CNS Tuberculosis imaging and

surgery
g y
Moderators
Dr Ashish Suri
Dr Deepak
p Gupta
p
Presented By
Dr Ajay Bisht

Tuberculosis
` As old as recorded history
` Symptoms described in the Rig Veda (1500 BC)
` Unequivocal lesions in Egyptian mummies
` Odier, Ford described meningeal TB 1790
` Surgical
S i l excision
i i W
Wernicke
i k and
d Hahn
H h 1882,
88
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CNS tuberculosis imaging and surgery

Tuberculosis
y CNS tuberculosis complicates 10% of all TB
y Never
N
the
h first
fi manifestation
if
i
y Occurs
O
within
ithi 6
612 months
th
y Circle
Ci l off Willis
Willi more frequently
f
tl involved
i
l d than
th the
th

basilar system

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CNS tuberculosis imaging and surgery

Mycobacterium tuberculosis
y Acid fast bacillus
y Does not stain on gram

stain
i
y Obligate aerobes
y Difficult
Diffi lt to
t grow
y High lipid in cell wall
y Hominis/
H i i /B
Bovine/
i /A
Avium
i

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CNS tuberculosis imaging and surgery

Pathogenesis
y May develop during initial infection/ reactivation
y Haematogenous dissemination
y
y
y

Commonest
Focus in brain (Rich focus)
Rupture of focus into subarachnoid/ ventricular space

y Contiguous spread

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CNS tuberculosis imaging and surgery

CNS tuberculosis
y Intracranial
y
y
y

Parenchymal
M i
Meningeal
l
Osseous

y Spinal
y
y
y
y

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Parenchymal
Meningeal
Arachnoiditis
h d
Osseous

CNS tuberculosis imaging and surgery

Epidemiology
y Incidence varies blacks > whites
y Predominantly in the young (50% <10)
y Abscess in 48% (20% with HIV)

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CNS tuberculosis imaging and surgery

Pathology
y Immature lesions multiple tubercles in oedematous

brain
y Mature: avascular mass, nodular extensions, yellowish

gritty casseous areas

y 60% attached to dura

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CNS tuberculosis imaging and surgery

Pathology (parrenchymal)
y Can be present anywhere
y Cerebellum in children
y Cerebral hemisphere and basal ganglia commoner in

adults

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CNS tuberculosis imaging and surgery

Pathology (tuberculoma)
y Tuberculoma ( classical lesion)
y Tuberculoma en plaque
y Tuberculous abscess
y Cystic tuberculoma
y Multiple grape like tuberculoma
y Microtuberculoma
y Calcified tuberculoma
y Tuberculous encephalopathy

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Pathology (tuberculoma)
y Dastur described six main types
y

Parenchymal changes.
y
y
y
y
y
y

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(1) Ventriculitis
(2) Borderzone encephalitis
( ) Infarction
(3)
I f
i
(4) Internal hydrocephalus
(5) Diffuse oedema
( ) Tuberculoma
(6)
b
l

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Pathology (meningeal)
y Classically Commonest in 6m 3 years
y Now adults 50%
y Thick exudate encasing nerves, vessels
y HCP, tuberculoma, arachnoiditis
y Diffuse perivasculitis
y Infarcts
y Pachymeningitis

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Diagnosis
y Montoux test
y Hb/ ESR
y CXR
y ELISA
y CSF
y PCR
y Imaging
y Biopsy

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Imaging
y X ray
y Angiography

of historical significance

y CT
y MRI

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Imaging
y Tuberculoma
y
y
y

Typically cortical and subcortical

M lti l in
Multiple
i 1035%
%
Milliary rare ( children)

y Meningitis (commonest form of CNS TB)

y
y

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Isolated meningitis is rare (5% in children)

Basal cisterns

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Imaging (CT tuberculoma)

` Cerebritis: hypodense areas
` Perilesional oedema out of proportion
` Early tuberculoma: iso to slightly hyper dense , ring

enhancement
` Evolved : well delineated ring enhancing mass, target sign
(
(central
l enhancement
h
or calcification)
l ifi i )
` Healed: often calcify
` Manifestations
x
x
x
x
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Small disc/ rings

Large rings with central lucency
Large
a ge nodular
odu a mass
ass with irregular
egu a outline
ou
e
Multiple lesions in 1520%
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Caseating tuberculosis granuloma

involving the left temporal lobe.
CECT shows a rim-enhancing
lesion in the left temporal lobe
consistent
with
a
caseating
tuberculosis granuloma
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Imaging (MRI tuberculoma)

y T1 : isointence
y T2: central hyper with hypo ring
y Marked thin rim enhancement
y Hypo on T2: fibrosis, gliosis, macrophage infiltration

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Parrenchymal tuberculosis. contrast-enhanced T1weighted MR image demonstrates multiple

enhancing
caseating
and
non-caseating
tuberculomas predominantly within the left frontal
tuberculomas,
and parietal lobes
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CNS tuberculosis imaging and surgery

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Milliary CNS tuberculosis. Axial contrast-enhanced T1weighted MR image shows multiple small high-signalintensity foci within both cerebral hemispheres
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(a) Sagittal T2- hyperintensity in the cervical spinal cord extending from C2 to C7. A
hypointense nodule representing the granuloma is noted at the C4 level.
(b) Sagittal T1 & (c) axial T1- with fat suppression after contrast reveal an area of
solid nodular enhancement representing non-caseating
non caseating tuberculosis granuloma of
the spinal cord. A smaller enhancing granuloma is also noted at the C2 level on the
sagittal image
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MRS

decrease in NAA/Cr
slight decrease in NAA/Cho
lipid lactate peaks are usually elevated (86%)
lipid-lactate

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A. Bernaerts, F. M. VanhoenackerTuberculosis of the central nervous system: overview of

neuroradiological findings. Eur Radiol (2003) 13:18761890

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Imaging (meningitis)
y Active
y Sequelae
y Hydrocephalus
y Ischemia and infarction
y
y
y
y

Medial lenticulostriate
Thalamoperforating
Cortex 25%
Bilateral 70%

75%

y Atrophy
y Calcification
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Imaging (CT meningitis)

` NCCT:
x
x
x
x
x
x

scans may be normal

Obliteration of basal cisterns by hypo/ iso dense exudate
en plaque
l
d l thickening
dural
hi k i
Popcorn calcification
Hydrocephalus
Sequelae of chronic meningitis
x Infarcts

` CECT:
x
x
x
x

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Abnormal meningeal enhancement (may persist)

Leptomeningeal enhancement sylvian fissures, tentorium
Granulomas in the basal meninges
Ependymitis
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Imaging (MRI meningitis)

y Unenhanced scan: does not show active meningitis
y Spine
y
y
y
y

CSF loculations
l
l
Obliteration of arachnoid space
Loss of cord outline in cervicodorsal cord
Thickening and clumping of roots in the lumbar cord

y Contrast T1 : basal meningeal enhancement

y spine
y

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Linear enhancement of cord/ roots

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Tuberculous meningitis. Axial contrast-enhanced

T1-weighted magnetic resonance (MR) image
shows florid meningeal enhancement that is most
pronounced within the basal cisterns

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Tubercular meningitis. Axial FLAIR-MR]

showing
h i
marked
k dh
hyperintensity
i t
it off the
th basal
b
l
cisterns and prominent temporal horns in a
patient with mild communicating
hydrocephalus

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Caseating dural /epidural tuberculosis granuloma or

abscess
a)

Axial T2
T2- nodular hyperintensity posterior to the clivus and anterior to the medulla (arrow).

b)

Axial T1 contrast- dural/epidural rim enhancement suggestive of caseating tuberculosis

granuloma or abscess.

c))

Sagittal
S
itt l enhanced
h
d T1T1 the
th caseating
ti
d
dural/epidural
l/ id
l tuberculosis
t b
l i granuloma
l
or abscess
b
posterior to the clivus. Abnormal meningeal enhancement is present
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Spinal tuberculous meningitis. Sagittal gadoliniumenhanced T1-weighted MR image of the thoracic spine
demonstrates
irregular,
linear,
nodular
meningeal
enhancement
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Enhanced T1-weighted magnetic resonance imaging with fat suppression show intense
enhancement of the subarachnoid space indicating arachnoiditis
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Tuberculous
b
l
pachymeningitis
h
` Rare
` Common sites of involvement are cavernous sinus, floor of

middle cranial fossa and tentorium.

` Radiographic features
` CT
hyperattenuating solid plaque like densities
( l f
(calcification
may be
b seen))
` MRI
x
x
x

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T1 : hypo
yp intense thickened duramater.
T2 : hypo intense thickened meninges.
T1 C+ (GAD) : intense homogenous enhancement of thickened
meninges.

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Management
y Medical therapy
y Surgery
y indications
y
y
y
y

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Vision
Vi
i or lif
life threatened
h
db
by mass effect
ff
Failure of response to medical therapy
Paradoxical increase in lesion size with therapy
py
Diagnosis in doubt

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Medical therapy

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WHO recommendations

WHO Treatment of tuberculosis: guidelines 4th ed.

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D ti off ttreatment
t
t
Duration
6 months
van Loenhout-Rooyackers JH, Keyser A, Laheij RJ, Verbeek AL, van der Meer JW.
Tuberculous meningitis: Is a 6-month treatment regimen sufficient? Int J Tuberc Lung Dis
2001;5:128-35.

12 months
Thwaites GE
GE, Hein TT.
TT Tuberculous meningitis: Many questions,
questions too few answers.
answers Lancet
Neurol 2005;4:160-70

18 months or Longer
Santosh Isac Poonnoose, Vedantam Rajashekhar: Rate of Resolution of histologically
verified intracranial tuderculomas. Neurosurgery 53:873-879, 2003

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Treatment
Rate of radiological resolution of intracranial tuberculoma
Series

duration of ATT

Wang 1996 (16)

Rajeshwari 1995 (6)
Awada 1998 (2)
Poonnoose 2003 (28)

residual lesions %

6
9
12
18

20
12
0
69.2

Santosh Isac Poonnoose, Vedantam Rajashekhar: Rate of Resolution of

histologically verified intracranial tuderculomas. Neurosurgery 53:873-879,
2003

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Medical management
y
y
y
y

4 drugs
d
x 34 months
h
2 drugs x 1416 months occasionally longer
Regression of size from 46
4 6 weeks
Most resolve in 1214 months
R Patir, R Bhatia, Tandon PN. Surgical management of tuberculous infections of the
nervous system. Schmidek and Sweet operative neurosurgical techniques 5th edition;
16171631

y AED to continue
y INH blocks phenytoin metabolism
y Steroids in all irrespective of age and stage
Prasad K, Singh MB. Corticosteroids for managing tuberculous meningitis.
Cochrane Database Syst Rev 2008;1:CD002244.

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Resistant tuberculosis
y MDR : resistant to INH and Rifampicin
y EDR/ XDR : MDR + resistance to Quinolones and

i j
injectable
bl second
d li
line d
drugs

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Second line drugs

Use at least 4 drugs

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Surgery
y Severe elevation of ICP
y Threatening life or vision
y Do not respond to drugs clinically/ radiologically
y Diagnosis in doubt
y Obstructive hydrocephalus
R Patir, R Bhatia, Tandon PN. Surgical management of tuberculous infections of the nervous
system. Schmidek and Sweet operative neurosurgical techniques 5th edition; 16171631

y Aim
Ai diagnosis/
di
i / relieve
li
pressure

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Surgical management
y Biopsy of the mass lesion
y Hydrocephalus
y
y

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Communicating (commoner)
Non communicating

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Surgery principles
y Non eloquent areas total excision (small lesion)
y Subtotal/ partial excision (large lesion/ eloquent

cortex))
y Conservative excision around vital structures
y Evacuation
E
i off centrall liquifactive
li if i portion
i in
i deep
d
seated lesions
y Residual lesions may respond to medical therapy
y

R Patir, R Bhatia, Tandon PN. Surgical management of tuberculous infections of the

nervous system. Schmidek and Sweet operative neurosurgical techniques 5th edition; 1617
1631

y Hydrocephalus
H d
h l
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MRC Grading for hydrocephalus

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Grading for hydrocephalus

Vellore grading

Modified Vellore grading

Palur R
R, Rajshekhar V,
V Chandy MJ,
MJ Joseph T,
T Abraham J.
J Shunt surgery for hydrocephalous in
tubercular meningitis: A long-term follow-up study. J Neurosurg 1991;74:64-9
Mathew JM, Rajshekhar V, Chandy MJ. Shunt surgery for poor grade patients with tuberculous meningitis
and hydrocephalus: Effect of response to external ventricular drainage and other factors on long-term
outcome. J Neurol Neurosurg Psychiatry 1998;65:115-8

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Rajshekhar V. Management of hydrocephalus in patients

with tuberculous meningitis. Neurol India 2009;57:368-74

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Hydrocephalus
y Inevitable in those who survive 46 weeks
y Mortality 20100%
y Grade at admission significant
y Early shunt for grade I,II

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y ETV
y

73.1% success rate for ETV in TBM with hydrocephalus

y

A chugh,
g M hussain et al. Surgical
g
outcome off tuberculous meningitis
g
hydrocephalus
y
p
treated byy endoscopic
p third
ventriculostomy: prognostic factors and postoperative neuroimaging for functional assessment of ventriculostomy: J
Neurosurg Pediatrics 3:000000, 2009

y Endovascular revascularization for ischemia

y STA MCA bypass
y

The left superficial temporal arteryMCA

artery MCA bypass was found to
be capable of preventing new ischemic events in the 21month
followup period
y

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Martin misch, Ultrich wilhelm et al. Prevention of secondary ischemic events by superficial temporal
arterymiddle cerebral artery bypass surgery after tuberculosisinduced vasculopathy in a 5yearold
child:Neurosurg Pediatrics 6:000000, 2010

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1992)
AIIMS DATA (1975
(19751992)

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SUPRATENTORIAL

78

PARIETAL

28

FRONTAL

26

TEMPORAL

155

BG / THALAMUS

SELAR/SUPRASELLAR

ORBITAL FISSURE

INFRATENTORIAL

50

CEREBELLUM

44

CP ANGLE

TENTORIUM

BRAINSTEM

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Thank you

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