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
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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)