Pathological analysis of intracranial space-occupying lesions in 1000 cases including children. 1. Age, sex and pattern; and the tuberculomas

Brainstem tuberculoma: A delayed IRIS

We describe a twenty six years old lady with tuberculous meningitis who developed new onset left ptosis and binocular diplopia with features of left fascicular 3rd nerve palsy after 9 months of anti tubercular therapy (ATT) and imaging revealed new onset tuberculoma in the mid-brain. Tuberculoma responded to steroids while continuing ATT. Formation of new tuberculoma as a part of immune reconstitution inflammatory syndrome (IRIS) is possible even after prolonged therapy of 9 months, which responded well to only steroids without altering ATT.

Tuberculosis of the Central Nervous System

PURPOSE OF REVIEW

This article details the epidemiology and clinical manifestations of central nervous system (CNS) tuberculosis (TB), provides guidance for diagnostic imaging and CSF testing, and recommends treatment strategies for tuberculous meningitis and other forms of CNS TB, illustrating key aspects of diagnosis and management with case presentations.

RECENT FINDINGS

Although improvements in our understanding of the pathogenesis and management of CNS TB have occurred over the past 50 years, the emergence of multidrug-resistant and extensively drug-resistant TB, the advent of acquired immunodeficiency syndrome (AIDS), and the subsequent availability of highly active antiretroviral therapy that can produce the immune reconstitution inflammatory syndrome have complicated the diagnosis and treatment of CNS TB. Advances in diagnostic assays promise to increase the speed of diagnosis as well as the percentage of people with a confirmed rather than a presumptive diagnosis. Advances in precision medicine have identified polymorphisms in the LTA4H gene that influence the risk for inflammation in patients with tuberculous meningitis.

SUMMARY

CNS TB continues to be a major cause of morbidity and mortality, with the majority of people affected living in low-income and middle-income countries. Newer diagnostic assays promise to increase the speed of diagnosis and improve appropriate selection of antituberculous therapy and anti-inflammatory medications. Despite these advances, CNS TB remains difficult to diagnose, and clinicians should have a low threshold for initiating empiric therapy in patients with presumptive infection.

Stereotactic Internal Shunt Placement in Congenital Intracranial Cysts

INTRODUCTION

Treatment of symptomatic intracranial cysts remains a controversial issue. We present a risk/benefit profile of a minimally invasive, not yet described, stereotactic internal shunt implantation technique. The provided data might serve as a reference against which other treatment modalities could be compared.

METHODS

From our prospective database, we identified a consecutive series of patients with symptomatic, untreated cysts who had undergone internal shunting from 2009 to 2017. We estimated the rates of clinical symptom improvement (RCSI), cyst reduction, total complications, and long-term complications. A minimal follow-up of 6 months was required. The prognostic factors were obtained from logistic regression models. Cyst recurrence-free survival was calculated using the Kaplan-Meier method. The outcomes data were compared with those from reported alternative treatment strategies using χ² statistics.

RESULTS

We included 38 patients. The cyst locations differed greatly and included the cerebellum (n = 2), brainstem (n = 5), and pineal area (n = 4). Cyst-associated hydrocephalus (n = 6) resolved after treatment. The 2-year cyst recurrence-free survival rate was 97%. The RCSI and rate of cyst reduction, total complications, and long-term complications was 91%, 97%, 11%, and 2.6%, respectively. We did not find any risk factors associated with the rate of total complications. The RCSI and rate of total and long-term complications compared favorably (P < 0.01) with the corresponding estimates of alternative treatments (P < 0.01).

CONCLUSIONS

The described stereotactic internal shunt implantation technique is safe and can be successfully applied for treatment of cystic formations in any location in the brain.

Clinical presentation and magnetic resonance findings in sellar tuberculomas

Background and Importance. Sellar tuberculomas are extremely rare lesions with nonspecific clinical manifestations. The tuberculous infection of the pituitary gland and sellar region is characterized by the presence of an acute or chronic inflammatory reaction and may occur in the absence of systemic tuberculosis. The diagnosis is difficult prior to the surgery. An adequate diagnostic and antituberculous drugs usually result in a good outcome. Clinical Presentation. We report four cases of sellar tuberculoma, 3/1 female/male, age range: 50–57 years. All patients had visual disturbances and low levels of cortisol. Conclusion. The clinical diagnosis of sellar tuberculoma is a challenge and should be suspected when a sellar lesion shows abnormal enhancement pattern and stalk involvement, and absence of signal suppression in FLAIR.

Isolated Pituitary Tuberculoma

Pituitary tuberculomas are extremely rare, even in the developing countries where tuberculosis is endemic. We report a rare case of isolated pituitary tuberculoma mimicking a pituitary adenoma or a Rathke’s cleft cyst in Japan, a developed country. The patient was a 69-year-old woman presented with visual disturbance. Head magnetic resonance imaging (MRI) with contrast enhancement revealed an isolated intrasellar mass showing central hypointensity with an irregularly enhancing rim. She was operated on via an endoscopic transsphenoidal approach. Histopathological findings and an interferon-gamma release assay were highly suspicious of an isolated tuberculous granuloma. After proper infection control management, she was treated with four-drug antituberculous therapy (ATT). Follow-up MRI showed no recurrence 3 years after the discontinuation of ATT. An isolated pituitary tuberculoma has rarely been reported, especially in developed countries. In conclusion, neurosurgeons should consider an isolated pituitary tuberculoma as one of the differential diagnoses for pituitary tumors, because special management for infection control is required for tuberculosis. An interferon-gamma release assay is helpful for the difficult diagnosis of an isolated pituitary tuberculoma with inactive tuberculosis.

Tuberculosis

Tuberculosis remains a serious health problem worldwide, particularly affecting the poorest in both high-income and developing countries. It was declared a global emergency by the World Health Organization in 1993. Central nervous system (CNS) tuberculosis is caused by mycobacteria belonging to the Mycobacterium tuberculosis complex, and is acquired through inhalation of aerosolized droplet nuclei. Meningitis represents the most frequent and severe form of CNS tuberculosis. Parenchymal CNS involvement can occur in the form of tuberculoma or, more rarely, abscess. Also, damage of the spinal cord, roots, and spine can occur in the form of spinal meningitis, radiculomyelitis, spondylitis, or spinal cord infarction. Diagnosis remains a challenge due to the slow growth of the organisms and the low yield of cerebrospinal fluid cultures, as well as the frequent absence of evidence of infection elsewhere. This results in frequent empirical therapy, based on a combination of four drugs (isoniazid, rifampicin, pyrazinamide and ethambutol) for 2 months, followed by 10 additional months with two drugs (isoniazid and rifampicin) to a total duration of 12 months. Shorter regimens have also been successful, but there have been few controlled trials in patients with extrapulmonary disease. Corticoid therapy seems to be associated with a reduced risk of death, and is usually indicated. Evidence of multidrug resistance requires variable combinations of first- and second-line drugs; fortunately, resistance does not seem to represent a serious threat for CNS tuberculosis at present, but still requires the utmost vigilance.

Suprasellar tuberculoma

Tuberculosis is among the most lethal infectious diseases. Although incidence of intracranial tuberculosis is low in developed countries, it is still rampant in the developing world. The most common location of intracranial tuberculomas in adults is the cerebral hemisphere, and in children, the posterior fossa. The suprasellar tuberculomas are extremely rare and pose a diagnostic challenge. We describe a patient with concomitant suprasellar and cerebellar tuberculoma.

[Brain tuberculoma in a 10-year-old child: the diagnosis is in the belly]

We report the case of a 10-year-old child from Reunion Island who was hospitalized because of headaches and partial convulsive fits. The brain MRI showed several conglomerated right frontal lesions suggestive of a tumor process. This girl, vaccinated with BCG, had familial risk factors for tuberculosis and a 20-mm tuberculin intradermo-reaction. Given the palpation of an abdominal mass, a thoracoabdominal scan was done, which revealed the presence of mesenteric adenopathies. Their biopsy confirmed the diagnosis of tuberculosis without having to perform neurosurgery. A 2-month quadritherapy and a 10-month dual therapy against tuberculosis led to the disappearance of brain damage and mesenteric adenopathies, with focal epilepsy the only sequela. The tuberculosis incidence in Reunion Island (8/100,000) is comparable with the French average, but the island is surrounded by high-endemic countries. Tuberculomas were responsible for one-third of expanding intracranial lesions in Europe in 1933, and their incidence remains high in developing countries. Even though extrapulmonary or disseminated tuberculosis has become rare in children in industrialized countries, this diagnosis must be kept in mind, in spite of vaccination. In accordance with international guidelines, this case report shows the importance of a systematic extensive check-up (cervical, thoracic and abdominopelvic) when brain tuberculosis is suspected in order to find more accessible tuberculosis lesions and to avoid the side effects of a brain biopsy.

Tuberculosis of the central nervous system in immunocompromised patients: HIV infection and solid organ transplant recipients

Central nervous system (CNS) tuberculosis (TB) is a devastating infection with high rates of morbidity and mortality worldwide and may manifest as meningitis, tuberculoma, abscess, or other forms of disease. Immunosuppression, due to either human immunodeficiency virus infection or solid organ transplantation, increases susceptibility for acquiring or reactivating TB and complicates the management of underlying immunosuppression and CNS TB infection. This article reviews how immunosuppression alters the clinical presentation, diagnosis, treatment, and outcome of TB infections of the CNS.

Intracranial tuberculomas in adults: a report of twelve consecutive patients in Houston, Texas

BACKGROUND

Intracranial tuberculomas are rare manifestations of tuberculosis (TB). An extensive literature review revealed that no study of consecutive adults with intracranial tuberculoma has been conducted in the USA.

METHODS

This retrospective study consisted of 12 adults consecutively identified with intracranial tuberculomas from 1995 to 2009 in Houston, Texas. Of the 12 cases, 8 had a histopathological diagnosis, while 4 had a probable diagnosis based on the following criteria: (1) Mycobacterium tuberculosis identified from a source outside the brain, (2) radiographic confirmation of an intracranial mass, (3) received chemotherapy with 2 or more anti-tuberculosis medications, and (4) clinical response at 1-y follow-up.

RESULTS

Common clinical manifestations were altered mental status, fever, and night sweats. Four patients (25%) had a human immunodeficiency virus (HIV) infection. Nine patients (75%) had concomitant M. tuberculosis at at least 1 extracranial site, including 5 patients with pulmonary TB. The median duration of therapy was 11 months. Patients had a 1-y mortality rate of 16.7% and an overall morbidity rate of 20%.

CONCLUSIONS

Intracranial tuberculomas in Houston, Texas, are rare. Hospital discharge predicted survival at 1 y, despite severe clinical presentations and invasive diagnostic procedures. However, tuberculoma cases are associated with higher mortality rates than non-central nervous system TB cases.

Sellar-suprasellar tuberculomas in children: 2 cases and literature review

Sellar and suprasellar tuberculomas are rare. Patients with these lesions usually experience headache, vomiting, and hypofunction of pituitary gland; imaging reveals an enhancing sellar-suprasellar mass. We report 2 rare cases of sellar-suprasellar tuberculomas in children aged 8 and 6 years. One child presented with features of headache and vomiting, and the other presented with posterior pituitary dysfunction. In both cases, imaging revealed sellar-suprasellar masses. Both cases were multidrug-resistant tuberculomas. We discuss sellar-suprasellar tuberculomas, a rare form of neurotuberculosis in the background of an overall increase in multidrug-resistant tuberculosis, especially in children.

Diabetes insipidus in sellar-suprasellar tuberculoma

Tuberculoma involving the sellar and suprasellar region is extremely rare. Sellar region tuberculoma usually presents with endocrinopathy of hypofunction, rarely hyperfunction or normal function of the anterior pituitary. However, sellar-suprasellar tuberculoma presenting with diabetes insipidus (DI) is very rare. We report the case of a 32 year old housewife presenting with DI and secondary amenorrhea, who had a sellar-suprasellar mass on MRI. She underwent a transnasal transsphenoidal surgical removal of the pituitary mass, which was tubercular in nature on histology. She received antitubercular treatment and hormonal replacement therapy. She was well at last follow-up, 3 years after surgery.

Intraventricular tuberculoma

A 38-year-old female presented with headaches, fever, and malaise. Computed tomography showed an intraventricular peripheral ring-enhanced lesion with central necrosis. The lesion was totally excised. Histological examination revealed a tuberculoma. The patient was treated with antituberculous chemotherapy. The patient was asymptomatic at 9 months. Ventricular involvement in neurotuberculosis is rare, but should be considered in the presence of other indicators of tuberculous infection.

Meningiomas in children and adolescents

PURPOSE

To review the diagnosis, treatment, and long-term outcome of children and adolescents with meningiomas diagnosed by a single institution and compare these findings with other published data.

PATIENTS AND METHODS

A 25-year retrospective analysis of 18 patients with meningioma diagnosed at Children's Hospital Medical Center, Cincinnati, Ohio was performed. A literature review of published reports was undertaken to compare evaluation. treatment, and outcome for similar patients.

RESULTS

Patients ranged from ages 19 months to 17 years at diagnosis. The most common symptoms were headache (5) and seizures (5), although most patients had multiple symptoms. The brain was the primary location of tumor in 17 patients, with the remaining tumor located in the spine. Comorbid diagnoses were common, including developmental delay, balanced chromosomal translocation, type I diabetes mellitus, neurofibromatosis, Klinefelter syndrome, and seizures. Eleven patients had gross total resection performed. Four patients had malignant meningiomas. Two patients were treated with radiotherapy only, one had chemotherapy only, and two underwent both. Karyotype abnormalities most commonly involved chromosome 22, but other abnormalities were present. Sixteen patients remain alive and two patients, having had malignant tumors, are dead of disease. Long-term sequelae include seizures, diabetes insipidus, blindness, neuropsychologic abnormalities, and multiple surgical procedures. Only three patients are self-described as being without problems.

CONCLUSIONS

Based on this study and a literature review, the roles of surgery, radiation, and chemotherapy remain unclear. Long-term outcome for patients with meningiomas, especially as it relates to cognitive function, is rarely reported. This group of patients has a high incidence of morbidity associated not only with treatment but also with preexisting diseases. These data indicate the need for a national cooperative group study to better understand the evaluation, treatment, and outcome for children and adolescents who are treated for meningiomas.

Central nervous system tuberculosis

Involvement of the central nervous system (CNS) by Mycobacterium tuberculosis, particularly meningitis, is the most severe form of tuberculous infection. Parenchymal CNS involvement can occur in the form of tuberculoma or, more rarely, abscess. Although surgery was initially advocated as the mainstay of therapy, more recent evidence suggests that parenchymal forms of CNS tuberculosis can be cured with medical treatment alone. Also, damage of the spinal cord, roots, and spine can occur in the form of spinal meningitis, radiculomyelitis, spondylitis, or spinal cord infarction.

Central nervous system tuberculoma: a case report

Pediatric cerebral tuberculoma is a disease rarely encountered in the United States. We report a case of central nervous system tuberculoma in a 6-month-old infant who presented to the emergency department with isolated right upper extremity paralysis. The discussion includes a brief review of central nervous system tuberculomas.

Etiological spectrum of symptomatic localization related epilepsies: a study from South India

Putative etiology was studied in 991 patients with symptomatic localization-related epilepsies seen in a university hospital in South India. They formed 39% of patients with various types of epilepsies and epileptic syndromes seen during the study period. Seizure occurred in close temporal association with an acute central nervous system (CNS) insult in 53% of patients. Infections of CNS including single CT enhancing lesion (SCTEL) accounted for 77% of patients with acute symptomatic epilepsy. Cerebrovascular diseases were the risk factors in 48% of patients with remote symptomatic epilepsy. Neurocysticercosis, SCTEL and small single cerebral calcific CT lesion (SSCCCTL) together accounted for 40% of etiological factors and neurotuberculosis for 10%. Infections of the central nervous system and SCTEL together were the putative risk factors in 52% of patients aged < or =40 years. Cerebrovascular diseases were the etiological factors in 64% of patients aged >40 years. Neurological handicaps from birth manifested by mental retardation and/or cerebral palsy was the feature in 21% of children. The type of seizure was either simple partial or complex partial with or without secondary generalization in 76% of patients. The remaining patients presented with either generalized tonic clonic seizures or unlocalized seizures. Localization to a single site of seizure origin proposed by the International League Against Epilepsy (ILAE) was possible in only 67.5% of patients. The most readily identifiable was motor cortex. In patients with unlocalized or generalized seizures the type of pathology was diffuse in 17% of patients and in 48.5% of patients, the lesion was located in the frontal brontoparietal lobe.

Evolution of brain tuberculomas under standard antituberculous treatment

The treatment of brain tuberculomas is primarily medical. Surgery, excision or biopsy, is generally performed when the diagnosis is in doubt or there is no response to medical therapy. The aim of this study was to determine the radiological evolution of intracranial tuberculomas under standard anti-tuberculous drug therapy and to establish guidelines for better management of these patients. Eighteen patients were studied retrospectively. None of them had surgical intervention and all were treated by standard antituberculous drugs and had serial computed tomography (CT) scans until disappearance or stabilization of brain lesions. The regression of lesions' size and number was slow in the first month (mean -7.3%) then became rapid after this (-15% to -20% per month). A paradoxical increase in size was noted in three patients in the first month. All three had associated meningitis. All tuberculomas disappeared on CT scan after 12 months of therapy. Most of the edema images disappeared by 6 months. This study would suggest that a long treatment regimen of 15-18 months may not be necessary in most intracranial tuberculomas occurring in non-immunocompromised patients. It also demonstrates that medical trial in well tolerated suspected cases should last for at least 2 months before considering other etiologies or surgical exploration.

Central nervous system tuberculosis: medical management and surgical indications

BACKGROUND

An increase in the incidence of tuberculosis in industrialized nations has prompted a need for earlier diagnosis, treatment, and isolation of disease. An associated rise in the number of patients with central nervous system tuberculosis (CNS TB) has forced neurosurgical services to reevaluate the indications for operative intervention.

METHODS

Seventeen cases of CNS TB were found in a retrospective review of all cases managed on the neurosurgical service between 1989 and 1994. These cases included eight with tuberculous meningitis, seven cases of supratentorial tuberculomas, and two cases of infratentorial tuberculomas.

RESULTS

Major permanent neurologic morbidity was seen in one case (6%). Five patients (29.4%) died of complications associated with their primary disease. Eleven patients (64.6%) had excellent outcomes. All patients in the latter group completed an 18-month course of antituberculous therapy. Cerebrospinal fluid shunts were necessary in three cases and emergent craniotomy was performed in three cases. Only four cases had human immunodeficiency virus (HIV) coinfection.

CONCLUSION

The neurosurgeon's role in the management of CNS TB has once again become more evident. In the present series it is unclear as to whether this is due to multiple drug-resistant strains of Mycobacterium tuberculosis or HIV coinfection. It is clear, however, that vigilance over patient compliance and serial neurologic evaluation will determine the need for operative intervention.

Thickening of the pituitary stalk: a finding suggestive of intrasellar tuberculoma? Case report

We describe the case of a patient with an exclusively intrasellar mass, disclosed because of a left sixth nerve palsy and headaches. No other manifestation of disease, namely, endocrinological, was present. The lesion was approached transsphenoidally, and the pathological examination revealed a tuberculoma. Complete removal was achieved, and the patient started postoperative antituberculous therapy. In some circumstances, thickening of the infundibulum and the pituitary stalk could preoperatively suggest the diagnosis of hypophysial tuberculoma.

Cerebral tuberculosis with expansion into brainstem tuberculoma. Report of two cases

There are only scattered case reports of intracranial tuberculosis in industrialized nations; brainstem tuberculoma is even more unusual, accounting for 2.5% to 8% of all intracranial tuberculoma. In developing nations, however, central nervous system tuberculosis (CNS-TB) is not rare and intracranial tuberculoma may account for 5% to 30% of all intracranial masses. The authors present two cases of CNS-TB with expansion to brainstem tuberculoma in patients who were undergoing treatment and had no known prior exposure to Mycobacterium tuberculosis.

Tuberculous meningitis in children

Between May 1988 and November 1992 the data from 52 patients with tuberculous meningitis (TBM) were noted down for their symptoms and signs, BCG vaccines, PPD tests; clinical, laboratory, radiologic and microbiologic findings. These data were discussed by means of literature knowledge. Cranial computed tomography (CT) demonstrated hydrocephalus (HC) in 98% of the patients. There was a statistically significant difference among the clinical stages on admission in respect to prognosis (P < 0.05). In addition, there was also a significant relationship between prognosis and HC (P < 0.05). However, we did not find any significant relationship between parenchymal involvement, basilar meningitis and prognosis (P > 0.05).

[Non tumor intracranial expansive processes: clinico-topographical correlation]

Presentation of clinical-tomographic correlation in 111 cases of non tumoral intracranial expansive processes seen between 1984-1988 in the Hospital Cayetano Heredia (Lima, Peru). Emphasis is given fundamentally to: (1) the importance of establishing the organicity of partial and late epilepsy; (2) the high incidence rate of inflammatory infectious processes with CNS compromise in underdeveloping countries; (3) the necessity of making public the importance of two parasitic diseases in the differential diagnosis of non tumoral intracranial expansive processes: free living amebiasis, and toxoplasmosis (especially in association with AIDS).

Intracranial tuberculosis in children: CT appearance and clinical outcome

We retrospectively evaluated the CT studies of 9 children who presented with intracranial tuberculosis during 1981-1987, and compared their radiographic appearance with the clinical outcome. The most common radiographic findings were: 1) ventriculomegaly (7/9) ,2) tuberculoma formation (6/9), and 3) infarction (4/9). Of 7 patients with ventriculomegaly, 3 required a ventricular shunt and 2 had spontaneous resolution of ventricular dilatation. Four children with ventriculomegaly were moderately or severely retarded, one had cognitive dysfunction, and one was neurologically normal. Four of six children with tuberculoma also had infarction and/or ventriculomegaly; of these four children, three were moderately or severely retarded. Two patients with tuberculoma as the only intracranial abnormality had complete resolution of the granuloma with normal neurologic outcome following antituberculous therapy. The four children with large vessel infarction also had ventriculomegaly; three had poor clinical outcome. The presence of tuberculoma alone is not necessarily predictive of poor neurologic outcome; age less than 20 months, infarct, and/or ventriculomegaly are usually associated with sequelae.

Brain stem tuberculoma in adult patients: diagnosis and treatment

A consecutive series of six adult patients ranging in age from 29 to 53 years is presented. The clinical and radiological features in each patient are described. Attention is drawn to the features demonstrated on computed axial tomography. In only one patient, the first encountered, was surgical excision undertaken and histological verification obtained. One patient died before any form of treatment could be instituted. The remaining four patients were treated with antituberculous chemotherapy alone and their progress monitored by sequential computed tomography. The excellent response and good outcome in this conservatively treated group are documented.

Avoiding empiric therapy for brain masses in Indian patients using CT-guided stereotaxy

Empiric therapy, especially antituberculous therapy, is frequently given to Indian patients with brain masses. This report documents our experience in avoiding such therapy using CT-guided stereotaxy. Out of 101 procedures done on 99 patients with brain masses, 80 were done to obtain a histological diagnosis and 21 for therapeutic purposes. There was no mortality and 2% morbidity. A positive diagnosis was obtained in 94% (75/80) of patients undergoing a biopsy. Diagnosis of tuberculous lesions was based mainly on the presence of acid-fast bacilli in the biopsy specimen or pus. In six patients the radiological diagnosis was wrong and in one the diagnosis was not certain. Inappropriate therapy was given to three patients, on the basis of a CT or MRI scan, before a biopsy was done. It is essential that a histological diagnosis be obtained in all patients with brain masses and there is no role for empirical therapy except in isolated cases.

Brain tumours in childhood in Bombay: I: Histopathology showing changing patterns; II: Tissue culture with light and electronmicroscopy, stressing ingestion & degradation of bacteria by glial cells in vitro

The pathological pattern of 86 brain 'tumours' in childhood during the years 1981-85 (out of a total of 586 for all ages), showed a higher proportion of neoplasms and a much lower of tuberculomas compared to the preceding three decades. A large number of histologically unusual cases was revealed. Through tissue culture of brain tumours we carried out morphological, histochemical and fine structural study of the tumour cells in vitro. The abundant presence of lysosomal acid phosphatase, in outgrowing cells, correlated with the detection of lysosomal dense bodies and vacuoles in araldite sections, by light and electronmicroscopy. In view of the phagocytic propensity of schwann cells for M. leprae as the important factor in leprous neuritis, TC preparations of gliomas, (in addition to acoustic schwannomas and meningiomas), were inoculated with two mycobacteria, M. scrofulaceum and the ICRC bacillus. There was a pronounced intracytoplasmic uptake, i.e. endocytosis, of acid-fast bacilli by the growing cells of these tumours. This was confirmed by electronmicroscopy which showed intact and degrading bacilli in various stages, in such cells of a typical cerebral astrocytoma used as an illustrative case in this paper. Ingestion and Digestion appear to be an inherent property of growing tumour cells in vitro. Fine structural examination of in vitro growth of an unusual subependymal giant cell astrocytoma, not inoculated with bacilli, served as a control. Cells of both tumours showed copious autophagic activity and cytoskeletal features of developing microtubules and filaments.

Paediatric intracranial meningiomas

Intracranial meningiomas are rare before the age of 16 years. Of 1397 intracranial meningiomas operated on by our service up to 1987, 19 (1.3%) were diagnosed before this age. In the literature accessible to us we have found another 274 cases. An analysis of the literature shows that intracranial meningiomas in paediatric patients differ from those in adults in the following respects: a slight predilection for males, a high frequency within the ventricular system, more frequent presence of intra- and peri-lesional cysts and more frequent absence of dural attachment. In addition, the neuroradiologic diagnosis of nature is more difficult in paediatric patients.

Intracranial tuberculoma. Evaluation and treatment

We used computerized tomography (CT) to screen 83 patients with partial seizures who had 1) increased intracranial pressure; 2) evidence of systemic tuberculosis; or 3) focal neurological deficit. We found intracranial tuberculoma in 20 (24%). In addition, of 55 patients with tuberculous meningitis, 12 had associated tuberculoma. The image morphology on CT scans showed ring lesions (14), discs (10), and irregular coalescing masses (8). Perilesional edema frequently was present. After appropriate antitubercular therapy, clinical outcome for seizures, neurological deficit, and increased intracranial pressure was satisfactory. CT lesions regressed within 12 weeks of inauguration of medical therapy in most patients. Medical management of tuberculoma is advocated, with surgery limited to those in whom such treatment is ineffective.

Tumours of the central nervous system in Chinese in Hong Kong: a histological review

One hundred and sixty-eight cases of tumours of the central nervous system (CNS) from Chinese patients in Hong Kong were reviewed histologically as well as by the immunoperoxidase techniques in equivocal cases. Detailed comparisons were made between this series and previously published series on CNS tumours in Chinese, in other Asians and in Caucasians. The percentage of gliomas was low, and the average age of patients with high grade astrocytomas was low. Meningiomas were relatively common tumours and microcystic meningiomas were a common histological subtype. The percentages of vascular malformations and haemangioblastomas were also higher than those recorded in the West. The difference in incidence in gliomas and vascular malformations between this series and previous reports from mainland China was attributed to a possible difference between southern and northern Chinese.

[Multiple cerebral tuberculomas: report of an autopsy case with 37 lesions]

An autopsied case of multiple cerebral tuberculomas with 37 lesions, the one with the greatest number of lesions described in the literature, is reported. The patient was a chronic alcoholic and had generalized tuberculosis. The literature on multiple cerebral tuberculomas is reviewed and the neurological clinical picture presented by the patient and the association between generalized tuberculosis and chronic alcoholism are commented upon.

Intraventricular tuberculoma. Report of four cases in children

Four cases of intraventricular tuberculoma (IVT) in children are here reported. In none of the patients was there clinical evidence pointing to the intraventricular location. CT scan findings comprised three stages of development, namely: immature, mature and old. Ependymal attachment and asymmetric hydrocephalus were present in three cases, meningitis in two and ependymitis in one. Septum pellucidum traction was clearly observed in two patients, strongly supporting an adhesive process characteristic of intraventricular tuberculosis. Following specific treatment, the tuberculomas remitted partially or entirely.

Meningiomas in childhood

The clinical presentation and pathological characteristics of 18 histologically verified meningiomas in the paediatric age group are reviewed. There was a 1:1 sex ratio. Two children presented with seizures. The majority were supratentorial in location and large in size. In 4 patients, the meningiomas showed sarcomatous changes, while in 6 patients they were cystic.

Tumors of the central nervous system in Taiwan, Republic of China

A series of 1012 surgically removed tumors of the central nervous system from two hospitals in Taiwan were reviewed, tabulated, and compared to series from the United States, Europe, and Asia. Among gliomas, a relatively high incidence of glioblastomas was found in patients less than 20 years old. The percentage of meningiomas in the two hospitals was very high: 20.22% and 26.72%, respectively. Neurilemmomas, as reported from Japan and mainland China, were also more common than in the United States or Europe. Germinomas and teratomas were more frequent than in Western countries, but less so than in Japanese series. Pituitary adenomas constituted 21.8% of cases from the Veterans General Hospital in Taipei, a percentage higher than that in any comparable series.

Neurosurgically relevant aspects of pathology and pathogenesis of intracranial and intraspinal tuberculosis

In view of the persisting high prevalence (though somewhat reduced compared to 20 years ago) of various forms of neurotuberculosis , especially in economically underpriviledged and undernourished urban paediatric populations of the world, some aspects of the neuropathology relevant to neurosurgeons, are briefly presented and discussed. The most conspicuous of these is the development of brain tuberculomas, which act as both space-occupying and inflammatory masses that result in severe oedema or direct destruction of brain parenchyma. The cellular reaction in the border zone of these tuberculomas is identical to that in tuberculous meningitis and consists of specialized large mononuclear cells-the epitheloid cells-which undertake a phagocytic function and also fuse with one another to form giant cells, as seen by both light and electron microscopy. These cells together with others like lymphocytes and plasma cells, also infiltrate the walls of small blood vessels, constituting vasculitis, and these vessels may undergo necrosis, in both the intracranial (mainly basal) and spinal leptomeningeal exudate. The latter is more frequent in young adults than in children, and may be the primary event in the CNS or secondary to extension downwards of the basal meningitis. The quantity and nature of the spinal exudate vary in duration and severity, the more common being extensively "tubular" and subacute, producing radiculopathy and myelopathy by compression of these structures, and rarely infiltration. The damage to the cord, mainly the white matter, occurs through oedema and ischaemia, rather than frank infarction, the larger arteries being rarely involved.(ABSTRACT TRUNCATED AT 250 WORDS)

Intracranial tuberculoma: conservative management

Twenty cases of intracranial tuberculoma were treated by us. A clinical-radiographic syndrome was recognized, consisting of an avascular enhancing mass lesion surrounded by marked edema and associated with relatively less severe clinical manifestations than would have been expected from the size and location of the lesion. This allowed successful medical therapy with three antituberculous drugs for an average of 12 months. Steroids, when used, were beneficial in relieving symptoms of cerebral edema without causing spread of tuberculosis. Medically treated patients had a significantly better functional recovery than those from whom the tuberculoma was excised.

[Intracranial tuberculoma: clinical and pathological aspects]

A retrospective analysis of 19.760 consecutive autopsies and 72.972 biopsies in a period of over 41 years disclosed 24 intracranial tuberculomas in 17 patients, representing 4,2% of the intracranial space-occupying lesions. Most intracranial tuberculomas were found the cerebral hemispheres whereas one third of them were located in the cerebellum. About two thirds of the patients were younger than 20 years old. The clinical picture of intracranial tuberculomas is similar to that of other space-occupying lesions, comprising signs of raised intracranial pressure and signs related to the anatomical site of the lesion.

[Primary intracranial tumors: analysis of a series of consecutive autopsies and biopsies]

A retrospective study of primary intracranial tumors found in 19.760 consecutive autopsies and 72.972 consecutive biopsies during a period of over 41 years was carried out. Two hundred and five neoplasms comprising 69,7% of the primary intracranial tumors were located in the supratentorial compartment whereas 84 tumors (28,6%) were infratentorial in site. Gliomas constituted the largest group of primary tumors comprising 60,9% of the intracranial primary neoplasms. Most of gliomas were found in the cerebral hemispheres, particularly in the frontal lobes. Of the total number of gliomas 40,2% were astrocytomas, 29,6% glioblastomas, 10,6% ependymomas, 10,1% medulloblastomas, 5% oligodendrogliomas and 2,2% choroid plexus papillomas. Meningiomas constituted the second most common primary intracranial tumors being found in 56 cases (19%), most of them in parasagittal region, sphenoid ridge and anterior fossa. In the sella region there were 39 neoplasms including 21 pituitary adenomas, seven meningiomas, five craniopharyngiomas, four epidermoid cysts and two teratomas. Six capillary hemangioblastomas of the cerebellum and two chordomas of the clivus were also found. Sixty-five tumors occurred in patients under 15 years of age, 53,3% of them infratentorial in location--36% in the cerebellum, 9,3% in the brainstem and 8% in the fourth ventricle. The majority of these tumors were astrocytomas, medulloblastomas and ependymomas. The present data are discussed in relation to other pathological series found in the literature.

Intracranial tumors in Enugu, Nigeria

Over a five-year period, there were 48 cases of intracranial tumors at the University of Nigeria Teaching Hospital, Enugu, Nigeria. All the patients were Nigerian Negroes. Glial tumors accounted for 20.8%, pituitary tumors 18.8%, and meningiomas 16.7%. There were five cases of tuberculomas and five cases of metastatic tumors. Miscellaneous tumors contributed 22.9% of the total. There were more males than females, especially in the meningioma and tuberculoma groups. Nearly one-half of the tumors were in people in their first and second decades of life; two-thirds of the tumors were in those under 30 years of age. One-third of the patients have died within the five years under review. The results of this survey are strikingly different from Caucasian series. The relatively low incidence of gliomas and the high incidence of meningiomas and pituitary tumors in this study are interestingly similar to the results of other workers who studied Negro populations and may underscore the importance of genetic factors in the development of some brain tumors.

Five cases of intracranial tuberculoma followed by serial computerised tomography

Five cases of intracranial tuberculoma in Asian adults are described, all of whom presented with epilepsy. The computerised tomographic (CAT) scanner displayed the lesions particularly well, and their characteristics are described. Only two cases were explored surgically, but triple antituberculous chemotherapy has the scan abnormalities in all of them to resolve completely. It is concluded that Asian patients with lesions likely to be tuberculous should be given a trail of antituberculous drugs, and only explored if they should deteriorate clinically, or if the lesion should fail to respond on serial scans.

Diagnosis and management of tuberculous paraplegia with special reference to tuberculous radiculomyelitis

Paraplegia occurred in eight of 17 patients with central nervous system tuberculosis. In six of these paraplegia was the presenting feature. Paraplegia may complicate tuberculous meningitis, or vertebral tuberculosis, but it may also occur, as in three of our cases, as a primary localised spinal tuberculous radiculomyelitis. These cases are presented in relation to the concept that paraplegia complicating these forms of tuberculosis is caused by radiculomyelitis.