Surgical Management of Tuberculosis-related Cerebral Disorders: A Retrospective Single-center Study.

BACKGROUND: Tuberculosis (TB) remains a significant global health concern, with extrapulmonary manifestations, including central nervous system involvement, posing substantial morbidity and mortality. While medical treatment with anti-TB drugs is the mainstay of therapy, certain TB-related cerebral complications, such as hydrocephalus, abscesses, and large symptomatic tuberculomas, may require surgical intervention. This study aimed to evaluate the outcomes of surgical management in patients with TB-related cerebral disorders. METHODS: A retrospective analysis was conducted on 24 patients who underwent surgical intervention for TB-related cerebral disorders, including tuberculomas, hydrocephalus, and abscesses, at a tertiary care center between 2005 and December 2020. Demographic data, clinical presentations, radiological findings, surgical techniques, and treatment outcomes were analyzed. RESULTS: The study cohort had a mean age of 35.8 ± 13.6 years, and the majority (62.5%) were male. Underlying immunodeficiency, primarily HIV infection, was present in 75% of the patients. The most common presenting symptoms were headache (83.3%), focal neurological deficits (75%), and altered mental status (54.2%). Radiological findings revealed 13 (54.2%) tuberculomas, 8 (33.3%) instances of hydrocephalus, and 3 (12.5%) abscesses. VP shunt inserted in 8 (33.3%) cases. Microscopic craniotomy performed in 7 (29.16%) cases. Aspiration through burr hole was done in 3 (12.5%) cases and stereotactic biopsy was performed in 6 (25%) cases. After 12 months of follow-up, favorable outcome achieved in 18 cases (75%) and the mortality occurred in 2 patients (8.3%). Surgical interventions included lesion resection (n = 10), stereotactic biopsy (n = 7), and ventriculoperitoneal (VP) shunt placement (n = 7). At 12-month follow-up, 18 (75%) patients had a favorable outcome, defined as clinical improvement or stabilization. Unfavorable outcomes were observed in 6 (25%) patients, including 2 deaths. CONCLUSION: Surgical management, in conjunction with appropriate anti-TB medical therapy, may be a valuable component of the comprehensive treatment approach for select patients with TB-related cerebral disorders. The favorable outcome rate observed in this study suggests that timely and tailored surgical intervention can contribute to improved patient outcomes. However, larger, prospective, multicenter studies are needed to further elucidate the role and long-term efficacy of surgical management in this patient population.

[Multiple intracranial lesions: a clinicalpathologic study of 62 cases].

OBJECTIVE: To study the clinicalpathologic features of intracranial multiple lesions. METHODS: The clinical, radiologic and pathologic features of intracranial multiple lesions in 62 cases during the period from 2005 to 2009 in Xuanwu Hospital were retrospectively reviewed. RESULTS: There were 32 males and 30 females in 62 cases. The mean age of seize onset and duration of disease were 37.4-year-old and 11.6 months, respectively. The lesions could affect cerebral hemisphere, basal ganglia, brain stem, cerebellum and other parts, most lesions were located above the tentorium. Pathological diagnosis as follows: 13 patients with glioma; metastatic tumors in 13 cases; 12 cases of central nervous system infection; immune-mediated inflammatory demyelinating disease in 8 cases; 5 cases of primary lymphoma of central nervous system; primary angiitis of the central nervous system 3 cases; mitochondrial encephalopathy 2 cases; vein thrombosis in 2 cases; Rosai-Dorfman disease in 2 cases; 2 case of radiation encephalopathy. Among them, mitochondrial encephalopathy and vein thrombosis lesions located in the cortex; metastatic tumor and blood-borne infection mainly involving junction of grey and white matter; glioma, radiation encephalopathy and demyelinating disease include white matter lesions; vascular inflammation showed cortical and subcortical white matter lesions. CONCLUSIONS: A variety of tumor and non-neoplastic diseases can be expressed in intracranial multiple lesions, which gliomas, metastatic tumor and central nervous system infections are more common. In order to improve the diagnosis of intracranial multiple lesions, active work in the brian biopsy, study the clinical, imaging and pathological findings must be closely.

Tuberculosis-The Great Mimicker: A Case of Traumatic Drainage of Cold Abscess.

BACKGROUND: Tuberculosis is characterized by cold abscess, which classically lacks the usual signs and symptoms of inflammation. This case report highlights an atypical presentation of tuberculous cold abscess in the form of appearance of massive swelling in the back overnight after a blunt trauma, mimicking post-traumatic hematoma. CASE DESCRIPTION: A 32-year-old man came to our outpatient department with sudden swelling over the right side of the upper back (25 × 8 × 8 cm) and loin (10 × 4 × 4 cm) after a fall from 1.5 to 2 m height the previous night. The possible differential diagnosis of a traumatic pathology, complicated by a bleeding disorder, resulting in massive hematoma was initially made. However, hematologic investigations were within normal limits. Magnetic resonance imaging suggested an anterior subligamentous abscess at the C7-T1 level tracking through the paraspinal muscles and communicating with the subcutaneous abscess, and at the L3 level, paraspinal abscess tracking to the subcutaneous plane. There was no cord compression or signal changes in the cord. Both the abscesses were pigtailed in antigravity fashion, and material was sent for culture, which proved to be tuberculosis. The patient was treated with antituberculosis treatment for 18 months and improved over the course with complete resolution of symptoms. At 4-year follow-up, the patient is asymptomatic with no evidence of recurrence. CONCLUSIONS: Appearance of massive swelling overnight in patients with cold abscess has not been described in the literature. While evaluating an atypical presentation such as sudden post-traumatic swelling over the thoracolumbar area, the clinician should keep a differential diagnosis of tuberculous abscess and investigate clinicoradiologically to rule out tuberculosis, especially in developing countries.

Stereotactic Aspiration in Management of Rare Case of Tuberculous Cerebellar Abscess.

Tuberculous brain abscess is an extremely rare form of central nervous system tuberculosis. This lesion usually occurs in the supratentorial space. Cerebellar tubercular abscesses are rare. Most of these cases occur in immunocompromised patients. We report an immunocompetent individual with tuberculous abscess of the cerebellum and discuss the role of stereotactic aspiration in the management of these rare lesions.

An algorithmic approach to intracranial mass lesions in HIV/AIDS.

We developed a diagnostic and therapeutic algorithm for intracranial mass lesions in patients with HIV/AIDS that obviates the need for neurosurgical intervention. The approach is based upon CD4(+) lymphocyte count, serum toxoplasma immunoglobulin G (IgG) serology, chest X-ray, routine lumbar puncture studies, cerebrospinal fluid (CSF) cytology, CSF adenosine deaminase or Mycobacterium tuberculosis polymerase chain reaction testing, single positron emission-computed tomography (SPECT) scanning for intracranial enhancing lesions, and limited therapeutic trials. Over a 12-month period involving 26 patients, we found that the algorithm correctly identified the aetiology of focal intracranial lesions in all 23 evaluable patients. Costs for SPECT scanning for the entire study cohort were more than offset by the savings achieved by reduced hospital stays for the four patients with lymphoma alone. An algorithmic approach can accurately identify the cause(s) of central nervous system (CNS) mass lesions in HIV-infected patients, and SPECT scanning can replace stereotactic brain biopsy in most cases where opportunistic malignancy is suspected.

A case of persistent hyponatraemia due to reset osmostat.

We report a case of a 65 year old Malay lady with long-standing diabetes mellitus, who presented to our institution with a one month history of worsening neck pain and progressive upper and lower limb weakness. She was stable despite severe hyponatraemia which was initially treated as syndrome of inappropriate anti-diuretic hormone (SIADH). This was consistent with her underlying illness which was concluded as cervical tuberculosis (TB) with spinal cord compression. She underwent decompression and bone grafting. Despite continuous treatment her serum sodium levels remained low. There were no other problems with her adrenals or thyroid. A water loading and hypertonic saline perfusion test was performed and supported the diagnosis of reset osmostat. Her serum sodium remained below the normal range and she was discharged well.

Worsening of longstanding headaches, dizziness, visual symptoms · Dx?

The clinical presentation and imaging studies of central nervous system tuberculosis are often indistinguishable from those of patients with malignant neoplasms or metastatic disease. Biopsies may be necessary to distinguish tuberculomas from other intracranial lesions such as pyogenic abscesses or necrotic tumors.

Tuberculous brain abscess in AIDS patients: report of three cases and literature review.

OBJECTIVE: Clinical description of tuberculous brain abscess in patients with acquired immunodeficiency syndrome (AIDS). METHODS: Clinical case report and review of the literature from January 1981 to January 2003 using the MEDLINE database. RESULTS: The authors report three cases of tuberculous brain abscess in AIDS patients and review nine similar cases. The mean age was 30 years (range: 18-56 years) with seven patients being male. Five (42%) were intravenous drug users, had prior history of extra-cerebral tuberculosis, and presented alterations on chest radiograph. Tuberculin skin test was anergic in six (75%) of eight patients. Three patients of nine had a CD4+ cell count higher than 200 cells/microL, and three had a CD4+ cell count lower than 100 cells/microl. All but one patient had a brain computerized tomography scan with a single lesion. All patients received anti-tuberculous treatment and underwent surgical procedures. Most patients (75%) showed appropriate clinical responses. CONCLUSION: Tuberculous brain abscess must be considered in the differential diagnosis of intracranial mass in AIDS patients. A careful epidemiological, clinical and laboratory evaluation may guide a diagnostic suspicion. Surgery combined with specific anti-tuberculosis treatment seems to determine a good outcome.

An unusual presentation of neurotuberculosis: subdural empyema. Case report.

Tuberculosis continues to be a major public health concern, especially in developing countries. Many types of neurotuberculosis have been described, but there is only one previously reported case of subdural empyema caused by tuberculous bacilli. A 1-year-old boy who had been treated for pulmonary tuberculosis was referred to the authors' institution with a diagnosis of right frontoparietal extraaxial abscess formation. Computerized tomography and magnetic resonance imaging revealed an extraaxial abscess with no evidence of calvarial infection. A craniotomy was performed to drain the pus, which was located subdurally. A polymerase chain reaction test yielded positive results, and histopathological examination revealed caseation. Antituberculous treatment was started after a diagnosis of subdural empyema with related neurotuberculosis had been made. At the end of a 12-month course of medical therapy, the patient was well with no evidence of tuberculosis.

Intracranial and spinal tuberculosis requiring neurosurgical intervention. The Wellington Hospital experience 1998-2001.

AIMS: To describe the Wellington Neurosurgical Unit's recent experience of managing tuberculosis between January 1998 and January 2001. METHODS: Patients with microbiologically confirmed tuberculosis of the central nervous system and whose management included surgery are described. Personal recall and review of the hospital records were used to extract relevant data. RESULTS: Five patients were identified. As well as involvement of the brain parenchyma, meninges, spinal cord or spinal column, all had evidence of tuberculosis elsewhere. All but one patient deteriorated neurologically after being started on antituberculous chemotherapy. CONCLUSIONS: The number of patients presenting with neurotuberculosis appears to have increased recently in the Wellington region. The high proportion of paradoxical progression in our series is unusual. Neurosurgical intervention may be required for diagnosis, to treat hydrocephalus, or to relieve mass effect. Management is prolonged and often complex, and close co-operation is required between the neurosurgical team and a physician experienced in the management of tuberculosis.

Intramedullary spinal tuberculoma--case report.

A healthy 33-year-old man presented with an intramedullary tuberculoma of the thoracic spinal cord manifesting as a 2-month history of progressive paraparesis and sphincter dysfunction. Magnetic resonance imaging showed ring enhancement of the intramedullary thoracic lesion with perifocal edema. General physical examination was unremarkable with no signs of inflammation except for a positive finding by the tuberculin skin test. Total resection of the intramedullary mass was performed through a posterior myelotomy following T11-12 laminectomy. Histological examination revealed a granulomatous lesion that contained Langhans giant cells, inflammatory cells, and caseating necrosis. Acid-fast bacilli staining of the specimens was positive, and cultures grew Mycobacterium tuberculosis. Postoperatively, the paraparesis and sphincter dysfunction improved sufficiently for the patient to return to his ordinary activities. Intramedullary spinal tuberculoma is rare, but must be considered in the differential diagnosis of spinal cord compression.

[Intramedullary tuberculomas. Five cases]. / Les tuberculomes intramédullaires. A propos de 5 cas.

Tuberculosis of the central nervous system is uncommon. The intramedullary localization is exceptional. We report five cases of intramedullary tuberculosis observed in four women and one man with a mean age of 43 years. Two patients had a prior history of tuberculosis. Spinal cord compression was found clinically in all cases. The spinal MRI visualized the tuberculoma in all patients; two had a double tumor. Complete removal of the tuberculoma was possible in only one patient. Outcome was stationary for four patients.

Tuberculous brainstem abscess: case report.

OBJECTIVE: Tuberculous brainstem abscess is a clinically rare condition with potentially high mortality and morbidity. We present this report to draw attention to the importance of early recognition and adequate treatment of tuberculous brainstem abscess. CLINICAL PRESENTATION: A 24-year-old man complained of longstanding fever, headache, and weakness followed by development of progressive slurred speech and hemiparesis of the right extremities. Magnetic resonance imaging revealed a large thick-walled cystic lesion lying within the brainstem. INTERVENTION: The patient demonstrated a remarkable clinical recovery after microsurgery combined with a course of antituberculous therapy. Microbiological and histological findings confirmed the diagnosis of a tuberculous abscess. CONCLUSION: Despite its rarity, the tuberculous brainstem abscess must be considered in the differential diagnosis of cystic brainstem mass lesions in vulnerable patients. When confronted with progressing neurological deterioration and poor response to antituberculous therapy, stereotactic or microsurgical management should be considered. Microsurgical excision combined with a complete course of antituberculous therapy in our patient led to a good outcome.

The surgical management of infections involving the cerebrum.

OBJECTIVE: Infection involving the cerebrum is a true neurosurgical emergency that requires rapid diagnosis and appropriate surgical and medical intervention to achieve good clinical outcome. METHODS: Because of the potential for devastating neurological sequelae, it is imperative that neurosurgeons be involved in the diagnosis and management of these serious conditions once an infection is suspected. With the advent of computed tomography and magnetic resonance imaging, it is now possible to detect an infectious process early in its course and follow the response to therapy. Although significantly more effective than in the past, antimicrobial therapy alone is insufficient to eradicate most intracranial infections, especially in the presence of compression or displacement of the cerebrum. Surgery remains an essential part of the management of intracranial infection because of its ability to provide immediate relief from pressure on neural structures and thereby result in clinical improvement. RESULTS: The most common infections affecting the brain, namely, cranial epidural abscess, subdural empyema, brain abscess, viral infection, tuberculosis, and neurocysticercosis, can each be associated with significant mass effect on the cerebrum that is greatly reduced through surgery. This relief, in combination with newer antimicrobial agents that have an improved ability to cross the blood brain barrier, has led to a reduction in the infection-related morbidity and mortality rates associated with intracranial infections. CONCLUSION: Combining advanced imaging and surgical techniques in the form of intraoperative magnetic resonance image-guided neurosurgery may further enhance clinical outcomes in these once uniformly fatal diseases.

Superior sagittal sinus thrombosis caused by calvarial tuberculosis: case report.

OBJECTIVE: Tuberculosis affects the central nervous system in various ways but has not been reported to cause venous sinus thrombosis. In this case report, extensive calvarial tuberculosis caused compression and occlusion of the superior sagittal sinus in an adult man. Early diagnosis combined with surgical and medical treatment resulted in cure of the disease. CLINICAL PRESENTATION: A 34-year-old man presented with a nonhealing sinus in the frontal area after a trivial injury without any neurological deficits or features of raised intracranial pressure. Magnetic resonance imaging scans showed evidence of extensive bilateral extradural granulations, bone destruction, and thrombosis of the anterior half of superior sagittal sinus. INTERVENTION: The affected bone and extradural granulations were surgically excised. Histopathology showed tuberculous osteomyelitis, and the patient received anti-tuberculous treatment, after which he had a good recovery. CONCLUSION: Calvarial tuberculosis as a cause of sagittal sinus thrombosis is a rare condition and is reported here for the first time, to our knowledge. Surgical excision of the compressing granulations followed by medical treatment is curative without sequelae if the intervention is performed before the disease extends intradurally.

An intradural extramedullary tuberculoma of the spinal cord in a non-HIV-infected patient: case report and review of the literature.

Spinal tuberculomas are extrapulmonary manifestations of tuberculosis involving the central nervous system. They are characterized as extradural, intradural extramedullary, or intradural, according to their location. Intradural extramedullary tuberculomas are extremely rare. There have been only 24 case reports found in English language literature. Our case is the only documented intradural extramedullary tuberculoma in a non-HIV-infected patient in North America. A literature review using a Medline search from 1966 to the present is performed to characterize the clinical spectrum of the three types of tuberculomas and review the diagnosis and management of this potentially curable disease. An analysis of the cases of intradural extramedullary tuberculomas published since 1984 is performed to highlight the unique characteristics of this rare disease.

Intramedullary cervical tuberculoma.

STUDY DESIGN: Case report. OBJECTIVE: To report a rare lesion of intramedullary cervical tuberculoma. SETTING: Department of Neurosurgery, Southwest Hospital, Third Military Medical University, Chongqing, The People's Republic of China. CASE REPORT: A 15-year-old boy presented with pain in the neck and shoulder. Examination showed mild left hemiplegia and pinprink hyperalgesia on the left side up to C3 level. Chest X-ray and CT scan showed patch and dot lesions indicating old tuberculous lesions and MRI showed a ring-enhancing intramedullary lesion at C3/4 level. Tuberculoma resection and antituberculous therapy was given. There was satisfactory recovery clinically. CONCLUSION: Intramedullary cervical tuberculoma is a rare, coexisting systemic tuberculosis and MRI scan helps in obtaining a correct diagnosis; combining surgery with anti-tuberculosis therapy is the treatment of choice.