  • FIG. 3.

    A: An intraoperative photograph demonstrates a firm grayish mass (yellow asterisk) arising from the dura). B: Original magnification ×60 and inset ×800 Histopathologically, the mass is shown to be a dense infiltration of inflammatory cells (hematoxylin and eosin) and Aspergillus hyphae at the center on high magnification (inset). Since the Aspergillus hyphae are denatured, Grocott stain and periodic acid-Schiff stain revealed only weak positivity (not shown). C: An intraoperative image of the endonasal sinus surgery demonstrates fungal abscess formation (black asterisk) in the left maxillary sinus.

  • 1

    Pagliano P, Caggiano C, Ascione T, et al. Characteristics of meningitis following transsphenoidal endoscopic surgery: a case series and a systematic literature review. Infection. 2017;45(6):841848.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 2

    Lee SJ, Cohen J, Chan J, Walgama E, Wu A, Mamelak AN. Infectious complications of expanded endoscopic transsphenoidal surgery: a retrospective cohort analysis of 100 cases. J Neurol Surg B Skull Base. 2020;81(5):497504.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 3

    Nyquist GG, Friedel ME, Singhal S, et al. Surgical management of rhinosinusitis in endoscopic-endonasal skull-base surgery. Int Forum Allergy Rhinol. 2015;5(4):339343.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 4

    Min JY, Chung SK, Kim HY, Kong DS, Dhong HJ. Clinical implications of rhinosinusitis detected by preoperative computed tomography for endoscopic endonasal transsphenoidal pituitary surgery. Acta Otolaryngol. 2012;132(suppl 1):S32S36.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 5

    Lee JJ, Deutsch BC, Kallogjeri D, Pipkorn P, Schneider JS, Klatt-Cromwell CN. Chronic rhinosinusitis as a risk factor for intracranial and extracranial complications after endoscopic transsphenoidal surgery. Am J Otolaryngol. 2022;43(1):103188.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 6

    Kim DH, Hong YK, Jeun SS, et al. Is coincidental rhinosinusitis a predisposing factor for postoperative central nervous system infection after endoscopic endonasal transsphenoidal surgery? J Craniofac Surg. 2018;29(3):e319e322.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 7

    Kusumi M, Oka H, Kimura H, Yamazaki H, Kondo K, Kumabe T. Fatal fungal aneurysm rupture due to aspergillosis after craniopharyngioma removal via endoscopic endonasal surgery: case report and comparison with seven reported patients. NMC Case Rep J. 2022;9:217223.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 8

    Radotra BD, Salunke P, Parthan G, Dutta P, Vyas S, Mukherjee KK. True mycotic aneurysm in a patient with gonadotropinoma after trans-sphenoidal surgery. Surg Neurol Int. 2015;6:193.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 9

    Eguchi S, Matsuoka G, Suzuki N, Ishikawa T, Yamaguchi K, Kawamata T. Aspergillus sphenoiditis growth on long cut ends of a non-absorbable sellar floor dura closure suture. Surg Neurol Int. 2021;12:567.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 10

    Honegger J, Grimm F. The experience with transsphenoidal surgery and its importance to outcomes. Pituitary. 2018;21(5):545555.

  • 11

    Nyquist GG, Rosen MR, Friedel ME, Beahm DD, Farrell CJ, Evans JJ. Comprehensive management of the paranasal sinuses in patients undergoing endoscopic endonasal skull base surgery. World Neurosurg. 2014;82(6)(suppl):S54S58.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 12

    Gardner PA, Vaz-Guimaraes F, Jankowitz B, et al. Endoscopic endonasal clipping of intracranial aneurysms: surgical technique and results. World Neurosurg. 2015;84(5):13801393.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 13

    Gómez-Amador JL, Ortega-Porcayo LA, Palacios-Ortíz IJ, Perdomo-Pantoja A, Nares-López FE, Vega-Alarcón A. Endoscopic endonasal transclival resection of a ventral pontine cavernous malformation: technical case report. J Neurosurg. 2017;127(3):553558.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 14

    Chakrabarti A, Denning DW, Ferguson BJ, et al. Fungal rhinosinusitis: a categorization and definitional schema addressing current controversies. Laryngoscope. 2009;119(9):18091818.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 15

    deShazo RD, Chapin K, Swain RE. Fungal sinusitis. N Engl J Med. 1997;337(4):254259.

  • 16

    Aït-Mansour A, Pezzettigotta S, Genty E, Faulcon P, Lecanu JB. Evaluation of the prevalence and specificities of asymptomatic paranasal sinus aspergillosis: retrospective study of 59 cases. Eur Ann Otorhinolaryngol Head Neck Dis. 2015;132(1):1923.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 17

    Jamjoom AB, al-Hedaithy SA, Jamjoom ZA, et al. Intracranial mycotic infections in neurosurgical practice. Acta Neurochir (Wien). 1995;137(1–2):7884.

  • 18

    Dubey A, Patwardhan RV, Sampth S, Santosh V, Kolluri S, Nanda A. Intracranial fungal granuloma: analysis of 40 patients and review of the literature. Surg Neurol. 2005;63(3):254260.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 19

    Memória JR Jr, Rufino EPL, Aquino PLDR, Filho FVG, Neto TM, de Vasconcelos HKNB. Brain aspergilloma in an immunocompetent individual: a case report. Surg Neurol Int. 2020;11:211.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 20

    Sung KS, Lim J, Park HH. Intracranial aspergillosis in immunocompetent adult patients without risk factors: a systematic review. Neurosurg Rev. 2022;45(3):20652075.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 21

    Nadkarni T, Goel A. Aspergilloma of the brain: an overview. J Postgrad Med. 2005;51(Suppl 1):S37S41.

  • 22

    Xiao A, Jiang S, Liu Y, Deng K, You C. Invasive intracranial aspergillosis spread by the pterygopalatine fossa in an immunocompetent patient. Braz J Infect Dis. 2012;16(2):192195.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 23

    Siddiqui AA, Shah AA, Bashir SH. Craniocerebral aspergillosis of sinonasal origin in immunocompetent patients: clinical spectrum and outcome in 25 cases. Neurosurgery. 2004;55(3):602611, discussion 611-613.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 24

    Espinel-Ingroff A. In vitro fungicidal activities of voriconazole, itraconazole, and amphotericin B against opportunistic moniliaceous and dematiaceous fungi. J Clin Microbiol. 2001;39(3):954958.

    • PubMed
    • Search Google Scholar
    • Export Citation

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