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Images in Neurology |

Subdural Collection as Initial Presentation of Granulomatosis With Polyangiitis

Naif M. Alotaibi, MD1; George M. Ibrahim, MD, PhD1; Hamza Jalal, MD, MSc2; Bayardo Perez-Ordonez, MD3; Mojgan Hodaie, MD, MSc1; Suneil K. Kalia, MD, PhD1
[+] Author Affiliations
1Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
2Department of Neurology, University of Toronto, Toronto, Ontario, Canada
3Department of Pathology, University Health Network, Toronto General Hospital, Toronto, Ontario, Canada
JAMA Neurol. 2016;73(5):602-603. doi:10.1001/jamaneurol.2015.4710.
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A woman in her late 50s was found to have subdural collection as an initial presentation of granulomatosis with polyangiitis.

A woman in her late 50s presented with decreased visual acuity and headache. She had a low-grade fever, episcleritis, and a mild left-sided pronator drift. Imaging revealed a right-sided subdural collection, temporal lobe edema, and enhancing leptomeninges (Figure 1A-C). Further workup revealed pulmonary and nasal cavitary lesions on computed tomography. Diagnosis of granulomatosis with polyangiitis (GPA), formerly known as Wegener granulomatosis, was confirmed serologically (antineutrophil cytoplasmic antibody, proteinase 3) and histopathologically via biopsy of her nasal and pulmonary lesions (Figure 1D). Her symptoms, including pyramidal weakness, subsided by the third day of treatment with pulsed steroids. Repeated imaging demonstrated complete resolution of the collection (Figure 2).

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Figure 1.
Imaging and Histopathological Analysis Prior to Treatment

A, Axial computed tomography (CT) showing subdural collection (arrowhead). B, Axial magnetic resonance imaging (MRI) with gadolinium showing the collection with dural enhancement (arrowhead). C, Axial T2-weighted MRI showing temporal lobe edema (arrowhead). D, Histopathological analysis of a section from the lung lesion biopsy specimen demonstrating diffuse inflammatory changes, fibrinoid necrosis, and multinucleated giant cells (arrowheads) (hematoxylin-eosin, original magnification ×20).

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Figure 2.
Axial Computed Tomographic Imaging After 3 Days of Treatment
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