Spinal tuberculous disease is common in tuberculous meningitis

Background: Tuberculous disease of spine (spinal TB) is under-recognized in tuberculous (TB) meningitis.The objective of the study was to evaluate the frequency, clinical and neuroimaging changes, andoutcome in the patients with spinal TB. Methods: All the patients with spinal TB admitted in the twolargest tertiary hospitals in Kuala Lumpur from 2009 to 2017 were recruited, the clinical features weredocumented, the magnetic resonance imaging (MRI) of the spine was performed. Clinical outcome wasassessed with Modified Rankin scale (MRS). Results: Twenty two patients were recruited. This wasout of 70 TB meningitis patients (31.4%) seen over the same period. Eighteen (81.8%) patients hadconcomitant TB meningitis. The clinical features consisted of systemic symptoms with fever (63.6%),meningitis symptoms with altered sensorium (45.5%), myelopathy with paraparesis (36.4%). Thefindings on spinal MRI were discitis (36.4%), spinal meningeal enhancement (31.8%), spinal cordcompression (31.8%), psoas abscess (27.3%), osteomyelitis (22.7%), and cord oedema (22.7%). Allexcept two patients (90.9%) had involvement in psoas muscle, bone or leptomeningeal enhancement,features that can be used to differentiate from myelopathy that affect the parenchyma only, such asdemyelination. Unusual manifestations were syringomyelia and paradoxical manifestations seen in 3patients each. The outcome were overall poor, with 68% having MRS 3 or more.Conclusion: Spinal TB is common in TB meningitis. The outcome is overall poor. A heightenedawareness is crucial to enable early diagnosis and treatment.

Role of cytokines in the assessment of clinical outcome and neuroimaging findings in patients with tuberculous meningitis

Background: Tuberculous meningitis is a life-threatening manifestation resulting from infection by Mycobacterium tuberculosis, especially in the developing countries. The molecular aspects of pathogenesis of tuberculous meningitis remain poorly understood. We evaluated the correlation of cerebrospinal fluid (CSF) and serum cytokine levels with the clinical outcome of 15 HIV-negative patients with tuberculous meningitis. We also assessed the association of CSF and serum cytokines with neuroimaging of brain findings in the patients. Methods: The prospective longitudinal study was conducted at the University Malaya Medical Centre between 2012 and 2014. Neuroimaging of the brain was performed and the findings of leptomeningeal enhancement, hydrocephalus, tuberculoma, infarcts and vasculopathy were recorded. The CSF and serum specimens were analyzed for IL-1ß, IL-8, IL-10, IL-18, IP-10, IFN-γ, MCP-1, TGF-ß, VEGF, TNF- α, IL-18BPa and MMP-9. The clinical outcome was graded at 3 months based on Modified Rankin scale (mRS). Results: On admission and at one month of anti-tuberculosis treatment, the CSF levels of IL-8, IL-1β, IP-10, IFN-γ and VEGF were elevated in all of the patients. Serum IP-10, MCP-1, IL-1β and IL-8 levels were increased on admission and at one month of anti-tuberculosis treatment. There were statistically significant differences between good and poor outcome (mRS at 3 months) for CSF IFN-γ (p=0.033), CSF IL-10 (p=0.033) and serum VEGF (p=0.033) at one month of treatment. None of the patients showed any association between CSF and serum cytokines on admission and at one month of anti-tuberculosis treatment with neuro-radiological findings. Conclusion: The CSF cytokine levels were not related to TBM disease severity on admission, and changes on MRI/CT scans. CSF levels of IFN-γ and IL-10 at one month of anti-tuberculosis treatment were associated with clinical outcome at 3 months. CSF cytokine levels on admission were not associated with the clinical outcome.

Neuroimaging findings are sensitive and specific in diagnosis of tuberculous meningitis

Objective: The primary objective of this study was to describe the neuroimaging changes of tuberculous meningitis (TBM), and to determine the role of neuroimaging in the diagnosis of TBM. Methods: Between January 2009 and July 2015, we prospectively recruited TBM patients in two hospitals in Malaysia. Neuroimaging was performed and findings were recorded. The control consists of other types of meningo-encephalitis seen over the same period. Results: Fifty four TBM patients were recruited. Leptomeningeal enhancement was seen in 39 (72.2%) patients, commonly at prepontine cistern and interpeduncular fossa. Hydrocephalus was observed in 38 (70.4%) patients, 25 (46.3%) patients had moderate and severe hydrocephalus. Thirty four patients (63.0%) had cerebral infarction. Tuberculoma were seen in 29 (53.7%) patients; 27 (50.0%) patients had classical tuberculoma, 2 (3.7%) patients had “other” type of tuberculoma, 18 (33.3%) patients had ≥5 tuberculoma, and 11 (20.4%) patients had < 5 tuberculoma. Fifteen (37.2%) patients had vasculitis, 6 (11.1%) patients had vasospasm. Close to nine tenth (88.9%) of the patients had ≥1 classical neuroimaging features, 77.8% had ≥ 2 classical imaging features of TBM (basal enhancement, hydrocephalus, basal ganglia / thalamic infarct, classical tuberculoma, and vasculitis/vasospasm). Only 4% with other types of meningitis/encephalitis had ≥1 feature, and 1% had two or more classical TBM neuroimaging features. The sensitivity of the imaging features of the imaging features for diagnosis of TBM was 88.9% and the specificity was 95.6%. Conclusion: The classic imaging features of basal enhancement, hydrocephalus, basal ganglia/thalamic infarct, classic tuberculoma, and vasculitis are sensitive and specific to diagnosis of TBM.

Spontaneous temporosphenoidal meningoencephalo cele as a rare cause of non-traumatic cerebrospinal fluid rhinorrhoea

Cranial encephaloceles are rare conditions, which are more commonly seen in the anterior rather than in the middle cranial fossa. Temporal lobe encephalocele can present with a variety of clinical symptoms, amongst which include occult or symptomatic cerebrospinal fluid (CSF) fistula. We present a case of a patient with a short history of rhinorrhea who was found to have a CSF pool in the sphenoid sinus and right anteromedial temporosphenoidal encephalocele, which mimics sphenoid mucocoele, a much more common entity. This case highlights the imaging findings of temporosphenoidal encephalocoele and the diagnostic clues in differentiating this rare condition from the commoner mimics.

Leptomeningeal glioblastoma multiforme presenting as cauda equina syndrome

Glioblastoma multiforme (GBM) is the commonest primary cerebral malignancy consisting of 12- 20% of intracranial brain tumours.1 We report here a patient with GBM with very unusual marked and widespread leptomeningeal GBM.

Hemodynamic effects resulting from a common carotid to middle cerebral bypass with varying degrees of proximal internal carotid stenosis

Objective: To investigate the degree of stenosis of the internal carotid artery required for continuous blood flow in an interposition vein bypass to the middle cerebral artery. Methods: Computational fluid dynamics techniques were used to investigate a case of common carotid to middle cerebral artery brain bypass with varying degrees of internal carotid artery stenosis. Blood flow patterns across the patient-specific brain bypass were evaluated. Results: Simulation found that for cross section stenosis of less than 60%, no flow occurred in the bypass graft. Further narrowing of the internal carotid artery increased flow linearly within the bypass graft. There was significant energy loss and pressure gradient difference between the proximal and distal anastomosis sites of the bypass. Conclusion: Computational fluid dynamics helps us to quantify the flow distribution, wall shear stress and pressure gradient in brain bypass surgery. The angle of the distal anastomosis had no effect on hemodynamic indices, allowing this consideration to be ignored in modeling. This modeling technique is useful to estimate the required degree of stenosis in the artery that is to be occluded to ensure sustained flow in the bypass. This will be of importance where there is staged surgery with a time interval between the bypass and the definitive internal carotid artery occlusion.