Intracranial tuberculomas: review of MRI findings and clinical features.

AIM: To present a comprehensive analysis of the clinical features and magnetic resonance imaging (MRI) findings of intracranial tuberculomas in Indonesia. MATERIALS AND METHODS: This was a retrospective analysis of brain MRI from 58 patients (29 women), mean age ± SD = 39 ± 2 years, diagnosed with intracranial tuberculomas. Clinical data, including symptoms, cerebrospinal fluid examination results, and MRI were also analysed. The diagnosis of intracranial tuberculoma was confirmed based on observed MRI changes following anti-tuberculosis therapy. RESULTS: A total of 603 tuberculomas were fully detected via MRI in all patients. Among these lesions, 507 (84%) were located in the cerebrum, 61 (10%) in the cerebellum, 19 (3%) in the basal ganglia, 12 (2%) in the brain stem, and four (1%) in the thalamus. The MRI signals were classified into two groups: tuberculomas with caseating granulomas and tuberculomas with non-caseating granulomas. Among the patients, 29 had concomitant meningitis, seven had hydrocephalus, and four had cerebral infarction. Evidence of pulmonary tuberculosis was found in 16 patients, with one patient having coexisting thoracic vertebral tuberculosis. CONCLUSION: The present study confirmed the significance of MRI as a valuable tool in the diagnosis of intracranial tuberculomas and the detection of associated abnormalities. The combination of MRI findings with clinical features can enhance the overall diagnostic accuracy for intracranial tuberculomas.

Clinical and Radiological End Points to Stop Anti-Tubercular Treatment in Central Nervous System Tuberculoma and Predictors of Poor Outcome: A Retrospective Study.

The clinical and radiological end points to stop anti-tubercular treatment in central nervous system (CNS) tuberculoma are not known. This retrospective study was done to determine end points to stop anti-tubercular treatment and find the predictors of poor outcome in patients with CNS tuberculoma. Patients who were admitted with a diagnosis of brain/spine tuberculoma between January 2015 and December 2019 and who completed a minimum of 1-year follow-up were enrolled. Clinical and radiological end points to stop anti-tubercular treatment and predictors of death and poor outcome (modified Rankin scale > 2) were analyzed. One hundred and eight patients (male-to-female ratio, 47 [43.5%]:61 [56.5%]; brain tuberculoma, 102; spinal cord tuberculoma, 14; brain and spinal cord tuberculoma, 8) were included in the study. Median duration of anti-tubercular treatment was 24 months. Radiological resolution of tuberculoma (resolution of gadolinium-enhancing lesion, gliosis, calcification, cord atrophy, or syrinx formation) and radiological halt (no increase in size/number of tuberculoma on magnetic resonance imaging scans done 6 months apart) were used as end points to stop anti-tubercular treatment in 69 and 7 patients, respectively. Seven patients stopped their treatment by themselves, and 25 patients died. Altered sensorium, motor weakness, infarcts, hydrocephalus, and constitutional symptoms of tuberculous meningitis were predictors of poor outcome or death in CNS tuberculoma patients. Radiological resolution or radiological halt of brain/spinal cord tuberculoma was a reasonable end point to stop anti-tubercular treatment. However, this may require 24 months or more of anti-tubercular treatment. Associated tuberculous meningitis and its complications portend a poor prognosis.

[The effect of surgical treatment of tuberculous abscesses and tuberculoma of the brain on the dynamics of neurological symptoms]. / Vliyanie khirurgicheskogo lecheniya tuberkuleznykh abstsessov i tuberkulem golovnogo mozga na dinamiku nevrologicheskoi simptomatiki.

OBJECTIVE: To evaluate the efficacy of surgery in reducing neurological symptoms in patients with focal brain tuberculosis. MATERIAL AND METHODS: Seventy-four patients with tuberculosis meningoencephalitis were studied. Among them, 20 people with a life expectancy of at least 6 months were identified, in whom foci with a ring-shaped accumulation of contrast along the periphery were determined during MSCT of the brain. Formed tuberculomas and abscesses were removed from 7 patients (group 1) under neuronavigation control. Indications for the operation were: the absence of a reduction in size for 3-4 months, the limitation of the lesion to 1-2 foci with reduction of perifocal edema according to MSCT and normalization of cerebrospinal fluid. Six patients had contraindications or refusals from operations (group 2). In 7 patients, there was a decrease in formations by the control period (group 3). Neurological symptoms in the groups at the beginning of the observation were similar. The duration of observation was 6-8 months. RESULTS: In group 1, patients were discharged with improvement, postoperative cysts were determined in all of them at discharge. In group 2, 67% died. In group 3, 43% of patients had a complete reduction of foci during conservative treatment, in 57% cysts formed in place of foci. Neurological symptoms decreased in all groups, with the most decrease in group 1. However, statistical analysis did not show significant differences between the groups regarding the reduction of neurological symptoms. A significant difference in the mortality criterion between groups 1 and 2 was obtained. CONCLUSION: Despite the absence of a significant effect on the reduction of neurological symptoms, the high survival rate of operated patients shows the need to remove tuberculosis formations in all the cases.

Brain tuberculoma in pediatric heart transplant recipient.

INTRODUCTION: Heart transplantation is the standard treatment for end-stage heart disease. Despite advances in the field, patients remain under risk of developing complications, including opportunistic infections, such as tuberculosis. We present the unprecedented case of cerebral tuberculoma in a 9-year-old heart transplant recipient. CASE SCENARIO: A 9-year-old female child, who underwent heart transplantation in December 2020, was admitted to the emergency department in September 2021 due to headache and vomiting. She had normal vital signs and a mild left hemiparesis. Laboratory findings included lymphopenia and a low C Reactive Protein and brain images showed expansive lesions. A biopsy of the intracranial lesion was performed and anatomopathological analysis was compatible with tuberculoma. After the diagnosis was established, treatment protocol for neurotuberculosis was initiated, the patient had a satisfactory clinical evolution and was discharged 22 days after admission. DISCUSSION: Clinical manifestation of tuberculosis usually occurs up to 6 months after transplantation, the findings are commonly atypical and symptoms may be mild. We could not find in medical literature any description of the disease in a heart transplant recipient as young as the one presented in this case report. We documented great response to treatment, even though conventional antituberculosis therapy may interfere with immunosuppression. CONCLUSION: Patients in the postoperative period following heart transplantation are at high risk for developing opportunistic infections such as tuberculosis, which may present with atypical symptoms. Therefore the clinician must have a high index of suspicion in order to make the correct diagnosis and promptly start treatment.

18 F-FMISO PET of an Intracranial Tuberculoma : A Great Mimicker.

ABSTRACT: Solitary intracranial tuberculomas are rare and frequently misdiagnosed as brain tumors. We report a case of intracranial tuberculous granuloma mimicking a high-grade glioma with avid uptake on 18 F-fluoromisonidazole PET/CT. It has been believed that hypoxia exists within the tuberculosis granuloma, and that this hypoxic environment causes Mycobacterium tuberculosis to lie dormant and asymptomatic infection to occur. This hypoxic and necrotic condition inside tuberculous granuloma may lead to high accumulation of 18 F-fluoromisonidazole in this case.

Concurrent cerebral infarction and intracranial tuberculoma induced by the carotid plaque complicated with miliary tuberculosis.

Cerebrovascular complications of central nervous system tuberculosis (TB) are predictors of poor prognosis and adverse outcomes. These complications are mainly intracranial arterial involvement, with occasional venous involvement. Here, we present a 67-year-old woman with concurrent cerebral infarction and intracranial tuberculoma induced by the carotid plaque complicated by miliary tuberculosis. Mycobacterium tuberculosis was observed on the luminal side of the carotid plaques in pathological specimens. Treatment with anti-TB drugs alone would likely not cure the patient, as M. tuberculosis would continue to disseminate. Endarterectomy could directly remove the embolic source, and a complete cure was achieved.

Intracranial giant tuberculoma: A 7-year institutional experience and literature review.

BACKGROUND: Intracranial tuberculomas are infrequent with a lower morbidity and mortality compared to tubercular meningitis. Giant intracranial tuberculomas are rarer but important differentials for intracranial space-occupying lesions causing focal neurological deficits depending on anatomical location and size. METHODS: Histopathologically confirmed giant intracranial tuberculomas selected based on institutional size criteria (<12 Years-old: ≥25 mm; 12-18 Years-old: ≥35 mm; ≥18 Years-old: ≥40 mm) were retrospectively reviewed and analyzed for clinical features, radiology, surgical management, and outcomes in patients admitted from 2015 to 2022. RESULTS: Ten patients were included (Males:Females = 3:7; Age: 8-68 Years, Average: 30.1 Years). Mean duration of symptoms was 2.84 months. Two patients demonstrated active systemic tuberculosis. Previous tubercular infections included pulmonary involvement in four, meningeal in three, and a cerebellar tuberculoma in one patient. Cerebrospinal fluid analysis in five patients demonstrated no tubercle bacilli. Seven lesions were supratentorial and three infratentorial. Giant tuberculomas demonstrated profound T2 hypointensity, sub-marginal T2 hyperintense crescents, and significant perilesional vasogenic edema. Craniotomy and excision were mainstay except in one case treated only with ventriculoperitoneal shunting. Three additional patients underwent ventriculoperitoneal shunting for hydrocephalus. One patient died from aspiration pneumonia and sepsis following a postoperative seizure. Anti-Tubercular Therapy (ATT) was advised for 18 months. Follow up ranged from 4 to 18 months. One patient was medically managed for ATT-induced hepatitis, hepatic encephalopathy, and coincidental paradoxical reaction. Remainder of patients showed complete resolution of symptomatology and absence of new symptoms till latest follow up. CONCLUSION: Clinical course of giant tuberculomas differ from non-giant variants in characteristic radiology, more intensive ATT, and possibility for partial debulking/excision.

Relationship between magnetic resonance imaging findings and prognosis of intracranial tuberculosis.

BACKGROUND: Intracranial tuberculosis (TB) is an intracranial infection caused by Mycobacterium tuberculosis. Magnetic resonance imaging (MRI), in particular enhanced MRI scan, has the ability to detect characteristic lesions of tuberculous meningitis or cerebral parenchymal TB. PURPOSE: To analyze the relationship between MRI findings and prognosis of patients with intracranial TB. MATERIAL AND METHODS: In this retrospective study, a total of 60 patients were confirmed with intracranial TB in the hospital from May 2019 to December 2020. All enrolled patients underwent TB-related laboratory examinations, cranial MRI, and contrast-enhanced MRI. Laboratory tests were analyzed and the relationship between clinical prognosis and cranial MRI features was evaluated. RESULTS: Of the 60 patients, 28 (46.67%) had disseminated TB complications, 20 (36.67%) had secondary TB complications, and the remaining 10 (16.66%) had lymphatic TB or spinal TB complications. Of the patients, 25 had good short-term prognosis and 35 had poor short-term prognosis; 44 patients had good long-term prognosis and 16 had poor long-term prognosis. The incidence of cerebral parenchymal tuberculomas on enhanced MRI was significantly higher in the group with good prognosis compared to that in the group with poor prognosis (P < 0.05). Logistic analysis suggested that hydrocephalus (odds ratio [OR] = 0.057, 95% confidence interval [CI] = 0.003-0.444; P = 0.018) and cistern involvement (OR = 0.100, 95% CI = 0.011-0.581; P = 0.017) were independent risk factors for poor short-term prognosis. CONCLUSION: MRI can display the pathological changes of intracranial TB in detail; hydrocephalus and cistern involvement were independent risk factors for poor short-term prognosis.

Neuromeningeal tuberculosis in HIV-negative patients: a retrospective study in Rabat, Morocco.

Neuro-Meningeal Tuberculosis (NMT) is a severe infection of the central nervous system which causes a public health problem in Morocco and in several countries in the world. In order to describe the epidemiological, clinical, paraclinical and outcome among NMT patients without HIV, we carried out a retrospective study at the neurology department of the Military Hospital of Rabat in Morocco, over a period of 17 years (2000-2017). Forty patients were included with a mean age of 44 years (± 18) and a sex ratio of 1.66. A history evoking the possibility of tuberculous origin was found in 8 patients (20%). Febrile confusion was the most common clinical manifestation and was observed in 22 patients (55%) followed by febrile meningeal syndrome in 12 patients (30%). The main abnormalities noted in brain magnetic resonance imaging (MRI) were: hydrocephalus in 13 cases (32.5%), intra-cranial tuberculomas in 10 patients (25%) and leptomeningitis in 9 cases (22.5%). Cerebrospinal fluid study found clear aspect in 29 patients (75%), direct acid fast bacilli smear examination was positive in 4 patients (10%) and positive culture in 4 patients (10%). The Polymerase chain reaction (PCR) study returned positive in 6 patients (35%) of the 17 patients tested. The outcome was good in 18 patients (45%) while 19 patients suffered from neurological sequelae (47.5%) and 3 cases of death recorded (7.5%). Febrile confusion was the most reported manifestation in our patients. Subacute onset of symptoms was the most predominant feature in our patients as reported in the literature. Our results are consistent with the literature and confirm the severity of this infectious disease, even in HIV-negative patients.

Central nervous system tubercular abscess masquerading as intracranial space-occupying lesion.

This is a case report of patient suffering from multiple central nervous system tuberculoma which progressed to tubercular abscess. Patient developed signs and symptoms of mass effect and compression. Computed tomography of brain and magnetic resonance spectroscopy confirmed the diagnosis. Patient underwent left temporal craniotomy with evacuation of pus. The abscess wall and the pus sent for histopathological and microbiological examination which confirmed the etiological agent - Mycobacterium tuberculosis. Appropriate treatment was started and discharged. Hence, early diagnosis and treatment of intracranial tuberculoma are pivotal in preventing morbidity and mortality of the condition.

Role of Caspase- 3, TNF-α, and IL6 mRNA Expression in Intracranial Tuberculoma.

The development of tuberculoma is a process of inflammation, necrosis, and apoptosis. Therefore, the pro-inflammatory cytokines and apoptosis biomarkers are likely to play an important role. In this study, we report the expression of TNFα, IL6, and caspase-3 at the mRNA level in the patients with tuberculous meningitis (TBM) and compare these biomarkers in the patients with and without tuberculoma. A total of 134 patients with TBM and 35 matched healthy controls were included. The clinical, cerebrospinal fluid (CSF), and cranial magnetic resonance imaging (MRI) findings were noted. The mRNA expression of TNFα, IL6, and caspase-3 in peripheral blood mononuclear cells was evaluated by reverse transcriptase polymerase chain reaction. On cranial MRI, 89 (64.2%) patients had tuberculoma, and their level of consciousness, severity of meningitis, CSF findings, and blood counts were not significantly different from those without tuberculoma. Patients with tuberculoma had a higher expression of TNFα and IL6 compared to the controls, but had lower expression compared to the patients without tuberculoma. TNFα expression positively correlated with the expression of caspase-3, but not with IL6. Twenty-five (18.6%) patients died: 12 (13.5%) in tuberculoma and 13 (28.9%) in the non-tuberculoma group. Death was related to higher expression of TNFα and caspase-3. The lower expression of TNFα and IL6 in intracranial tuberculoma suggests that these patients are unlikely to be benefited with TNFα blockers.

[Cerebral manifestationsof tuberculosis].

Almost two billion people are infected with M. Tuberculosis. The most common manifestation of TB is pulmonary; however, severe manifestations of TB can affect the central nervous system. This case report describes a young refugee with onset of sixth nerve palsy and an MRI consistent with a pontine tumor. Stereotactic biopsy showed giant cells and acid-fast rods, Quantiferon test was positive, thus fulfilling the criteria for tuberculoma. The patient immediately began antituberculous treatment and slowly recovered. The purpose of this article was to elucidate the necessity of screening migrants from TB-endemic areas.

Giant cerebral tuberculoma mimicking a high-grade tumour in a child.

We present an 11-year-old girl who manifested with unprovoked right-sided focal motor seizures. CT revealed a large lobulated hypodense mass in the left temporoparietal lobe, with perilesional oedema and postcontrast peripheral enhancement. Diagnostic uncertainty resulted in further neuroimaging, which included MRI with modalities including diffusion-weighted imaging, perfusion imaging, as well as spectroscopy. We discuss the radiological features of the lesion, which steered us in the direction of an infective cause. Definitive diagnosis was achieved by brain needle biopsy, which demonstrated necrotising granulomatous inflammation indicative of tuberculous infection on histology. In addition, GeneXpert yielded a positive result. We believe this unique case highlights the diagnostic dilemma clinicians face in differentiating ring-enhancing lesions on neuroimaging in tuberculosis-endemic regions. It also highlights the potential benefit of a brain needle biopsy (histology and GeneXpert) in cases of uncertainty.

Multiparametric magnetic resonance imaging features of giant intracranial tuberculomas.

OBJECTIVES: To evaluate Magnetic Resonance Imaging (MRI) features of Giant Tuberculomas (GT) of the brain and deduce characteristic imaging phenotypes which may differentiate GT from higher grade glioma. METHODS: A retrospective analysis of MRI was done on Tuberculomas of size >2 cm. The diagnosis was established by histopathology or presumed from size reduction on follow-up MRI while on empirical anti-tubercular therapy (ATT). Multimodality characteristics of GT on T1/T2W, Fluid attenuation recovery (FLAIR), Diffusion-Weighted imaging (DWI), Susceptibility Weighted Imaging (SWI), Spectroscopy (MRS) and Perfusion weighted sequences were assessed. These imaging features were also evaluated in WHO Grade IV, IDH-wild type glioma (histopathologically and genetically proven) and a comparative analysis of the imaging features between GT and glioma was done. RESULTS: Thirty-two GT and 20 glioma were evaluated. Pronounced intralesional T2 hypointensity (n = 8;25%), T2 hyperintense crescent beneath the periphery (n = 25, 78.1%), T2W lamellated/whorled appearance (n = 17;53.125%), hyperintense rim on T1W MT (n = 25;78.1%), peripheral rim of diffusion restriction (n = 22; 68.75%), peripheral rim of blooming on SWI (n = 20, 62.5%), prominent lipid resonance on MR spectroscopy (n = 30; 93.75%), overshoot of the signal intensity-time curve above the base line (n = 9/10; 90%) on dynamic susceptibility contrast (DSC) perfusion, were remarkable imaging characteristics. Reduction of peripheral T1 hyperintensity, compaction of T2 hypointense core, expansion of sub-marginal T2 hyperintense rim and increased peripheral susceptibility (n = 20; 62.5%) during follow-up imaging, while on ATT, were standout features. GT could be differentiated from WHO grade IV (IDH-wild type) glioma on the basis of a significantly higher proportion of GTs showing a whorled/lamellated appearance, T1 hyperintense rim, T2 hypointense core, DWI-ADC mismatch, well-defined rim on SWI, prominent lipid peak on MRS and a submarginal T2 hyperintense rim. GT showed a higher normalized ADC ratio from the core as well as the rim. Significantly higher proportion of glioma showed a T1 hypointense and T2 hyperintense core and a nodular rim enhancement. A significantly higher r CBV, Choline to creatine, choline to NAA ratio and mean thickness of the peripheral enhancing rim were defining features among gliomas. CONCLUSION: Neuroimaging features of GT have been elucidated. Reduction of peripheral T1 hyperintensity, compaction of T2 hypointense core, expansion of sub-marginal T2 hyperintense rim, and increased peripheral susceptibility on follow-up may be considered imaging markers of response to anti-tubercular therapy. Multiparametric MRI features can differentiate GT from WHO grade IV (IDH-wild type) glioma.

Ruptured intraventricular tuberculous brain abscess mimicking cystic neoplasm: a case report.

Central nervous system (CNS) tuberculosis is a potentially life-threatening condition that may manifest in different forms and simulate other pathologies. It rarely involves the ventricles and the occurrence of primary intraventricular tuberculous brain abscess (TBA) has exceptionally been reported. As far as we know, ruptured intraventricular TBA has not been described before. An immunocompetent 56-years-old man was admitted for sub-acute intracranial hypertension with behaviour disorders. Cranial magnetic resonance imaging (MRI) showed a cystic lesion of the third ventricle containing fluid-fluid level with biventricular hydrocephalus and debris in the occipital horns. A ruptured cystic neoplasm was first considered. The patient underwent surgery via a right transcortical transventricular approach, combining both microscope and endoscope. The puncture of the lesion brought pus and the Ziehl-Neelson (ZN) staining demonstrated acid-fast bacilli. Intraventricular tuberculous abscess is an extremely rare condition that can take an unusual radiological appearance. This observation highlights the consideration of tuberculosis within the list of differential diagnosis of intraventricular cystic lesions in immunocompetent hosts.