RESUMO
Background: The diagnosis of brain tuberculoma (BT) is sometimes challenging. Herein, we presented a case series to evaluate the combined-diagnostic methods, including acid-fast bacilli (AFB) stain, polymerase chain reaction (PCR), Gene Xpert, and histopathology, of tuberculoma tissue specimens (TTSs). Patients and Methods: A total of 16 patients (11 human immunodeficiency virus [HIV]-positive, 5 HIV-negative) with BT confirmed by combined-diagnostic methods of TTS were included in this study. Clinical data, including clinical symptoms, laboratory tests, neuroimaging features, histopathology, treatment, and prognosis, were assessed in all patients. Results: There were 10 male and 6 female patients (range, 18-73 years). Acid-fast bacilli stain and PCR of TTSs were positive in 11 and 10 patients, respectively. The sensitivity of Gene Xpert of TTSs was (80.0%; 8/10). Nine (56.3%; 9/16) patients were diagnosed with BT by histopathology. After receiving antituberculosis treatment, 12 (75.0%; 12/16) patients improved clinically to a considerable extent. Conclusions: The combined-diagnostic methods of TTS may improve the diagnostic efficiency of BT.
Assuntos
Tuberculoma Intracraniano , Humanos , Masculino , Feminino , Adulto , Pessoa de Meia-Idade , Adolescente , Adulto Jovem , Idoso , Tuberculoma Intracraniano/diagnóstico , Tuberculoma Intracraniano/tratamento farmacológico , Tuberculoma Intracraniano/diagnóstico por imagem , Encéfalo/patologia , Encéfalo/diagnóstico por imagem , Reação em Cadeia da Polimerase/métodos , Mycobacterium tuberculosis/isolamento & purificação , Mycobacterium tuberculosis/genética , Sensibilidade e EspecificidadeRESUMO
AIM: To present a comprehensive analysis of the clinical features and magnetic resonance imaging (MRI) findings of intracranial tuberculomas in Indonesia. MATERIALS AND METHODS: This was a retrospective analysis of brain MRI from 58 patients (29 women), mean age ± SD = 39 ± 2 years, diagnosed with intracranial tuberculomas. Clinical data, including symptoms, cerebrospinal fluid examination results, and MRI were also analysed. The diagnosis of intracranial tuberculoma was confirmed based on observed MRI changes following anti-tuberculosis therapy. RESULTS: A total of 603 tuberculomas were fully detected via MRI in all patients. Among these lesions, 507 (84%) were located in the cerebrum, 61 (10%) in the cerebellum, 19 (3%) in the basal ganglia, 12 (2%) in the brain stem, and four (1%) in the thalamus. The MRI signals were classified into two groups: tuberculomas with caseating granulomas and tuberculomas with non-caseating granulomas. Among the patients, 29 had concomitant meningitis, seven had hydrocephalus, and four had cerebral infarction. Evidence of pulmonary tuberculosis was found in 16 patients, with one patient having coexisting thoracic vertebral tuberculosis. CONCLUSION: The present study confirmed the significance of MRI as a valuable tool in the diagnosis of intracranial tuberculomas and the detection of associated abnormalities. The combination of MRI findings with clinical features can enhance the overall diagnostic accuracy for intracranial tuberculomas.
Assuntos
Tuberculoma Intracraniano , Humanos , Feminino , Tuberculoma Intracraniano/diagnóstico por imagem , Tuberculoma Intracraniano/tratamento farmacológico , Estudos Retrospectivos , Encéfalo/patologia , Imageamento por Ressonância Magnética , GranulomaRESUMO
The clinical and radiological end points to stop anti-tubercular treatment in central nervous system (CNS) tuberculoma are not known. This retrospective study was done to determine end points to stop anti-tubercular treatment and find the predictors of poor outcome in patients with CNS tuberculoma. Patients who were admitted with a diagnosis of brain/spine tuberculoma between January 2015 and December 2019 and who completed a minimum of 1-year follow-up were enrolled. Clinical and radiological end points to stop anti-tubercular treatment and predictors of death and poor outcome (modified Rankin scale > 2) were analyzed. One hundred and eight patients (male-to-female ratio, 47 [43.5%]:61 [56.5%]; brain tuberculoma, 102; spinal cord tuberculoma, 14; brain and spinal cord tuberculoma, 8) were included in the study. Median duration of anti-tubercular treatment was 24 months. Radiological resolution of tuberculoma (resolution of gadolinium-enhancing lesion, gliosis, calcification, cord atrophy, or syrinx formation) and radiological halt (no increase in size/number of tuberculoma on magnetic resonance imaging scans done 6 months apart) were used as end points to stop anti-tubercular treatment in 69 and 7 patients, respectively. Seven patients stopped their treatment by themselves, and 25 patients died. Altered sensorium, motor weakness, infarcts, hydrocephalus, and constitutional symptoms of tuberculous meningitis were predictors of poor outcome or death in CNS tuberculoma patients. Radiological resolution or radiological halt of brain/spinal cord tuberculoma was a reasonable end point to stop anti-tubercular treatment. However, this may require 24 months or more of anti-tubercular treatment. Associated tuberculous meningitis and its complications portend a poor prognosis.
Assuntos
Tuberculoma Intracraniano , Tuberculose Meníngea , Humanos , Masculino , Feminino , Tuberculose Meníngea/diagnóstico por imagem , Tuberculose Meníngea/tratamento farmacológico , Tuberculose Meníngea/complicações , Estudos Retrospectivos , Tuberculoma Intracraniano/diagnóstico por imagem , Tuberculoma Intracraniano/tratamento farmacológico , Medula Espinal/diagnóstico por imagem , Medula Espinal/patologia , Radiografia , Imageamento por Ressonância Magnética , Antituberculosos/uso terapêuticoRESUMO
BACKGROUND: Intracranial tuberculomas are infrequent with a lower morbidity and mortality compared to tubercular meningitis. Giant intracranial tuberculomas are rarer but important differentials for intracranial space-occupying lesions causing focal neurological deficits depending on anatomical location and size. METHODS: Histopathologically confirmed giant intracranial tuberculomas selected based on institutional size criteria (<12 Years-old: ≥25 mm; 12-18 Years-old: ≥35 mm; ≥18 Years-old: ≥40 mm) were retrospectively reviewed and analyzed for clinical features, radiology, surgical management, and outcomes in patients admitted from 2015 to 2022. RESULTS: Ten patients were included (Males:Females = 3:7; Age: 8-68 Years, Average: 30.1 Years). Mean duration of symptoms was 2.84 months. Two patients demonstrated active systemic tuberculosis. Previous tubercular infections included pulmonary involvement in four, meningeal in three, and a cerebellar tuberculoma in one patient. Cerebrospinal fluid analysis in five patients demonstrated no tubercle bacilli. Seven lesions were supratentorial and three infratentorial. Giant tuberculomas demonstrated profound T2 hypointensity, sub-marginal T2 hyperintense crescents, and significant perilesional vasogenic edema. Craniotomy and excision were mainstay except in one case treated only with ventriculoperitoneal shunting. Three additional patients underwent ventriculoperitoneal shunting for hydrocephalus. One patient died from aspiration pneumonia and sepsis following a postoperative seizure. Anti-Tubercular Therapy (ATT) was advised for 18 months. Follow up ranged from 4 to 18 months. One patient was medically managed for ATT-induced hepatitis, hepatic encephalopathy, and coincidental paradoxical reaction. Remainder of patients showed complete resolution of symptomatology and absence of new symptoms till latest follow up. CONCLUSION: Clinical course of giant tuberculomas differ from non-giant variants in characteristic radiology, more intensive ATT, and possibility for partial debulking/excision.
Assuntos
Tuberculoma Intracraniano , Tuberculose Meníngea , Masculino , Feminino , Humanos , Criança , Adolescente , Adulto Jovem , Adulto , Pessoa de Meia-Idade , Idoso , Estudos Retrospectivos , Imageamento por Ressonância Magnética , Tuberculoma Intracraniano/diagnóstico por imagem , Tuberculoma Intracraniano/cirurgia , Quimioterapia Combinada , Craniotomia , Tuberculose Meníngea/diagnóstico , Antituberculosos/uso terapêuticoRESUMO
This is a case report of patient suffering from multiple central nervous system tuberculoma which progressed to tubercular abscess. Patient developed signs and symptoms of mass effect and compression. Computed tomography of brain and magnetic resonance spectroscopy confirmed the diagnosis. Patient underwent left temporal craniotomy with evacuation of pus. The abscess wall and the pus sent for histopathological and microbiological examination which confirmed the etiological agent - Mycobacterium tuberculosis. Appropriate treatment was started and discharged. Hence, early diagnosis and treatment of intracranial tuberculoma are pivotal in preventing morbidity and mortality of the condition.
Assuntos
Mycobacterium tuberculosis , Tuberculoma Intracraniano , Abscesso/diagnóstico , Encéfalo , Humanos , Imageamento por Ressonância Magnética , Tuberculoma Intracraniano/diagnóstico por imagem , Tuberculoma Intracraniano/patologiaRESUMO
Almost two billion people are infected with M. Tuberculosis. The most common manifestation of TB is pulmonary; however, severe manifestations of TB can affect the central nervous system. This case report describes a young refugee with onset of sixth nerve palsy and an MRI consistent with a pontine tumor. Stereotactic biopsy showed giant cells and acid-fast rods, Quantiferon test was positive, thus fulfilling the criteria for tuberculoma. The patient immediately began antituberculous treatment and slowly recovered. The purpose of this article was to elucidate the necessity of screening migrants from TB-endemic areas.
Assuntos
Refugiados , Tuberculoma Intracraniano , Tuberculose , Humanos , Pulmão/patologia , Imageamento por Ressonância Magnética , Tuberculoma Intracraniano/diagnóstico por imagem , Tuberculoma Intracraniano/tratamento farmacológico , Tuberculose/complicações , Tuberculose/diagnóstico , Tuberculose/tratamento farmacológicoRESUMO
We present an 11-year-old girl who manifested with unprovoked right-sided focal motor seizures. CT revealed a large lobulated hypodense mass in the left temporoparietal lobe, with perilesional oedema and postcontrast peripheral enhancement. Diagnostic uncertainty resulted in further neuroimaging, which included MRI with modalities including diffusion-weighted imaging, perfusion imaging, as well as spectroscopy. We discuss the radiological features of the lesion, which steered us in the direction of an infective cause. Definitive diagnosis was achieved by brain needle biopsy, which demonstrated necrotising granulomatous inflammation indicative of tuberculous infection on histology. In addition, GeneXpert yielded a positive result. We believe this unique case highlights the diagnostic dilemma clinicians face in differentiating ring-enhancing lesions on neuroimaging in tuberculosis-endemic regions. It also highlights the potential benefit of a brain needle biopsy (histology and GeneXpert) in cases of uncertainty.
Assuntos
Neoplasias , Tuberculoma Intracraniano , Tuberculoma , Criança , Feminino , Humanos , Imageamento por Ressonância Magnética , Neuroimagem , Tuberculoma/diagnóstico por imagem , Tuberculoma Intracraniano/diagnóstico por imagem , Tuberculoma Intracraniano/tratamento farmacológicoRESUMO
OBJECTIVES: To evaluate Magnetic Resonance Imaging (MRI) features of Giant Tuberculomas (GT) of the brain and deduce characteristic imaging phenotypes which may differentiate GT from higher grade glioma. METHODS: A retrospective analysis of MRI was done on Tuberculomas of size >2 cm. The diagnosis was established by histopathology or presumed from size reduction on follow-up MRI while on empirical anti-tubercular therapy (ATT). Multimodality characteristics of GT on T1/T2W, Fluid attenuation recovery (FLAIR), Diffusion-Weighted imaging (DWI), Susceptibility Weighted Imaging (SWI), Spectroscopy (MRS) and Perfusion weighted sequences were assessed. These imaging features were also evaluated in WHO Grade IV, IDH-wild type glioma (histopathologically and genetically proven) and a comparative analysis of the imaging features between GT and glioma was done. RESULTS: Thirty-two GT and 20 glioma were evaluated. Pronounced intralesional T2 hypointensity (n = 8;25%), T2 hyperintense crescent beneath the periphery (n = 25, 78.1%), T2W lamellated/whorled appearance (n = 17;53.125%), hyperintense rim on T1W MT (n = 25;78.1%), peripheral rim of diffusion restriction (n = 22; 68.75%), peripheral rim of blooming on SWI (n = 20, 62.5%), prominent lipid resonance on MR spectroscopy (n = 30; 93.75%), overshoot of the signal intensity-time curve above the base line (n = 9/10; 90%) on dynamic susceptibility contrast (DSC) perfusion, were remarkable imaging characteristics. Reduction of peripheral T1 hyperintensity, compaction of T2 hypointense core, expansion of sub-marginal T2 hyperintense rim and increased peripheral susceptibility (n = 20; 62.5%) during follow-up imaging, while on ATT, were standout features. GT could be differentiated from WHO grade IV (IDH-wild type) glioma on the basis of a significantly higher proportion of GTs showing a whorled/lamellated appearance, T1 hyperintense rim, T2 hypointense core, DWI-ADC mismatch, well-defined rim on SWI, prominent lipid peak on MRS and a submarginal T2 hyperintense rim. GT showed a higher normalized ADC ratio from the core as well as the rim. Significantly higher proportion of glioma showed a T1 hypointense and T2 hyperintense core and a nodular rim enhancement. A significantly higher r CBV, Choline to creatine, choline to NAA ratio and mean thickness of the peripheral enhancing rim were defining features among gliomas. CONCLUSION: Neuroimaging features of GT have been elucidated. Reduction of peripheral T1 hyperintensity, compaction of T2 hypointense core, expansion of sub-marginal T2 hyperintense rim, and increased peripheral susceptibility on follow-up may be considered imaging markers of response to anti-tubercular therapy. Multiparametric MRI features can differentiate GT from WHO grade IV (IDH-wild type) glioma.
Assuntos
Encéfalo/diagnóstico por imagem , Encéfalo/metabolismo , Imageamento por Ressonância Magnética Multiparamétrica/métodos , Tuberculoma Intracraniano/diagnóstico por imagem , Tuberculoma Intracraniano/metabolismo , Adolescente , Adulto , Criança , Pré-Escolar , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Adulto JovemRESUMO
A 35-year-old Sudanese man experienced bitter tastes on the right side of his tongue from January 2012. He was admitted to our hospital in March 2012 because of the appearance of distress, right facial palsy, nausea, and dizziness from late February 2012. A neurological examination revealed Bruns nystagmus, which increased on rightward gaze, as well as total hypoesthesia in the distribution of the maxillary branch of the right trigeminal nerve, moderate right peripheral type facial nerve palsy, and limb ataxia on the right side. Neither muscle weakness nor sensory disturbance was observed. Slight hyperreflexia was noted in the right extremities, and bilateral plantar responses were flexor. He showed wide-based ataxic gait and was unable to do tandem gait. Brain CT scans and magnetic resonance (MR) images revealed a mass lesion in the right pons to the right middle cerebellar peduncle with ring enhancement, suggestive of a "target" sign. Laboratory tests, including hematological and biochemical analyses, tumor markers, and antibodies, had normal values while the tuberculin reaction and QuantiFERON-TB Gold were strongly positive. Cerebrospinal fluid analysis revealed a slight increase in the protein level (76âmg/dl) with a normal cell count (2 per µl), and polymerase chain reaction-based tests and cultures were negative for Mycobacterium tuberculosis three times. Right subclavicular lymph node and right adrenal gland showed accumulation of fluorodeoxyglucose on positron emission tomography-CT, as did the mass lesion in the brainstem. These findings suggested a possibility of a metastatic malignant tumor or extrapleural tuberculoma. Because of the patient's religious belief, we were unable to perform a biopsy of the lymph node, and thus administered anti-tuberculous drugs. With treatment, his neurological symptoms such as facial palsy and ataxia improved steadily except for paradoxical worsening for the initial five days, and the gadolinium-enhanced lesion shrunk markedly. Follow-up MR images demonstrated that the lesions did not expand further for 9 months. From this course of treatment, we diagnosed the patient's tumor as brainstem tuberculoma. Brain tuberculoma sometimes resembles a malignant tumor, and it is therefore challenging to diagnose brainstem tuberculosis in cases without lung lesions. It is important to make a comprehensive diagnosis based on the patient's background, imaging, and course of treatment, and to treat brainstem tuberculoma promptly.
Assuntos
Tronco Encefálico/diagnóstico por imagem , Tuberculoma Intracraniano/diagnóstico , Adulto , Antituberculosos/uso terapêutico , Neoplasias Encefálicas , Diagnóstico Diferencial , Humanos , Imageamento por Ressonância Magnética , Masculino , Tomografia por Emissão de Pósitrons combinada à Tomografia Computadorizada , Tomografia Computadorizada por Raios X , Resultado do Tratamento , Teste Tuberculínico , Tuberculoma Intracraniano/diagnóstico por imagem , Tuberculoma Intracraniano/tratamento farmacológicoRESUMO
The patient of the report is a six- month-old Libyan female, who presented with a history of fever, persistent cough, and an attack of seizure. The patient has been diagnosed with a case of brain Tuberculoma and cavitation in the right lung based on the Brain Magnetic resonance imaging and the Chest Computed tomography scan, respectively. Subsequently, the patient was treated with antituberculous drugs and corticosteroids. After finishing the treatment, the patient has been cured. This case illustrates the possibility of developing early disseminated tuberculosis during infancy and highlights the difficulties of the diagnosis during the early stages of the disease. The case emphasizes the benefits of early diagnosis and treatment to prevent severe consequences in infancy.
Assuntos
Tuberculoma Intracraniano/patologia , Tuberculose Pulmonar/patologia , Feminino , Humanos , Lactente , Líbia , Imageamento por Ressonância Magnética , Tomografia Computadorizada por Raios X , Tuberculoma Intracraniano/complicações , Tuberculoma Intracraniano/diagnóstico por imagem , Tuberculose Pulmonar/complicações , Tuberculose Pulmonar/diagnóstico por imagemAssuntos
Encéfalo/diagnóstico por imagem , Imageamento por Ressonância Magnética , Neuroimagem , Tuberculose Miliar/diagnóstico , Adulto , Encéfalo/microbiologia , Humanos , Masculino , Convulsões/etiologia , Tuberculoma Intracraniano/diagnóstico , Tuberculoma Intracraniano/diagnóstico por imagem , Tuberculoma Intracraniano/patologia , Tuberculose Miliar/diagnóstico por imagem , Tuberculose Miliar/patologiaRESUMO
Tuberculosis is emerging worldwide across diverse populations and geographies; unrestricted by the social divide and the geographical barriers in today's interconnected world. This rise in its prevalence can be linked to multiple factors including urbanisation, spurt in global travel, population explosion, migration and HIV infection. The varied and complex clinical presentation of intracranial tuberculosis tricks even the best of the clinicians. This along with the other facets associated with its management including drug resistance, paradoxical reaction, underlying HIV infection can make it particularly challenging. Imaging has a definitive role in the evaluation and follow-up of intracranial tuberculosis and MRI is the cornerstone in this regard. Typical features of intracranial tuberculosis are well-described. However, it is not infrequent to encounter atypical and bizarre presentations, both clinically and on imaging. A holistic clinical and imaging review of difficult cases, including newer MRI techniques, is necessary for the neuroradiologist, neurologist and the neurosurgeon to arrive at the right diagnosis in a timely fashion.
Assuntos
Infecções por HIV , Tuberculoma Intracraniano , Tuberculose Meníngea , Antituberculosos/uso terapêutico , Humanos , Imageamento por Ressonância Magnética , Tuberculoma Intracraniano/diagnóstico por imagem , Tuberculoma Intracraniano/tratamento farmacológico , Tuberculose Meníngea/tratamento farmacológicoRESUMO
CONTEXT: Intracranial tuberculomas are rare yet lethal forms of tuberculosis. Diagnosis is often difficult because of its nonspecific symptoms and radiological findings. AIM: This study aims to perform a literature review of multiple tuberculomas to improve disease recognition and management in immunocompetent patients along with presenting a case report on the topic. DATA SOURCES: Scopus, LILACS, Ovid MEDLINE and EMBASE. STUDY SELECTION: Case reports and case series up to December 2018 in English, Spanish, and Portuguese focusing on intracranial tuberculomas in adult and pediatric immunocompetent patients. Data on presentation, diagnostic workup, and treatment was analyzed. DATA EXTRACTION: Cochrane Collaboration/Cochrane Handbook and PRISMA guidelines. RESULTS: Twenty reports involving 21 patients were included. Most patients were male (57.14%). The average age at diagnosis was 26.9 ± 14.9 years. Headache was the most common presenting symptom (52.4%; 11/21), followed by motor weakness (47.6%; 10/21) and vomiting (23.8%; 5/21). MRI was the most used image technique (17/21). Most lesions occurring in the cerebral hemispheres (16/21); we found five or more lesions in 66.6% (14/21) of the patients. The majority treated with anti-tuberculous drugs resulted in a favorable outcome. CONCLUSIONS: Immunocompetent patients living in TB endemic areas whose clinical evaluation and neuroimaging findings are compatible with tuberculoma should undergo anti-tubercular treatment despite a lack of bacteriological confirmation.
Assuntos
Antituberculosos/uso terapêutico , Encefalopatias/diagnóstico por imagem , Glucocorticoides/uso terapêutico , Tuberculoma Intracraniano/diagnóstico por imagem , Tuberculose Pulmonar/diagnóstico por imagem , Cegueira/fisiopatologia , Encéfalo/diagnóstico por imagem , Encefalopatias/tratamento farmacológico , Encefalopatias/imunologia , Encefalopatias/fisiopatologia , Ataxia Cerebelar/fisiopatologia , Dexametasona/uso terapêutico , Quimioterapia Combinada , Doenças Endêmicas , Etambutol/uso terapêutico , Feminino , Humanos , Imunocompetência , Isoniazida/uso terapêutico , Imageamento por Ressonância Magnética , Náusea/fisiopatologia , Nistagmo Patológico/fisiopatologia , Peru , Pirazinamida/uso terapêutico , Quadriplegia/fisiopatologia , Rifampina/uso terapêutico , Tomografia Computadorizada por Raios X , Tuberculoma Intracraniano/tratamento farmacológico , Tuberculoma Intracraniano/imunologia , Tuberculoma Intracraniano/fisiopatologia , Tuberculose Pulmonar/tratamento farmacológico , Tuberculose Pulmonar/imunologia , Vômito/fisiopatologia , Adulto JovemRESUMO
Cerebral tuberculoma of the brain are uncommon presentation of tuberculosis (1%). A 17-year female presented to the emergency with a Glasgow Coma Score of (eye-1, verbal-1 and motor-3), 5/15 bilateral fixed pupils with laborious breathing. The radiological features were suggestive of aintracerebral abscess/ glioma. Intraoperatively the brain was very tense and a large, vascular, mass was present that was excised completely. Her histopathology revealed features of tuberculoma and she was started on anti-tubercular treatment. She is discharged home with regular follow-up for the last 10 months.Cerebral tuberculoma although uncommon should be thought of in developing countries as differential of cystic enhancing lesions of the brain. Keywords: Abscess; central nervous system; glioma; tuberculoma; tuberculosis.
Assuntos
Lobo Frontal/fisiopatologia , Tuberculoma Intracraniano/patologia , Inconsciência , Adolescente , Feminino , Humanos , Nepal , Resultado do Tratamento , Tuberculoma Intracraniano/diagnóstico por imagem , Tuberculoma Intracraniano/cirurgiaRESUMO
PURPOSE: The duration of antiepileptic drug (AED) treatment in the management of seizures due to ring enhancing lesions (REL) remains a matter of debate. We undertook a prospective cohort study to look into the seizure patterns and incidence of recurrence in association with two of the most common causes of RELs after gradually stopping AEDs at least 18 months after acheiving seizure control. METHODS: Ninety patients with neurocysticercosis (NCC) and twenty-nine patients with tuberculoma were treated with anti-helminthic and anti-tubercular drugs according to current recommended guidelines, and followed up for a minimum of 2 years after the last seizure free day. In every patient included in the study, AEDs were tapered within six months of attaining a seizure-free interval of 18 months. We looked at the incidence of recurrent seizures after stopping AEDs in both groups of patients. RESULTS: The frequency of baseline seizures (2.1 vs 1.5 per year, p < 0.001) and number of antiepileptic drugs (2.12 vs 1.48, p < 0.001) were greater in patients with NCC than those with tuberculoma. Patients with NCC had a greater incidence of recurrent seizures (1.17 vs 0.07 in the next six months, p < 0.001) after stopping the AEDs. The median interval to seizure recurrence after stopping AEDs was 2.2 months in patients with NCC. CONCLUSIONS: Among RELs, NCC lesions have a greater epileptogenic potential than tuberculomas. AEDs can be tapered in patients with tuberculoma after a seizure free period of 18 months with a very low risk of recurrence.