CME
Introduction
TB meningitis (TBM)
TB meningitis
Tuberculous granuloma (tuberculoma)
Miliary and leptomeningeal granuloma
Tuberculous cerebellar abscess
Tuberculous encephalopathy
Tuberculous cerebritis
Vasculitis and infarction
Cranial neuropathy
Non-osseous spinal cord tuberculosis
Calvarial tuberculosis, subdural and epidural abscess
* Associate Professor, ** Junior Resident, *** Lecturer, Department of Radiodiagnosis, **** Associate Professor,
***** Professor, Department of Medicine, Sarojini Naidu Medical College, Agra - 282 002, Uttar Pradesh.
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Tuberculous abscess
Tuberculous abscesses are occasionally seen. They occur
in less than 10% of patients with CNS TB and are more
common in the elderly and immunocompromised. They
may be solitary or multiple and are frequently
multiloculated. On imaging, a TB abscess may be
indistinguishable from a caseating tuberculoma or a
pyogenic abscess. However, TB abscess has thinner and
smoother enhancing walls, is larger (> 3 cm in diameter),
and it has peripheral oedema and mass effect (Fig. 6a, b).
Differentiation of TB abscess from pyogenic abscess can
be done with MR spectroscopy and magnetisation
transfer (MT) imaging8. On MR spectroscopy, TB abscess
does not demonstrate aminoacids at 0.9 ppm as
compared to pyogenic abscess which shows amino acids
at 0.9 ppm. MT ratio in a TB abscess is lower than that found
in a pyogenic abscess.
Tuberculous encephalopathy
Tuberculous encephalopathy, a syndrome exclusively
present in infants and children, has been described by
Udani and Dastur9 in Indian children with pulmonary
tuberculosis. The characteristic features of this entity are
the development of a diffuse cerebral disorder in the form
of convulsions, stupor, and coma, without signs of
meningeal irritation or focal neurological deficit.
Pathologically, there is diffuse oedema of cerebral white
matter with loss of neurons in the grey matter.
Neuroimaging shows severe unilateral or bilateral cerebral
oedema. On T2-weighted images, hyper-intensity is seen
in white matter suggesting myelin loss.These patients also
show diffuse alteration of MT ratio in white matter which
reverts back to normal after clinical recovery.
Fig. 6 a, b: Tuberculous cerebellar abscess: Axial T2W (a) and postcontrast T1W (b) shows ring-enhancing well-defined regular thin-walled
abscess.
Tuberculous cerebritis
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Cranial neuropathies
Cranial neuropathies are seen commonly in association
with TB meningitis. These are partly due to vascular
Fig. 7 a, b: Tuberculous cerebritis: Axial T2W FLAIR image (a) shows welldefined round hypo-intense tuberculous nodule with caseation and postcontrast T1W image (b) shows patchy enhancement.
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Fig. 9 a, b, c: Tuberculoma causing compression neuropathy of optic nerve: In a patient with visual symptoms, post-contrast T1W image (a) revealed enhancing
lesions in the suprasellar cistern compressing the optic chiasma. Sagittal plain T1W image (b) and post-contrast T1W image (c) shows contrast enhancement.
The visual symptoms were due to optic chiasma compressed by the TB granuloma.
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literature were in patients younger than 10 years, and 70 90% were younger than 20 years. The disease is rarely seen
in infants. It is believed that calvarial tuberculosis occurs
by haematogenous seeding of bacilli into the diploic
space. Lymphatic dissemination of tuberculosis, common
in other bones, is not thought to occur in the skull12,13.
Fig.10 a, b, c: Intramedullary granulomas: Post-contrast T1W images (a, b & c) show multiple intramedullary ring-enhancing lesions in the upper cervical cord
with adjacent dural enhancement.
Fig. 11 a, b: Epidural abscess with osteomyelitis: Axial T2W image (a) shows a well-defined epidural hyperintense focus with thinning of adjacent inner table of
skull and extracranial soft-tissue swelling. Post-contrast T1W image (b) shows ring enhancement and dural tail.
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Conclusion
CNS TB is a major cause of morbidity and mortality in
patients with tuberculosis. MR imaging plays a crucial role
in diagnosis because of its inherent sensitivity and
specificity in detecting CNS lesions earlier than CT. We
conclude that conventional imaging supplemented by
advanced MRI techniques helps in improved detection
and characterisation of CNS tuberculosis and may help in
better management of these patients.
References
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