Tuberculous optochiasmatic arachnoiditis

The leptomeninges as a critical organ for normal CNS development and function: First patient and public involved systematic review of arachnoiditis (chronic meningitis)

BACKGROUND & IMPORTANCE

This patient and public-involved systematic review originally focused on arachnoiditis, a supposedly rare "iatrogenic chronic meningitis" causing permanent neurologic damage and intractable pain. We sought to prove disease existence, causation, symptoms, and inform future directions. After 63 terms for the same pathology were found, the study was renamed Diseases of the Leptomeninges (DLMs). We present results that nullify traditional clinical thinking about DLMs, answer study questions, and create a unified path forward.

METHODS

The prospective PRISMA protocol is published at Arcsology.org. We used four platforms, 10 sources, extraction software, and critical review with ≥2 researchers at each phase. All human sources to 12/6/2020 were eligible for qualitative synthesis utilizing R. Weekly updates since cutoff strengthen conclusions.

RESULTS

Included were 887/14286 sources containing 12721 DLMs patients. Pathology involves the subarachnoid space (SAS) and pia. DLMs occurred in all countries as a contributor to the top 10 causes of disability-adjusted life years lost, with communicable diseases (CDs) predominating. In the USA, the ratio of CDs to iatrogenic causes is 2.4:1, contradicting arachnoiditis literature. Spinal fusion surgery comprised 54.7% of the iatrogenic category, with rhBMP-2 resulting in 2.4x more DLMs than no use (p<0.0001). Spinal injections and neuraxial anesthesia procedures cause 1.1%, and 0.2% permanent DLMs, respectively. Syringomyelia, hydrocephalus, and arachnoid cysts are complications caused by blocked CSF flow. CNS neuron death occurs due to insufficient arterial supply from compromised vasculature and nerves traversing the SAS. Contrast MRI is currently the diagnostic test of choice. Lack of radiologist recognition is problematic.

DISCUSSION & CONCLUSION

DLMs are common. The LM clinically functions as an organ with critical CNS-sustaining roles involving the SAS-pia structure, enclosed cells, lymphatics, and biologic pathways. Cases involve all specialties. Causes are numerous, symptoms predictable, and outcomes dependent on time to treatment and extent of residual SAS damage. An international disease classification and possible treatment trials are proposed.

Neuro-ophthalmic manifestations of tuberculosis

Neuro-ophthalmic features are a known association in tuberculosis, especially common in central nervous system tuberculosis (CNS-TB). They are mostly the result of the visual pathway and/or ocular motor and other cranial nerve involvement. Furthermore, toxic optic neuropathy and paradoxical response to anti-tubercular drugs (ATT) are also not uncommon. The etiopathogenesis is by the complex interplay of various factors like exudates, vasculitis, arachnoiditis, presence of tuberculomas, hydrocephalus, brain infarcts and/or immune-mediated reaction. The entity often poses a diagnostic dilemma for the ophthalmologists/neuro-ophthalmologists and may lead to irreversible vision loss. The presence of neuro-ophthalmic features not only affect the visual outcome but are also predictors of systemic morbidity of the disease. Therefore, understanding and knowledge about this entity are necessary for the comprehensive management of the disease. While various forms of TB including CNS-TB have been well-dealt with in literature, little is discussed specifically about the neuro-ophthalmic manifestations of tuberculosis. Therefore, the purpose of this review is to highlight current understanding of the types of neuro-ophthalmic involvement in tuberculosis, its etiopathogenesis, diagnosis and management.

Tuberculous optochiasmatic arachnoiditis: a devastating form of tuberculous meningitis

Tuberculous meningitis is primarily a disease of the meninges of brain and spinal cord along with adjacent brain parenchyma. The characteristic pathological changes are meningeal inflammation, basal exudates, vasculitis and hydrocephalus. Tuberculous meningitis has a strong predilection for basal parts of the brain. Exudates, if dominantly present in the interpeduncular, suprasellar and Sylvian cisterns, result in optochiasmatic arachnoiditis and tuberculoma. Optochiasmatic arachnoiditis and tuberculoma are devastating forms of tuberculous meningitis and often associated with profound vision loss. This clinical entity more frequently affects young adults. In a recent study, on the multivariate logistic regression analysis, female sex, younger age and raised cerebrospinal fluid protein content were identified as predictors for developing optochiasmatic arachnoiditis. Frequently, optochiasmatic tuberculoma and optochiasmatic arachnoiditis develop paradoxically while a patient is being treated with anti-TB drugs. MRI reveals confluent enhancing lesions that are present in the interpeduncular fossa, pontine cistern, and the perimesencephalic and suprasellar cisterns. Management of tuberculous optochiasmatic arachnoiditis and optochiasmatic arachnoiditis tuberculoma has been variable. Treatment of optochiasmatic arachnoiditis continues to be a challenge and the response is generally unsatisfactory. In isolated case reports and in small series, corticosteroids, methyl prednisolone, thalidomide and hyaluronidase have been used with variable success. The benefit from neurosurgery is controversial and deterioration may follow the initial temporary improvement. Management of paradoxical optochiasmatic arachnoiditis is also controversial. Some patients regain vision following treatment with anti-TB drugs and continued usage of corticosteroids. Neurosurgery may be considered in the patients with either treatment failure or when diagnosis is in doubt. In conclusion, presence of optochiasmatic arachnoiditis or tuberculoma has important therapeutic and prognostic implications for patients of tuberculous meningitis.

Tuberculous meningitis-related optic neuritis: recovery of vision with thalidomide in 4 consecutive cases

Blindness is an uncommon but devastating complication of tuberculosis meningitis. The main causes are chronically raised intracranial pressure (hydrocephalus and/or tuberculomas) or direct involvement of the optic chiasm or optic nerves by the basal arachnoiditis (inflammation and/or compression). Antituberculosis therapy combined with corticosteroids and control of intracranial pressure constitutes the mainstay of therapy for tuberculous meningitis. Despite these treatment measures, some patients develop blindness, mainly as a result of progressive optochiasmatic arachnoiditis. This led us to explore the role of adjuvant thalidomide therapy, and we describe the dramatic recovery of vision in 4 consecutive cases. Clinical recovery was accompanied by marked radiological improvement on magnetic resonance imaging (MRI) of the brain.

Recovery of vision after adjuvant thalidomide in a child with tuberculous meningitis and acute lymphoblastic leukemia

A 7-year-old child, on maintenance chemotherapy for acute lymphoblastic leukemia, developed tuberculous meningitis complicated by progressive basal meningeal inflammation and abscess formation, in spite of adequate tuberculosis treatment and adjunctive corticosteriod therapy. The child became blind as a result of involvement of the optic chiasm. After 2 months of adjunctive thalidomide therapy, the child regained vision and cranial magnetic resonance imaging showed marked reduction of the inflammatory changes previously demonstrated. Progression of intracranial tuberculous infection, in spite of a treatment that is generally considered to be adequate, is well recognized. Previous reports of a possible beneficiary role of thalidomide in these cases support an immunological basis. The present case suggests a role for thalidomide in the treatment of blindness due to involvement of the optic chiasm in progressive basal tuberculous meningitis.

Progressive visual loss due to a muslinoma--report of a case and review of the literature

Intracranial internal carotid artery (ICA) aneurysms are frequently treated either by microsurgical clipping of the aneurysm neck, by endovascular coiling of the aneurysm sac or by balloon occlusion of the parent vessel. For some broad-based aneurysms that may not be suitable for any of these options, microsurgical wrapping of the aneurysm wall with muslin or gauze rarely is applied. We report the case of a patient who suffered from a minor stroke because of arterio-arterial embolism from an intracranial ICA aneurysm. The aneurysm was treated by wrapping muslin material. After 12 months, he experienced progressive visual loss. Cranial magnetic resonance testing magnetic resonance tomography (MRT) revealed a granulomatous inflammation surrounding the site of the aneurysm and affecting optochiasmatic structures. A muslin-induced optic neuropathy is a rare but serious complication of a chronic inflammatory reaction in response to muslin or gauze used in intracranial aneurysm wrapping. If the foreign body inflammatory reaction to muslin or gauze leads to a mass formation, the term muslinoma or gauzoma is applied. Various treatment strategies include surgery, steroids and cyclophosphamide, but recovery of the vision is not predictable. As a consequence, muslin or cotton gauze should only be applied with great caution in neurovascular surgery.

Imaging of the optic nerve and visual pathways

The visual pathway extends from the globes anteriorly to the occipital cortex posteriorly. A wide variety of disease processes may produce visual dysfunction. Because the optic nerve is a fiber tract of the brain covered by meninges, it can be affected by many of the same pathologic processes that occur in the brain and meninges. Physical examination and diagnostic tests of visual function performed by the clinician can frequently identify the anatomic location of the causative lesion in the patient with vision loss. This enables the radiologist to optimize the imaging evaluation of the patient. This article reviews the normal anatomy of the optic nerve and visual pathways, presents computed tomography (CT) and magnetic resonance (MR) imaging techniques for evaluation of these structures, and discusses the pathologic processes intrinsic to the optic nerve and visual pathways.

Tuberculous meningitis with blindness and perichiasmal involvement on MRI

An 11-year-old boy with tuberculous meningitis developed blindness, a rare complication of this disease in the United States. Magnetic resonance imaging demonstrated perichiasmal enhancement, suggesting that arachnoiditis caused the visual loss. Serial neuroimaging over 7 months revealed a persistent inflammatory process in the chiasmatic cistern, hydrocephalus, and progressive cerebral infarctions.

Severe optochiasmatic arachnoiditis after rupture of an internal carotid artery aneurysm

The case of a 24-year-old man with progressive visual loss due to optochiasmatic arachnoiditis is presented. The cause of the arachnoiditis was subarachnoidal bleeding due to rupture of an internal carotid artery aneurysm. The aneurysm was clipped 5 years after the first episode of bleeding. The diagnosis of optochiasmatic arachnoiditis was confirmed during the operation. This case is presented in order to discuss the causes, the symptoms and the therapeutical possibilities of this rare condition.

Bilateral internuclear ophthalmoplegia in systemic lupus erythematosus

Internuclear ophthalmoplegia has been infrequently described in patients with systemic lupus erythematosus. We report a 23-year-old woman with lupus who presented with bilateral internuclear ophthalmoplegia and skew deviation. Additional neurologic findings included dysarthria, hemifacial weakness, hemiparesis, and dysmetria. Computed tomography of the patient's brainstem was unremarkable while magnetic resonance scanning demonstrated two areas of infarction. Magnetic resonance imaging is superior to computed tomography in both neuroradiographic study of the brainstem as well as evaluation of patients with neurologic complications of lupus.

Tuberculous meningitis: role of CT in management and prognosis

Serial computed tomographic scans were performed during the course of tuberculous meningitis in 25 patients aged 1-70 years. Hydrocephalus rarely occurred without other abnormalities. Marked ventricular enlargement was associated with extensive basal enhancement. Basal meningeal enhancement was not a good indicator of the clinical state although marked enhancement was a risk factor for the development of basal ganglia infarction. Infarcts were much more common in children than in adults and were sometimes asymptomatic. Radiological abnormalities sometimes developed during treatment and often did not resolve completely. Many patients had severe residual neurological problems.

Chiasmal osteoma following tuberculous meningitis. Case report

Clinical and radiological signs of a chiasmal lesion developed in a man 25 years after successful treatment of tuberculous meningitis. Surgical exploration and pathological examination demonstrated a mature chiasmal osteoma. The bony growth may have been a sequela of the prior infection.