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Ayhan Blk/ND -
Ulk Trk/ ND--
Emel Ariba/ ND---
Zekeriya Kkrek/ ND----
- Department ofNeurology/
!nn University/ Turgut Ozal
Nedical Shcool
Nalatya/TURKEY
-- Department of Neurology/
Kartal Resarch Hospital
!stanbul/ TURKEY
--- Depatment of !nfection
and Clinical Nicrobiology/
Seluk University / Nedical
School
Konya/ TURKEY
---- Department of
Pschyhiatry/ !stanbul
Univesity/ Cerrahpaa Nedical
School
!stanbul/ TURKEY
&RUUHVSRQGHQFH
$GUHVV
Dr 1 Ayhan Blk
!nn Universitesi Tip
Fakltesi/ Turgut Ozal Tip
Nerkezi/ Nroloji
Anabilimdali/
Nalatya/ Trkiye
Tel= +755, 67439930:3
Fax= +755, 6743:5</
65874651
We presented 6 cases of intracranial tuberculomas with clinical features/
CSF and NR! findings1 Three cases with intracranial tuberculoma were
diagnosed with emphasis on NR! and the clinical findings11 One patient died
during antituberculous treatment1 !n two patients/ antituberculous
medications were effective with marked clinical improvement1
.H\ZRUGV= !ntracranial tuberculoma/ NR! findings1
QWUDNUDQLDO WXEHUNXORP= NOLQLN YH 05, EXOJXODU
!ntrakranial tberkulom tanisi alan 6 vaka klinik zellikleri/ BOS bulgulari ve
NR! bulgulari ile sunuldu1vakalar klinik ve NR! bulgulari agirlikli olarak
degerlendirildi1 Bir vaka antituberkloz tedavi sirasinda kaybedildi1 !ki
vakada/ antitberkloz tedavisi etkili oldu ve klinik dzelme izlendi1
$QDKWDU NHOLPHOHU= !ntrakranial tuberkuloma/ NR! bulgulari
Tuberculosis is still endemic in developing countries/ although recently a
number of studies have reported cases of tuberculosis in association with
A!DS infection in the USA and Haiti
4/5
1 !n Turkey/ where tuberculosis is
endemic/ A!DS is still rare disease and no association has been reported yet1
!n developing countries/ tuberculomas may account for 8( to 6318 ( of
intracranial space occupping masses1 Nost published reports emphasize the
greater frequency in children and young adults1 Clinical recognition of
tuberculosis rests mainly on the evidence of the general disease1 !n most
series/ tuberculous lesion in other organ or a definite history of tuberculous
disease are present in only about half the patient operated for intracranial
tuberculoma
6
1
Nagnetic resonance imaging study has been used in the diagnosis of
tuberculoma in the brain
7/8
/ brainstem
8/9
and spinal cord
:/;
1 As with bacterial
menengitis/ NR! is more sensitive than CT to subtle enhancement along the
bony inner table of the skull
<
1 We presented here/ three cases with the
clinical and NR! findings of intracranial tuberculoma1
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&DVH 41 A 89 year0old man was admitted to our
hospital because of headache and vomiting over
7 months/ and somnolonce for two weeks1 He
has been received antituberculous therapy for
pulmonary tuberculous for two years1
On examination he was drowsy/ had bilateral
papilaedema and right hemiparesis1 Deep
tendon reflexes were exaggreated and rigth
plantar reflex was extensor1 His temperature
was 6;18
3
C1 The sedimentation rate + ESR , was
:3mm2h1 WBC + White blood cell count, was
5313331 Chest X0 ray showed on inferior opacity
in the right lung1 Examination of cerebrospinal
fluid showed 88 mg2dl protein/ 6 WBC and Koch
bacilus was negative1
NR of the brain/ T
4
W! showed a hypointense
mass with peripheral hyperintense rim on the
left thalamus and multiple lesions on the right
periventriculer white matter1
T
5
W! showed a hyperintense mass surrounded
by a hypointense rim on the left thalamic region
+Figure4,1
He was treated with isoniazid +; mg2kg per
day,/ rifampicine +43 mg2kg per day,/
ethambutol +53 mg2kg per day,1
Dexamethazone +7mg every 9h !v, was given
43 for days1 The patient's condition was
deteriorated and he died on the 46th hospital
day1
&DVH 51 A 7< year0old woman has been
diagnosed tuberculous menengitis one year ago1
She was treated with rifampicine/ ethambutol/
izoniazid for nine months1 She was discontinued
the antituberculous treatment before three
months1 She admitted to our hospital because of
severe headaches/ vomiting/ deafness/ diplopia
and pitosis for three weeks1
On admission she was alert and well oriented1
There was palsy of the right 6
rd
/ ;
th
/ <
th
/ 43
th
45
th
nerves and bilateral horizontal nistagmus1 Deep
tendon reflexes were exaggreated with bilateral
Aschilles' clonus1 Both plantar reflexes were
extensor1 Cerebellar tests were positive on the
rigth side1 She was ataxic1 The temperature was
6;1<
3
C1 Chest X0ray was normal1 ESR was
78mm2h1 The blood count count showed 431;33
leukocyties1 CSF releaved 783 WBC with ;8(
PLN1 Protein was 7<3 mg2dl1 Glucose was 418
mmol1 On NR! with intravenous contrast media/
T
4
W! showed hypointense mass with
hyperintense ring enchancment in the left
cerebellar hemisphere +Figure 5,1
Antituberculous treatment +izoniazid/
rifampicine/ pyrazinamid/ and ethambutol
combined with dexamethasone, was started
orally1 Antituberculous treatment was continued
for < months1 Her general condition improved
progressively1
&DVH 61 A 95 year old0man was admitted to our
hospital because of headache and right
hemiparesis for one month1 He had diabetes
)LJXUH 41 Axial T
5
W! shows a hyperintense mass
surrounded by edema on the left talamic region1
)LJXUH 51 Axial T
4
W! with contrast media shows
hypointense mass with hyperintense ring
enchancement on the left cerebellar hemishere1
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mellitus for 48 years1 Six months previously/ he
was diagnosed as pulmoner tuberculosis and
treated with rifampicine/ izoniazid and
ethambutol 1 The treatment was discontinued
before 6 months 1
On admission he was alert and well oriented and
afebrile1 He showed right hemiparesis1 Chest X0
ray was normal/ ESR was 89mm2h1 Laboratory
investigations showed high WBC +481333,1 CSF
count showed no cell/ 58 mg2dl protein1 On T5W
NR/ multiple tuberculomas were seen in the
lentiform nucleus on the left and gray
matter+Figure16,1
He received antituberculous treatment
+izoniazid/ rifampicine/ pyrazinamid and
ethambutol,1 He showed progressive
improvement 1 Nine month later/ he had fully
recovered1
',6&866,21
!n contrast to less developed countries where it
still remains a major problem/ tuberculosis of
the central nervous system is a relatively rare
clinical problem in the industrialized western
nations/ accounting for less than 318( of the
cases of the tuberculosis in the United States1
Unfortunately/ the infrequency of the disease
often results in the diagnostic oversights1 The
promptness with which treatment is initiated is
the most important physician controlled factor
influencing the prospect of the recovery and the
avoidance of serious neurologic sequelae
:/;
1 The
most common form of intracranial tuberculosis is
tuberculous menengitis/ but involvement of the
brain may also take the a solid granulomatous
mass
<
1 !n developing countries/ it still accounts
for 48(063( of neurosurgical cases and affect
mainly children and young adults
</43
1 Although
rare in the industrialized countries/ tuberculomas
have not completely disappeared and represent
3148( to 314;( of intracranial tumors
43/44/45
1
Three patients with intracranial tuberculoma
+two men and one women aged 7<095, were
diagnosed in our clinic1 !ntracranial tuberculoma
is a rather common neurological disorder in
many areas of the world that results from
hematogenous spread from a focus of
tuberculous infection
46
1 Although it occurs at
any age/ ;9 ( of patients with intracranial
tuberculoma are under the age of 58 years in
developing countries such as China and !ndia
46/47
1 !n contrast in USA most patient are over
53 and tuberculosis results from reactivition of
dormant disease
43/48
1 A past history of
tuberculosis is common / occuring in about (83
of cases in most series
44/46/47,
1Such evidence is
of great value in differential diagnosis/ but does
not exclude the diagnosis 1 One of our case had
suffered tuberculosis in the past and two
patients had evidence of active disease
elsewere in the bodies1 The clinical
manifestations of intracranial tuberculoma may
be pleomorphic/ and recognition of a typical
syndrome is not possible1 The pleomorphism is
mainly related to indiuvidual difference in the
size and topogrphy of the lesions1 Symptoms of
raised intracranial pressure are the usual
presenting feature1 Arseni reported symptoms of
intracranial hypertention in :5 (1
48
1 The
incidence of papillaedema was ;<( in Chile
47
/
;6( in !ndia
46
and 75(088( in the United
States series
49/4:
1 Papillaedema was noticed in
two of our cases All patient had papillaedema1
Lateralizing sings are not common in patients
with intracranial tuberculoma1 Two cases had
hemiparesis1 !n one series/ 58( had fever
4:
but
only 43( in another
49
1 One of our patients
noticed somnolonce/ which could be related to
perilesional edema rather than to the lesion
itself1 !t was reported that clinical manifestations
of intracranial tuberculoma are usually present a
period of weeks or months before diagnosis
4;/4<
1 !n our patients/ the durations of symptoms
before diagnosis varied from two weeks to three
months1 Tuberculin skin test may be also useful
)LJXUH 61 Axial T
5
W! shows a hyperintense mass on
the left lentiform nucleus and posterior limb of
internal capsular region and multiple hyperintense
lesions in the periventicular white matter on the both
sides1
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on the regions where tuberculosis is not
endemic
43/4:
1 However we could not use this
test as a reliable indicator of active disease
because of the high incidence of positive results
in the population of our country1 The CSF
examination had a little aid in the diagnosis of
intracranial tuberculoma1 !solated protein
elevation was the most commun abnormality
found in ;; ( of sampled patients in one report
49
/ but only 69 ( in another
4;
1 Smears of CSF
for acid0fast bacilli are not very sensitive and
negative smears should not be taken as proof
aganist the diagnosis1 !n our cases/ the CSF was
examined in all patiens1 Two patints showed
elevated protein and increased white blood cells
counts in one patients/ but none of them had
positive smears for acid 0fast bacilli in CSF1 !n
tuberculous menengitis the appearance of new
neurological symptoms and signs may indicate
the development of cerebral tuberculoma which
may occur in the first 5 months of succesfull
treatment
53
1 This is generally recognized as a
paradoxical response to therapy1 The
explanation of new lesions or the expanstion of
existing ones is elusive1 The exact mechanism
might be due to a complex host0organism
interaction
53/54
1 Chemotherapy of any
tuberculous focus causes destruction of acid0fast
bacilli and liberation of tuberculoprotein/
therefore invoking an inflammatoryresponse
with resulting edema and swelling in cervical
nodes during treatment for tuberculosis1 The
mechanism by which intracranial tuberculomas
enlarge may be similar
;/53/55
1 The usual
presentation include not only the clinical picture
but also the absence of the classical CSF
findings1 The CSF changes in untreated
tuberculous menengitis are lymphocytic
pleocytosis with high protein and low glucose
56
1
This condition was seen in one of our patient1
The CSF may not initially show any
abnormalities in patient with severe tuberculosis
of the brain or spinal cord1 This condition was
seen in two of our patients1 The absence of the
classical clincal picture and CSF findings should
not misguide the treating physician/ and the
patient has to be started an anti0tuberculous
drugs/ if there is a high index of clinical
suspicion1
NR! has an important role in the diagnosis of
intracranial tuberculoma1 Tuberculoma may vary
in appearance1 Lesions with central necrosis
tend to show central hyperintensity on T
5
W! and
to have a peripheral hypointensity rim
7
1
However/ more organized solid lesions often
appear strikingly hypointense on the T
5
W! as a
result of the granulation tissue and compressed
glial tissue in the central core1 Occasionally/
alteranating rings of hypointense and
hyperintense signal form as a result of layers of
granulations tissue deposition1 !n all cases/
lesions appear to be of gray matter intensity on
T
4
W!1
Prior to the development of chemotherapy/ the
mortality of intracranial tuberculoma was very
high1 Now all patients receive antituberculous
chemotherapy/ which results in an improvement
in most/ and cure in some current medical
therapy includes isoniasid/ rifampin/
pyrazinamid/ plus ethambutol hydroclorid and
or streptomycine sulfate1 !n our cases/ after the
initiations of antituberculous chemotherapy/
marked clinical improvement was observed in
two patients1 One patient died in two weeks
despite the initiations of antituberculous
therapy1 This patient showed poor neurological
status on admission1 !ntracranial tuberculoma in
this patient was too late diagnosed1 The optimal
duration of treatment is uncertain1 Lepper and
Spies found no recurrence of tuberculous
menengitis after one or more years of the
treatment
57
1 Nayer et al suggested triple drug
therapy for the first 6 months
4:
1 The use of
dexamethasone is contraversial
4:/57
1
Dexamethasone was given to two patients over
43 days/ a dose of 7 mg every 9 h1
!ntracranial tuberculoma is a potentially curable
disease that must be differentiated from other
space0occupying lesion of the brain1 Wide
spread use of modern neuroimaging techniques
has led to better recognition of such extremely
rare cases1 Early diagnosis and prompt therapy
with antituberculous therapy are important in
preventing mortality and reducing morbidity1
5()(5(1&(6
41 Pitchenik D/ Cole C/ Russell BW1 Tuberculosis/ a typical mycobacterium/
and acquired immunodeficiency syndrome among Haitian and non0Haitian
patients in South Florida1 Ann !ntern Ned 4<;8> 434= 97409781
51 Bahemuka N/ Narungi J1 Tuberculosis of the nervous system= a cilnical/
radiological and pathological study of 6< consecutive cases in Riyadh1 J
Neurol Sci 4<;<> <3 = 9:0:91
61 Ramamurthi B/ Ramamurthi R/ vasudevan NC1 Changing concepts in the
treatment of tuberculomas of the brain1 Childs Nerv Syst 4<;9> 5= 5750
5761
71 Gupta RK/ Jena A/ Sharma A et al1 NR imaging of intracranial
tuberculomas J Comput Assit Tomogr 4<;;> 45= 5;305;81
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7XUJXW g]DO 7S 0HUNH]L 'HUJLVL 8+5/6,=4<<; 184
81 venger BH/ Dion FN/ Rouah E et al1 NR imaging of pontine tuberculoma1
AJNR 4<;:>;=447<044831
91 Eiichiro N1 A case of intracranial tuberculoma serially studied by CT scan
and NR!1 Jpn Neurol Ned 4<<4> 68=7807<1
:1 Sheller JR / Des Prez RN1 CNS tuberculosis1 Neurol Clin 4<;9> 7= 4760
48;1
;1 Lee S/ vasantha Kumar AR/ Lober B1 Tuberculosis of the CNS presenting
as mass lesions1 Pennsylvania Nedicine 4<:<> ;5= 6906<1
<1 Selekler K/ Erbengi A/ Sariba O1 Giant calcified and ossified midbrain
tuberculoma1 - Neurosurg 4<;6> 8;= 46604681
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literature1 Neurology 4<;4> 64= 446604469
441 Dastur NH/ Desai AD1 A Comperative study of brain tuberculomas and
gliomas based upon 43: case records of each1 Brain 4<98> ;;= 6:806<91
451 Naurice0Williams RS= Tuberculomas of the brain in Britian1 J Postgrad
Ned 4<:5> 7;= 9:;09;4
461 Ramamurhti B1 !ntracranial tumors in !ndia= incidence and variations1 !nt
Surg 4<:6> 8;= 875087:1
471 Asenjo A/ valladares H/ Fierro J1 Tuberculomas of the brain1 Arch Neurol
Psychiatry 4<84>98=479048<1
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tuberculomas1 Neurology 4<;:> 5;= 58905931
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analysis of 44 patients1 Arch Neurol 4;<;> 79= 85<08681
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weekly clinicopathological exercises1 N Eng J Ned 4<:6> 5;<= 69906:41
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4;61
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4390456