Neuroradiological manifestations of tuberculous meningitis

Pakistan Journal of Neurological Sciences (PJNS), Dec 2014

Tuberculous meningitis (TBM) represents the most severe form of extra pulmonarytuberculosis (1).The early and exact diagnosis of TBM is important but difficult due to time consuming definitive microbiological procedures (2).Neuroimaging is an important initial investigation in tuberculous meningitis(3).This study was conducted to evaluate the neuroradiological findings in patients with tuberculous meningitis, as a useful modality for itsearly diagnoses and prompt treatment.

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Neuroradiological manifestations of tuberculous meningitis

Pakistan Journal of Neurological Sciences (PJNS) Neuroradiological manifestations of tuberculous meningitis Sumaira Nabi 0 1 2 Haris Majid Rajput 0 1 2 Pakistan Institute of Medical Sciences,Islamabad,Pakistan 0 Pakistan Institute of Medical Sciences , Islamabad , Pakistan 1 Pakistan Institute of Medical Sciences , Islamabad 2 Pakistan Institute of Medical Sciences , Islamabad , Pakistan Follow this and additional works at: http://ecommons.aku.edu/pjns Part of the Neurology Commons Recommended Citation - Article 5 NEURORADIOLOGICAL MANIFESTATIONS OF TUBERCULOUS MENINGITIS Introduction: Tuberculous meningitis (TBM) represents the most severe form of extra pulmonarytuberculosis ( 1 ).The early and exact diagnosis of TBM is important but difficult due to time consuming definitive microbiological procedures (2).Neuroimaging is an important initial investigation in tuberculous meningitis(3).This study was conducted to evaluate the neuroradiological findings in patients with tuberculous meningitis, as a useful modality for itsearly diagnoses and prompt treatment. Materials and methods: A consecutive series of 100 patients diagnosed with TBM admitted to the PIMS neurology ward were studiedbetween 15thMarch 2013 and 14thApril 2014. Cranial imaging results were obtained by non-contrast enhanced CT brain (NECT) and MRI brain with contrast. Results: The mean age was 34.86 ± 17.56 years with a female preponderance (55%). On admission, 72% were in MRC stages II or III. The in-hospital mortality was 16%. NECT was obtainedin all the patients and was abnormal in 67% of the patients. The most common CT findings were hydrocephalus (58%), edema (24%) and infarcts (5%). MRI was obtained in 62% of the patients and was abnormal in 87% of these cases. Out of these patients hydrocephalus (60%), tuberculomas (53%), leptomeningeal involvement (45%)and infarcts (13%)were the most frequent signs. Tuberculomas were almost always multiple involving both the supracortical and infracortical regions. In 10% patients with a normal NECT, MRI revealed positive findings. Conclusion: Neuroimaging techniques are a handy tool in the early diagnosis of TBM. MRI is particularly helpful in defining findings, such as hydrocephalus, tuberculomas, leptomeningeal involvement, or infarcts. INTRODUCTION Tuberculosis captain of the men of death with its various forms is still a challenging problem in Pakistan (4). Tuberculous meningitis (TBM) also known as meningeal tuberculosis is the most common presentation ofneurotuberculosis (5) and a serious disease of worldwide importance. It is one of the most lethal forms of tuberculosis, seen in 5 to 10% of extra pulmonary tuberculosis (TB), and accounts for approximately 1% of all TB cases (6).The case fatality rate of untreated TBM is almost 100% and a delay in treatment may lead to permanent neurological damage, therefore prompt diagnosis is needed for the timely initiation of antituberculous therapy (7). The early and exact diagnosis of TBM is difficult due to nonspecific symptoms (5) and time consuming definitive microbiological procedures (8). Diagnosis is often based on the clinical features and cerebrospinal fluid (CSF) findings. TBM is characterized by a broad spectrum of manifestations, posing a diagnostic challenge and requiring a high index of clinical suspicion. TBM tends to present sub acutely, over a period of variable duration that ranges in literature from weeks to months but in majority of patients there is a history of vague nonspecific symptoms of duration of two to eight weeks prior to meningeal irritation. These prodromal symptoms are constitutional and include malaise, fatigue, anorexia, fever and headache. CSF routine examination shows a lymphocytic pleocytosis with reduced glucose levels (<60mg/dL) and raised proteins (>45mg/dL). CSF culture for mycobacterium tuberculosis or CSF smear remain the reference standard for diagnosing CNS TB, however these are time-consuming investigations and can be negative in 15-75% of cases 8. Modern neuroimaging is a cornerstone in the early diagnosis of CNS tuberculosis and may prevent unnecessary morbidity and mortality due to treatment delay. Contrastenhanced MR imaging is generally considered as the modality of choice in the detection and assessment of CNS tuberculosis (8). However, the efficacy and utility has not been fully evaluated and validated. The specific findings of the disease on imaging studies are tuberculomas, inflammatory exudates at basal cisterns (basal meningitis), meningeal enhancement, hydrocephalus, brain abscess, cerebral oedema, calcificationand infarcts (due to vasculitis) (3, 9, 10). These characteristic findings can be more accurately identified by magnetic resonance imaging (MRI) brain which can be useful for early diagnosis, prognosis and also for follow-up(2, 11). MRI brain provides high definition ofinfratentorial lesions and the early cerebral changes of TBM, but data regarding the diagnostic sensitivity and speci (...truncated)


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Sumaira Nabi, Sadaf Khattak, Mazhar Badshah, Haris Majid Rajput. Neuroradiological manifestations of tuberculous meningitis, Pakistan Journal of Neurological Sciences (PJNS), 2014, pp. 16-21, Volume 9, Issue 2,