Search

Background: Central nervous system (CNS) tuberculomas often mimic tumors on conventional imaging, differentiation of which may not be possible without invasive tissue sampling. Diffusion tensor imaging (DTI), owing to its unrivalled property of characterizing molecular diffusion, may help in better lesion characterization and tractography may help understand the pattern of white matter involvement by tuberculomas. Purpose: To estimate qualitative and quantitative diffusion tensor changes in brain tuberculomas and to evaluate patterns of white matter involvement using 3D tractography. Material and Methods: Thirty patients with brain tuberculomas were evaluated on a 3-T magnetic resonance scanner. Diffusion tensor images were acquired along 20 non-colinear encoding directions with two b-values (b = 0, b = 1000). Regions of interest (ROIs) were drawn on quantitative fractional anisotropy (FA) and apparent diffusion coefficient (ADC) maps in the center of the tuberculoma and perilesional area. Similar ROIs were placed in contralateral hemispheres for comparison. Tractography maps were also generated. Results: Mean FA in the center and perilesional area of tuberculomas were 0.098 ± 0.041 and 0.311 ± 0.135, respectively. ADC values in corresponding regions were 0.920 ± 0.272 ×10−3 mm2/s and 1.157 ± 0.277 ×10−3 mm2/s. These values were significantly different compared to contralateral similar brain parenchyma. Tractography revealed interruption of white fibers in the center with deviation of fibers at the periphery in the majority of tuberculomas with none showing infiltration of white matter described in tumors. Conclusion: Significant qualitative as well as quantitative DTI changes were seen in tuberculoma and perilesional areas compared to contralateral hemisphere with tractography showing a pattern different from that described in tumors. These findings may help to differentiate tuberculomas from infiltrating tumors. [ABSTRACT FROM AUTHOR]

Background: Due to the lack of a standard case definifion and the diffuculty in estabilishing a definitive diagnsos, TB in children needs increasing attention by physicians caring for pediatric patients. Tuberculous meningitis (TBM) is the most serious form of extrapulmonary tuberculosis that is associated with significant morbidity and mortality rate in the pediatric age group, especially in infants. This descriptive study was conducted in an University hospital, at the South of Turkey, from May 1999 to May 2019. Methods: The hospital records of 26 TBM infant that was diagnosed at our hospital were retrospectively evaluated. The epidemiological findings (age, gender, family history of TB, tuberculin skin test results, status of BCG scaring), stage of TBM at admission and clinical, laboratory and radiological features were collected. Results: Of the 26 infants, 61.5% were male and mean age of the patients was 7,65±2,6 (range, 3-12 months). The history of close contact with an infected adult was encountered in 73.1% (19 infant) of the cases. Only 69.2% of the patients (18 case) had a BCG scar. The prodromal stage (period between the onset of symptoms to hospital admission) ranged from 4 days to 180 days (39±51.3). 2 cases were defined as stage I, 10 cases as stage II and 14 cases as stage III TBM. Only two patients were initially positive for PPD test. While no neurological findings were found in 2 patients (diagnosed as stage I), neurologic findings at the time of admission included increased intracranial pressure; alteration in consciousness (92.3%), seizures (88.4%), vomiting (61.5%) cranial nerve palsy (23%), irritability 19.2%, hemiplegia 15.3% and meningeal signs (7%, only 2 patients). The presence of hepatomegaly 26.9 % and/or splenomegaly 11.5 % and/or extrapulmonary lymphadenopathy 3.8 % in nearly half of the cases suggested that totally 42,2% of cases had disseminated of tuberculosis. On admission, 46.1% of the patients were noted to have hyponatremia. Microbiologic confirmation was established in eleven (42.3%) of the 26 infant. A positive CSF culture for Mtb and/or smear for AFB and/or PCR was obtained in only 5 (19.2%) patients, whereas 3 of the cases had accompaining gastric aspirate examination positivity. Pulmonary consolidation in 14 (53.8%) patients, miliary patern in 10 (41.6%) and pulmonary hilar lymphadenopathy in only 5 (20.8%) patients. 23 (88.4 %) had hydrocephalus, 15 (57.6 %) infarction, 10 (38.4 %) basilar meningitis and 9 (34.6%) tuberculomas. Empiric anti-tuberculosis treatment was instituted in all, at a median of 3 days (range 1-15 days) following admission. 8 (30.7%) died, 3 (11.5%) recovered completely, and 15 (57.6%) recovered with sequelae. 12 case (2 died) of the infants had required ventriculoperitoneal shunting. Conclusion: As early diagnosis and specific treatment appears to prevent serious complications and reduce mortality, a high index of suspicion among pediatricians is especially required in an infant with an atypical picture suggestive of tuberculosis infection. [ABSTRACT FROM AUTHOR]

Prof B Ramamurthi was a pioneer of Indian neurosurgery and a major force in the development of Indian neuroscience. Founding the Madras Institute of Neurology and later the A Lakshmipathi Neurosurgical Centre (ALNC), both at Madras (or Chennai as it is now called), he developed centres of excellence in his career that spanned over five decades. During this period of time he made Madras, a destination for neurosurgery and neuroscience. Along with his colleagues a large number of publications were produced which influenced the world. Notable among his contributions were those in Stereotaxy for movement disorders, epilepsy, pain and psychiatric illness. He also had notable contributions in brain tumours especially acoustic neurinomas and pituitary tumours. His papers on the low incidence of aneurysms is still quoted widely. Head injuries formed a major part of the neurosurgical work and major contributions were made in that field too. As a developing country with socio-economic issues, infections of the nervous system were seen commonly. His publications on tuberculomas of the brain are noteworthy. He was intrigued by the neurophysiological basis of consciousness. He writings on the subject reflect his attempt to bring together ancient eastern thoughts and concepts of consciousness and life and western science. In the later part of his career he spoke on ethics in and the changing milieu of neurosurgery. While contributions to spinal surgery were not seen in the first half of his career, he along with his colleagues from ALNC published original articles on spinal surgery especially tumours and OPLL. Prof B Ramamurthi, has not only influenced, taught and mentored, during his lifetime, a great many neuroscientists, but he also continues to do so through his publications which continue to be relevant in todays world. A glimpse into his contributions show us how without the technology of today a lot was achieved - and we need to see that, to inspire us to achieve more and to strive for greater heights. [ABSTRACT FROM AUTHOR]

A unique case of tubercular meningitis, developing shunt complication, is being reported. We present a pediatric patient with disseminated tubercular granulomas along the ventricular catheter of a nonfunctional ventriculoperitoneal shunt. [ABSTRACT FROM AUTHOR]

A five-month-old infant presented with fever and cough for 3 weeks. She was diagnosed with multiple tuberculomas and cavitating pulmonary tuberculosis. She was a household contact of an open case of tuberculosis (TB) and developed severe disease, although she had received the Bacillus Calmette–Guérin (BCG) vaccine and had no primary or secondary immunodeficiency. In infants, due to low levels of cell mediated immunity, tuberculosis can be severe and dissemination of tuberculosis to the central nervous system (CNS) can occur very early without following the usual time frame. CNS TB may not have symptoms in the early stages in infants and may require neuroimaging for diagnosis. This is the youngest child that has been reported with multiple CNS tuberculomas. [ABSTRACT FROM AUTHOR]

• Paradoxical tuberculomas are associated with early CSF deterioration. • Neutrophils play an important role in tuberculosis-associated paradoxical reactions. • Early worsening of CSF parameters predicts subsequent development of tuberculomas. We investigated whether early worsening of cerebrospinal fluid (CSF) predicts the later paradoxical tuberculomas and is a potential predictive biomarker. Patients of HIV-negative tuberculous meningitis fulfilling the inclusion criteria(n = 98) underwent clinical and CSF evaluation, together with repeated neuroimaging. We compared the baseline clinical data and continuous CSF of patients who did (n = 36) and did not (n = 62) develop paradoxical tuberculomas, and reported the changes associated with symptomatic tuberculomas. A logistic regression analysis was developed to reveal predictors for paradoxical tuberculomas. The proportion of worsening CSF parameters (WBC count and percent neutrophils) in the paradoxical tuberculomas group (27/36, 75.0%) was significantly higher than the non-paradoxical tuberculomas group (15/62, 24.2%). The logistic regression analysis revealed that worsening CSF parameters was the highest risk predictor for paradoxical tuberculomas. Most worsening CSF parameters (81.0%) occurred within two weeks after treatment (2–24 days, median 7 days), and paradoxical tuberculomas commonly happened two weeks later (12 days to 13 months, median 22 days). The period between worsening CSF parameters and paradoxical tuberculomas ranged from 6 to 383 days (median 21days). There were no significant differences in mortality and prognosis between the two groups. Early worsening of CSF parameters predicts subsequent development or progression of tuberculomas. [ABSTRACT FROM AUTHOR]

Background Endocrine dysfunction is known to occur in various infectious diseases of the brain. The neuroendocrine dysfunction is not well studied in patients of Tuberculous meningitis (TBM). In this study, we aimed at knowing pattern of endocrine dysfunction in newly diagnosed patients of tuberculous meningitis, structural changes occurring in hypothalamic-pituitary region, assessing its predictors and correlative factors related to outcome. Materials and methods This was a prospective observational study. All newly diagnosed patients of tuberculous meningitis were subjected to clinical, laboratory, and hormonal evaluation along with neuroimaging of hypothalamic-pituitary region. All the patients were treated with antituberculous drugs along with corticosteroids as per WHO guidelines. The clinical outcomes of the patients were assessed at the end of 3 months. Results Out of 115 patients enrolled in the study, endocrine dysfunction was seen in 62 (53.9%) patients. Out of these 62 patients, single axis involvement was seen in 35 (30.4%) patients, while multiple axis dysfunction was observed in 27 (23.5%) patients. Most common hormonal axis involved was gonadotropic axis (33.9%) followed by hyperprolactinemia (22.6%), thyrotropic axis (17.4%), corticotropic axis (13%), SIADH (Syndrome of Inappropriate Antidiuretic Hormone secretion) (9.6%) and somatotropic axis (7.8%). None had diabetes insipidus. The presence of multiple cranial nerve palsies, hypotension, stage II and III of TBM, baseline MBI ≤ 12 and basal exudates were significantly higher in endocrine dysfunction group, while the presence of basal exudates independently predicted the occurrence of endocrine dysfunction on multivariate analysis. Though the poor outcome was significantly higher in endocrine dysfunction group at the end of 3 months, on multivariate analysis factors independently associated with poor outcome were the presence of altered sensorium and stage III of TBM. Conclusion Endocrine dysfunction occurs in a significant proportion of patients with tuberculous meningitis. The presence of basal exudates is significantly associated with the occurrence of endocrine dysfunction. Patients with endocrine dysfunction had a poorer outcome although it was not an independent predictor of the same nor associated with increased mortality. [ABSTRACT FROM AUTHOR]

Tuberculosis never stops fascinating physicians. The burden of tuberculosis is a major cause of disability. While drugs are often blamed when patients develop new focal deficits on treatment, the deterioration in these patients can have a myriad of causes including the development of new tuberculomas. Recognizing the critically located tuberculomas as potential causes of vision loss is indispensable. Here, we report two patients with strategic tuberculomas leading to vision loss. In one patient, the cause of visual morbidity was compression of the optic pathways; in the other patient, cortical vision loss was noted due to strategic location of tuberculomas. [ABSTRACT FROM AUTHOR]

Aims: Differentiating intracranial mass lesions on CT scan is challenging. The purpose of our study was to determine the perfusion parameters in various intracranial space-occupying lesions (ICSOL), differentiate benign and malignant lesions, and differentiate between grades of gliomas. Materials and Methods: We performed CT perfusion (CTP) in 64 patients, with age ranging from 17 to 68 years, having space-occupying lesions in brain and calculated relative cerebral blood flow (rCBF) and relative cerebral blood volume (rCBV). Results: We found significantly lower perfusion in low-grade gliomas as compared to high-grade tumors, lymphoma, and metastases. Similarly in infective lesions, TWT and abscesses showed significantly lower perfusion compared to TOT. In ring enhancing lesions, capsule of TWT showed significantly lower perfusion as compared to abscesses, TOT, and metastases. Conclusion: Thus, in conclusion, infective lesions can be differentiated from tumors like lymphomas, high-grade gliomas, or metastases based on perfusion parameters. The cut off value of rCBV 1.64 can be used to differentiate between low grade and high grade gliomas. However, depending only on perfusion parameters, differentiation between the tumors like lymphomas, high-grade gliomas, and metastases may not be possible. [ABSTRACT FROM AUTHOR]

Background: Central nervous system tuberculosis remains a prevalent problem in developing countries. Also, this disease has been an important problem in developed countries due to the increased incidence of acquired immunodeficiency syndrome. Tuberculosis of the central nervous system is seen in 10% of immunocompetent patients with primary tuberculosis. Case Report: We report two patients with tuberculoma in the central nervous system. The first case had a lesion located in the medulla oblongata, and the second case had a lesion in the medulla spinalis between the 5th cervical and 1st thoracic vertebral level. Both of these patients underwent surgery. Conclusion: CNS tuberculomas may not always show typical magnetic resonance imaging (MRI) signs, but when a neurosurgeon encounters a brown- yellow rubber-like lesion that is easily extirpated from the glial tissue, tuberculoma should be considered; anti-tuberculous and corticosteroid therapy should be initiated as soon as possible to prevent meningitis and the immune-mediated destructive effects of tuberculosis on the CNS. Whether or not anti-tuberculous therapy is continued can be decided upon by following definitive pathologic diagnosis. [ABSTRACT FROM AUTHOR]

Neurological tuberculosis can very rarely involve the hypophysis cerebri. We report a case of an eighteen year old female who presented with five months duration of generalised apathy, secondary amenorrhea and weight gain. She was on irregular treatment for tuberculosis of the central nervous system for the last five months. Neuroimaging revealed sellar and suprasellar tuberculomas and communicating hydrocephalus requiring emergency decompression. Endocrinological investigation showed hypopituitarism manifesting as pituitary hypothyroidism, hypocortisolism, hypogonadotropic hypogonadism, and hyperprolactinemia. Restarting anti-tuberculosis treatment, hormone replacement therapy, and a ventriculo-peritoneal shunt surgery led to remarkable improvement in the general condition of the patient. [ABSTRACT FROM AUTHOR]

Tuberculosis (TB) is a bacterial infection with Mycobacterium tuberculosis; it is a public health problem worldwide and one of the leading causes of mortality. Since December 2019, the COVID-19 pandemic has created unprecedented health challenges and disrupted the TB health services, especially in high-burden countries with ever-increasing prevalence. Extrapulmonary and even pulmonary TB are an important cause of nonspecific clinical and radiological manifestations and can masquerade as any benign or malignant medical case, thus causing disastrous conditions and diagnostic dilemmas. Clinical manifestations and routine laboratory tests have limitations in directing physicians to diagnose TB. Medical-imaging examinations play an essential role in detecting tissue abnormalities and early suspecting diagnosis of TB in different organs. Radiologists and physicians should be familiar with and aware of the radiological manifestations of TB to contribute to the early suspicion and diagnosis of TB. The purpose of this article is to illustrate the common radiologic patterns of pulmonary and extrapulmonary TB. This article will be beneficial for radiologists, medical students, chest physicians, and infectious-disease doctors who are interested in the diagnosis of TB. [ABSTRACT FROM AUTHOR]

Purpose: To evaluate intracranial tuberculomas using quantitative magnetic resonance (MR) techniques such as T2 relaxometry, magnetization transfer (MT), and diffusion-weighted imaging (DWI). Material and Methods: Thirty-three patients with intracranial tuberculomas (histologically confirmed in 22) were evaluated using proton density/T2-weighted, T1-weighted (with and without MT), and echo-planar diffusion-weighted imaging sequences. T2 relaxation times, MT ratios (MTR), and apparent diffusion coefficient (ADC) values were calculated from the center of the lesion, the periphery, perilesional edema, and contralateral normal white matter. The mean and standard deviation values of each variable were calculated and correlated using Pearson's test (P = 0.05). Results: The measured mean values of T2 relaxation time, MTR, and ADC in the center of lesions were 155.5 ms, 14.1, and 1.27×10-3 mm2/s, respectively, compared to 117 ms, 23.72, and 0.74×10-3 mm2/s in normal white matter, and a T2 relaxation time of 187.45 ms in normal gray matter. Significant inverse correlations were noted between T2 relaxation values and MTR (P<0.001) and between MTR and ADC (P = 0.046). Significant positive correlation was seen between T2 relaxation and ADC values (P = 0.03). Conclusion: Intracranial tuberculomas are characterized by relatively short T2 relaxation times (compared to normal gray matter), decreased MTR, and mostly no restriction of diffusion. A combination of these quantitative parameters could be of help in the noninvasive diagnosis of tuberculomas. [ABSTRACT FROM AUTHOR]

Purpose: To review magnetic resonance (MR) diffusion-weighted imaging (DWI) and spectroscopy findings in patients with focal cerebral tuberculosis and to assess whether these techniques can adequately characterize focal cerebral tubercular lesions.Material and Methods: Sixteen patients with single or multiple lesions were evaluated on a 1.5T MR system. DWI was performed with three 'b' values of 50, 500, and 1000 s/mm2 and the apparent diffusion coefficient maps were calculated. MR spectroscopy was performed using the point-resolved single-voxel technique with 2 echo time values of 135 ms and 270 ms. The signal intensities of the tubercular lesions on diffusion images and the apparent diffusion coefficients (ADCs) of their centers, along with MR spectroscopy findings, were analyzed in relation to their T2-weighted MR appearances.Results: DWI identified 17 of the 20 lesions evaluated. Increased signal intensity was seen in 9 of the 17 lesions. The ADCs of the lesions ranged from 0.406 to 2.64 x 10(-3) mm2/s (mean +/- SD: 1.038 +/- 0.609 mm2/s). Most of the lesions with hyperintense centers on T2-weighted images were of increased intensity on diffusion images, while those with hypointense centers on T2-weighted images were of decreased signal intensity on diffusion images. However, no statistical difference in the ADCs was found between lesions with increased and those with decreased signal intensity centers on T2-weighted images. MR spectroscopy revealed a lipid peak at 0.9-1.3 ppm in all of the 14 lesions evaluated. An increase in normalized choline:creatine ratio was found in all the lesions in which the spectra were obtained with the voxel, including a variable portion of the lesion wall.Conclusion: DWI and MR spectroscopy help in determining the nature of cerebral tubercular lesions; however, since the findings are varied, they do not help in specific characterization. [ABSTRACT FROM AUTHOR]

We have compared and analyzed the value of in vivo proton MR spectroscopy (PMRS) and T1 weighted magnetization transfer (MT) MR imaging in tissue characterization of brain tuberculomas. We studied 33 cases of proven intracranial tuberculomas with in vivo PMRS and T1 weighted MT MR imaging. MT ratios from the rim and core of the tuberculomas were calculated and compared with metabolites seen on PMRS. Final diagnosis of tuberculoma was based on histopathology (n = 26) and/or associated tuberculous meningitis (n = 7) in all the cases. Out of the 33 patients who underwent both PMRS and T1 weighted MT MR imaging, spectroscopy showed only lipids at 0.9 ppm, 1.3 ppm, 2.0 ppm, and 2.80 ppm in 26 cases while lipids at 0.9 ppm, 1.3 ppm, 2.0 ppm and 2.80 ppm along with choline at 3.22 ppm was seen in remaining 7 patients. MT ratios from the core or solid necrosis varied from 21–29% while from the rim or cellular region varied from 16–24%. MT ratios from all the 33 lesions were consistent with tuberculomas while PMRS showed choline along with lipids in 7 predominantly cellular lesions simulating a neoplasm. We conclude that T1 weighted MT MR imaging appears to be more consistent in the tissue characterization of brain tuberculomas. [Copyright &y& Elsevier]

The purpose of this article is to review the many facets of central nervous system tuberculosis (CNS-TB). The entities described are tuberculous meningitis (TBM) and its complications, spinal cord disorders, tuberculomas and co-infection with the human immune-deficiency virus (HIV). The latter has become a common problem worldwide becoming a more fulminant disease. The accuracy of the conventional and the modern molecular techniques for the diagnosis of TBM have a high specificity but a low to moderate sensitivity. Computerised tomographic scans and magnetic resonance imaging have many characteristic features which have vastly improved the diagnostic accuracy of CNS-TB. The recommended therapeutic regimens are an extrapolation of the regimen used for pulmonary TB, hence the optimal composition, dosage and duration of the therapy are not yet established. Multidrug resistant TB is emerging as a global threat and the delay in recognition of drug resistance combined with the lack of data on appropriate drug regimen adds to its high mortality. • The neurological manifestations of CNS TB. • The clinical features of the various entities and complications. • The difficulties in making a definitive diagnosis. • Co-infection of TB with HIV. • The problems associated with the guidelines recommended therapeutic regimen. [ABSTRACT FROM AUTHOR]

Paradoxical reactions in tuberculosis have been reported in patients with tuberculous meningitis and appear as intracranial tuberculomas within 14-270 days of starting antituberculous therapy (ATT). Paradoxical reactions are due to the immune response of the host to ATT. They are commonly seen in the intensive phase of chemotherapy. However, paradoxical reactions occurring after completion of ATT are rare. We report 2 patients with tuberculous meningitis who had already completed ATT and then developed tuberculomas. [ABSTRACT FROM AUTHOR]