CT of the brain in tuberculous meningitis. A review of 289 patients

Clinical Outcome of Tuberculous Meningitis with Hydrocephalus - A Retrospective Study

Background

To study the clinical outcome of tuberculous meningitis with hydrocephalus (TBMH) and the factors contributing to its poor clinical outcome.

Methods

Clinical data of 143 adult patients diagnosed with TBM over a 6-year period in two tertiary hospitals in Malaysia were retrospectively reviewed. Relevant clinical and radiological data were studied. Patients with TBMH were further analysed based on their clinical grade and rendered treatment to identify associated factors and outcome of this subgroup of patients. The functional outcome of patients was assessed at 12 months from treatment.

Results

The mean age of patients was 35.6 (12.4) years old, with a male gender predominance of 67.1%. Forty-four percent had TBMH, of which 42.9% had surgical intervention. In the good modified Vellore grade, 76.5% was managed medically with concurrent anti-tuberculosis treatment (ATT), steroids and osmotic agents. Four patients had surgery early in the disease as they did not respond to medical therapy and reported a good outcome subsequently. Poor outcome (65.2%) was seen in the poor modified Vellore grade despite medical and surgical intervention. Multivariate model multiple Cox regression showed significant results for seizure (adjusted hazard ratio [aHR]: 15.05; 95% CI: 3.73, 60.78), Glasgow coma scale (GCS) (aHR: 0.79; 95% CI: 0.70, 0.89) and cerebrospinal fluid (CSF) cell count (aHR: 1.11; 95% CI: 1.05, 1.17).

Conclusion

Hydrocephalus was seen in 44% of patients in this study. GCS score, seizure and high CSF cell count were factors associated with a poor prognosis in TBM. Patients with TBMH treated medically (TBMHM) had better survival function compared to TBMH patients undergoing surgical intervention (TBMHS) (P-value < 0.001). This retrospective study emphasises that TBMH is still a serious illness as 47.6% of the patients had poor outcome despite adequate treatment.

Cerebrospinal fluid Gene XPERT (CBNAAT) in children with tuberculous meningitis

Objectives

To observe the role of CSF Gene XPERT (CBNAAT) in diagnosis of tuberculous meningitis (TBM) and determine its sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV).

Methods

A prospective study was done from October 2017 to March 2020. CSF samples of 55 children diagnosed as tuberculous meningitis as per defined clinical and imaging criteria, were subjected to routine CSF analysis, MGIT culture and CBNAAT. Children on prior anti-tuberculous therapy for more than one month were excluded from study.

Results

Of 55 children, meningeal signs were present in 54.5% children. Neurological deficits were present in 47.3%. Common CT brain findings were communicating hydrocephalus followed by infarct and basal exudates. CSF Gene XPERT (CBNAAT) were positive in 9 (16.4%), of which 6 was also culture positive and 3; negative. Two children were rifampicin resistant. Fifteen (27.3%) children had positive CSF culture. Gene XPERT showed sensitivity, specificity, PPV, NPV and diagnostic accuracy of 40%, 92.5%, 66.7%, 80.4% and 78.2% respectively as compared to culture.

Conclusion

Although sensitivity of CSF CBNAAT is low i.e. 40% but positive result not only confirm bacteriological diagnosis of tuberculous meningitis but also reveal about rifampicin sensitivity and resistance for plan of therapy.

MRI imaging features of HIV-related central nervous system diseases: diagnosis by pattern recognition in daily practice

With the advent of antiretroviral therapy (ART), the prognosis of people infected with human immunodeficiency virus (HIV) has improved, and the frequency of HIV-related central nervous system (CNS) diseases has decreased. Nevertheless, mortality from HIV-related CNS diseases, including those associated with ART (e.g., immune reconstitution inflammatory syndrome) remains significant. Magnetic resonance imaging (MRI) can improve the outlook for people with HIV through early diagnosis and prompt treatment. For example, HIV encephalopathy shows a diffuse bilateral pattern, whereas progressive multifocal leukoencephalopathy, HIV-related primary CNS lymphoma, and CNS toxoplasmosis show focal patterns on MRI. Among the other diseases caused by opportunistic infections, CNS cryptococcosis and CNS tuberculosis have extremely poor prognoses unless diagnosed early. Immune reconstitution inflammatory syndrome shows distinct MRI findings from the offending opportunistic infections. Although distinguishing between HIV-related CNS diseases based on imaging alone is difficult, in this review, we discuss how pattern recognition approaches can contribute to their early differentiation.

A pilot study of inflammatory mediators in brain extracellular fluid in paediatric TBM

Tuberculous meningitis (TBM) is the most fatal form of tuberculosis and frequently occurs in children. The inflammatory process initiates secondary brain injury processes that lead to death and disability. Much remains unknown about this cerebral inflammatory process, largely because of the difficulty in studying the brain. To date, studies have typically examined samples from sites distal to the site of disease, such as spinal cerebrospinal fluid (CSF) and blood. In this pilot study, we examined the feasibility of using direct brain microdialysis (MD) to detect inflammatory mediators in brain extracellular fluid (ECF) in TBM. MD was used to help guide neurocritical care in 7 comatose children with TBM by monitoring brain chemistry for up to 4 days. Remnant ECF fluid was stored for offline analysis. Samples of ventricular CSF, lumbar CSF and blood were collected at clinically indicated procedures for comparison. Inflammatory mediators were quantified using multiplex technology. All inflammatory markers, with the exception of interleukin (IL)-10 and IL-12p40, were detected in the ECF. Cytokine concentrations were generally lower in ECF than ventricular CSF in time-linked specimens. Individual cases showed ECF cytokine increases coinciding with marked increases in ECF glycerol or decreases in ECF glucose. Cytokine levels and glycerol were generally higher in patients with more severe disease. This is the first report of inflammatory marker analysis from samples derived directly from the brain and in high temporal resolution, demonstrating feasibility of cerebral MD to explore disease progression and possibly therapy response in TBM.

Tubercular meningitis presenting as cerebral salt wasting syndrome in an adult: A case report

Introduction

Cerebral salt wasting syndrome (CSWS) is a cause of hyponatremia in the setting of intracranial pathologies such as Central Nervous System (CNS) trauma, infections, and tumors. It is important to differentiate CSWS from the syndrome of inappropriate antidiuretic hormone secretion (SIADH) as their management differs. CSWS leads to hypovolemia as opposed to euvolemia or hypervolemia in SIADH. SIADH is managed with fluid restriction and this could worsen CSWS which is managed with adminstration of intravenous crystalloids to correct hyponatremia.

Case summary

A 42-year-old male was admitted after a week of low-grade fever with easy fatigability, hypersomnolence, and excessive thirst. He had polyuria which started 5 days before presentation, and unintentionally lost 3 kg of weight in the past month. He had orthostatic hypotension, and was dehydrated, but vital signs were normal with the exception of his temperature. Cerebrospinal fluid (CSF) analysis revealed a glucose of 42 mg/dl, protein 170 mg/dl, cell count 28/mm³ with 65% lymphocytes which was consistant with tubercular meningitis. CSF AFB culture was positive in addition to a positive CSF PCR for M. tuberculosis.

Discussion

Presentation of CNS infection with tuberculosis may be non-specific and its insidious onset could lead to delayed or missed diagnosis; however persistent constitutional symptoms and signs with history of weight loss and a close contact with tuberculosis may raise the possibility of tuberculosis. Early diagnosis and treatment has an excellent prognosis, but any delay contributes to death and disability despite anti-tubercular drug therapy.CSWS should be managed with salt and volume replacement, but more importantly, the causative CNS insult should also be confirmed and addressed.

•

Presentation of tubercular meningitis may be non-specific and its insidious onset could lead to delayed or missed diagnosis.

•

CSWS is characterized by hyponatremia along with increased urinary sodium excretion and extracellular volume contraction.

•

Early diagnosis and treatment has an excellent prognosis, but any delays contribute to death and disability despite of ATT in patient with tubercular meningitis.

Standardized approaches for clinical sampling and endpoint ascertainment in tuberculous meningitis studies

Tuberculous meningitis (TBM), the most severe manifestation of tuberculosis, has poorly understood immunopathology and high mortality and morbidity despite antituberculous therapy. This calls for accelerated clinical and basic science research in this field. As TBM disproportionally affects poorer communities, studies are often performed in resource-limited environments, creating challenges for data collection and harmonisation. Comparison of TBM studies has been hampered by variation in sampling strategies, study design and choice of study endpoints.  Based on literature review and expert consensus, this paper provides firstly, practical recommendations to enable thorough diagnostic, pathophysiological and pharmacokinetic studies using clinical samples, and facilitates better data aggregation and comparisons across populations and settings. Secondly, we discuss clinically relevant study endpoints, including neuroimaging, functional outcome, and cause of death, with suggestions of how these could be applied in different designs for future TBM studies.

Standardized approaches for clinical sampling and endpoint ascertainment in tuberculous meningitis studies

Tuberculous meningitis (TBM), the most severe manifestation of tuberculosis, has poorly understood immunopathology and high mortality and morbidity despite antituberculous therapy. This calls for accelerated clinical and basic science research in this field. As TBM disproportionally affects poorer communities, studies are often performed in resource-limited environments, creating challenges for data collection and harmonisation. Comparison of TBM studies has been hampered by variation in sampling strategies, study design and choice of study endpoints.  Based on literature review and expert consensus, this paper provides firstly, practical recommendations to enable thorough diagnostic, pathophysiological and pharmacokinetic studies using clinical samples, and facilitates better data aggregation and comparisons across populations and settings. Secondly, we discuss clinically relevant study endpoints, including neuroimaging, functional outcome, and cause of death, with suggestions of how these could be applied in different designs for future TBM studies.

The Utility of CSF Xpert MTB/RIF in Diagnosis of Tubercular Meningitis in Children

OBJECTIVE

To determine the utility of CSF Xpert MTB/RIF (GeneXpert) in diagnosis of tubercular meningitis in children in the age group of 2 mo to 12 y.

METHODS

This hospital based prospective observational study was conducted at Department of Pediatrics, Karnataka Institute of Medical Sciences (KIMS), Hubli from December 2015 through November 2016. All children with clinically suspected tuberculous meningitis (TBM) were included in the study. These children underwent a detailed history taking, clinical examination, blood investigations, lumbar puncture and CT brain. Cerebrospinal fluid (CSF) samples were sent for CSF GeneXpert examination. Statistical analysis was done using IBM SPSS Statistics Version 20.

RESULTS

A total of 28 children were enrolled in the study. Six (21.4%), 4 (14.3%) and 18 (64.3%) cases were definite, probable and possible TBM cases respectively. Most common age group affected was <5 y (83.33%) with median age 2.5 y (IQR 4.875). Male:female ratio was 1.5:1. CSF GeneXpert was tested positive in 6 cases (21.4%). The sensitivity of the test against the clinical scoring (>/=10) was 46.15% (95% CI, 19.22-74.87) and specificity was 100% (95% CI, 78.20-100). There was a significant association between CSF GeneXpert and Mantoux test (P = 0.002), CSF cell type >50% lymphocytes (P = 0.005) and CSF protein >100 mg/dl (P = 0.025) along with CT hydrocephalus (P = 0.021), granuloma (P = 0.009) and basal exudates (P = 0.025). None of the cases were tested smear positive for acid-fast bacilli (AFB).

CONCLUSIONS

CSF GeneXpert is superior to smear for AFB in TBM.

Tuberculous meningitis in children: Clinical management & outcome

Although the occurrence of tuberculous meningitis (TBM) in children is relatively rare, but it is associated with higher rates of mortality and severe morbidity. The peak incidence of TBM occurs in younger children who are less than five years of age, and most children present with late-stage disease. Confirmation of diagnosis is often difficult, and other infectious causes such as bacterial, viral and fungal causes must be ruled out. Bacteriological confirmation of diagnosis is ideal but is often difficult because of its paucibacillary nature as well as decreased sensitivity and specificity of diagnostic tests. Early diagnosis and management of the disease, though difficult, is essential to avoid death or neurologic disability. Hence, a high degree of suspicion and a combined battery of tests including clinical, bacteriological and neuroimaging help in diagnosis of TBM. Children diagnosed with TBM should be managed with antituberculosis therapy (ATT) and steroids. There are studies reporting low concentrations of ATT, especially of rifampicin and ethambutol in cerebrospinal fluid (CSF), and very young children are at higher risk of low ATT drug concentrations. Further studies are needed to identify appropriate regimens with adequate dosing of ATT for the management of paediatric TBM to improve treatment outcomes. This review describes the clinical presentation, investigations, management and outcome of TBM in children and also discusses various studies conducted among children with TBM.

Central Nervous System Tuberculosis : Etiology, Clinical Manifestations and Neuroradiological Features

PURPOSE

As a result of multilateral migration and globalization in times of humanitarian crises, western countries face a possible increase in the incidence of central nervous system tuberculosis (CNS TB). The diagnosis of CNS TB is challenging and often delayed due to the manifold and often non-specific presentation of the disease. The aim of this review is to analyze and summarize imaging features and correlated clinical findings of CNS TB.

METHODS

The different manifestations of CNS TB are explained and illustrated by characteristic neuroradiological as well as neuropathological findings. An overview on diagnostic and therapeutic approaches is provided. For clarity, tables summarizing the lesion patterns, differential diagnoses and diagnostic hints are added.

RESULTS

The CNS TB can be manifested (1) diffuse as tuberculous meningitis (TBM), (2) localized as tuberculoma or (3) tuberculous abscess or (4) in extradural and intradural spinal infections. Information on clinical presentation, underlying pathology and the distinguishing features is demonstrated. The TBM is further described, which may lead to cranial nerve palsy, hydrocephalus and infarction due to associated arteritis of the basal perforators. The differential diagnoses are vast and include other infections, such as bacterial, viral or fungal meningoencephalitis, malignant causes or systemic inflammation with CNS. Complicating factors of diagnosis and treatment are HIV coinfection, multi-drug resistance and TB-associated immune reconstitution inflammatory syndrome (IRIS).

CONCLUSIONS

Neurologists and (neuro-)radiologists should be familiar with the neuroradiological presentation and the clinical course of CNS TB to ensure timely diagnosis and treatment.

Pediatric Tubercular Meningitis: A Review

Childhood tuberculosis (TB) has a high incidence and prevalence in developing countries like India with tubercular meningitis (TBM) being the most common cause of death. Most cases of TBM are diagnosed late when despite adequate therapy; morbidity and mortality continue to remain high. This review aims to provide a pragmatic approach at dealing with cases of tubercular meningitis in children including clinical features, laboratory and radiological criteria, treatment options and prognostic implications. The objective of this review is to assist in early identification, proper investigation and timely treatment of TBM in children in order to reduce neurological morbidity and mortality associated with it.

Holistic care of complicated tuberculosis in healthcare settings with limited resources

In recent years, most of the focus on improving the quality of paediatric care in low-income countries has been on improving primary care using the Integrated Management of Childhood Illness, and improving triage and emergency treatment in hospitals aimed at reducing deaths in the first 24 hours. There has been little attention paid to improving the quality of care for children with chronic or complex diseases. Children with complicated forms of tuberculosis (TB), including central nervous system and chronic pulmonary TB, provide examples of acute and chronic multisystem paediatric illnesses that commonly present to district-level and second-level referral hospitals in low-income countries. The care of these children requires a holistic clinical and continuous quality improvement approach. This includes timely decisions on the commencement of treatment often when diagnoses are not certain, identification and management of acute respiratory, neurological and nutritional complications, identification and treatment of comorbidities, supportive care, systematic monitoring of treatment and progress, rehabilitation, psychological support, ensuring adherence, and safe transition to community care. New diagnostics and imaging can assist this, but meticulous attention to clinical detail at the bedside and having a clear plan for all aspects of care that is communicated well to staff and families are essential for good outcomes. The care is multidimensional: biomedical, rehabilitative, social and economic, and multidisciplinary: medical, nursing and allied health. In the era of the Sustainable Development Goals, approaches to these dimensions of healthcare are needed within the reach of the poorest people who access district hospitals in low-income countries.

Tuberculous Meningitis in Children and Adults: New Insights for an Ancient Foe

PURPOSE OF REVIEW

Tuberculous meningitis is the most devastating manifestation of infection with Mycobacterium tuberculosis and represents a medical emergency. Approximately one half of tuberculous meningitis patients die or suffer severe neurologic disability. The goal of this review will be to review the pathogenic, clinical, and radiologic features of tuberculous meningitis and to highlight recent advancements in translational and clinical science.

RECENT FINDINGS

Pharmacologic therapy includes combination anti-tuberculosis drug regimens and adjunctive corticosteroids. It is becoming clear that a successful treatment outcome depends on an immune response that is neither too weak nor overly robust, and genetic determinants of this immune response may identify which patients will benefit from adjunctive corticosteroids. Recent clinical trials of intensified anti-tuberculosis treatment regimens conducted in Indonesia and Vietnam, motivated by the pharmacologic challenges of treating M. tuberculosis infections of the central nervous system, have yielded conflicting results regarding the survival benefit of intensified treatment regimens. More consistent findings have been observed regarding the relationship between initial anti-tuberculosis drug resistance and mortality among tuberculous meningitis patients. Prompt initiation of anti-tuberculosis treatment for all suspected cases remains a key aspect of management. Priorities for research include the improvement of diagnostic testing strategies and the optimization of host-directed and anti-tuberculosis therapies.

Central Nervous System Tuberculosis

Central nervous system tuberculosis (CNS-TB) takes three clinical forms: meningitis (TBM), intracranial tuberculoma, and spinal arachnoiditis. TBM predominates in the western world and presents as a subacute to chronic meningitis syndrome with a prodrome of malaise, fever, and headache progressing to altered mentation and focal neurologic signs, followed by stupor, coma, and death within five to eight weeks of onset. The CSF formula typically shows a lymphocytic pleocytosis, and low glucose and high protein concentrations. Diagnosis rests on serial samples of CSF for smear and culture, combined with CSF PCR. Brain CT and MRI aid in diagnosis, assessment for complications, and monitoring of the clinical course. In a patient with compatible clinical features, the combination of meningeal enhancement and any degree of hydrocephalus is strongly suggestive of TBM. Vasculitis leading to infarcts in the basal ganglia occurs commonly and is a major determinant of morbidity and mortality. Treatment is most effective when started in the early stages of disease, and should be initiated promptly on the basis of strong clinical suspicion without waiting for laboratory confirmation. The initial 4 drug regimen (isoniazid, rifampin, pyrazinamide, ethambutol) covers the possibility of infection with a resistant strain, maximizes antimicrobial impact, and reduces the likelihood of emerging resistance on therapy. Adjunctive corticosteroid therapy has been shown to reduce morbidity and mortality in all but late stage disease.

Neurological complications after tuberculous meningitis in a multi-state cohort in the United States

BACKGROUND AND PURPOSE

To assess the rate of neurological complications and mortality after tuberculous meningitis in the United States.

METHODS

The authors performed a retrospective cohort study of all patients 18years or older hospitalized for tuberculous meningitis in California between 2005 and 2010, New York between 2006 and 2012, and Florida between 2005 and 2012. Outcomes of interest were mortality and the following neurological complications: stroke, seizure, hydrocephalus requiring a ventriculoperitoneal shunt, vision impairment, and hearing impairment. Kaplan-Meier survival statistics were used to assess the cumulative rate of neurological complications and death. Cox proportional hazards regression was used to compare rates of complications in patients with and without human immunodeficiency virus (HIV) after adjustment for comorbidities.

RESULTS

806 patients with tuberculous meningitis were identified, among whom the cumulative rate of any complication or death was 55.4% (95% CI, 51.5-59.3%). More than two-thirds of complications occurred during the initial hospitalization for tuberculous meningitis. Individual neurological complications were not uncommon: the cumulative rate of stroke was 16.8% (95% CI, 14.0-20.0%), the rate of seizure was 18.8% (95% CI, 15.4-22.8%), and the rate of ventriculoperitoneal shunting was 8.4% (95% CI, 6.4-10.9%). Vision impairment occurred in 21.6% (95% CI, 18.5-25.1%) of patients and hearing impairment occurred in 6.8% (95% CI, 4.9-9.4%). The mortality rate was 21.5% (95% CI, 18.4-24.9%). Patients with HIV infection were not at increased risk of complications compared to patients without HIV (hazard ratio, 1.2; 95% CI, 0.9-1.6).

CONCLUSIONS

Tuberculous meningitis is associated with significant risk of neurological complications and death in the United States.

A Study of Haematological and Haemostasis Parameters and Hypercoagulable State in Tuberculosis Patients in Northern India and the Outcome with Anti-Tubercular Therapy

INTRODUCTION

Tuberculosis is one of the leading infectious diseases with high morbidity and mortality in the developing countries. Tuberculosis is also rarely associated with hypercoagulable state and very limited literature is available on this association.

AIM

To study the haematological and haemostasis laboratory parameters, to correlate the abnormalities for a hypercoagulable state and to study the outcome with anti-tubercular therapy.

MATERIALS AND METHODS

The study population included 128 patients with newly diagnosed tuberculosis. Anti-tubercular therapy naïve patients were studied for haemostasis parameters like Prothrombin time, Activated Partial Thromboplastin time, Factor VIII, Fibrinogen and D-dimer and haematological parameters like Haemoglobin, White Blood Cells, Platelet count, Erythrocyte Sedimentation Rate (ESR), Lactate Dehydrogenase, C-reactive protein and albumin. At the end of the second month of anti-tubercular therapy, results were compared and analysed using statistical package for the social sciences software (SPSS).

RESULTS

Prothrombin levels were deranged in 50%. Activated Partial Thromboplastin time levels were deranged in 18%. Deranged Factor VIII levels were found in 35.15%. Fibrinogen levels were deranged in 57%. D-Dimer positivity was found in 57.8% patients. Anaemia was found in 75.78%, Leukocytosis in 49.21%, Thrombocytopenia in 37.5% and Hypoalbuminaemia in 75%. ESR levels were raised in 98.43%. Follow up comparison analysis revealed significant p-value for all the parameters except Factor VIII and Activated Partial Thromboplastin time. Similar trend was also observed within different groups of Tuberculosis patients.

CONCLUSION

Tuberculosis does favour a hypercoagulable state with increased risk of developing thrombosis and significant improvement with the anti-tubercular treatment alone.

Tuberculous Meningitis in an Immunocompetent Host: A Case Report

Patient: Male, 57

Final Diagnosis: Tuberculous meningitis

Symptoms: Altered mental state • headache

Medication: —

Clinical Procedure: Lumbar puncture

Specialty: Infectious Diseases

GeneXpert for Diagnosis of Tubercular Meningitis

Diagnosis of tubercular meningitis (TBM) is difficult in children. The GeneXpert MTB/RIF assay has been recommended by WHO in 2013 to be used in children and in extra pulmonary clinical specimens. The present study was designed to assess the diagnostic utility of GeneXpert in detecting Mycobacterium tuberculosis in cerebrospinal fluid (CSF) in TBM cases and to compare the results with liquid culture BACTEC 460. Thirty four subjects <15 y were diagnosed as TBM based on clinical, CSF and imaging details. Sensitivity of GeneXpert in CSF was 38.24 % as compared to Bactec culture which was only 14.71 % (p 0.0279). To conclude, GeneXpert MTB/RIF test is able to rapidly confirm diagnosis of TBM with higher sensitivity as compared to conventional methods and liquid culture.

Adult tuberculous meningitis in Qatar: a descriptive retrospective study from its referral center

BACKGROUND

Tuberculous meningitis is the severest and commonest form of central nervous system tuberculosis causing high mortality and morbidity. We aim to study the clinical, biochemical, and radiological characteristics of tuberculous meningitis in adult patients in Qatar and to calculate the incidence.

METHODS

A descriptive retrospective 7-year study was conducted at the Hamad General Hospital (the only tertiary referral center and sole health care provider for tuberculosis in Qatar) between the 1st of January 2006 and the 31st of December 2012, to describe the clinical presentation, diagnosis, treatment, outcome, and the incidence of adult tuberculous meningitis in Qatar.

RESULTS

Tuberculous meningitis was diagnosed in 80 patients (65 male, 15 female), with a mean age of 30.3 ± 8.9. The majority of patients (76.3%) were from the Indian subcontinent. The commonest clinical features were fever (79%), headache (71%), and meningism (56%). Cerebrospinal fluid tuberculosis culture was positive in 44% of patients. Almost 39% of patients were in Stage I, 46% in Stage II and 15% in Stage III of the disease. The commonest neuroimaging features were leptomeningeal enhancement (34%) and hydrocephalus (33%). Cranial nerve palsy, limb weakness, and an elevated C-reactive protein were associated with a poorer outcome. Sixty eight percent had complete recovery, 10% had residual neurological sequelae without disability, 17% had disability, and 5% died. The average incidence of tuberculous meningitis over 7 years was 0.9 per 100,000 adult population.

CONCLUSION

The characteristics of tuberculous meningitis were described in our population. Our data indicate that the incidence of tuberculosis meningitis in Qatar has increased. Tuberculous meningitis in Qatar is mainly an imported disease.

Surgery in hydrocephalus of tubercular origin: challenges and management

BACKGROUND

Hydrocephalus of tubercular origin is one of the most dreaded and difficult to manage complications of brain tuberculosis. Traditionally, the management has been ventriculoperitoneal shunting, but in recent years emerging interest is in endoscopic ventriculostomy. In this article, we discuss the management protocol of hydrocephalus in various stages of disease.

METHODS

A total of 424 cases of tubercular origin hydrocephalus were managed between years 2000 and 2009. Initially the cases were managed by ventriculoperitoneal shunting, which was followed by use of endoscopic third ventriculostomy. Drug-resistant cases were also encountered and managed according to drug sensitivity.

RESULTS

The results provided through evaluation of retrospective data showed a high mortality in cases of hydrocephalus of acute origin if endoscopic third ventriculostomy was performed. The cerebrospinal fluid protein level and neurological status of the patient determined the success or failure of the procedure. For better management, patients were divided into six groups and their management underlined.

CONCLUSION

The cases of tubercular meningitis with aqueductal stenosis presenting in early stages should be given a trial of endoscopic third ventriculostomy where chronic burnt-out cases or cases with communicating hydrocephalus should be managed by ventriculoperitoneal shunting.

Reliability and diagnostic performance of CT imaging criteria in the diagnosis of tuberculous meningitis

Introduction

Abnormalities on CT imaging may contribute to the diagnosis of tuberculous meningitis (TBM). Recently, an expert consensus case definition (CCD) and set of imaging criteria for diagnosing basal meningeal enhancement (BME) have been proposed. This study aimed to evaluate the sensitivity, specificity and reliability of these in a prospective cohort of adult meningitis patients.

Methods

Initial diagnoses were based on the CCD, classifying patients into: ‘Definite TBM’ (microbiological confirmation), ‘Probable TBM’ (diagnostic score ≥10), ‘Possible TBM’ (diagnostic score 6–9), ‘Not TBM’ (confirmation of an alternative diagnosis) or ‘Uncertain’ (diagnostic score of <6). CT images were evaluated independently on two occasions by four experienced reviewers. Intra-rater and inter-rater agreement were calculated using the kappa statistic. Sensitivities and specificities were calculated using both ‘Definite TBM’ and either ‘Definite TBM’ or ‘Probable TBM’ as gold standards.

Results

CT scan criteria for BME had good intra-rater agreement (κ range 0.35–0.78) and fair to moderate inter-rater agreement (κ range 0.20–0.52). Intra- and inter-rater agreement on the CCD components were good to fair (κ  =  ranges 0.47–0.81 and 0.21–0.63). Using ‘Definite TBM’ as a gold standard, the criteria for BME were very specific (61.5%–100%), but insensitive (5.9%–29.4%). Similarly, the imaging components of the CCD were highly specific (69.2–100%) but lacked sensitivity (0–56.7%). Similar values were found when using ‘Definite TBM’ or ‘Probable TBM’ as a gold standard.

Discussion

The fair to moderate inter-rater agreement and poor sensitivities of the criteria for BME suggest that little reliance should be placed in these features in isolation. While the presence of the CCD criteria of acute infarction or tuberculoma(s) appears useful as rule-in criteria, their absence is of little help in excluding TBM. The CCD and criteria for BME, as well as any new criteria, need to be standardized and validated in prospective cohort studies.

Atypical cause of stroke in a 27 year old male

BACKGROUND

Central nervous system (CNS) Tuberculosis (TB) meningitis is a progressive disease that can present in many forms. CNS TB is encountered frequently in areas of high prevalence of tuberculosis and dissemination is common, but TB meningitis is a disease that has a relatively low prevalence in North America.

CASE REPORT

27 year-old African American male presented with complaints of headache, altered mental status (AMS), and seizure activity. He was found to have fever, encephalopathy, and leukocytosis. Work up of his AMS revealed cerebral spinal fluid (CSF) consistent with acute lymphocytic meningitis and magnetic resonance imaging (MRI) revealed right basilar meningeal enhancement with acute right basal ganglia infarction. Given the characteristic CSF and MRI finding for Tuberculosis (TB) a computed tomography (CT) of the chest was performed which revealed right upper lobe nodules with central cavitations. Biopsy results revealed Tuberculosis. The patient showed significant improvement once empiric tuberculosis therapy was begun.

CONCLUSIONS

CNS TB is a treatable disease that will be fatal if not recognized early. It is imperative to be aware of the key clinical features of TB meningitis, and maintain a high level of suspicion when dealing with CNS infection if the cause is unknown.

Description of primary multidrug-resistant tuberculous meningitis in an Italian child

Tuberculous meningitis is the most severe form of tuberculosis and causes substantial morbidity and mortality in adults and children. The prevalence of multidrug-resistant (rifampin-isoniazid) strains requires the use of more toxic second-line drugs. We report a case of tuberculous meningitis in a 3-year-old Italian child.

The neurosurgical and acute care management of tuberculous meningitis: evidence and current practice

Tuberculous meningitis (TBM) is the most lethal form of tuberculosis; mortality is high and survivors are often left neurologically disabled. Several factors contribute to this poor outcome, including cerebrovascular involvement with ensuing brain ischemia, hydrocephalus and raised intracranial pressure, direct parenchymal injury, hyponatremia, and seizures. However, there is little standardisation of management with respect to these aspects of care across different centers, largely because the evidence base for much of the supportive treatment of patients with TBM is poor, leading to substantial differences in management protocols. This review emphasizes some of the uncertainties and controversies pertinent to the surgical treatment of hydrocephalus in TBM and the medical supportive management of the patient during the acute phase of the illness, with the aims of raising awareness and stimulating debate. The focus is on the management of hyponatremia, cerebral hemodynamics and intracranial pressure, medical and surgical treatment for hydrocephalus, and the intensive care management of patients in the acute severe stage of the illness. Very little data are available to address these issues with good evidence and so institutional preferences are common; this is perhaps most notable for the management of hydrocephalus, and so in this the review highlights our personal practice. The brain needs protection while the source of the illness is addressed. Without attention to these aspects of management there will always be a limit to the effectiveness of antimicrobial therapy in TBM, so there is a strong imperative for the controversies to be resolved and the limitations of our current care to be addressed. Existing protocols should be rigorously examined and novel strategies to protect the brain should be explored. To this end, a prospective, multi-disciplinary and multi-centered approach may yield answers to the questions raised in this review.

MRI to demonstrate diagnostic features and complications of TBM not seen with CT

BACKGROUND

Computed tomography (CT) findings in children with tuberculous meningitis (TBM) often do not explain the clinical presentation and may even be normal. Magnetic resonance imaging (MRI) has the potential to diagnose TBM with greater sensitivity than CT and also to detect more infarcts.

AIM

The aim of this study was to determine whether MRI demonstrates features and complications of TBM not present on CT.

MATERIALS AND METHODS

Retrospective, blinded evaluation and comparison of CT and MRI findings in children with TBM were performed.

RESULTS

Of 30 children included, MRI demonstrated eight more with basal enhancement and four more with infarctions. Overall, MRI demonstrated an additional 104 sites of infarction (of a total 172) than CT. Of these, 89 were acute and visualized only on diffusion-weighted image. MRI showed five more patients with unilateral and two more with bilateral basal ganglia infarcts than CT as well as 19 brainstem infarcts. Hydrocephalus was equally detected by MRI and CT.

CONCLUSION

MRI is superior to CT for diagnosing TBM (by detecting basal enhancement in more patients) and prognosis (by detecting many more infarcts in strategic locations). The role of CT is defined for the acute setting in detecting hydrocephalus for surgical management.

British Infection Society guidelines for the diagnosis and treatment of tuberculosis of the central nervous system in adults and children

SUMMARY AND KEY RECOMMENDATIONS: The aim of these guidelines is to describe a practical but evidence-based approach to the diagnosis and treatment of central nervous system tuberculosis in children and adults. We have presented guidance on tuberculous meningitis (TBM), intra-cerebral tuberculoma without meningitis, and tuberculosis affecting the spinal cord. Our key recommendations are as follows: 1. TBM is a medical emergency. Treatment delay is strongly associated with death and empirical anti-tuberculosis therapy should be started promptly in all patients in whom the diagnosis of TBM is suspected. Do not wait for microbiological or molecular diagnostic confirmation. 2. The diagnosis of TBM is best made with lumbar puncture and examination of the cerebrospinal fluid (CSF). Suspect TBM if there is a CSF leucocytosis (predominantly lymphocytes), the CSF protein is raised, and the CSF:plasma glucose is <50%. The diagnostic yield of CSF microscopy and culture for Mycobacterium tuberculosis increases with the volume of CSF submitted; repeat the lumbar puncture if the diagnosis remains uncertain. 3. Imaging is essential for the diagnosis of cerebral tuberculoma and tuberculosis involving the spinal cord, although the radiological appearances do not confirm the diagnosis. A tissue diagnosis (by histopathology and mycobacterial culture) should be attempted whenever possible, either by biopsy of the lesion itself, or through diagnostic sampling from extra-neural sites of disease e.g. lung, gastric fluid, lymph nodes, liver, bone marrow. 4. Treatment for all forms of CNS tuberculosis should consist of 4 drugs (isoniazid, rifampicin, pyrazinamide, ethambutol) for 2 months followed by 2 drugs (isoniazid, rifampicin) for at least 10 months. Adjunctive corticosteroids (either dexamethasone or prednisolone) should be given to all patients with TBM, regardless of disease severity. 5. Children with CNS tuberculosis should ideally be managed by a paediatrician with familiarity and expertise in paediatric tuberculosis or otherwise with input from a paediatric infectious diseases unit. The Children's HIV Association of UK and Ireland (CHIVA) provide further guidance on the management of HIV-infected children (www.chiva.org.uk). 6. All patients with suspected or proven tuberculosis should be offered testing for HIV infection. The principles of CNS tuberculosis diagnosis and treatment are the same for HIV infected and uninfected individuals, although HIV infection broadens the differential diagnosis and anti-retroviral treatment complicates management. Tuberculosis in HIV infected patients should be managed either within specialist units by physicians with expertise in both HIV and tuberculosis, or in a combined approach between HIV and tuberculosis experts. The co-administration of anti-retroviral and anti-tuberculosis drugs should follow guidance issued by the British HIV association (www.bhiva.org).

Cerebral infarction and neurodevelopmental outcome in childhood tuberculous meningitis

INTRODUCTION

Cerebral infarction is an important cause of neurological sequelae in childhood tuberculous meningitis (TBM).

AIM

To investigate neurodevelopmental outcome and development of motor sequelae in TBM-related cerebral infarction.

METHODS

A group of 64 children with TBM and computerized tomographic (CT) evidence of infarction were compared with regard to motor sequelae and neurodevelopmental outcome, with 54 children with TBM but no radiological evidence of infarction. The association between infarct number, size, location and outcome was investigated in the infarct group. Selected covariates were entered into a multivariate model to better understand the independent contribution of each factor on neurodevelopmental outcome.

RESULTS

An association was found between the presence, number and size of hemispheric infarcts and motor handicap on follow-up. Location of single basal ganglia infarcts, however, did not correlate with motor outcome. The Griffiths general developmental quotient (GQ) was significantly lower in children with bilateral (p<0001) and unilateral multiple infarcts (p=0.0239) compared to those without infarcts. The GQ of children with unilateral single infarcts was not significantly lower than those without infarction (p=0.2282).

CONCLUSION

Infarct characteristics should be taken into account when neurodevelopmental outcome is prognosticated in TBM. Young age, unilateral multiple or bilateral infarction on CT at 1 month, advanced stage of TBM and the interaction term stage x Glasgow coma score are the best predictors of neurodevelopmental outcome at 6 months.

[Managing adult patients with acute community-acquired meningitis presumed of bacterial origin]

Early clinical data must lead to suspect bacterial meningitis if fever, the most frequent sign, is present and if it is associated with more or less constant neurological and meningeal signs (consciousness impairment, headache, neck stiffness, focal neurological deficit, seizure, etc.). A skin rash is frequent in case of meningococcal meningitis whereas cranial nerve palsy is more in favor of tuberculous or Listeria meningitis. Presence of otitis, sinusitis, pneumonia, or a recent head trauma strongly suggests a pneumococcal involvement. Tuberculous meningitis is generally characterized by a slow evolution of meningeal signs together with aspecific signs. The main prognostic factors are consciousness impairment, circulatory instability, focal neurological signs, and advanced age. Morbidity and mortality are increased in case of pneumococcal compared to meningococcal meningitis. Cranial tomodensitometry gives further information about intracranial complications of meningitis. In some cases, particularly if focal neurological or intracranial hypertension signs are present, it must be performed before a lumbar puncture. The risk factors of meningitis must be investigated and treated if possible according to the bacterium. The management of patient after hospital discharge depends on evolution after treatment. The presence of neurological sequels imposes a specialized ambulatory follow-up. Neuropsychological sequels (cognitive dysfunction, memory impairment) can also persist for years even in absence of other neurological disorders.

Clinical and laboratory characteristics of cerebral infarction in tuberculous meningitis: a comparative study

Cerebral infarction as a complication of tubercular (TB) meningitis is not uncommon, but an adequate comparison of patients with and without stroke has not been carried out. This study was performed to evaluate the clinical characteristics of cerebral infarction secondary to TB meningitis, and to investigate predictive factors for cerebral infarction in patients with TB meningitis. Patients with TB meningitis were recruited over a period of 56 months. They were divided into two groups, those with and those without stroke. Demographic features and clinical, laboratory, and neuroradiological findings were compared between the two groups. We classified strokes into subtypes using neuroimaging findings. Of the 38 patients who were diagnosed with TB meningitis, eight also experienced cerebral infarction. The percentage of cerebrospinal fluid leukocytes that were neutrophils was significantly higher in patients with stroke (68%) than in patients without stroke (31%; p=0.0001). Upon initial CT imaging, meningeal enhancement was found in 11 patients, and of these patients, six experienced stroke. There were no significant differences between the groups with respect to other clinical and laboratory features, including demographic features, time between meningitis onset and treatment initiation, peripheral white blood cell count, and cerebrospinal fluid findings. Five of the eight patients who developed stroke had lacunar infarcts. One of the three patients with territorial nonlacunar infarction died due to herniation. When treating patients with TB meningitis, the possibility of cerebral infarction should be considered when patients develop focal neurological signs, meningeal enhancement on a CT scan, and sustained polymorphic cerebrospinal fluid pleocytosis.

Fuzzy clustering of CT images for the measurement of hydrocephalus associated with tuberculous meningitis

Computed tomography is used as an aid in the diagnosis of tuberculous meningitis (TBM) for the examination of a number of visual indicators of the disease. We present an algorithm that uses modified fuzzy c-means clustering to segment CT images of the brain into different tissue types. The ventricle/brain ratio is then calculated to measure hydrocephalus, a common sign of TBM in children.

Clinical and radiological features of symptomatic central nervous system tuberculomas

Tuberculomas may present with meningitis, may lead to meningitis, or may develop during the treatment of TBM. In this study, we report a series of 22 adult cases of symptomatic central nervous system tuberculomas, in eight of them tuberculomas were coexisting with TBM on admission and in 14 of them symptomatic tuberculomas developed during anti-tuberculosis therapy. We also aimed to compare the clinical, laboratory and outcome data of the 14 TBM patients that developed symptomatic tuberculomas, with the data of 41 TBM that did not, under the same treatment regimen. Most of the patients developed symptomatic tuberculomas in the first 6 weeks of treatment. Five patients developed late tuberculomas. The characteristics of tuberculomas and the role of corticosteroids in TBM patients are discussed. In conclusion, although steroids may diminish neurologic symptoms and improve outcome, tuberculomas may appear during the course of anti-tuberculosis and steroid treatment. Because of the possibility of late development of tuberculomas after initial successful treatment, all TBM patients need to be followed-up carefully for a long period.

Inflammation and brain edema: new insights into the role of chemokines and their receptors

Brain edema is associated with a variety of neuropathological conditions such as brain trauma, ischemic and hypoxic brain injury, central nervous system infection, acute attacks of multiple sclerosis, and brain tumors. A common finding is an inflammatory response, which may have a significant impact on brain edema formation. One critical event in the development of brain edema is blood-brain barrier (BBB) breakdown, which may be initiated and regulated by several proinflammatory mediators (oxidative mediators, adhesion molecules, cytokines, chemokines). These mediators not only regulate the magnitude of leukocyte extravasation into brain parenchyma, but also act directly on brain endothelial cells causing the loosening of junction complexes between endothelial cells, increasing brain endothelial barrier permeability, and causing vasogenic edema. Here we review junction structure at the BBB, the effects of pro-inflammatory mediators on that structure, and focus on the effects of chemokines at the BBB. New evidence indicates that chemokines (chemoattractant cytokines) do not merely direct leukocytes to areas of injury. They also have direct and indirect effects on the BBB leading to BBB disruption, facilitating entry of leukocytes into brain, and inducing vasogenic brain edema formation. Chemokine inhibition may be a new therapeutic target to reduce vasogenic brain edema.

Cerebral infarcts complicating tuberculous meningitis

Cerebral infarction (CI) is a serious complication of tuberculous meningitis (TBM). It can be asymptomatic or symptomatic, causing stroke. We studied 40 TBM patients. All had initial CT brain scan, CT/MRI brain scan 3 months later and urgent CT brain scan for deterioration. CI was classified into lacunar infarction (LI) or large artery infarction (LAI). Twelve (30%) had CI, in 9 (23%) it was symptomatic and in 3 (8%) silent. Seven (58%) had LAI +/- LI. Eight (67%) had multiple CI. Two died from brainstem CI and 6 were dependent at 1 year. Patients with LAI might develop posterior circulation CI more frequently than those with LI only. CI is a common complication of TBM locally, with LAI and multiple CI being common. Two thirds of TBM patients complicated by CI had poor prognosis despite adjunctive dexamethasone treatment.

Value of early follow-up CT in paediatric tuberculous meningitis

BACKGROUND

The value of CT in the diagnosis of tuberculous meningitis (TBM) in children is well reported. Follow-up CT scanning for these patients is, however, not well described and, in particular, the value of early follow-up CT has not been addressed for children with TBM.

OBJECTIVE

To assess the value of early follow-up CT in children with TBM in identifying diagnostic, prognostic and therapeutically relevant features of TBM.

MATERIALS AND METHODS

A retrospective 4-year review of CT scans performed within 1 week and 1 month of initial CT in children with proven (CSF culture-positive) and probable TBM (CSF profile-positive but culture-negative) and comparison with initial CT for the diagnostic, prognostic and therapeutic CT features of TBM.

RESULTS

The CT scans of 50 children were included (19 "definite" TBM; 31 "probable" TBM). Of these, 30 had CT scans performed within 1 week of the initial CT. On initial CT, 44 patients had basal enhancement. Only 24 patients had contrast medium-enhanced follow-up scans. Important findings include: 8 of 29 patients (who were not shunted) developed new hydrocephalus. New infarcts developed in 24 patients; 45% of those who did not have infarction initially developed new infarcts. Three of the six patients who did not show basal enhancement on initial scans developed this on the follow-up scans, while in seven patients with pre-existing basal enhancement this became more pronounced. Two patients developed hyperdensity in the cisterns on non-contrast medium scans. Eight patients developed a diagnostic triad of features. Three patients developed CT features of TBM where there was none on the initial scans.

CONCLUSIONS

Early follow-up CT is useful in making a diagnosis of TBM by demonstrating features that were not present initially and by demonstrating more sensitive, obvious or additional features of TBM. In addition, follow-up CT is valuable as a prognostic indicator as it demonstrates additional infarcts which may have developed or become more visible since the initial study. Lastly, follow-up CT has therapeutic value in demonstrating hydrocephalus, which may develop over time and may require drainage. We advise routine follow-up CT in patients with suspected TBM within the first week of initial CT and optionally at 1 month.

Tuberculous meningitis and HIV

OBJECTIVE

To identify factors associated with HIV-infected status in children admitted with tuberculous meningitis (TBM), and to find out whether HIV co-infection affects in-hospital outcome.

METHODS

This prospective hospital-based study was conducted from May 2000 to August 2003. All consecutive children, aged 1 month to 12 years of age, admitted with a diagnosis of TBM were enrolled. Relationship between 35 features viz., two demographic factors, nine clinical features, 13 neurological features, five laboratory (including cerebrospinal fluid) parameters, six radiological (including computed tomography scan brain) features, and the two outcomes (disabled survivor or death); with HIV-infected status was assessed.

RESULTS

Of a total 123 TBM cases enrolled, eight (6.5%) were HIV-infected. There was no significant difference between the two groups, except that more children in the HIV-infected group had Hb < 8 gm/dl: both on bivariate analysis, (OR, 12.0; 95% CI, 2.6-55.9; P = 0.001) and on multivariate analysis (OR, 12.30; 95% CI, 1.9-79.6; P = 0.008). Outcome was similar in both the groups.

CONCLUSION

Only presence of Hb < 8 gm/dl was associated with HIV-infected status. HIV co-infection did not affect the outcome.

Definitive neuroradiological diagnostic features of tuberculous meningitis in children

BACKGROUND

Although CT scanning is used widely for making the diagnosis and detecting the complications of tuberculous meningitis (TBM) in children, the radiological features are considered non-specific. CT is particularly suggestive of the diagnosis when there is a combination of basal enhancement, hydrocephalus and infarction, and even then the diagnosis may be in doubt. In this paper we introduce a new CT feature for making the diagnosis of TBM, namely, hyperdensity in the basal cisterns on non-contrast scans, and we assess which of the recognized CT features is most sensitive and specific.

OBJECTIVE

To determine the sensitivity and specificity of the presence of high-density exudates in the basal cisterns (on non-contrast CT) and basal enhancement (on contrast-enhanced CT) for the diagnosis of TBM in children, and to correlate these with the complications of infarction and hydrocephalus.

MATERIALS AND METHODS

Retrospective review of CT scans with readers blinded to the diagnosis, which was based on a definitive culture of cerebrospinal fluid (CSF) for TBM or other bacteria. Computer-aided conversion of hard-copy film density to Hounsfield units was employed as well as a density threshold technique for determining abnormally high densities.

RESULTS

The most specific feature for TBM is hyperdensity in the basal cisterns prior to IV contrast medium administration (100%). The most sensitive feature of TBM is basal enhancement (89%). A combination of features (hydrocephalus, infarction and basal enhancement) is as specific as pre-contrast hyperdensity, but has a lower sensitivity (41%). There were statistically significant differences in the presence of hydrocephalus (p=0.0016), infarcts (P=0.0014), basal enhancement (P<0.0001) and pre-contrast density (P<0.0001) between the negative and positive TBM patient groups. The presence of granulomas was not statistically significant between the two groups (P=0.44).

CONCLUSIONS

The presence of high density within the basal cisterns on non-contrast CT scans is a very specific sign for TBM in children. This will enhance diagnostic confidence, allow early institution of therapy and could reduce expenditure on contrast medium, scan time and radiation exposure. With the use of threshold techniques we believe that the pre-contrast hyperdensity may be detectable by a computer program that will facilitate diagnosis, and may also be modified to detect abnormal enhancement. Basal enhancement is a sensitive sign for the diagnosis of TBM and should be sought after contrast medium administration when no hyperdensity is seen in the basal cisterns or when this finding needs to be confirmed. The CT scan feature of hyperdense exudates on pre-contrast scans should be added to the inclusion criteria for the diagnosis of TBM in children.

Primary diffuse leptomeningeal sarcoma with rhabdomyoblastic differentiation. A case report and immunohistochemical study

Primary meningeal neoplasias are rare, and their diffuse growth within the subarachnoid space may simulate inflammatory processes or metastatic neoplastic dissemination. We report here the case of a boy with an 18-day history of fever and progressive neurological deterioration. While in the hospital, the patient showed neurological deterioration and did not respond to antituberculosis treatment. His cerebrospinal fluid (CSF) cytology disclosed an elevated white blood cell count accompanied by a mildly elevated protein level and a slightly decreased glucose level. The child died, and pathology revealed that his meningeal process was a sarcoma. The immunophenotype of the neoplastic cells showed expression of a sarcomeric actin marker, characterizing rhabdomyoblastic differentiation of the cells that occupied the subarachnoid space and invaded superficially the encephalon. Rhabdomyoblastic differentiation in leptomeningeal diffuse primary sarcoma (LDPS) is an aspect rarely observed in this malignant meningeal neoplasia, with few reported cases. The present case is the first reported in the Portuguese literature and the fifth reported in the English literature.

Endoscopic third ventriculostomy in tuberculous meningitis

INTRODUCTION

We report our preliminary experience with two cases of tuberculous meningitis (TBM) in which endoscopic third ventriculostomy (ETV) was performed to treat non-communicating hydrocephalus. For many years, the insertion of ventriculoperitoneal shunts has been the standard treatment for hydrocephalus in patients with TBM, although the indications for and timing of surgery are not uniformly accepted. Shunt insertion is associated with a high incidence of complications, particularly with long-term follow-up. An alternative treatment for hydrocephalus in this group of patients would clearly be of great benefit. The indications for ETV have increased in the last decade, and there are reports of some effectiveness of the procedure in patients with hydrocephalus due to bacterial meningitis. To our knowledge, ETV has not been described in the management of TBM.

METHODS

We report the early results of our preliminary experience with ETV in two patients who presented with neurological compromise due to hydrocephalus and raised intracranial pressure. The clinical context and pre-operative investigation of these patients are presented. The emphasis is placed on the distinction between communicating and non-communicating pathologies as a guide to management options. We detail our surgical findings and the peculiar endoscopic challenges that the condition presented to us. Follow-up in these patients included clinical and investigational data suggesting early effectiveness of the procedure in converting non-communicating hydrocephalus into a communicating one, which can then be treated medically.

DISCUSSION

Endoscopic third ventriculostomy is presented as a new application of a procedure accepted for other indications in the treatment of non-communicating hydrocephalus. There are particular aspects of the use of this procedure related to the unique pathology of TBM that are significantly different. We explain our rationale for endoscopy in these patients, and suggest a protocol in which endoscopy may play a role in the management of patients with raised intracranial pressure due to tuberculous hydrocephalus.

Conventional and diffusion-weighted MR imaging of intracranial tuberculomas. A case report

Intracranial tuberculoma is a rare form of central nervous system tuberculosis. We here report on conventional and diffusion-weighted cranial MR images of a non-immunocompromised patient with multiple intracranial tuberculomas, tuberculous lymphadenitis and pulmonary tuberculosis. Conventional MR imaging revealed multiple ring-enhancing mass lesions. At follow-up MR, appearances of both edema and number and size of nodules were decreased. Diffusion-weighted MR was normal and normal ADC values were found in this case of tuberculomas.