[Clinical features and influencing factors of long-term prognosis in patients with tuberculous meningitis].

Objective: To investigate the clinical features and influencing factors of long-term prognosis of tuberculous meningitis(TBM), and to provide a recommendation for treatment and early intervention of TBM. Methods: Clinical data of TBM patients were retrospectively collected at Peking Union Medical College Hospital from January 2014 to December 2021. Patients who were followed-up more than one year were divided into two groups according to modified Rankin Scale (mRS). Risk factors associated with long-term prognosis were analyze by conditional logistic stepwise regression. Results: A total of 60 subjects were enrolled including 33 (55%) males and 27 (45%) females with age 15-79 (44.5±19.8) years. There were 30 cases (50%) complicated with encephalitis, 21 cases (35%) with miliary tuberculosis. The diagnosis was microbiologically confirmed in 22 patients (36.7%), including 5 cases (22.7%, 5/22) by acid-fast staining, 8 cases (36.4%, 8/22) by Mycobacterium tuberculosis (MTB) culture, and 20 cases (90.9%, 20/22) by molecular biology. The median follow-up period was 52(43, 66 ) months in 55 cases surviving more than one year. Among them, 40 cases (72.7%) were in favorable group (mRS 0-2) and 15 cases (27.3%) were in unfavorable group (mRS 3-6) with poor prognosis. The mortality rate was 20% (11/55). Elderly (OR=1.06, P=0.048 ) , hyponatremia(OR=0.81,P=0.020), high protein level in cerebrospinal fluid (CSF) (OR=3.32,P=0.033), cerebral infarction(OR=10.50,P=0.040) and hydrocephalus(OR=8.51,P=0.049) were associated with poor prognosis in TBM patients. Conclusions: The mortality rate is high in patients with TBM. Molecular biology tests improves the sensitivity and shorten the diagnosis time of TBM. Elderly, hyponatremia, high protein level in CSF, cerebral infarction and hydrocephalus are independent risk factors of long-term survival in TBM patients.

Prognostic factors of adult tuberculous meningitis in intensive care unit: a single-center retrospective study in East China.

BACKGROUND: Tuberculous meningitis (TBM) is the most lethal form of tuberculosis worldwide. Data on critically ill TBM patients in the intensive care unit (ICU) of China are lacking. We tried to identify prognostic factors of adult TBM patients admitted to ICU in China. METHODS: We conducted a retrospective study on adult TBM in ICU between January 2008 and April 2018. Factors associated with unfavorable outcomes at 28 days were identified by logistic regression. Factors associated with 1-year mortality were studied by Cox proportional hazards modeling. RESULTS: Eighty adult patients diagnosed with TBM (age 38.5 (18-79) years, 45 (56 %) males) were included in the study. An unfavorable outcome was observed in 39 (49 %) patients and were independently associated with Acute Physiology and Chronic Health Evaluation (APACHE) II > 23 (adjusted odds ratio (aOR) 5.57, 95 % confidence interval (CI) 1.55-19.97), Sequential Organ Failure Assessment (SOFA) > 8 (aOR 9.74, 95 % CI 1.46-64.88), and mechanical ventilation (aOR 18.33, 95 % CI 3.15-106.80). Multivariate Cox regression analysis identified two factors associated with 1-year mortality: APACHE II > 23 (adjusted hazard ratio (aHR) 4.83; 95 % CI 2.21-10.55), and mechanical ventilation (aHR 9.71; 95 % CI 2.31-40.87). CONCLUSIONS: For the most severe adult TBM patients of Medical Research Council (MRC) stage III, common clinical factors aren't effective enough to predict outcomes. Our study demonstrates that the widely used APACHE II and SOFA scores on admission can be used to predict short-term outcomes, while APACHE II could also be used to predict long-term outcomes of adult patients with TBM in ICU.

Neurotuberculosis: A Clinical Review.

In September 2018, the United Nations General Assembly held the first ever meeting to discuss the global epidemic of tuberculosis (TB) and adopted a political declaration titled "United to end tuberculosis: an urgent global response to a global epidemic." The timing of the meeting was prescient but overdue since Mycobacterium tuberculosis surpassed the human immunodeficiency virus as the world's leading infectious killer in 2014. Infection of the central nervous system by Mycobacterium tuberculosis, herein referred to as neurotuberculosis, is the most feared and dangerous form of tuberculosis, requiring a high level of suspicion and clinical experience for prompt diagnosis and treatment. Neurologists, infectious disease specialists, orthopedic surgeons, neurosurgeons, and hospitalists in all countries need to recognize the spectrum of neurotuberculosis and be able to integrate clinical information, laboratory data, and radiological findings to make a diagnosis with or without microbiological confirmation.

Matrix Metalloproteinases in Pulmonary and Central Nervous System Tuberculosis-A Review.

Tuberculosis (TB) remains the single biggest infectious cause of death globally, claiming almost two million lives and causing disease in over 10 million individuals annually. Matrix metalloproteinases (MMPs) are a family of proteolytic enzymes with various physiological roles implicated as key factors contributing to the spread of TB. They are involved in the breakdown of lung extracellular matrix and the consequent release of Mycobacterium tuberculosis bacilli into the airways. Evidence demonstrates that MMPs also play a role in central nervous system (CNS) tuberculosis, as they contribute to the breakdown of the blood brain barrier and are associated with poor outcome in adults with tuberculous meningitis (TBM). However, in pediatric TBM, data indicate that MMPs may play a role in both pathology and recovery of the developing brain. MMPs also have a significant role in HIV-TB-associated immune reconstitution inflammatory syndrome in the lungs and the brain, and their modulation offers potential novel therapeutic avenues. This is a review of recent research on MMPs in pulmonary and CNS TB in adults and children and in the context of co-infection with HIV. We summarize different methods of MMP investigation and discuss the translational implications of MMP inhibition to reduce immunopathology.

Tuberculous meningitis: Challenges in diagnosis and management.

Tuberculous meningitis (TBM) is the most lethal and disabling form of tuberculosis. In 2017, approximately 10 million people developed TB worldwide, of whom more than 100,000 new cases of TBM are estimated to occur per year. In patients who are co-infected with HIV-1, TBM has a mortality approaching 50%. Diagnosis of TBM is often delayed by the insensitive and lengthy culture technique required for disease confirmation. GeneXpert represents the most significant advance in TBM diagnostics over the past decade, but it lacks sensitivity and cannot be used to rule out the diagnosis. Higher volume of cerebrospinal fluid (CSF) seems to be interesting to improve the diagnosis performances. New rapid and accurate diagnostic tools are necessary. Better advances have been made concerning the anti-tuberculosis chemotherapy of TBM, with the publication of clinical trials and pharmacokinetic studies exploring the use of higher rifampicin doses and fluoroquinolones. The rise of drug-resistant TBM is another challenge for management because TBM caused by multidrug resistant organisms results in death or severe disability in almost all sufferers.

Human immunodeficiency virus in patients with tuberculous meningitis: systematic review and meta-analysis.

INTRODUCTION: Human immunodeficiency virus (HIV)-infected individuals are at increased risk for all forms of extrapulmonary tuberculosis (TB), including tuberculous meningitis (TBM). This study aimed to investigate the frequency of HIV in patients with TBM. METHODS: PubMed, Embase, Web of Science and Cochrane Library were searched for articles including relevant data. Stata version 14.0 (StataCorp, College Station, Texas, USA) was used to analyse the data. RESULTS: Twenty studies were identified. The pooled frequency of HIV among adult patients with TBM was 38.0% (95% CI: 21.0-57.0; I2 = 97%). In children (under the age of 15 years), 6.0% (95% CI: 1.0-13.0; I2 = 0.0%) had HIV infection. In patients with bacterial meningitis other than TBM, 36.0% (95% CI: 19.0-53.0; I2 = 100%) were HIV-infected. CONCLUSIONS: A relatively high frequency of HIV in patients with TBM was indicated by our study. Establishment of diagnostic criteria and effective treatment strategies for TBM/HIV co-infection are recommended for better management of patients with TBM+HIV.

Clinical presentations and outcomes of the children with tuberculous meningitis: An experience at a tertiary care hospital.

OBJECTIVE: To determine the clinical presentations and outcomes of the children suffering from tuberculous meningitis. METHODS: This prospective, descriptive study was conducted at the Children's Hospital and the Institute of Child Health, Multan, Pakistan, from February to December 2015. The Pakistan Paediatric Association scoring chart for tuberculosis was used as a tool for the probable diagnosis. The clinical symptoms with their durations were noted. Clinical stages of tuberculous meningitis, cerebrospinal fluid analysis and computerised tomography brain findings were noted for each patient. The outcomes in the form of death or neurological disabilities at the time of hospital discharge were noted. SPSS 19 was used for data analysis. RESULTS: Of the 40 participants, 25(62.5%) were males and 15(37.5%) were females. The mean age of the patients was 4.24±3.32 years. Besides, 26(65%) patients were less than 5 years of age. All the patients (100%) were categorised as stage 3 tuberculous meningitis. The history of prolonged duration of fever 39(97.55%) and altered level of sensorium 40(100%) were the most common clinical presentations. Moreover, 2(5%) patients died during this study. All the 38(95%) survivors had neurological disabilities. There were motor deficits in 37(97.4%) patients, altered level of sensorium in 35(92%), cranial nerve palsies in 9(23.5%), epilepsy in 29(76.3%) and hydrocephalus in 32(84%) patients. CONCLUSIONS: The children were the most vulnerable group for the worst form of tuberculous meningitis and had a grave outcome.

Standardized Methods for Enhanced Quality and Comparability of Tuberculous Meningitis Studies.

Tuberculous meningitis (TBM) remains a major cause of death and disability in tuberculosis-endemic areas, especially in young children and immunocompromised adults. Research aimed at improving outcomes is hampered by poor standardization, which limits study comparison and the generalizability of results. We propose standardized methods for the conduct of TBM clinical research that were drafted at an international tuberculous meningitis research meeting organized by the Oxford University Clinical Research Unit in Vietnam. We propose a core dataset including demographic and clinical information to be collected at study enrollment, important aspects related to patient management and monitoring, and standardized reporting of patient outcomes. The criteria proposed for the conduct of observational and intervention TBM studies should improve the quality of future research outputs, can facilitate multicenter studies and meta-analyses of pooled data, and could provide the foundation for a global TBM data repository.

Possible role of transforming growth factor ß in tuberculous meningitis.

BACKGROUND: Transforming growth factor ß (TGF-ß) is an anti-inflammatory cytokine and its role in hydrocephalus and stoke has been suggested. Tuberculous meningitis (TBM) is associated with exudates, stroke, hydrocephalus and tuberculoma, but the role of TGF-ß has not been evaluated in relation to these changes. AIM: To evaluate the cerebrospinal fluid (CSF) TGF-ß level in the patients with TBM, and correlate these with clinical findings, MRI changes, paradoxical response and outcome at 6months. METHODS: TBM patients diagnosed on the basis of clinical, CSF and MRI criteria were prospectively included. The clinical details including duration of illness, seizures, focal motor deficit, Glasgow Coma Scale (GCS) score and stage of TBM were noted. Presence of exudate, hydrocephalus, tuberculoma and infarction in MRI was also noted. MRI was repeated at 3months and presence of paradoxical response was noted. Cerebrospinal fluid TGF-ß was measured using ELISA on admission and repeated at 3months and these were compared with 20 controls. RESULTS: TGF-ß level was significantly higher in TBM compared to the controls (385.76±249.98Vs 177.85±29.03pg/ml, P<0.0001). TGF-ß correlated with motor deficit, infarction and tuberculoma on admission but did not correlate with CSF abnormalities, drug induced hepatitis, paradoxical response and outcome. TGF-ß level at 3months was significantly lower than the baseline but remained higher than the controls. CONCLUSION: CSF TGF-ß levels are elevated in TBM and correlate with infarction and tuberculoma.

Comparison of clinical features and prognostic factors in HIV-negative adults with cryptococcal meningitis and tuberculous meningitis: a retrospective study.

BACKGROUND: The incidence of cryptococcal meningitis (CM) and tuberculous meningitis (TBM) have gradually increased in recent years. These two types of meningitis are easily misdiagnosed which leads to a poor prognosis. In this study we compared differences of clinical features and prognostic factors in non-HIV adults with CM and TBM. METHODS: We retrospectively reviewed the medical records of CM and TBM patients from January 2008 to December 2015 in our university hospital in China. The data included demographic characteristics, laboratory results, imaging findings, clinical outcomes. RESULTS: A total of 126 CM and 105 TBM patients were included. CM patients were more likely to present with headache, abnormal vision and hearing, and they might be less prone to fever and cough than TBM patients (P < 0.05). Higher percentage of CM patients presented with cerebral ischemia/infarction and demyelination in brain MRI than TBM patients (P < 0.05). CM patients had lower counts of WBC in CSF, lower total protein in CSF and serum CD4/CD8 ratio than TBM patients (P < 0.05). After three months of treatment, CM group have worse outcome than TBM group (P < 0.05). Multivariate analysis showed that age more than 60y (OR = 4.981, 95% CI: 1.955-12.692, P = 0.001), altered mentation (OR = 5.054, 95% CI: 1.592-16.046, P = 0.006), CD4/CD8 ratios < 1 (OR = 8.782, 95% CI: 2.436-31.661, P = 0.001) and CSF CrAg ≥ 1:1024 (OR = 4.853, 95% CI: 1.377-17.098, P = 0.014) were independent risk factors for poor prognosis for CM patients. For TBM patients, hydrocephalus (OR = 7.290, 95% CI: 1.630-32.606, P = 0.009) and no less than three underlying diseases (OR = 6.899, 95% CI: 1.766-26.949, P = 0.005) were independent risk factors, headache was a protective factor of prognosis. CONCLUSIONS: Our study provided some helpful clues in the differential diagnosis of non-HIV patients with CM or TBM and identified some risk factors for the poor prognosis of these two meningitis which could help to improve the treatment outcome. Further studies are worth to be done.

Tuberculous tales: an East London experience.

Tuberculous meningitis presents a diagnostic and therapeutic challenge, and considering its long history and increasing global incidence, the evidence base for its treatment is relatively scanty. Many UK neurologists will have little first-hand experience of this deadly condition, and if faced with a patient with possible tuberculous meningitis will find decision making less than straightforward. In parts of East London (UK) the rates of tuberculosis and tuberculous meningitis are among the highest in Western Europe, and so the neurologists and respiratory physicians at the Royal London Hospital have encountered many such patients over the years. We have found experience to be a valuable teacher and so would like to share five cases that illustrate the complexities of diagnosis and management of the disease, and complications of its treatment.

Spinal cord involvement in tuberculous meningitis.

OBJECTIVES: To summarize the incidence and spectrum of spinal cord-related complications in patients of tuberculous meningitis. SETTING: Reports from multiple countries were included. METHODS: An extensive review of the literature, published in English, was carried out using Scopus, PubMed and Google Scholar databases. RESULTS: Tuberculous meningitis frequently affects the spinal cord and nerve roots. Initial evidence of spinal cord involvement came from post-mortem examination. Subsequent advancement in neuroimaging like conventional lumbar myelography, computed tomographic myelography and gadolinium-enhanced magnetic resonance-myelography have contributed immensely. Spinal involvement manifests in several forms, like tuberculous radiculomyelitis, spinal tuberculoma, myelitis, syringomyelia, vertebral tuberculosis and very rarely spinal tuberculous abscess. Frequently, tuberculous spinal arachnoiditis develops paradoxically. Infrequently, spinal cord involvement may even be asymptomatic. Spinal cord and spinal nerve involvement is demonstrated by diffuse enhancement of cord parenchyma, nerve roots and meninges on contrast-enhanced magnetic resonance imaging. High cerebrospinal fluid protein content is often a risk factor for arachnoiditis. The most important differential diagnosis of tuberculous arachnoiditis is meningeal carcinomatosis. Anti-tuberculosis therapy is the main stay of treatment for tuberculous meningitis. Higher doses of corticosteroids have been found effective. Surgery should be considered only when pathological confirmation is needed or there is significant spinal cord compression. The outcome in these patients has been unpredictable. Some reports observed excellent recovery and some reported unfavorable outcomes after surgical decompression and debridement. CONCLUSIONS: Tuberculous meningitis is frequently associated with disabling spinal cord and radicular complications. Available treatment options are far from satisfactory.

Clinical management of tuberculous meningitis: experiences of 42 cases and literature review.

Tuberculous meningitis (TBM) is common infectious disease. Early diagnosis and timely treatment are critical for the cure of the disease. Thwaites standard is widely accepted but not the golden standard. Here, we analyzed 42 cases of TBM patients in local hospital and combined with literature review to provide more information in TBM management.

Tuberculoma masked by glioma: a case report.

Tuberculous meningitis (TM), a common infectious disease of the central nervous system that is also seen in other types of tuberculosis infections, has higher mortality rates in young and middle-aged patients. TM is difficult to diagnose and treat owing to its non-specific clinical features and often atypical cerebrospinal fluid changes. Patients who present with focal neurologic signs, cough, low-grade fever and illness duration of more than 5 days, have intracalvarial abnormalities, and do not meet Thwaites' criterion findings should be diagnosed using computed tomography or magnetic resonance imaging. Mycobacterium infections can also be diagnosed by acid-fast staining of smears, cerebrospinal fluid culture, diagnostic polymerase chain reaction for Mycobacterium tuberculosis, and purified protein derivative test. To prevent TM misdiagnosis, clinicians must have sufficient knowledge of the clinical manifestations of tuberculosis. Appropriate application of tuberculosis chemotherapy drug principles, including early diagnosis and treatment, combination therapies, and consistent administration of treatment at appropriate dosages, can greatly reduce TM mortality rates and improve satisfactory treatment outcomes.

Paradoxical improvement of function more than 2 years after onset of tuberculous meningitis.

OBJECTIVE: To document the unexpected improvement made by a 50 year-old patient over 2 years after being diagnosed with tuberculous meningitis (TBM). METHODS: Regular neuropsychological assessments were carried out, initially with a test for patients in reduced states of awareness and later with more demanding tests. RESULTS: The patient was diagnosed with TBM in November 2008 and was mute, stuporous and barely more than minimally conscious for over 2 years. By February 2011, following the cessation of TBM medication, her conscious level had improved and she could be assessed on a range of neuropsychological tests. The patient presented with diffuse cognitive impairments coupled with focal neurological signs, but showed marked improvements in cognitive functioning compared to when admitted. CONCLUSIONS: This study demonstrates that late stage neuropsychological improvement is possible, even after 2 years of showing minimal awareness. Such paradoxical improvement of function is considered in the light of other paradoxical phenomena in TBM, comparisons are offered with similar neurological conditions and possible mechanisms underlying the dramatic improvement that took place are suggested.

Vascular endothelial growth factor in tuberculous meningitis.

Vascular endothelial growth factor (VEGF) is linked to brain edema and infarction, but there is paucity of studies correlating VEGF level with magnetic resonance imaging (MRI) changes in tuberculous meningitis (TBM). The aim of this study was to measure serum VEGF level in TBM and correlate it with clinical, laboratory, and MRI findings. Forty patients with TBM underwent cranial evaluation, cranial MRI, and MR angiography (MRA). Presence of exudates, hydrocephalous, infarction, tuberculoma, and MRA abnormalities was noted. Serum VEGF level was measured by enzyme-linked immunosorbent assay and compared in patients and controls. The VEGF level was also correlated with clinical, MRI, and MRA findings. The median age of the patients was 26.5 years. There was a trend towards higher serum VEGF level in TBM patients (100.7 ± 110.6 pg/ml) compared to the controls (60.6 ± 20.3 pg/ml). There was also a trend towards higher VEGF level in patients with shorter duration of illness (127.5 ± 152.4 pg/ml vs 76.5 ± 40.9 pg/ml), MRI evidence of infarction (131.4 ± 150.7 pg/ml vs. 73.0 ± 41.4 pg/ml), and paradoxical response (122.3 ± 157.6 pg/ml vs. 88.8 ± 50.8 pg/ml). Five patients died, and death was not related to VEGF level. It can be concluded that serum VEGF level in TBM patients is insignificantly higher in those with shorter duration of illness and infarction.

Tuberculous meningitis in adults: a prospective study at a tertiary referral centre in Sri Lanka.

INTRODUCTION: Central nervous system tuberculosis is the most severe form of extrapulmonary TB and it is associated with a substantial morbidity and mortality. OBJECTIVES: To describe the demographic profile, clinical features, laboratory and imaging results of a cohort of adult patients with TBM (Tuberculous meningitis). METHODS: This study encompasses a prospective analysis of all adult cases of TBM diagnosed from 1st January 2010 to 31st December 2011 in the Neurology unit 2, National Hospital of Sri Lanka. Consensus case definitions for TBM were used for clinical case classification and patients were given a definite, probable, or possible tuberculous meningitis status accordingly. RESULTS: A total of 89 patients fulfilled the established diagnostic criteria for TBM and there were 22 definitive cases, 46 probable cases and 21 possible cases. The mean age of the series was 44 years and 56 (63%) were males. TBM presented with fever in 64 (71%), general constitutional symptoms in 61 (68%), headache in 53 (59%), and diminished level of consciousness in 36 (40%) patients. CSF biochemistry revealed elevated protein in all patients. MRI brain showed meningeal enhancement in 73 (82%). Twenty four (27%) died during hospitalisation and out of 65 who survived 44 (49%) had residual sequelae at the time of discharge. CONCLUSIONS: MRI evidence and biochemical analysis of CSF are still the main supportive diagnostic modalities. TBM is a relatively common but difficult to diagnose disease, which results in significant morbidity and mortality.

Effects of the implantation of Ommaya reservoir in children with tuberculous meningitis hydrocephalus: a preliminary study.

OBJECTIVE: The role of Ommaya reservoir implantation in children with tuberculous meningitis hydrocephalus (TBMH) has been seldomly reported. Therefore, we performed this study to determine the role of the Ommaya reservoir in the treatment of children with TBMH. METHODS: We retrospectively analyzed the effects of Ommaya reservoir implantation in 12 children with TBMH. Intracapsular puncture of the reservoir was performed for draining the cerebrospinal fluid and the TBM was treated by intraventricular injection of isoniazid. RESULTS: The ideal treatment outcome was observed in nine (75 %) of the 12 children; two (16.7 %) children developed serious disabilities and one of them (8.3 %) eventually died. The treatment method was effective for all six (100 %) children with Palur grade II TBM but showed no effect in three (50 %) children with grade III and IV TBM. The number of leukocytes in the cerebrospinal fluid decreased to 20 × 10(6)/L (75 %) within 2 weeks after implantation of the reservoirs. Finally, the Ommaya reservoirs in eight children were removed but were retained in four children. Four children had to undergo ventriculoperitoneal shunt. CONCLUSION: Ommaya reservoir implantation has been shown to be effective in treating children with TBMH. This method may be largely suitable for children with early grade II TBM or partly in children with grade III TBM who have mild or moderate hydrocephalus that can alleviate after short-term treatment. Thus, a good proportion of children who undergo Ommaya reservoir implantation can avoid ventriculoperitoneal shunt surgery.

Predictors of mortality in patients with meningeal tuberculosis.

BACKGROUND: Meningeal tuberculosis (TB) has higher mortality compared to other forms of central nervous system TB. However, data on predictors of mortality is limited. AIMS: To determine the predictors of mortality in patients with meningeal TB. MATERIALS AND METHODS: This study retrospectively analyzed the data of patients admitted with a diagnosis of meningeal TB between January 2006 and December 2008. Thwaites' index score of four or less was used for the diagnosis of meningeal TB which is a weighted diagnostic index score for dichotomised clinical variables. Predictors of mortality were analyzed separately for both patients with human immunodeficiency virus (HIV) infection and without. STATISTICAL ANALYSIS: Univariate analysis and multinomial logistic regression was done. RESULTS: Univariate analysis showed age >40 years, Glasgow Coma Scale (GCS) score <8, absence of headache, cerebrospinal fluid (CSF) protein ≤60 mg% and Medical Research Council (MRC) Stage III at presentation to predict in-hospital mortality. In multinomial logistic regression age >40 years was a risk factor for mortality when HIV patients were included (P=0.049) as well as when they were excluded (P=0.048). CSF protein ͳ 60 mg% was found to be a significant risk factor when both HIV seropositive persons (P=0.011) as well as seronegative persons (P=0.004) were included. HIV seropositivity, steroid treatment or delay in treatment did not affect mortality. CONCLUSIONS: Identification of factors predictive of in-hospital mortality will help to prognosticate patients with meningeal TB at the time of admission.

Tuberculous hypertrophic pachymeningitis presenting as visual blurring and headaches.

Hypertrophic cranial pachymeningitis is a rare chronic fibrosing inflammatory disease characterised by localized or diffuse thickening of duramater, leptomeninges, and tentorium. The etiology is diverse and includes infectious, granulomatous and inflammatory disorders, collagen vascular disorders, carcinoma, lymphoma, meningioma en plaque, sarcoidosis, haemodialysis, mucopolysaccharidosis, intrathecal drug administration, and meningeal carcinomatosis diseases. Intracranial hypotension is also an important image mimicker. Most often patients present with complaint of headache, vomiting, cranial nerve palsy, ataxia, raised intracranial pressure and focal neurological deficit. Other signs and symptoms are inconstant and variable. The imaging features of hypertrophic cranial pachymeningitis include dural thickening, dural mass, sinus thrombosis, venous congestion with white matter changes. Extensive preoperative imaging studies usually are essential by Computerised Tomography (CT) or Magnetic Resonance Imaging (MRI). The radiological findings may be characteristic of hypertrophic cranial pachymeningitis, may not divulge the underlying etiology. Meningeal biopsy is essential for diagnosing the cause. We reviewed a case of a tuberculous hypertrophic cranial pachymeningitis.