Scribd
Upload
61 views55 pages

Cns Tuberculosis: K Mohamed Rafi

This document discusses central nervous system tuberculosis. It notes that CNS involvement occurs in 2-5% of TB patients and up to 15% of those with AIDS-related TB. Tuberculous meningitis is the most common manifestation, seen more often in children, while tuberculomas are more common in younger adults. Imaging findings include basilar meningeal enhancement on CT or MRI for meningitis, and ring-enhancing lesions for tuberculomas. Differential diagnoses include fungal meningitis, other bacterial meningitis, and carcinomatous meningitis.

Uploaded by

Thiyagarajan Shanmugam
Copyright
© Attribution Non-Commercial (BY-NC)
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PPTX, PDF, TXT or read online on Scribd
61 views55 pages

Cns Tuberculosis: K Mohamed Rafi

This document discusses central nervous system tuberculosis. It notes that CNS involvement occurs in 2-5% of TB patients and up to 15% of those with AIDS-related TB. Tuberculous meningitis is the most common manifestation, seen more often in children, while tuberculomas are more common in younger adults. Imaging findings include basilar meningeal enhancement on CT or MRI for meningitis, and ring-enhancing lesions for tuberculomas. Differential diagnoses include fungal meningitis, other bacterial meningitis, and carcinomatous meningitis.

Uploaded by

Thiyagarajan Shanmugam
Copyright
© Attribution Non-Commercial (BY-NC)
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PPTX, PDF, TXT or read online on Scribd
You are on page 1/ 55

CNS TUBERCULOSIS

K MOHAMED RAFI
 Incidence
 Definition
 Pathophysiology
 TB and arteries
 Diagnostic clue
 Location
 Ct findings
 Other modalities
 Differential diagnosis
INCIDENCE
 CNS involvement is thought to occur in 2 - 5% of
patients with tuberculosis and up to 15% of those
with AIDS related tuberculosis
 Male-to-female ratio is 1:1

 Although CNS involvement by tuberculosis is seen


in all age groups, there is a predilection for
younger patients, with 60 - 70% of cases occurring
in patients younger than 20 years of age
 In endemic regions, tuberculomas account for as

many as 50% of all intracranial masses


CNS TUBERCULOSIS
 Definitions
 Infection by Mycobacterium tuberculosis (TB), an acid-fast bacillus

causes tuberculous meningitis


 General Features

 Most TB CNS infections are secondary result of

hematogenous spread (often pulmonary)

 Meningitis is most frequent manifestation of CNS


TB and is more common in children

 Childhood TB is typically a primary infection

 Adult TB is most often post primary infection up to 30% due to


primary infection
Potential manifestations include:
 Tuberculous meningitis : most common

 Intracranial tuberculous granuloma (tuberculoma)

 Focal tuberculous cerebritis

 Intracranial tuberculous abscess

 Tuberculous encephalopathy

 Complications

 secondary cerebral infarction from obliterative

end arteritis
 arachnoid fibrosis with resultant hydrocephalus
Pathophysiology

 CNS TB almost always secondary to


pulmonary TB
rarely GI or GU tract

TBM pathophysiology
 Penetration of meningeal vessel walls by

hematogenous spread
 Rupture of subependymal or subpial

granulomata into the CSF


Tuberculoma pathophysiology
 Hematogenous spread (GM-WM junction

lesions)
 Extension of meningitis into parenchyma via

cortical veins or small penetrating arteries


TB And Arteries
 Arteritis: More common in children, HIV+

 Arteries directly involved by basilar exudate or


indirectly by reactive arteritis (up to 40% of
patients)
 Infection causes arterial spasm resulting in
thrombosis and infarct
 Lenticulostriate arteries, MCA,
thalamoperforators most often affected
 Infarcts most common in basal ganglia, cerebral
cortex, pons, cerebellum
Best diagnostic clue
 Basilar meningitis + extracerebral TB
(pulmonary)
 Meningitis + parenchymal lesions highly

suggestive.
Location

 TBM: Basal meningitis

Tuberculomas: Typically parenchymal,


supratentorial (often parietal lobes)
Infratentoriallesions are less common, can
involve brainstem (up to 8%)
 Dural tuberculomas may occur
 Size:Tuberculomas range from 1 mm to 6 cm
TB MENINGITIS
CT Findings
 NECT: May be normal early (10-15%)
 Isodense to hyperdense exudate effaces CSF

spaces, fills basal cisterns, sulci.

 CECT: Intense basilar meningeal


enhancement
Tuberculoma

CT Findings
 Hypodense to hyperdense round or lobulated

nodule/mass with moderate to marked


edema
 Solid or ring-enhancing "Target sign” with

contrast
 BASAL MENIGITIS WITH COMMUNICATING
HYDROCEPHALUS
TB MENINGITIS
 Parenchymal cerebritis may cause hypoattenuation with little or
no enhancement.

 Parenchymal tuberculomas demonstrate various patterns.

 Noncaseating granulomas are homogeneously enhancing


lesions.

 Caseating granulomas are rim enhancing; if these have a central


calcific focus, they may form a targetlike lesion. Granulomas
may also form a miliary pattern with multiple tiny nodules
scattered throughout the brain. All lesions are surrounded by
hypoattenuating edema in active stage.
TB CALCIFIED GRANULOMA
TUBERCULOSIS INFARCT
Extensive infarcts of the right
basal ganglia and internal
capsule after the appearance
of vasculitis in the
thalamoperforating arteries
in a child treated for
tuberculous meningitis
 Focal tuberculous cerebritis
CT scan will show intense focal gyral
enhancement
 Tuberculous encephalopathy

severe unilateral or bilateral cerebral edema


is seen
 Magnetic Resonance Imaging
 MRI is more sensitive than CT scanning in

determining the extent of meningeal and


parenchymal involvement.
MRI, T1-weighted gadolinium-
enhanced

T1-weighted gadolinium-
enhanced MRI in a patient
with multiple enhancing
tuberculomas in both
cerebellar hemispheres.
MRI, T2-weighted

T2-weighted MRI of a
biopsy-proven, right
parietal tuberculoma.
Note the low-signal-
intensity rim of the
lesion and the
surrounding
hyperintense vasogenic
edema.
MRI, T1-weighted gadolinium-
enhanced

T1-weighted gadolinium-
enhanced MRI in a child with a
tuberculous abscess in the left
parietal region. Note the
enhancing thick-walled abscess.
MR spectroscopy
 MR spectroscopy with a single-voxel proton technique
can be used to characterize tuberculomas and
differentiate them from neoplasms
 Tuberculomas show elevated fatty-acid spectra that are
best seen by using the stimulated-echo acquisition mode
technique and a short echo time. The necrosis of the
waxy walls of mycobacteria within the granuloma is
believed to cause the elevation of fatty-acid peaks. The
lactate peak is caused by anaerobic glycolysis and is
found in inflammatory, ischemic, and neoplastic lesions
of the brain; this finding is nonspecific.
Proton spectroscopy trace of
a patient with an
intracerebral tuberculoma
demonstrating an elevated
lactate peak (LA) with
diminished N-acetyl
aspartate (NAA) and choline
(CH) peaks typical of an
inflammatory mass in the
brain.
Nuclear Imaging
 Single photon emission CT scanning with

hexamethylpropyleneamine oxime (HMPAO) can be used to


assess the degree and extent of cerebral ischemia resulting
from TBM cerebral vasculitis.

Angiography
 Although not currently in routine use in patients with CNS TB,

cerebral angiography demonstrates findings of vasculitis.


These findings include vascular irregularity, vascular
narrowing, and vascular occlusion. Vessels commonly
affected include the terminal portions of the internal carotid
arteries, as well as the proximal parts of the middle and
anterior cerebral arteries.
 The primary differential diagnoses are
 fungal meningitis,
 Other bacterial meningitis,
 carcinomatous meningitis
 neurosarcoidosis
 THANK YOU…….
 CHOROID PLEXITIS
X RAY IN TUBERCULOSIS
 Skull radiographic findings are usually
normal. Rarely, in healed tuberculosis
meningitis, faint parenchymal calcification is
evident

You might also like