Acute Ischemic Stroke in Tubercular Meningitis Patients Without Conventional Vascular Risk Factors: A Retrospective Case Control Study

A Case Report of Acute Ischaemic Stroke Associated with T​uberculous Meningitis

Background

Tuberculous meningitis (TBM) is a severe form of tuberculosis (TB) that affects the meninges, frequently causing major neurological problems. Timely diagnosis and care are crucial to avoid unfavourable consequences, particularly in vulnerable populations.

Purpose

This case report aims to highlight the diagnostic problems and management complications of TBM, especially when combined with rare neurological events such as acute ischaemic stroke (AIS).

Methods

An 84-year-old female presented with disorientation, seizures, aphasia and hemiparesis. The initial imaging revealed normotensive hydrocephalus and bilateral delta activity on the electroencephalogram (EEG). Despite anti-fungal treatment, CT imaging revealed widespread inflammatory alterations. Sputum and cerebrospinal fluid (CSF) tests were done and revealed the presence of Mycobacterium tuberculosis. MRI indicated several acute lesions, which are symptomatic of TBM.

Results

The patient developed AIS, a relatively rare complication of TBM. Treatment was initiated with a combination of anti-TB drugs and corticosteroids. While corticosteroids reduced inflammation and mortality risk, their potential to contribute to long-term disability was noted as an area of concern.

Conclusion

This case underscores the critical role of MRI in the early detection of TBM-related complications. Although corticosteroids improve short-term outcomes, their impact on long-term disability necessitates further research. Effective management strategies tailored to vulnerable populations are essential to improve the prognosis of TBM patients.

Acute ischemic stroke in tuberculous meningitis

Background

The underlying mechanism for stroke in patients with tuberculous meningitis (TBM) remains unclear. This study aimed to investigate the predictors of acute ischemic stroke (AIS) in TBM and whether AIS mediates the relationship between inflammation markers and functional disability.

Methods

TBM patients admitted to five hospitals between January 2011 and December 2021 were consecutively observed. Generalized linear mixed model and subgroup analyses were performed to investigate predictors of AIS in patients with and without vascular risk factors (VAFs). Mediation analyses were performed to explore the potential causal chain in which AIS may mediate the relationship between neuroimaging markers of inflammation and 90-day functional outcomes.

Results

A total of 1,353 patients with TBM were included. The percentage rate of AIS within 30 days after admission was 20.4 (95% CI, 18.2-22.6). A multivariate analysis suggested that age ≥35 years (OR = 1.49; 95% CI, 1.06-2.09; P = 0.019), hypertension (OR = 3.56; 95% CI, 2.42-5.24; P < 0.001), diabetes (OR = 1.78; 95% CI, 1.11-2.86; P = 0.016), smoking (OR = 2.88; 95% CI, 1.68-4.95; P < 0.001), definite TBM (OR = 0.19; 95% CI, 0.06-0.42; P < 0.001), disease severity (OR = 2.11; 95% CI, 1.50-2.90; P = 0.056), meningeal enhancement (OR = 1.66; 95% CI, 1.19-2.31; P = 0.002), and hydrocephalus (OR = 2.98; 95% CI, 1.98-4.49; P < 0.001) were associated with AIS. Subgroup analyses indicated that disease severity (P for interaction = 0.003), tuberculoma (P for interaction = 0.008), and meningeal enhancement (P for interaction < 0.001) were significantly different in patients with and without VAFs. Mediation analyses revealed that the proportion of the association between neuroimaging markers of inflammation and functional disability mediated by AIS was 16.98% (95% CI, 7.82-35.12) for meningeal enhancement and 3.39% (95% CI, 1.22-6.91) for hydrocephalus.

Conclusion

Neuroimaging markers of inflammation were predictors of AIS in TBM patients. AIS mediates < 20% of the association between inflammation and the functional outcome at 90 days. More attention should be paid to clinical therapies targeting inflammation and hydrocephalus to directly improve functional outcomes.